NSAIDs – The True Cause of Headaches and Neck Pain?

headaches and neck pain MOHWhen headaches and neck pain occur together there can be a variety of explanations ranging from concussion after a serious fall, head and neck tumours causing obstructed circulation or nerve activity, stress and muscle tension and even, it seems, overuse of NSAIDs for neck pain leading to medication-related headaches.

Around 1% of the US population is thought to experience medication overuse headaches and while these are more common in those with primary headaches it may be that neck pain is also a trigger.

Headaches and neck pain can be part of the same condition, may occur together but have separate causes, or may trigger one another. For example, if someone has chronic neck pain this may cause increased stress, tension, and even suboptimal diet and lifestyle habits that increase the likelihood of headaches developing. Conversely a persistent headache can cause a person’s posture to change, increasing muscle tension and precipitating neck pain.

What’s a Rebound Headache?

Rebound headaches, or medication overuse headaches (MOH), have been observed for many years in patients with chronic pain. Ironically, MOH may occur as a result of medication for an ongoing headache, creating a vicious cycle where primary and secondary symptoms are almost impossible to distinguish. With neck pain and the use of non-steroidal anti-inflammatory drugs (NSAIDs) it may be easier to figure out the chicken and egg scenario.

Medication overuse headaches are defined as a headache present for at least 15 days a month in a person using any analgesic for at least 3 months at a minimum level (which differs for each medication). Common analgesics are defined as being overused if taken more than 15 days a month while 10 days a month is deemed overuse of ergotamine, combination analgesics, triptans, opioids, and/or combined short-term analgesics.

Progression of MOH

Anyone experiencing medication overuse headaches and neck pain will usually have worse headache during the time they are overusing medication and headache that resolves within 2 months of discontinuing use of the medication(s). Of course, it can be difficult to determine when headaches are due to medication overuse and when they are a symptom of something else entirely.

The development of rebound headaches can occur over a long period of time and is more common in those with primary headaches rather than those taking pain medications for other conditions, including neck pain. However, as headaches and neck pain often coincide it may be that a headache-prone person with neck pain is more at risk of MOH.

Symptoms and Triggers for Medication Overuse Headaches and Neck Pain

Symptoms of medication overuse headaches usually involve a headache occurring shortly after waking, combined with neck pain. Other causes of early morning headaches can include low blood sugar, dehydration, poor sleep posture, stress about the upcoming work day or the school-run, a lack of good quality sleep, bright light in the bedroom, squinting at an iPhone whilst barely awake, and a range of other issues.

Caffeine withdrawal may also be a factor for some, with the headache relieved by their first coffee, or by taking medications for headaches and pain. In fact, headache medications or over-the-counter analgesics that contain caffeine are particularly associated with an increased risk of MOH, while there appears to be little risk of MOH with aspirin and ibuprofen.

In one review by Bigal et al, people with episodic migraines were found to experience a degree of protection against MOH when analgesics were used less than 9 days a month. More than 10 days of use a month increased the risk of MOH, and the risk was higher for women than for men.

Of course, simply discontinuing pain medications to treat medication overuse headaches and neck pain leaves patients vulnerable to chronic and acute pain. Any withdrawal of medications needs to be accompanied by alternative pain management strategies. This may involve:

Top recommendations for minimising the risk of medication overuse headaches and neck pain include restricting NSAID use, and the use of other headache medications, to less than 10 days a month, and avoiding caffeinated headache medications unless prescribed or recommended by a physician.

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