Analgesic-Rebound Headache: Overdiagnosed?

In a recent editorial, Dr Robert S. Kunkel raises serious questions about analgesic-rebound headache, and meets the issues with skeptical pragmatism:

“I certainly agree that analgesic-rebound headache due to combination-type analgesics and ergotamine tartate is a very significant problem that I see daily in my headache clinic. However, I am not convinced that the frequent use of small amounts of pain aspirin, acetaminophen, or an NSAID is very often a significant factor in the etiology of transforming an episodic headache into a chronic daily headache…”

“I feel we are mislabeling a lot of patients with chronic headache as analgesic-rebound headache simply because they take aspirin or ibuprofen once or twice a day. Hopefully, this condition will be better defined in the future as we learn more about the cause of pain in the head.”

Kunkel RS. Analgesic-rebound headache: headache of the nineties. Headache Quarterly 1998;9:231-232.

Stress, Hunger, and Headache

This study evaluated two recognized headache triggers—hunger and stress. The study participants were 56 students who had suffered from both migraines and tension-type headaches for at least six months.

The researchers created four different test scenarios for the patients: stress, with no food; stress, with food; no stress, food; and no stress, no food. The 56 subjects were randomly assigned to one of the test groups.

When testing the triggers separately, 58% of the food-deprived subjects reported headaches. Previous studies had associated hunger with migraines, yet this study found that hunger can also trigger tension-type headaches. In fact, the researchers measured forehead EMG levels, and found that the “no food” patients had significantly elevated EMG readings.

The researchers found that stress was indeed a potent trigger for headache—93% of subjects reported the start or a worsening of headache symptoms during the “stress, with food” experiment.

Martin P, Seneviratne H. Effects of food deprivation and a stressor on head pain. Health Psychology 1997; 16(4): 310-318.

Recent Onset Headache

This study examined 100 consecutive patients who presented at neurological unit with headache of recent onset (described as headache that “appeared for the first time ever in the last 12 months. Patients with past history of headache were excluded except, if a change of character of the previous headache had been the reason for the referral.”) Every patient was examined by a physician and given a CT scan with and without intravenous contrast. Some of the patients were given lumbar puncture, blood tests, MRI, and magnetic resonance angiography, if needed.

90% of the patients had headaches for the first time, while 10% had previous—but now different—headaches.

The study reported that the neurological examination was normal in 80% of the patients. Further investigations, however, turned up some very serious conditions: Intracranial neoplasm (21%); subacute meningitis (5%); intracranial hematoma (3%); and hydrocephalus (2%). In all, “Headaches were considered organic in 39 (39%) of the 100 patients, and in 21 (26%) of the 80 with normal neurological examination.”

“It has been suggested that with recent-onset headache, a CT or MRI should be obtained if the headache is severe or occurs with nausea, vomiting or abnormal signs. However, headache in four patients with intracranial tumors in our study was mild, no nausea or vomiting occurred, and was not aggravated by Valsalva nor did it awake them during the night, and were unassociated with abnormal neurological signs.”

“We suggest that neuroimaging studies should be performed in all adult patients with non-vascular headache of recent-onset, and no previous history, irrespective of the characteristics of the headache…”

Duarte J, Sempere AP, Delgado JA, et al. Headache of recent onset in adults: a prospective population-based study. Acta Neurologica Scandinavica 1996;94:67-70.

Neck Pain and Headache in Kids

Neck pain and headaches in kids:
More common than parents think

Preteens may experience headaches and neck pain far more often than their parents would expect. A Swedish study of 131 students ages 10-13 years old compared the spinal health of students with and without pain. A surprising finding was that parents significantly under-reported their child’s experience of pain.

The study found a wide discrepancy between what the children and parents reported regarding the child’s health. Children rated their experience and frequency of pain on surveys, prior to the assessment. Parents were asked separately to answer the same questions on behalf of their children.

31% of children reported that they “often” had neck pain and/or headaches, compared with 6% of parents. Similarly, 61% of children reported trauma to the head and/or neck region but only 20% of the parents said that their children had experienced such trauma.

Significance of these findings for chiropractors:

  • 40% of students ages 10-13 may some experience neck pain and/or headaches
  • Parents may not be aware of the presence of pain in their children or the history of head trauma
  • Children reported that computer use and long period of reading made pain worse

To address the prevalence of headaches, chiropractors can:

  • Educate adult patients about the high levels of neck pain and headaches among youth
  • Encourage parents to talk with their children about neck pain and/or headaches and its origins
  • Teach families techniques to prevent headaches following computer or reading time

Chiropractors who continue to educate themselves on the latest findings and techniques in pediatric chiropractic will be best equipped to protect the development of children’s spines.

Weber Hellstenius S A, Recurrent Neck Pain and Headaches in Preadolescents Associated with Mechanical Dysfunction of the Cervical Spine: A Cross-Sectional Observational Study With 131 Students. Journal of Manipulative and Physiological Therapeutics, October 2009. (32)8:625-634.

Muscle Hardness and Tension Type Headache

Studies have indicated that the pericranial muscles are more tender in chronic tension-type patients than in controls. It has also been reported that tension-type headache patients have harder pericranial muscles. This study examined the muscle hardness in such cases to see if it was influenced by the presence or absence of headache or if it was related to the muscle tenderness.
The researchers define and distinguish the terms hardness and tenderness as, “Tenderness is pain provoked by palpation and reflects a subjective feeling of pain. Muscle hardness is an objective parameter measured by the hardness meter defined as the degree of deformity of muscle tissue to a given pressure.”

