from The Richeimer Pain Institute
August 2000


Headaches are the single most common pain complaint that patients bring to doctors. There are many potential causes of headaches: tension, migraines, sinus problems, vascular problems, neck problems, dental problems, visual problems, high blood pressure, tumors, infections, hemorrhages, etc. It is rare that any of these causes will produce severe headaches on a daily basis. Yet by the time most patients make it to my door at the Pain Management Center, they have in fact developed severe, daily headaches. Let me explain why this happens.

I will describe a typical situation. Pam is a 47 year old woman who started getting migraine headaches in her early twenties. These were severe headaches that lasted for 1-2 days, and occurred approximately once a month, especially around the start of her monthly menses. With the help of her doctors, Pam discovered that ibuprofen, sumatriptan (Imitrex), and Fioricet could help ease the headache. With these medicines she could usually stay at work.

Pam's headaches continued, but were controlled. Then in the last few years, Pam's life became much more stressful. She never had enough time for family, exercise, sleep, and certainly not enough for fun and time off. She woke up tired every morning, but a couple cups of coffee helped to provide energy. Pam's headaches were increasing. She noticed that she used to go for a month between headaches, but now she was getting headaches almost every week. These more frequent headaches were not quite as severe, but severe enough to send Pam to her medications for help. The medications did seem to help. Gradually, the frequency of the headaches increased to 2-3 times per week. She didn't sleep well, and found that she needed the coffee "boost" several times through the workday.

Pam had an MRI scan and was told that her brain was normal. She thought that she might have allergies, so she started a special diet and got an air purifier. The doctors tried her on several medications to try to prevent the headaches. None of this worked very well. The headaches continued to increase till she reached the point that not a day passed without a headache. By the time Pam came to our clinic, she was using Imitrex 2 tablets, 1-2 times a day; Fioricet with codeine 2 tablets, 3 times a day; and Ibuprofen 3 tablets, 3-4 times a day. Her diagnosis was severe, chronic, daily headaches, and she was miserable.

Pain pills, headache medicines, and caffeine all cause headaches! Is this true in everyone? No, only among those who are prone to headaches. How does one know if they are prone to headaches? If you get headaches more than once a month. If someone gets headaches more than once per month, then the surest way for them to get another headache is to consume an anti-headache medicine, an anti-pain medicince, or caffeine.

The three most common causes of chronic daily headaches are:
1. stress and tension,
2. the use of pain and headache medications,
3. the use of caffeine,
and commonly they all go together.

The reason is because of a phenomenon called rebound. The medication eases the headache for a short time, but then as the medicine wears off, the headache comes back even worse, and the headache sufferer takes more medicine. Quickly, a vicious cycle develops. The medicines are needed for the bad headaches, but they also make the headaches worse. Caffeine causes the same vicious cycle. A couple of cups of coffee will actually help many headaches (notice that caffeine is in many over-the-counter headache medicines), but when the caffeine wears off, that's when the caffeine withdrawal headaches start! Many experts believe that caffeine withdrawal is the number one cause of headaches in the United States.

The first thing that I do is I taper my patients off all short-acting headache and pain medicines. If necessary, I may put them on low doses of a long-acting pain medicine such as Methadone. Because long-acting medicines stay in the blood continuously, there is never a rebound or withdrawal phase. Eventually, we may try to taper off even the long-acting pain medicines. Once the patient is off all caffeine and short-acting medicines, then we may re-try some of the headache prevention medicines that the doctors had tried earlier. These medicines which wouldn't work on rebound headaches, now have a chance to work on the underlying, core headache problem. At the same time, I enroll the patient in an intensive stress management and exercise program. We encourage the patient to do what Mother always taught: eat regularly and healthily, exercise regularly, deal with (rather than ignoring) stress, have regular bedtime and sleep hours, and don't smoke.

The results are often phenomenal. It takes hard work, but if the patient perseveres, they will usually see a dramatic reduction in the severity and frequency of their headaches. Some headaches will persist; Pam continued to have moderate headaches 1-2 times a month, but the daily headaches were gone.

Remember the take home message: If you get headaches more than once a month, headache medicines, pain pills, and caffeine all cause headaches!

Until next time…Steven Richeimer, M.D.

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Steven Richeimer, MD
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