Substance Abuse and Headaches

Written by Deirdre O’Donnell

Introduction

Substance abuse is the excessive and/or harmful intake of chemical substances that are ingested or absorbed by the body. Ingestion may be accomplished via the oral consumption of food or beverages (e.g., alcohol), which typically then elicits psychoactive and/or physiologic effect(s) that can be quite reinforcing of repeat or continued use.
Substance intake is considered abusive when the behavior significantly impacts other areas of normal daily routine, social activities, and professional life. Substance abuse can affect a number of physiologic processes, ultimately leading to profound deteriorations in health and heightened risk of certain neurologic conditions, including headache.

Headaches

Subjectively, headaches are the perception of pain—which may be severe or intense—localized within the head or skull or to a certain part of it. These conditions may be acute or chronic.

Chronic

Chronic headaches are typically defined as the presence of the same type of headache pain occurring on 15 or more days per month.1

Acute

Acute headaches appear with a frequency of 15 days of each month or less.

Headaches are divided into a number of categories or subtypes, based on the region of the skull affected, and also (possibly) an associated precipitating neurological disorder. These disorders typically constitute some form of damage or dysfunction in major cranial or peripheral nerves associated with the specific part of the head in which the pain is felt.

Cluster-Type Headaches

This is a headache type characterized by a number of headaches occurring in quick succession. The frequency of these may be as high as 8 in a single day.

Cluster-type headaches may occur in regular episodes lasting a number of weeks or be consistent (i.e., chronic).2 The pain of this headache type is usually felt over one eye or in one temple.

They can be quite debilitating—those afflicted report that the experience ranks amongst the worst pain they have ever experienced.2 It may be associated with significant decreases in functional status.3

Migraines

This type of headache is usually perceived unilaterally—emanating from just above or behind one eye—but may spread to other areas of the face if left untreated.

Like cluster-type headaches, migraines may be chronic or episodic. Migraines are regarded as one of the most prevalent headache types, but the rates of incidence and burden associated with this condition vary.4

Some types of migraine are associated with damage to the trigeminal nerve—the 5th major cranial nerve, frequently abbreviated ‘CN V’—and are termed a form of trigeminal neuralgia.

Some patients with migraines also report that their headaches are associated with specific ‘triggers,’ which may be:

• Light
• Certain smells
• Sound
• The intake of certain substances

Tension-Type Headaches

This is a type of headache in which the patient may perceive an intense pressure or muscular tightness on the skull. Again, this may take chronic or episodic forms.

Chronic tension-type headaches are associated with considerable disability and may be extremely painful.5 They affect up to 3% of the population and are associated with a range of risk factors, which may include stress and sleep disturbances.5

Substance Abuse and Headaches

Substance abuse may be linked to the increased risk of headache in many ways. These may include the fact that many drugs cause headache as a side effect, or an effect of withdrawal.

In some cases, headaches in those who use or abuse substances may be indicative of other, more severe, underlying conditions.6 These potentially emergent conditions include hemorrhages in, or in the membranes that surround, the brain.7

Common forms of intracranial hemorrhage include:⁷

• Subdural (those associated with the dura mater or dural membrane, which surrounds the brain and spinal cord, and is adjacent to the interior surface of the skull).
• Subarachnoid hemorrhages (those which occur in a dangerously space-limited area between brain tissue and the overlying arachnoid membrane).
• Intracerebral hemorrhages (those which occur within the brain tissue).

The reasons for this are not completely understood, but are likely to be associated with pre-existing (congenital, in some cases) malformations in some of the blood vessels in the brain.

Intracranial hemorrhage increases the risks of changes in the pressure within the skull and of the rupture of certain weak spots (or aneurysms) in some arteries of the brain or meningeal membranes.7

One study of 10 patients with a history of substance abuse presenting with intracerebral hemorrhage detected aneurysms in 7 patients and other vascular malformations in 3 patients.8

Another study of 39 patients with sudden-onset intracerebral hemorrhage found the most common underlying cause were similar malformations.9

Up to 20% of the cases of stroke in the Western world are associated with intracranial hemorrhage.9 This condition is related to significant disease burden and mortality worldwide.9

“Some healthcare professionals recommend drug screening for all young adults who’ve experienced a stroke.”
Because of the recognized risk of substance abuse contributing to intracranial bleeds, some healthcare researchers recommend toxicological analysis as a part of routine diagnostic procedure in cases of stroke in younger adults.8

Spontaneous headaches, especially if they are abnormally intense and of a type not normally experienced by the patient, may be a symptom of an intracranial hemorrhage. These headaches may be perceived as occipital (base of the skull), cluster-type or generally pervading the entire skull, based on the location of the hemorrhage.

Alcohol Abuse and Headaches

Alcohol abuse is a prevalent form of substance abuse, with a copious list of negative health implications. Amongst the many serious health complications and risks is that of increased cardiovascular disease.

