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Long-term Follow-up of Patients Treated
for Chronic Headache with Analgesic Overuse
Posted: August 2004  
Editorial Commentary: WB Young & SD Silbersten
Thomas Jefferson University Hospital
& Headache Center
Philadelphia, PA

In their article, Pini et al. (1) raise important issues about the treatment of chronic daily headache (CDH) associated with analgesic overuse. They provide observational data on a cohort of CDH patients over 4 years, comparing outcomes in subjects with analgesic overuse who became non-over-users, those who fail to successfully detoxify themselves over 4 years despite treatment, and control subjects who were never overusing analgesics.

Their results significantly challenge what has been the standard teaching in many clinics. The first level of analysis was consistent with our beliefs. The duration of CDH and the amount of overused medicine predicted a failure to remain detoxified. As in previous studies, combination medication overuse was associated with recidivism. These findings, again, support the concept that medication overuse is a factor in the evolution of daily headache into more frequent and more refractory headache. Surprising was the low levels of maintained detoxification, 36/90 patients contacted at follow-up in contrast to most previous studies. 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.

Quality of life, as might be expected, was better in non-overusing controls than in prior over-users. Most surprising was the poor quality of life in patients who were successfully detoxified. The authors suggest that daily analgesics improve quality of life, independent of headache severity. There are, however, other potential explanations. First and foremost, quality of life may originally have been worse in ex-over-users. This could have been part of the motivation to discontinue analgesics. This is a very likely explanation as quality of life was not measured at baseline. Secondly, quality of life was better in the control group of daily headache patients without analgesic overuse who had a shorter duration of illness. Thus, duration of illness may affect both quality of life and need for treatment. Other features of the ex-over-user group (not measured), such as pre-treatment psychiatric comorbidity, could affect both quality of life as well as the ability to be detoxified. This concept is consistent with the observation that quality of life improved in subjects with migraine and worsened in those with chronic tension headache.

There could be errors of under-ascertainment. Subjects who continue to overuse may be reluctant to inform their physician. Warner has recently reported that only one of 29 of his patients who remained fully detoxified for 1 year failed to achieve the goal of six consecutive headache-free days. Although the follow-up period is less in this study than in the study by Luigi-Alberto, and his outcome measures differ, these findings suggest the outcome of detoxification is not so bleak. In most studies the positive results are >50% at 3-60 months follow-up.

It has not been proven that quality of life is better in persistent over-users. If this were so, how could it be? Could analgesic overuse benefit depression or anxiety, or some other factor? This will require careful study, describing pre-treatment patient characteristics, treatments received and consecutive quality of life measurements. Successfully detoxified patients, with comorbid depression and anxiety, not getting specific treatment, could add to the low quality of life scores. How firmly should we urge our patients with persistent daily headache after analgesic overuse to abstain from analgesic overuse? The standard of care is still abstention. There may, however, be a group of particularly refractory patients for whom daily analgesic use is appropriate. The decision to condone overuse cannot be taken lightly.