Severe drug-induced headache with its possible recurrent statuses in a patient with chronic tension headache

The paper deals with the actual problem of managing patients with drug-induced headache (DIH) in patients with primary headaches. It describes a clinical case of extremely severe DIH in a patient with chronic tension headache (TH). The paper analyzes the typical and atypical manifestations of DIH and discusses the role of prolonged stress in the development of TH. Special attention is paid to the problems with therapy and compliance during a long-term follow-up of the patient. Based on the clinical features of pain syndrome in the described patient, the authors suggest for the first time that the use of extremely high number of daily doses of combined narcotic analgesics for many years can result in recurrent DIH statuses. The paper discusses whether it is expedient to introduce the concept “DIH severity” and whether an additional clinical parameter “the number of doses of painkillers per month” can be of informative value, which has not been proposed yet in the literature. All the issues given in the paper are conjectural and are raised by the authors for further investigation of the DIH problem.

Drug-induced headache: an analysis of therapeutic strategies

To manage patients with drug-induced headache (DIH) is an unsolved problem of modern neurology in developed countries, since DIH is becoming a common cause of temporary disability and leads to lower quality of life in patients. Patients with primary headache (for example, those with tension headache or migraine) frequently take symptomatic headache relief medications uncontrollably, which can result in the higher frequency and intensity of DIH episodes. In turn, new headache attacks make the patients take the increasing number of symptomatic medications, which leads to the development of DIH.The International Classification of Headache Disorders, 3 rd Edition, defines DIH as a distinct form of secondary headache. To date, there is no consensus on the tactics of DIH treatment and prevention. The paper discusses different approaches to DIH prevention and treatment, the effectiveness and appropriateness of their use, as well as factors influencing illness course and possible outcomes. Particular attention is paid to the management of patients during the withdrawal period, risk factors for DIH recurrences, and ways of their prevention.

Drug-induced headache in young people of reproductive age with tobacco addiction

Drug-induced headache (DIH) is one of the most common forms of chronic headache (CH). Management of patients with DIH remains a pressing problem of modern medicine. This condition is characterized by headache over 15 days a month for more than 3 months. On the basis of the BSMU Clinic, we assessed the health status of young people with DIH and nicotine addiction. Patients with nicotine addiction were evaluated for the degree of negative effect of smoking on respiratory function. It was found that the majority of patients took monocomponent analgesics, and the minority of patients took combined analgesics and triptans; compared with young men, young women were less likely to seek medical advice if the episodes of headache became more frequent; however, uncontrolled use of painkillers was observed more often in males. In the absence of an analgesic effect 30 h after medication intake, young men repeated the medication in 60% of cases. Educational programs about DIH and the development of CHs with associated nicotine addiction may play an important in preventing the development of the condition.

Migraine

The vast majority of patients presenting with headache and no physical signs will have migraine, or, less commonly, a variant such as cluster headache. Some migraine patients will have a typical visual, sensory, or speech aura, while others will have less clear-cut premonitory symptoms. A careful history will establish whether there are any atypical features that might warrant further investigation and/or suggest an alternative diagnosis. It is essential that the initial assessment ascertains the frequency and severity of the attacks, as this will determine whether analgesic or prophylactic treatment or both should be offered. The patient’s previous medication should be recorded, noting the largest doses given and the reason why each had been discontinued. Many will be overusing analgesics, particularly opiates, and these can easily lead directly to a chronic drug-induced headache. The real skill in headache management is ensuring that the patient’s history is fully and accurately recorded.

Medication overuse headache

It is a widely accepted idea that medications taken to relieve acute headache pain can paradoxically worsen headache if used too often. This type of secondary headache is referred to as medication overuse headache (MOH); previously used terms include rebound headache and drug-induced headache. In the absence of consensus about the duration of use, amount, and type of medication needed to cause MOH, the default position is conservative. A common recommendation is to limit treatment to no more than 10 or 15 days per month (depending on medication type) to prevent headache frequency progression. Medication withdrawal is often recommended as a first step in treatment of patients with very frequent headaches. Existing evidence, however, does not provide a strong basis for such causal claims about the relationship between medication use and frequent headache. Observational studies linking treatment patterns with headache frequency are by their nature confounded by indication. Medication withdrawal studies have mostly been uncontrolled and often have high dropout rates. Evaluation of this evidence suggests that only a minority of patients required to limit the use of symptomatic medication may benefit from treatment limitation. Similarly, only a minority of patients deemed to be overusing medications may benefit from withdrawal. These findings raise serious questions about the value of withholding or withdrawing symptom-relieving medications from people with frequent headaches solely to prevent or treat MOH. The benefits of doing so are smaller, and the harms larger, than currently recognized. The concept of MOH should be viewed with more skepticism. Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication. Frequent use of symptom-relieving headache medications should be viewed more neutrally, as an indicator of poorly controlled headaches, and not invariably a cause.

Medication Overuse Headache: A Trap for the Headache Patients

Medication Overuse Headache (MOH) was previously termed analgesic rebound headache, drug-induced headache, and medication-misuse headache. It is not a primary headache but frequently coexists with primary chronic daily headache. All acute symptomatic medications used to treat headaches have the potential for causing MOH. Highest with opioids, butalbital-containing combination analgesics, and aspirin/ acetaminophen/caffeine combinations. The development is typically preceded by an episodic headache disorder, usually migraine or tension-type headache, that has been treated with frequent and excessive amounts of acute symptomatic medications. The diagnosis is based upon clinical impression. A history of analgesic use averaging more than two to three days per week in association with chronic daily headache is suggestive. The diagnosis is made when the pattern of frequent headaches fulfills the diagnostic criteria for MOH. The basic steps in the management: Patient education, withdrawal of the offending medication, bridge (transitional) therapy, establishment of a headache treatment regimen covering acute and preventive care, follow up and relapse prevention. Birdem Med J 2013; 3(2): 94-98 DOI: http://dx.doi.org/10.3329/birdem.v3i2.17213