Analgesic cessation

Regular use of analgesics for whatever reason can give rise to medication induced headache; this can occur in the context of a primary headache disorder such as migraine or where analgesia is being taken for systemic or regional pain (chronic low back pain etc.). It is more common with opioids and paracetamol but can complicate treatment with NSAIDS or triptans.

Complete withdrawal of all analgesics is necessary, but this very frequently causes severe rebound headaches which can be vary in severity from day to day and can last for some time (typically 2 to 4 weeks, although the withdrawal period can go on for months).

Below is a framework, adapted from that used by the regional headache centre at the University Hospital of North Midlands, designed to help patients get through the withdrawal period.

Appointment with general practitioner first – this is to agree a date for commencement and receipt of necessary medications to help manage withdrawal symptoms.
Medications to treat ‘rebound’ headache – If no contra-indications naproxen 500mg BD or diclofenac soluble 50mg TDS. To be used a maximum of 2 to 3 days a week if the headaches are very severe. Ideally no painkillers should be taken. Stomach protection with the general practitioners preferred agent may be advised
Anxiolytic and antiemetic treatment – lorazepam 1 to 2 mg BD PO for severe anxiety symptoms – this should be used for no more than 4 weeks. Domperidone 20mg TDS for nausea and vomiting if required.
Hydration and avoidance of caffeine - It is recommended that the patient drinks at least 3L of water a day. Caffeine is dehydrating and can contribute to headaches so this should be avoided.
Prednisolone ‘rescue’ therapy- in patients who develop severe, refractory headache, not-responding to the approved NSAIDS, a short course of steroids -100mg prednisolone for a maximum of 6 days – should be considered. Long-term steroids should not be given and have no place in the management of medication induced headache.

In addition to analgesic cessation it is likely that the patient may have been commenced on a new anti-migraine prophylactic. Please make sure that the patient persists with this unless the side-effects are un-manageable.

This page has been adapted from the Analgesic cessation Leaflet produced by Brendan Davies, University Hospital of North Midlands