Painkillers may be making a million headaches worse

A warning that overusing certain painkillers can cause a "vicious cycle" of disabling headaches is widely reported in the papers today.  "More than one million people in Britain may be suffering from constant, crippling headaches because they are taking too many painkillers," the Guardian explains.

The stories are based on new guidance for doctors and other health professionals from the National Institute of Health and Clinical Excellence (NICE) on the diagnosis and treatment of headaches.

While the guidance covered many different types of headaches, NICE was especially keen to highlight what are known as "medication overuse headaches" – possibly because this condition is often not recognised by either the public or health professionals.

Medication overuse headache is a poorly understood but well-established condition where long-term use of painkillers, such as aspirin, paracetamol and the non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, actually worsen the headache, both in terms of severity and frequency.

NICE warns that people who regularly take certain common painkillers could be "causing themselves more pain than relief". The guidance calls on GPs and other healthcare professionals to consider the possibility of "medication overuse" in their patients.

You should contact your GP for advice if:

• you take paracetamol, aspirin or an NSAID for 15 days or more in a month to control headaches
• you take an opiate-based painkiller, such as codeine, triptans or ergots,  or a combination of different painkillers, for 10 days or more to control headaches

Who produced the guidance ?

The guidance was produced by the National Institute for Health and Clinical Excellence (NICE), the independent body that makes recommendations for the NHS on the diagnosis and management of health conditions, including treatments that should be available.

What does NICE say about the links between chronic painkiller use and persistent headaches?

NICE says that GPs and other health professionals should be alert to the possibility of medication overuse in people whose headache developed or worsened while they were taking any of the following drugs for three months or more:

• Paracetamol, aspirin or an NSAID (non-steroidal anti-inflammatory drug), either alone or in combination, on 15 days a month or more.  NSAIDs include over-the-counter medications such as ibuprofen and naproxen. These drugs are widely used to relieve pain and fever and are also often used for many chronic musculoskeletal conditions such as arthritis or low back pain.
• Triptans, opioids, ergots or combination painkillers on 10 days a month or more. These are stronger pain medications that may be prescribed by doctors when over-the-counter medications are ineffective. Triptans (for example, sumatriptan, brand name Imigran) are drugs with a different method of action from standard painkillers and are prescribed to relieve migraine or cluster headaches (where there is severe pain or throbbing usually in a particular place, such as around one eye). Opioids are strong painkillers used to relieve persistent pain; there are many opioids ranging from codeine and tramadol to strong opioids such as morphine. Ergots are painkillers that can be used for migraine, though they are rarely prescribed now due to side effects (triptans are prescribed more commonly for migraine).

NICE says the only treatment for headaches caused by medication overuse is to stop using the medication in question. It says the medication should be "stopped abruptly" rather than gradually. It also advises that after stopping the painkiller, headache symptoms are likely to become worse in the short term before they improve and that there may be associated withdrawal symptoms. People stopping their medication for this reason, it says, will need "close follow-up and support" from health professionals.

A neurologist quoted by The Guardian said that some people "would have an awful two to three weeks" and would understandably have problems with activities such as working. If you are concerned that this may apply to you it may be possible to take sick leave from your job.

The neurologist also recommended that you contact friends and family to let them know what you will be going through so that they can provide support.

NICE also says that some patients suffering from medication overuse should be referred to a specialist, and possibly admitted to hospital, for help to stop taking painkillers. This group includes people using strong opioids, people with other significant medical illness, and those for whom previous attempts to stop medication overuse have been unsuccessful. 

It also says that for people with medication overuse headache, doctors should consider preventative treatment for the underlying headache disorder, in addition to the withdrawal of overused medication. Preventative (or prophylactic) treatment will depend on the type of headache that has been diagnosed. For example, the guidance recommends a course of acupuncture to help prevent "tension-type headache" (NICE also calls this “every day” headache, meaning the common mild-moderate, pressure-type headache most people have when they say they have a headache) and, to help prevent migraine attacks, drugs called topiramate or propranolol (respectively, a type of antiepileptic drug and a beta blocker, both licensed for migraine prevention).

