What would you call it when someone with headache becomes trapped in a vicious cycle of an increasing number of attacks, needing more and more medicine to stop them, with a sinking feeling that the next headache or migraine is fast on the heels of the last pill swallowed? When ever stronger medicine is sought to halt the attacks, but this only seems to fuel the fire? When someone becomes trapped by headache, and might even start behaving like he or she is addicted to migraine medication?
A number of labels have been attached to this phenomenon over the years. They all seem to have negative connotations: “rebound headache” sounds like a misguided relationship (and could apply to a withdrawal headache—a different thing), “medication abuse headache” implies the patient is at fault, “medication overtreatment headache” pins the blame on the doctor, and so on. These labels may reflect what we see happening on the outside, but the real cause is not captured by them, nor is it fully known. The “accepted” term these days is “medication overuse headache;” it’s a little less blameful, but still doesn’t encapsulate the whole picture, including what could be happening biologically.
What IS happening, really? The more a person takes a medication, does it just wear off faster and faster, and are ever higher doses needed to achieve the same result, as in tolerance? Maybe, but does “medication tolerance headache” sound appropriately inclusive? What pushes someone to keep taking more and more medication, even to the point of self harm, when it’s obvious it’s an exercise in futility? That sounds like addiction, doesn’t it? Is it addiction? Traditionally “addiction” is applied to repeated behavior directed toward attaining pleasure or reward despite negative outcomes. But patients aren’t doing this for kicks, they’re trying to get relief. Some would say a better term is “pseudoaddiction,” but is it really? Perhaps it is a little more precise, but not only does it fail to describe fully what is happening, it sounds fake (pseudo), and still has that negative flavor of labeling someone as an addict.
Many old medical terms have been pushed to the wayside, some because their use became commonplace insults in casual conversation (idiot, moron, retard – these words historically referred to specific IQ levels), some because they label a patient as a disease (we don’t refer to people with epilepsy as “epileptics” anymore). So isn’t it time we updated “medication overuse headache?”
Going back to the possible biology, some believe that repeated use of medication to relieve headache actually causes physiological changes in the nervous system which cause a person to experience migraine more readily. An animal study with sumatriptan (Imitrex) supports this. Individuals seem to have different thresholds for becoming susceptible to this, though. One person might be able to take their medication several days per week and never get worse or lose the effect of their medication, while someone else might get into trouble with just a few doses of an opioid. So what then constitutes “overuse?” One could say it is how the nervous system “adapts” in this scenario, so a fitting name could be “medication adaptation headache.” That does sound better indeed. Another neurologist, an English professor, a Philosophy professor, and I have discussed various names and their appropriateness or inappropriateness based on where the center of blame or cause lies (see below). We wrote a paper (our Philosophy professor was the first author) in which we suggested “medication adaptation headache” should officially replace “medication overuse headache.” We will be petitioning the Headache Classification Group to make this change.
|Blame the Patient||Blame the Doctor||Mechanism-Based|
|Medication abuse headache||Medication overtreatment headache||Medication induced headache (maybe with type 1, type 2, etc.)|
|Drug abuse headache||Iatrogenic headache||Freed-forward headache|
|Medication misuse headache||Drug-transformed (or amplified) headache|
|Medication Overuse Headache||Medication Adaptation Headache|
The picture will become clearer as research sharpens our focus and helps to uncover the real facts behind …. whatever this should be called! But research takes time, expertise, and funding. We all know how precious time is. All experts are at one time novices, who need to be trained by other experts, which takes time and funding! With greater awareness of these needs and a big push to fulfill them, the landscape of headache medicine can change. You can help by letting your friends know about AHDA, writing to Congress, talking about these issues with your doctor, encouraging young scientists- and doctors-in-training you meet to take interest in our cause, and so many other ways. Be creative! And remember, too much is not enough.
Stephanie J. Nahas, M.D., M.S.Ed
Jefferson Headache Center; Philadelphia, Pennsylvania