Can Migraine Meds Actually Trigger an Attack? What to Know

Taking medications at too-high doses or too frequently can cause what’s known as rebound headaches. They can be severe, often occur in the morning, and might involve pain around the neck and shoulders.

People who have had migraine episodes know it’s more than a one-off headache. It often affects your day-to-day life.

Migraine medications can sometimes make the difference between feeling OK or not. But can they actually result in the opposite effect?

Read on to learn how migraine medication can actually trigger symptoms in certain cases, plus how to prevent that from happening.

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Can medication make migraine worse?

The point of migraine medication is to prevent or reduce migraine pain and frequency.

Migraine medication is a pivotal tool for patients and the providers who care for them, says Megan Donnelly, DO, a North Carolina-based migraine expert with Novant Health Neurology and Sleep.

“Anyone with migraine should have access to medication to treat their condition,” says Donnelly.

But in some cases, medication can actually make the problem worse, causing what’s known as a “rebound headache.”

What is a rebound headache?

Rebound headaches occur when your migraine medication isn’t relieving your symptoms, isn’t targeting your symptoms, or is being used too frequently. This is sometimes referred to as medication overuse or medication adaptation headaches.

A 2018 research review suggests that the prevalence of patient medication overuse has varied in research from 30–50%. Reported numbers tend to be higher at headache specialist centers.

“Rebound headaches, or medication overuse or misuse, are when you are using a medication for migraine that is ineffective, too broad of a medication, or you are using it too frequently to the point it causes you to have headaches,” says Neil Patel, MD, a neurologist at Stony Brook Medicine.

Thomas Berk, MD FAHS, neurologist, headache specialist, and medical director of Neura Health, says the difference between migraine and rebound headache symptoms can be subtle.

“We do usually see more frequent and severe headache attacks, many times in the morning and with more musculoskeletal pain around the neck and shoulders,” Berk says.

The type of medication matters

The likelihood of experiencing rebound headaches is connected to the type of medication used.

“It depends on the medication,” says Berk. “Each class of medication has its own limitations.”

For instance, Berk says some medications can worsen a headache even if only taken once weekly.

These medications include:

• opiates
• narcotics, like butalbital
• medications derived from phenobarbital, like Fioricet

Donnelly says the frequency of rebound headaches is why the American Headache Society recommended against using opioids or butalbital as a first-line migraine treatment in 2013.

NSAIDs, DHE, and triptans

Other medications can also cause rebound headaches if taken too frequently, including:

• nonsteroidal anti-inflammatory drugs (NSAIDs)
• acetaminophen
• dihydroergotamine (DHE)
• triptans (serotonin receptor agonists)

Donnelly notes that these medications can cause rebound headaches if taken more than 10 days per month.

However, Berk says that anti-inflammatories generally don’t cause rebound headaches and “may actually be helpful and preventive if they are alternated with other acute medications.”

An older 2008 study suggests that NSAIDs might protect against chronic headaches in people with a low to moderate number of headache days per month.

Medications that aren’t known to cause rebound headaches

Berk says medications that likely won’t cause rebound headaches include:

• gepants (CGRP receptor antagonists)
• muscle relaxants
• anti-nausea medications

Why do medications affect migraine symptoms?

Patel says the way the medications change the brain is likely the root of rebound headaches.

“We believe the cause of these rebound headaches is that, after using the medications often enough, it changes how the brain accepts the normal neurotransmitters,” Patel says. “It upregulates the receptors, meaning that your body adjusts for those medications by creating more receptors that make it easier to trigger a migraine.”

This creates a reinforcing cycle, with people then increasing their medication use to treat the headache.

“Headaches [can] become daily when the analgesics wear off, which tricks the body into thinking more analgesics are needed,” Donnelly says.

Diagnosis, prevention, and treatment of rebound headaches

Is it a rebound headache or pain from something else?

Here’s how to tell, plus how to prevent and treat rebound headaches:

Diagnosis

Patel says doctors will take a personalized approach to help patients determine whether they’re experiencing rebound headaches.

The timing of the headaches, frequency of medication use, and headache frequency are all part of diagnosing rebound headaches.

“A rebound headache can be different for everyone,” Patel says. “The only thing that will clarify it as a rebound headache is the history of using the medication and [it] initially being effective and then not being effective.”

From there, treatment and counseling on prevention can begin.

Treatment

Experts caution against attempting to self-manage symptoms.

“If you think that you have medication adaptation headache, schedule an appointment with your specialist so that you can develop a plan to manage it,” Berk says.

“Depending on the severity, you’ll need to slowly taper off of the acute medication causing this complication and remain off it for several months,” Berk adds.

Donnelly also stresses the potential need for a slow taper.

“Some medications can safely be stopped abruptly, such as the NSAIDs and triptans, whereas butalbital-containing medications might need to be tapered because of the risk of life threatening withdrawal if someone is on a higher daily dose,” Donnelly says.

Preventing rebound headaches

Rebound headaches from migraine medication can be painful and frustrating. Plus, Berk says you’re more likely to have repeat occurrences if you’ve experienced them before.

To prevent rebound headaches, it’s important to cycle through medications rather than relying on the same one every day.

General headache prevention is also key for preventing rebound headaches. If you use medications every day or almost every day, this regular use can lead to medication withdrawal headache pain.

Some doctors consider about 2–3 headache days per week a turning point for considering preventive meds instead of just acute treatments, but you and your doctor can discuss your benchmark for starting preventive treatment.

Preventives are typically taken every day and have fewer side effects and a lower chance of withdrawal than acute treatments. Additionally, learning your triggers and avoiding them can help prevent frequent headaches and lower the risk of rebound.

“It’s important to develop a robust acute toolkit with your provider so that you have multiple acute treatments that wouldn’t contribute to adaptation headache,” Berk says.

These tools can include slowly tapering from medications and adding additional pharmaceutical interventions that could prevent rebound headaches.

“Medications including triptans and acetaminophen will be limited to twice per week. You can use these more than once daily, and that would be considered ‘one day’ of usage,” Berk says. “Anti-inflammatory medications would be limited to 3 days per week and may actually be helpful and preventive if they’re alternated with other acute medications.”

Berk says other strategies to prevent rebounds include:

• taking fremanezumab (Ajovy)
• alternating acute medications
• using a neuromodulation device

Ajovy is a medication that’s specifically helpful for preventing rebounds.

A 2020 trial of more than 1,100 people suggests that participants who took Ajovy required less medication than those who took the placebo.

Neuromodulation involves using a device to stimulate nerves with electrical impulses to increase or decrease nerve activity.

A 2020 study suggests that using a remote electrical neuromodulation device along with standard migraine care could reduce the use of acute migraine medications and, therefore, lower the risk of medication overuse headaches.

Some available neuromodulation devices include:

• Relivion
• Savi Dual
• Cefaly
• gammaCore
• SpringTMS

Takeaway

The important thing to remember? Rebound headaches are treatable.

“It’s important to know that the cycle of medication overuse headache can be broken and reversed,” Donnelly says.

Switching medications or using preventive medications, neuromodulation, and gepants for as-needed therapy are all options you can discuss with a healthcare professional.