Clinical features of withdrawal headache following overuse of triptans and other headache drugs
AlexanderMauskop, New York Headache Center New YorkNYHeadache@aol.com
Submitted December 19, 2001
I commend Katsarava et al. [1] for undertaking the difficult task of
a prospective study that involved hospitalizing a large number of
patients, and for producing an incredible long-term success rate of 97%.
But I wish the authors had taken the extra step of double-blinding the
trial. My concern is that their report describes clinical features of a
condition that may not exist. While withdrawal from caffeine has been
shown to cause headaches in a double-blind experiment [2], the existence
of withdrawal or rebound headaches due to daily use of a simple analgesic,
ergotamine or a triptan has never been scientifically demonstrated. It
may be that a number of anecdotal reports have created a myth of
medication overuse headache that is not supported by facts. In the study
under discussion, there are plausible alternative explanations of the
observed phenomena. Hospitalizing a patient under close observation for
14 days is a major intervention that should cause improvement in a
significant number of patients even without other treatment. Caffeine is
another variable that must be considered. The prolonged duration of
withdrawal headaches in the group of patients using combination analgesics
(most of which contain caffeine) as compared to the triptan group is
consistent with my clinical impression that the daily use of caffeine-
containing drugs almost always causes rebound headaches, while daily use
of triptans almost never does.
References:
1. Z. Katsarava, G. Fritsche, M. Muessig, H.C. Diener, V. Limmroth
Clinical features of withdrawal headache following overuse of triptans and
other headache drugs. Neurology 2001;57:1694-1698.
2. Silverman K, Evans S., Strain E., Griffiths R. Withdrawal syndrome
after the double-blind cessation of caffeine consumption. N Engl J Med
1992;327:1109-1114.
I commend Katsarava et al. [1] for undertaking the difficult task of a prospective study that involved hospitalizing a large number of patients, and for producing an incredible long-term success rate of 97%. But I wish the authors had taken the extra step of double-blinding the trial. My concern is that their report describes clinical features of a condition that may not exist. While withdrawal from caffeine has been shown to cause headaches in a double-blind experiment [2], the existence of withdrawal or rebound headaches due to daily use of a simple analgesic, ergotamine or a triptan has never been scientifically demonstrated. It may be that a number of anecdotal reports have created a myth of medication overuse headache that is not supported by facts. In the study under discussion, there are plausible alternative explanations of the observed phenomena. Hospitalizing a patient under close observation for 14 days is a major intervention that should cause improvement in a significant number of patients even without other treatment. Caffeine is another variable that must be considered. The prolonged duration of withdrawal headaches in the group of patients using combination analgesics (most of which contain caffeine) as compared to the triptan group is consistent with my clinical impression that the daily use of caffeine- containing drugs almost always causes rebound headaches, while daily use of triptans almost never does.
References:
1. Z. Katsarava, G. Fritsche, M. Muessig, H.C. Diener, V. Limmroth Clinical features of withdrawal headache following overuse of triptans and other headache drugs. Neurology 2001;57:1694-1698.
2. Silverman K, Evans S., Strain E., Griffiths R. Withdrawal syndrome after the double-blind cessation of caffeine consumption. N Engl J Med 1992;327:1109-1114.