Martin Underwood, a GP and professor of primary care research at Warwick Medical School, who chaired the guideline's development, said: "We have effective treatments for common headache types. However, taking these medicines for more than ten or fifteen days a month can cause medication overuse headache, which is a disabling and preventable disorder.

"Patients with frequent tension-type headaches or migraines can get themselves into a vicious cycle, where their headaches are getting increasingly worse, so they take more medication which makes their pain even worse.

"I hope this guideline will improve awareness of medication overuse headache both in primary care and among the general public, because prevention is simple and treatment is difficult. Explaining to patients that they should abruptly stop their medication, knowing that their headache will get much worse for several weeks before it will improve, is not an easy consultation."

Did the guidance raise any other important points?

The new guidance covers the diagnosis and treatment of the most common types of "primary" headaches in young people (aged 12 years or older) and adults. Primary headaches are those which are not caused by an underlying disease and are normally classified as tension-type headache, migraine or cluster headache. NICE recommends that doctors diagnose these different types of headache according to patients' symptoms (there is a characteristic symptom pattern with each), and recommends specific treatments for each type. It also sets out the circumstances where further investigation should be considered.

In particular, NICE says people diagnosed with these headaches should be given an explanation of the diagnosis and reassured that their headaches are not caused by any underlying disease or illness.   Any discussion with the patient should include recognition that "headache is a valid medical disorder that can have a significant impact on the person or their family or carers".  Options for treatment should also be discussed.

NICE also advises that people diagnosed with a primary headache or with medication overuse headache should not be referred for further investigations (for example, CT or MRI scans of the brain) "solely for reassurance". Manjit Matharu, an honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery and a guideline developer, said that although brain imaging was "an important diagnostic tool", most people's headaches will not be caused by brain tumours or other serious health problems, and so these scans should not be offered to patients solely for reassurance.

NICE did, however, mention a number of potential "red flag" indicators that in its opinion warranted further investigation, which could include referral to a specialist. They included:

• headaches that develop after a head injury that happened within the past three months
• headaches that are getting worse and are accompanied by a fever
• headaches that start very suddenly
• problems with speech or balance that happen regularly and are getting worse
• problems with memory or changes in behaviour that happen regularly and are getting worse
• feelings of confusion or disorientation
• a change in personality
• headaches that start after coughing, sneezing or straining
• headaches that start after exercise
• headaches that are worse when sitting or standing up
• a red or painful eye(s)
• a substantial change in the headache symptoms

Further testing or referral to a specialist is also recommended if:

• your immunity is low, for example because you are HIV positive or are taking medication that lowers immunity
• you are aged under 20 and have had any type of cancer
• you have had a type of cancer that can spread to the brain
• you are vomiting for no obvious reason

The guidelines also say that many of the current treatments used to treat migraines and cluster headaches had good evidence of being effective and should continue to be used. Read more about the treatment of migraines and cluster headaches.

What should I do if I think my painkillers are contributing to my headaches?

The only treatment for medication overuse headaches is to stop the medication in question for at least one month, according to NICE. You may feel you can manage this yourself, if you have been taking painkillers for months rather than years. If you find the idea of this difficult, see your GP. Your headache is likely to get worse in the short term before it improves and you may have temporary symptoms of withdrawal such as feeling sick or problems sleeping. You should be offered the support you need to stop taking these drugs.

If you are using a strong opioid or have other health problems, or you have tried stopping painkillers without success, your health professional may refer you to a specialist or to hospital.

Your healthcare professional should see you 4-8 weeks after you stop taking the drugs to check whether stopping has reduced your medication overuse headache.

Your health professional should also advise you of treatments to prevent any underlying headache disorder that  caused you to overuse painkillers. 

How accurately did the media cover the guidance?

The media covered the guidance on medication overuse headaches accurately and included some useful advice from specialists in the field.

Most reports did not look at other aspects of the guidance, such as recommended treatments for headache prevention, migraines or cluster headaches. This is not surprising as the press release about the guidance focused on the problem of medication overuse headache and NICE’s recommendations in that area.