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  • Updated 04.08.2024
  • Released 01.21.1994
  • Expires For CME 04.08.2027

Headache associated with illicit drug use



In general, most physicians are not familiar with headache syndromes induced by the use of illicit drugs such as cocaine, marijuana, and opioids. Some patients may develop thunderclap headache and reversible cerebral vasoconstriction syndrome. In this article, the author provides an update on the underlying pathophysiology and reviews the clinical aspects of headache syndromes induced by illicit drugs in light of the criteria presented in the International Classification of Headache Disorders, 3rd edition (ICHD-3), published in January 2018. Patients with cluster headache tend to use illicit drugs; in contrast, patients with migraine are less likely to use them (46). Greco and colleagues suggest that the endocannabinoids and related lipids may be candidates for migraine treatment (24).

Key points

• Illicit drugs, including cocaine, methamphetamine cannabis, and opioids, can induce headache. However, acute withdrawal of opioids can also induce headache.

• The diagnostic criteria of headache induced by illicit drugs are provided in the third edition of The International Headache Classification (ICHD-3), which was published in January 2018.

• Reversible cerebral vasoconstriction syndrome manifesting as thunderclap headache was reported as a complication of the use of illicit drugs such as cannabis.

• Cocaine- and amphetamine-induced acute severe headache may be related to a sympathomimetic effect.

• Modulation of the metabolic pathways of the endocannabinoid system may be a basis for new migraine treatment.

• Compared with the normal population, patients with migraine are less likely to use illicit drugs, but patients with cluster headache were more likely to use illicit drugs.

Historical note and terminology

Although the use of opium and its derivatives dates back to the 3rd century BC, headache caused by illicit drugs appears to be a relatively recent phenomenon, with the earliest reports dating from the mid-1980s (31; 20; 40). El-Mallakh described the appearance of migraine headaches after the abrupt discontinuation of long-term marijuana use. Satel, Gawin, Lipton and colleagues have described migraine-like headaches as also being associated with cocaine use. Neurologic complications, including headache, are rarely reported in association with ecstasy (3,4-methylenedioxymethylamphetamine, MDMA) use (05; 04).

The third edition of the International Classification of the Headache Disorders (ICHD-3) defines four headache syndromes related to illicit drug use; they include cocaine-induced headache, cannabis-induced headache, opioid-overuse headache, and opioid-withdrawal headache (27).

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