Painkillers for chronic pain should only be used under medical supervision

The NDR-Viste report highlights the potential consequences of uncoordinated pain management. Kidney damage, chronic headaches, and psychological complications resulting from medication overuse necessitate adequate monitoring. Medication overuse headache (MOH) is a common problem in specialized headache centers, with approximately 50-70% of patients presenting with these symptoms. Hospital studies have shown that painkiller tolerance is significantly more prevalent than dependence on other medications, such as tranquilizers, sleeping pills, or stimulants.

Headache medications are among the most frequently used medications in Germany.

Among the 20 best-selling medications in Germany, twelve are painkillers. The bestsellers are combination drugs, which carry a particularly high risk of medication-induced headaches. Based on sales figures, it can be assumed that approximately 1 to 3% of the German population takes painkillers daily – up to ten times a day. Three percent of Germans suffer from daily headaches, which equates to about 2.4 million people. It is not precisely known how many of these sufferers experience this daily affliction due to medication-induced headaches, or how many experience pain exacerbated by incorrect medication use.

Eighty percent of affected individuals experience a daily, persistent headache every day of the month, from waking up until bedtime. The remaining patients have headaches on more than 20 days per month. Over half suffer from a dull, pressing headache, while the rest experience a throbbing headache or describe it as both dull and throbbing. Nausea, vomiting, and sensitivity to noise and light are also present in over 80% of cases. Dizziness, difficulty concentrating, forgetfulness, fatigue, feeling cold, mood swings, sleep disturbances, and other accompanying symptoms may be observed. These symptoms allow for a reliable differentiation between medication-induced headaches and chronic tension-type headaches. A significant proportion of people also suffer from considerable psychosocial problems, either at work or within their families. Sixty-five percent of individuals report a very severe degree of disability in their lives due to persistent headaches. On average, these individuals are unable to work for 25 days per year. Nine percent have even had to give up their jobs because of this condition. Many patients report other illnesses in addition to medication-induced headaches, particularly in the areas of the musculoskeletal system and the psyche.

Few people realize that their headaches have increased in frequency, intensity, and duration due to the regular use of headache medication. On the contrary, sufferers often try to find the one medication that will solve all their symptoms. For this reason, medications are frequently changed, and new substances are tried. This can lead to a veritable "headache tourism" phenomenon. People travel from headache specialist to headache specialist, sparing no time or expense in their quest to be freed from their suffering.

I can't do without painkillers anymore

At the beginning of the tour, many patients don't believe that their headaches are actually being perpetuated by the medication: they've learned that skipping it reliably leads to severe headaches after a few hours, and that taking headache medication provides equally reliable relief – at least for a few hours. Many patients don't dare go out without their headache medication. For example, they ritually check their handbags again before leaving the house to make sure they have their migraine tablets – because after four to five hours the headaches return, and only by taking more medication can they get through the day. During a medical examination, the following statement is typical:

"Doctor, I'm already taking so many medications and yet my headache isn't getting any better!"

In this situation, only thorough consultation helps. Some patients suspect the connection between their suffering and their medication, but most do not. Responsible pharmacists who advise a doctor's visit or even a reduction in painkillers when purchasing medication are avoided. To maintain appearances, some patients go to pharmacy A on Monday, pharmacy B on Wednesday, and pharmacy C on Saturday. If possible, they order large or even hospital-sized packages to always have some on hand.

Many organs are damaged by the long-term use of painkillers

In addition to the actual painkiller, people often also take sedatives, laxatives, sleeping pills, nasal drops, and other medications. Medical examinations often reveal the effects of medication abuse in many individuals, such as gastritis, stomach ulcers, anemia, or nerve damage (polyneuropathy). The condition is often recognizable at first glance. These people are pale, have a sallow complexion, and dark circles under their eyes. Their lips are pale, and their skin has lost its elasticity and appears withered. Most patients only realize they need to take fundamental action after approximately 10 to 15 years of suffering.

The most important step in therapy

The most important step in therapy is the patient's realization: "My headaches are so bad precisely because I take so many medications so often!" The reason for continuous medication use is withdrawal headache, which occurs with predictable severity when the medication's effect wears off. In 90% of the patients examined at the Kiel Pain Clinic, this headache is of moderate to severe intensity and is accompanied by nausea, vomiting, anxiety and restlessness, circulatory problems, dizziness, and sometimes even fever. Taking one or two tablets relieves this torment—unfortunately, only temporarily—and simultaneously leads to a progressive worsening of the condition.

High risk with combination drugs!

With regular and excessive use of migraine medication, a steady increase in dosage can occur. Since discontinuing triptans and/or painkillers after prolonged use leads to withdrawal headaches, a feedback mechanism develops, creating an ever-increasing need for medication. Continued use of migraine medication leads to temporary relief in the short term. The problem is exacerbated by the use of combination drugs or multiple medications. This is particularly true when combined with phenobarbital, benzodiazepines, and other substances that act on the central nervous system.

Because of this risk, both the administration of combination drugs and the indiscriminate use of multiple medications simultaneously should be avoided. Patients should be specifically informed about the risk of medication-overuse headache. To minimize the likelihood of developing medication-induced chronic headache, a time limit should be observed when taking migraine medication, as dictated by the 10-20 rule. Due to its crucial importance, this rule is reiterated here.

The “10-20 rule” against medication overuse headache

Painkillers and specific migraine medications, such as triptans, should be used for a maximum of 10 days per month. At least 20 out of 30 days should therefore be free of their use. This rule does not count the number of tablets taken on those 10 days, but only the day itself, regardless of the amount taken. This also means: It's better to treat properly once than to treat only a little bit frequently!

Combination painkillers should be completely avoided. In various dialysis centers, between 1 and 32% of treated patients have engaged in painkiller overuse, which is considered a cause of their dialysis-dependent kidney disease. Analysis of the medical histories of affected patients reveals that caffeine in combination with a painkiller is by far the most frequent cause. Other substances commonly used in headache therapy follow with relatively equal frequency.