The abuse of alcohol is associated with a number of factors, which may include:

• Mental health issues.
• Male gender.
• Younger age.10

This is currently regarded as a serious social and public health problem, affecting a wide demographic slice of the population.

“Drinking alcohol may trigger migraine-type headaches in some people.”

Some studies have reported that alcohol intake may act as a “trigger” for some patients with migraine-type headaches.10 Others indicate that the rate of alcohol intake may be reduced in patients with this condition.10

A study investigated the rate of alcohol abuse in 62 patients with tension-type headaches and 81 with migraine-type headaches. The rate of alcohol use problems were 5.2% in the migraine patients compared to 16.1% (a moderately significant difference) in those with tension-type headaches.¹⁰

The headache impact scores were inversely proportional to those of alcohol use disorder in this study.10 This may indicate that alcohol use leads to an increase in headache severity or frequency, thus discouraging its intake.

A study of 217 patients found that intake equal to 2 or more alcoholic beverages in a day was associated with an increased risk of intracerebral hemorrhage.11 In addition, the pharmaceutical treatment for alcohol abuse itself may be associated with the increased risk of headaches.

Naltrexone (trade names: ReVia, Vivitrol) and other opioid (see below) receptor “blockers” are often used as adjunct substances that modulate cravings and physiological reward. As such, they are beneficial in some cases of alcohol abuse treatment.12

A newer opioid antagonist, nalmefene (trade name: Selincro), has been associated with headache in clinical trials. This adverse effect was reported as severe for approximately 10% of the patients included.¹³

Drug Use and Headaches

The excessive and/or abusive intake of many drugs (including prescription medications) may be associated with the onset or risk of headaches, as well as the phenomenon known as rebound headache.

Medication-overuse headaches are associated with the excessive intake (e.g., regular intake or intake beyond the recommended dose) of many drugs, including those available by prescription.1 This is regarded by some researchers as a serious enough healthcare issue for it to be categorized as an epidemic.1

“Medication overuse headaches are estimated to affect as much as 4% of the global population.14 Estimates suggest that up to 50% of cases are associated with the abuse of conventional medications recommended to treat headache.¹⁴”
These include migraine treatments such as triptans, analgesics, and other drugs such as barbiturates.¹⁵ All of these can elicit a pronounced rebound headache with frequent and/or long-term use.

Many patients with this condition are also often affected by primary headache disorders such as those listed above, but their symptoms may mutate into daily or quasi-daily headache in response to medication overuse.¹⁵

Smoking and Headaches

Regular and/or excessive tobacco smoking may have many indirect effects on the risk of headaches. A study on intracerebral hemorrhage found that current smoking was a risk factor in this condition.11

Withdrawal from nicotine (e.g., during cessation therapy) is also associated with many adverse effects, including headache.16 The use of varenicline (trade name: Chantix), a drug often used as a nicotine-replacement therapy, may also cause headaches.¹⁷

Illicit Drugs and Headaches

Illicit drugs may be related to headache conditions in a number of ways. Some patients may seek stronger painkillers to alleviate the pain of severe or chronic headaches.

Illicit drugs may also affect the risk of headaches, either as a side effect or as a symptom of a severe adverse event such as an intracranial hemorrhage.

A study of 210 cluster headache patients found that nearly 72% of this group used illicit drugs before the onset of this condition.18 The prevalence of intensive illicit drug use was high in the study’s male patients.18

Of the illicit substances reported, the recent or current use of cannabis (marijuana) or cocaine was significantly higher for the male patients compared to matched healthy controls, as was the recent or lifetime use of amphetamines.¹⁸

Common Illicit Drugs Associated with Effects on Headaches

Amphetamines

This class of drugs contains generally illicit compounds such as methamphetamine and 3,4-methyldioxymethamphetamine (MDMA or ‘Ecstasy’), but can also include prescribed amphetamine compounds such as Adderall and Ritalin.

The abuse of ecstasy or MDMA—another illicit drug with stimulant activity—is also associated with intracranial hemorrhages.⁷

Cocaine

This drug, with widespread illicit abuse, is also associated with the types of intracranial hemorrhage as listed above.⁷

Ketamine

Ketamine is an often-illicit drug associated with analgesia (pain relief), increased blood pressure, and the increased risk of psychosis. Its analogue methoxetamine (street name: mexxy, MXE) is also associated with some cases of psychosis and also with the adverse effect of prolonged headache.¹⁹

Opioids

Opioids—from street heroin to prescriptions such as OxyContin and hydrocodone—are powerful analgesics that interact with receptors found throughout the body to modulate the process of pain “signaling” arising from tissue damage or other factors contributing to pain.

The desired result from opioid analgesia is decreased central nervous system perception of this stimulus. Additionally, though, opioids may have other side effects, such as euphoria or increased sedation. As a result of this other side effect profile, opioids are regarded as having a high addiction and abuse potential.

