Nasal decongestant and chronic headache: a case of naphazoline overuse headache?

Cherubino Di Lorenzo,Francesco Pierelli,Valeria La Salvia,Gianluca Coppola

doi:10.12688/f1000research.2-237.v1

Cherubino Di Lorenzo, Francesco Pierelli + Show 2 more

Open Access

https://doi.org/10.12688/f1000research.2-237.v1

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Abstract

Chronic headache is an incapacitating condition afflicting patients at least for 15 days per month. In the most cases it is developed as a consequence of an excessive use of symptomatic drugs. Here we report the case of a 34 year-old man suffering from chronic headache possibly related to the overuse of naphazoline nitrate nasal decongestant, used to treat a supposed chronic sinusitis. However, the patient did not suffer from sinusitis, but from a medication overuse headache (ICHD-II 8.3; ICD-10 44.41) that appeared to be due to excessive use of naphazoline. The use of naphazoline nitrate may result in an analgesic effect upon first use, through activation of adrenergic and opioidergic systems, followed by a pro-migraine effect via a late induction of an inflammatory cascade, modulated by nitric oxide and arachidonic acid. The observation that naphazoline detoxification relieved the patient's headache, indicates that prolonged use of naphazoline may cause chronic headaches. Therefore, physicians should ask for details on the use of nasal decongestants in patients complaining of chronic headache, as they could potentially be suffering from a medication-overuse headache.

Highlights

Chronic headache (≥ 15 days/month) is an incapacitating condition affecting the 4–5% of the general population[1], and can be primary or secondary[2]
During the patient’s visit to the clinic, respiratory examination, blood pressure, heart rate, mental status, reflexes, sensory system, cranial nerve, motor system, gait and coordination were normal. Since his headache characteristics were suggestive for a migraine-like headache, further evaluations were required to exclude the diagnosis of an acute sinusitis
The case we report is suggestive for a chronic headache secondary to naphazoline nitrate overuse, since drug discontinuation interrupted the clinical symptoms

Summary

Introduction

Chronic headache (≥ 15 days/month) is an incapacitating condition affecting the 4–5% of the general population[1], and can be primary (in which case the headache is not due to other causes but is the disease per se) or secondary (i.e., the symptom of another condition)[2]. The patient had been treated by his GP with medication to relieve the headache (metamizole, rizatriptan, zolmitriptan, acetylsalicylic acid, nimesulide, ibuprofen, naproxen sodium), consumed more than once a day, until the age of 24. Since he had stopped the consumption of such painkillers because he found that naphazoline nitrate nasal spray was more effective. During the patient’s visit to the clinic, respiratory examination, blood pressure, heart rate, mental status, reflexes, sensory system, cranial nerve, motor system, gait and coordination were normal Since his headache characteristics were suggestive for a migraine-like headache, further evaluations were required to exclude the diagnosis of an acute sinusitis. One year after naphazoline detoxification, the patient has suffered from a few attacks during the year, treated with triptans

Discussion

Rumack BH

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