In the management of the Analgesic-Overuse Headache Syndrome, fear is a primary concern.  This fear-of-pain actually drives the analgesic overuse, accelerates the headaches, resists treatments, and encourages relapses.  Unless this fear is specifically allayed, the prognosis of this syndrome is poor.  In this terse editorial, I shall discuss the Analgesic-Overuse Headache Syndrome and the specific management of the fear that propels it.
      In the headache field, numerous published studies support the concept that analgesic overuse is primarily responsible for the Transformed Migraine Syndrome. The Transformed Migraine Syndrome represents the progressive increase in the frequency and severity of headaches—from that of the natural migraine rhythm of few headaches per month to that of a daily or near daily headache that defies preventive treatments.  Analgesic overuse is defined as the taking of more than two doses of anti-headache pills per week, the dose being one or two tablets.  The analgesics overused include the non-steroidal anti-inflammatory drugs, triptans, acetaminophen, narcotics, and all other medications that are utilized to reduce headache pain.
      The Analgesic-Overuse Headache Syndrome is a major confounder of preventive therapies because it is commonly overlooked by treating physicians.  Consequently, patients who unwittingly continue to overuse their headache-analgesics also continue to fail accepted treatments.  A careful headache history is mandatory to uncover such analgesic habits because patients almost always underestimate their analgesic use and seldom volunteer that information unless specifically interrogated.
      Addressing the Analgesic-Overuse Headache Syndrome and asking patients to desist from using analgesics is seldom enough.  This is because stopping the analgesics causes rebound headaches, which frighten the patients back into analgesic overuse.  The magnitude of fear among these headache sufferers is most impressive when subjected to quantization. (H.A.Saadah MD, HEADACHE FEAR.  Journal of the Oklahoma State Medical Association 1997; 90:179-184.)
      To affect recovery, the rebound headaches have to be tempered.  This can be done by giving a long-acting cortisone injection at the time of analgesic discontinuation.  For patients with a low fear score, this simple intervention may be sufficient.  However, for those with a high fear score, the fear will have to be allayed before they are able to stop analgesics.  Experience has shown that the success of analgesic cessation is inversely proportional to the fear score.  When the fear is high, education alone is seldom enough to affect analgesic cessation and a fear transposition becomes necessary.
      The fear transposition is done with a simple analogy.  The patient is asked to imagine himself a prisoner under the rule of a jailer who comes each morning, opens his jail cell, and whips him brutally.  Then the patient is asked what frightens him most, the whip or the jailer?  Most patients chose the whip and will need to be reminded that the whip cannot whip them without the jailer’s hand and that the jailer can beat them up without the whip.  Once they realize that, then they are told that the jailer is their overuse of analgesics while the whip is their headache.  After they internalize this concept, they are then asked to become afraid of the analgesics instead of the headaches.
      What had actually caused the analgesic overuse was the fear of headache pain rather than the pain itself.  This fear is now allayed by transposition from a fear of pain to a fear of analgesics.  The power of this fear is now harnessed to reinforce the abstinence from analgesics, which is what the patient needs to recover.