As a first-line treatment for many types of serious pain, it is unfortunate that these drugs can also result in numerous adverse effects and events, including:

• Respiratory depression and distress.
• Constipation.
• Nausea.

The abrupt discontinuation of opioid intake often results in unpleasant withdrawal symptoms. These include severe pain and the magnification of pre-existing painful conditions, including headaches.²⁰ This may be explained by a variety of mechanisms, including the re-establishment of ‘active’ pain-receptor populations following their suppression by opioids.

The prominent opioid morphine may be associated with transient headache as an adverse effect, especially if combined with alcohol.²¹

Codeine is another mild opioid that may be available on prescription or restricted sale.¹⁵ Despite its intentional use as a legal prescription medication, it is also linked to increased risks of abuse and to illegal trade. It is also associated with the development of medication-overuse headache.¹⁵

Methadone is an opioid often used in maintenance or replacement therapy in cases of the abuse of other similar drugs such as morphine or heroin.20 Some cases of cluster headache associated with treatment for heroin abuse with this drug have been reported.²⁰

THC/Cannabinoids

Tetrahydrocannabinol (THC) is the main active drug ingredient associated with cannabis (e.g., weed). Legality of the drug varies under certain circumstances, and is dependent on geographical location. In addition, there are also synthetic cannabinoids, or newer drugs based on the structure of THC, available for recreational use or other applications.

The use of cannabis is associated with increased risks of impaired functional status, addiction and mental illness.^22,23 Therefore, these drugs may have potential for abuse.

Some isolated cases of subarachnoid hemorrhage, accompanied by intense headache pain, have been reported in association with the use of synthetic cannabinoids.⁶

Other Illicitly Used Drugs

A quick review of the scientific literature will reveal that any number of other potentially abused substances, from over-the-counter dextromethorphan (DM, DXM) to the volatile chemicals in many illicitly used inhalants have resulted in reported headache as a relatively common side-effect.

Alternate Headache Therapies for Substance Abusers

Many forms of headache are treated with conventional medications associated with effective reductions in pain. However, many of these are associated with the onset of medication-overuse headache or rebound headache, as mentioned above.

Many of the issues of this type might be mitigated with more judicious use of such analgesic aids. Attempts can be made to reverse medication overuse using a variety of methods and techniques, including:15

• A trial discontinuation of the medication in question.
• Alternate pharmaceutical treatment if withdrawal headaches are resulting from the above, if applicable.
• Placing more strict limits on patient intake of the medication in question.
• Therapeutic headache prevention – this may be a combination of:
• Identifying and avoiding triggers (if applicable).
• Alternative treatments (meditation, acupuncture, breathing exercises, etc.).
• Patient education.
• Preventing the recurrence of medication overuse through education, monitoring, or other forms of patient management.

Alternative Pain Management Strategies

Alternative, non-pill type treatments for severe and/or chronic headache include nerve block, in which major nerves implicated in headache disorders (e.g., the occipital nerve) are numbed by injecting drugs such as local anesthetic and/or corticosteroids into their immediate vicinity.24 These are associated with effective, medium-term relief in conditions such as cluster-type headaches.24 Even Botox is now FDA approved for its potential to treat certain intractable migraines.

Diagnostic Imaging

In suspected instances of more serious headache etiology, various radiological or other diagnostic imaging can be helpful (if not life-saving). For example, intracranial hemorrhages are diagnosed using a variety of techniques, including:

• Magnetic resonance imaging (MRI).
• Computerized tomography (CT).
• Fluoroscopy.
• Angiography (in which the blood vessels of interest are injected with a contrast dye and then visualized using a technique as above).

Some types of headache may be diagnosed using some of the imaging methods as above. In the case of headache secondary to trigeminal neuralgia, studies such as these may allow the visualization of nerve tissue damage.

Seeking Professional Treatment for Substance Abuse

Substance abuse may be best addressed by seeking specific professional treatment for the problem. Abstinence is a goal for many treatment types. However, from a harm reduction viewpoint, treatment may also include drug replacement or maintenance therapy, as above.²⁵

Substance abuse rehabilitation methods vary from program to program, but may also involve psychological or motivation-based therapies including cognitive-behavioral therapy (CBT), conventional psychotherapy, and counseling.25

Some treatment methods or programs may include a combination of the approaches as above.26 These may help to quit the intake of the substance in question, and to treat mental health issues or other factors contributing to the tendency to abuse it.

Substance abuse therapy may also contribute to improvements in any associated concurrent or dual diagnosis health complaints (e.g., headache).27 More to this point, many substance abuse treatment programs utilize a variety of therapeutic approaches and employ a multidisciplinary staff of professionals to simultaneously address the problems of addiction and concurrent mental or physical health issues effectively.

Such specialized treatments for substance abuse may be provided through a variety of settings, including:

• Private medical facilities.
• Rehabilitation clinics.
• Community healthcare settings.
• Other specific clinics, depending on location.