Abstract
Dear Sir In their recent and very interesting article, Pini et al. (1) discussed the long-term follow-up of patients treated for chronic headache with analgesic overuse. Two of their main conclusions were that ‘long-term analgesic overuse by patients with chronic daily headache will persist in the majority despite aggressive treatment intervention’ and, ‘as their treating clinicians, we should admit the possibility that frequent analgesic use not infrequently may assist in improving the lives of these unfortunate patients’. These conclusions were partially based on the low numbers of patients who remained detoxified (36/90 patients). Young and Silberstein (2), in their editorial commentary, highlighted that ‘also distressing is the persistence of high headache severity index despite successful detoxification. This contrasts with previous studies, which suggest that successful detoxification is associated with improvement in headache frequency, intensity and duration’ (3).
These findings also contrast with a study being conducted in a specialty centre where one of the objectives is to describe the treatment carried out in a tertiary centre and patient outcome. To help address this issue we are presenting preliminary data.
Clinical records from a headache specialty clinic were reviewed and identified 456 patients with chronic daily headache (CDH) and analgesic overuse with resultant analgesic rebound headache (ARH) that had been followed up for at least 1 year. We defined drug-related headaches on the basis of drug consumption and drug-seeking behaviour. We compared the headache index (frequency × intensity of pain) scores obtained in the first and the last visit performed at the centre. The follow-up period ranged from 1 to 15 years (mean 6.3 years).
Our sample consisted of 456 patients with ARH, 347 (76%) females, with ages ranging from 11 to 74 years (mean 42.8 years). Maintenance of ‘detoxification’ was observed in 318 (69.7%) of patients over the 1-year period. The evolution of the mean of the headache index, comparing patients that stopped using excessive analgesics with those that did not, is displayed in Fig. 1. The mean headache score is significantly lower in patients that stopped overuse compared both with the initial scores of this group and with the final scores observed in patients that did not stop overusing analgesic medication.
Evolution of the mean of the headache index in subjects who stopped or continued analgesic overuse. ∗P<0.001. ▪, Initial; □, final.
The importance of discontinuation of a potentially offending medication which is being overused in a patient with CDH is a reasonably well-accepted standard of care. Mathew et al. (4) showed that the results of combining discontinuation of the overused analgesics with the initiation of preventive medication resulted in headache improvement at 2-month follow-up in about 80% of patients (4). In a recent prospective study of 95 patients, the duration and severity of withdrawal headache were investigated after complete withdrawal from overused symptomatic medications (5). At the end of the 2-month observation period, 85% of patients were pain-free. The authors' assertion based on these findings was that discontinuation of the overused analgesic medication is the treatment of choice for medication-overuse headache.
Our preliminary data strongly support the concept that successful detoxification is necessary to ensure improvement in the headache status when treating ARH patients (6, 7). Despite this, we do agree that there may be a small subset of patients with CDH who are extremely refractory to aggressive attempts at treatment, both out-patients and in-patients, for whom daily, long-acting analgesic use could be appropriate (1). When successful, this treatment often improves disability and enhances function, without making the patient headache-free. The results of Pini et al. (1) may be, however, due to the fact that at least some of these patients did not have adequate prophylactic, behavioural or supportive therapy on a long-term basis. We must conclude by agreeing with Young and Silbertein (2), that the standard of care for patients with CDH and ARH still remains analgesic detoxification followed by an intensive, long-term treatment plan which usually includes preventive medication.