This article describes the "bridge" therapies used to try to wean migraineurs and other people with headaches off of analgesics that keep them trapped in analgesic rebound headache. The treatment strategy is very individualized and no story is identical, although the root problem may be quite similar. There are, however, several commonalities in people with chronic daily headaches and especially those with analgesic rebound.

Approximately 80% of people with analgesic rebound headache overuse medications such as acetaminophen, aspirin, ibuprofen, codeine, hydrocodone, butalbital and agents that contain combinations of these medications. Indeed, my belief is that many people with frequent headaches fall into the pattern of treating their anxiety about the next bad headache by using opiates and the barbiturates as an anxiety-reducing tool. It clearly doesn’t work since these agents contribute to the process of addiction. Addiction has nothing to do with the medication; it has to do with the repetitive process of repeatedly taking the same medication over and over again, thus reinforcing the behavior.

There are two consistent traits among people with chronic headaches and chronic pain issues: an anxiety disorder about the next severe event and a poor sleep pattern. If you think about it, most people with chronic daily headaches will tell you they never feel refreshed in the morning and they sleep poorly with multiple wakeups during the night. These can be due to headache itself or due to an inadequate sleep pattern. Another issue is that the short acting analgesics tend to wear out after three to four hours. So, what the patient really experiences as an all analgesic-offset headache.

One approach I have successfully utilized with thousands of headache and pain patients is to help create a stable and sound sleep platform. There are many agents that can help sleep onset: zolpidem, zaleplon, eszopiclon, ramelteon, quetiapine, trazodone. The first three agents are more for sleep onset and the last three are more for sleep maintenance, or both. One agent I’ve found particularly useful is tizanidine, an alpha₂ agonist that has multiple pharmacologic activities. For instance, it is very sleep-promoting, it blocks pain transmission, it reduces headaches, it is a powerful muscle relaxant and it helps with twitching at night, cramping, and restless legs. So, in detoxifying patients from their useless medications (that are keeping them trapped in headaches) creating sleep is very important. If more clinicians pay attention to this one feature, their efforts would be magnified.