Abstract
In their article Saper et al. propose to include in future iterations of the International Headache Society (IHS) classification the behavioural aspects of medication overuse headache (1). In principle I agree. Many patients with medication overuse headache (MOH) have psychiatric comorbidity (depression, anxiety disorders) and many are addicted to their headache medication. This problem is more often seen in the USA than in other countries. Many European countries banned barbiturates from pain medication within the last 20 years. In Germany this happened in 1979 after we had published about the addictive properties of barbiturates in headache patients (2). Within a few weeks many headache patients were admitted to neurology or psychiatry departments either with withdrawal symptoms or with seizures. Opioids are not popular and are not used in Europe for the treatment of headache. Again, this problem is much more prominent in the USA. Europeans and physicians in other countries have parenteral treatment options in the emergency room for the treatment of acute headache not available in the USA, such as i.v. aspirin (3), i.v. paracetamol or i.v. dipyrone (4, 5).
Basically there are two approaches to the problem: one can amend the IHS classification to include ‘complex’ MOH requiring drug withdrawal and a programme for the treatment of addiction and psychiatric comorbidity. A much better way would be an initiative from physicians and patient groups to ban the use of barbiturates in pain medication and to teach physicians and patients that opioids are not an appropriate treatment for headache.
Another important aspect mentioned by Saper et al. is the fact that many patients with MOH continue the use of their medication even if it is no longer effective (1). We observed in our study published in 1984 a much higher use of nasal decongestants and laxatives as well as sleeping pills in migraine patients with MOH than in controls. The misuse is usually not captured when taking the history.
The final aspect is the success of drug withdrawal. Our prospective studies in MOH patients showed a low relapse rate in patients overusing triptans while almost all patients with opioid use relapsed after initially successful withdrawal (6, 7). This is an additional argument for avoiding opioids for the treatment of headache.