The study evaluated 20 tension-type headache patients and compared their findings to 20 healthy controls.

The scores for both hardness and tenderness were higher in patients than in the controls. Hardness did not differ on days with headache than on days without headache. The authors surmise, “This indicates that muscle hardness is permanently altered in chronic tension-type headache and that muscle hardness does not fluctuate with actual pain.”

The hardness scores correlated to the tenderness scores on both the days with and without headache. But, hardness scores did not correlate to headache frequency or intensity. Furthermore, tenderness scores were higher in patients on days without headache than in healthy controls—which implies tenderness is permanently increased and not just a result of the headache episode.
This study confirms that chronic tension-type headache patients have increased pericranial muscle hardness and tenderness, as compared to a healthy population. Yet, the study concludes that tenderness and hardness in these patients is not related to the actual headache state.

Ashina M, Bendtsen L, Jensen R, Sakai F, Olesen J. Muscle hardness in patients with chronic tension-type headache: relation to actual headache state. Pain 1999;79: 201-205.

Headache Type and Neck Mobility

Cervicogenic headache has been receiving considerable attention in the literature the last few years. A new study from Norway provides some new information that can aid clinicians in diagnosing cervicogenic headache and differentiating it from other types of headache.

The study compared 90 headache patients to 51 control subjects in regard to neck range of motion. The headache patients were further divided into three groups by headache type: migraine (28), tension-type (34), and cervicogenic (28). Each test subject was given a thorough range of motion examination.

When the controls, migraine patients, and the tension-type patients were compared, the author found no significant difference in ROM between any of the groups; the cervicogenic patients, however, showed significantly lower ROM in flexion/extension and rotation. There was no difference in lateral flexion.

On average, the cervicogenic headache patients showed an approximately 13% reduction in rotation and a 17% reduction in flexion/extension. “The present findings indicate that there are pathophysiological differences between [cervicogenic headache], [tension headache], and [migraine].

The study concludes by stating that a careful examination of ROM is critical in confirming a diagnosis of cervicogenic headache.

Zwart JA. Neck mobility in different headache disorders. Headache 1997;37:6-11.

Headache, Diet, and Exercise

Two new studies have been published that examine the role of diet or exercise in headaches.

The first1 was a survey given to 112 migraine sufferers. The researchers found that 70% of migraine patients felt that diet played a role in their headaches, and the most common triggers of a headache attack were, 1) chocolate, 2) skipping a meal, and 3) alcohol.

The second study2 examined the role of aerobic exercise in tension-type headaches in seven women. The women maintained a daily headache and medication diary for two weeks pre- and post-intervention, as well as during a six-week aerobic exercise regimen. This class consisted of “10 to 15 minutes stationary and moving warm-up and stretches; 20 to 30 minutes of low-impact cardiovascular training, and 10 to 15 minutes of cool-down and stretching exercises.” The women attended the class three times a week.

Headache levels did not change for the women. However, there were significant reductions in medication usage, depression, and anxiety. “…clients may turn to exercise in lieu of analgesic medications to manage their headache pain. With respect to decreased anxiety and depression levels, it is possible that engaging in aerobic exercise may improve mood which may alleviate some of the distress caused by chronic headache, and thus improve the quality of these patients’ lives.”

  1. Ciervo CA, Gallagher RM, Mueller L, Perrino D. The role of diet in treated migraine patients. Headache Quarterly, Current Treatment and Reseach 1996;7(4):319-323.
  2. Peters ML, Turner SM, Blanchard EB. The effects of aerobic exercise on chronic tension-type headache. Headache Quarterly, Current Treatment and Reseach 1996;7(4):330-334.

Whiplash Symptoms – Headache

Headache and whiplashNeck pain is the second most common symptom experienced after a whiplash, reported by over 90% of patients.

Like neck pain, headache also can have a variety of different causes from an auto collision. The first step in treating post-traumatic headache is to diagnose the root cause of the pain. Watch the video below, or browse our articles to learn more about the different causes of headache and how to approach treatment.

About Headaches and Migraines

Chiropractic and Headaches

Other Headache and Migraine Treatments


3rd Cervical Root Compression After Whiplash

A New Kind of Whiplash-Associated Headache?

EEG Differences in Post-Traumatic Headache Patients

Headaches After Auto Injuries

Headache Type and Neck Mobility

Muscular Tension After Whiplash

Post-Concussion Syndrome After Mild Brain Injury

Post-traumatic Migraine

Post-Traumatic Headache and Cerebral Blood Flow

Similarities Between Whiplash and Brain Injury

The C2 Nerve Root Ganglion and Whiplash

Understanding Headache After Auto Injuries

Whiplash-Associated Headache

Whiplash Pain May Affect Structure of the Brain

Headache and Migraine Treatments

Headaches are a common pain problem in our stressful lives. Browse the following articles to learn about some of the different options available to treat pain from headaches and migraines.

Headaches, Migraines, and Chiropractic


Analgesic-Rebound Headache: Overdiagnosed?

Botulinum Toxin Treatment of Cervicogenic Headache

Drug-Free Migraine Relief through Massage

Headache, Diet, and Exercise

Migraine Headaches, Physical Therapy, and Thermal Biofeedback

Natural treatment for migraines during pregnancy

Stress, Hunger, and Headache

Tired of Reaching for the Ibuprofen? Try a Massage for Your Tension Headaches!