Medication Overuse Worsens Chronic Daily Headache

Abstract

Source: Wiendels NJ, van der Geest MCM, Neven AK, et al. Chronic daily headache in children and adolescents. Headache. 2005;45:678–683. A retrospective review of medical records of 79 children and adolescents younger than age 16 years with headache more than 15 days a month is reported from Leiden University Medical Center, the Netherlands. Chronic daily headache (CDH) occurred in 57 (72%) patients for more than 6 months. Headache duration was more than 4 hours a day in 60% of the cases. Analgesics were used by 60 children (76%), with daily use in 13 (16%). Frequent school absenteeism and sleeping problems were reported in one-third of patients. Twenty-eight patients (35%) could be classified according to the International Headache Criteria: 17 (22%) had chronic tension-type headaches, 5 (6%) had chronic migraine, 6 (8%) had medication overuse headache, 15 (19%) did not fit any category, and 36 (46%) presented insufficient data for classification. Withdrawal of all analgesic medication is recommended in CDH management.Dr. Millichap has disclosed no financial relationships relevant to this commentary.CDH is defined as primary headaches occurring 15 or more days a month and lasting more than 4 hours a day. The International Classification of Headache Disorders (ICDH-II) for Adults includes 4 types of CDH, each with or without medication overuse: chronic migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua.1 CDH may evolve over time, beginning as episodic migraine or tension-type headache and becoming chronic and persistent. Secondary headache disorders, such as post-traumatic headache, are excluded. No specific pediatric CDH criteria have been developed, but the recent increased recognition and interest in this health problem has prompted recommendations by the Pediatric Committee of the American Association for the Study of Headache.2 Areas of interest include: CDH prevalence in children (estimated at 0.9% in children compared to 4% in adults); a uniform definition specific for pediatric CDH; psychological profiles and interventions; and treatment strategies other than medication. Headache severity in children is dependent on coping characteristics, functional disability indicators such as missed school days and sleep disorders, and disrupted peer and social activities. Adolescents with CDH often state that the pain is severe while having symptoms of la belle indifference. A history of school phobias and family problems is common.In adults, CDH commonly is associated with medication overuse,3 and in children in the above study, 16% used analgesics daily. Analgesic overuse for migraine or tension-type headache may cause rebound headache and is a significant risk factor for CDH development, sometimes delayed in onset. 4 Medication overuse headache is probably more prevalent in the older adolescent, leading to the recommendation of withdrawal of all medication in CDH treatment. A general, practical approach to pediatric CDH management includes: discontinuance of analgesics and caffeine; adequate sleep; elimination of tyramine-containing cheese, caffeine-containing beverages, and other headache triggers from the diet;5 no skipped meals; daily exercise; biofeedback; and psychological intervention.6If ever there were a need to repeat this type of study prospectively using a headache diary rather than a medical record alone, this retrospective study is it. Until then, an empirical trial of removal of analgesic medication still seems like something we should be aching to try on our patients with CDH.