HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

ARTICLES: Z. Katsarava, G. Fritsche, M. Muessig, H.C. Diener, and V. Limmroth Clinical features of withdrawal headache following overuse of triptans and other headache drugs Neurology 2001; 57: 1694-1698 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Reply to Dr. Mauskop's Letter to the Editor

Z Katasarava, "G Fritsche, M Muessig, HC Diener, V Limmroth"   (19 December 2001)

Clinical features of withdrawal headache following overuse of triptans and other headache drugs

Alexander Mauskop   (19 December 2001)

Reply to Dr. Mauskop's Letter to the Editor 19 December 2001
Z Katasarava University Hospital Essen Essen Germany, "G Fritsche, M Muessig, HC Diener, V Limmroth" Send Correspondence to journal: Re: Reply to Dr. Mauskop's Letter to the Editor volker.limmroth{at}uni-essen.de Z Katasarava, et al.	We appreciate the interest of Dr. Mauskop in our study. Firstly, we would like to emphasize that the entity of medication overuse headache (MOH) cannot seriously be called into question. Following dozens of clinical descriptions (beginning in the early fifties [1], for review see a meta-analysis including 29 studies with 2612 patients) [2] the International Headache Society (IHS) integrated MOH (initially as drug- induced headache) into its classification of 1988 as an entity of its own. [3] Secondly, from our point of view the existence of withdrawal headache is well established. [2, 4] However, we agree that withdrawal headache is studied less, mainly because most centers use replacement therapy during the withdrawal period. In our population we could clearly observe an increase of headache intensity (beyond the normal MOH-intensity) between day 2 and 4 and a steady decrease afterwards. Since our patients did not receive any replacement therapy, a blinding of the study was not possible. In contrast, Silverman et al. [5] aimed to confirm the existence of withdrawal symptoms following discontinuation of chronic caffeine administration, which allowed a double-blind approach (caffeine versus placebo). This, however, was not the issue of our study. Our goal was rather to characterize clinical differences of withdrawal symptoms due to different drugs. The success rate of 97% does not reflect the long-term success rate but rather confirms the diagnosis of medication overuse headache, as defined by the IHS (reduction of headache days per month of at least 50%). The long-term success is clearly lower and depends mainly on the time of the follow-up and other several aspects. The few available studies evaluating long-term success rates, suggest a relapse rate of 30-40% in the first year after withdrawal. For our group of patients, the one-year follow-up data are now available (but not published) and show a relapse rate of 35%. We agree that hospitalization of patients under close observation may itself influence (improve) the headache. Since all patients regardless the type of overused medication underwent withdrawal under the same conditions, the hospitalization itself is unlikely to influence the results. Finally, as an important result of our study, we found that patients overusing analgesics (mostly containing caffeine or codeine) had a longer and more severe withdrawal than patients overusing ergots or triptans. Whether the additional withdrawal from caffeine and codeine worsened the withdrawal symptoms is an interesting aspect, which cannot be excluded but warrens further studies. References: 1. Peters GA, Horton BT: Headache : with special reference to excessive use of ergotamine preparations and withdrawal effects. Mayo Clin Proc 1951;26:214-226. 2. Diener HC, Dahlöf CGH. Headache associated with chronic use of substances. Olesen, J., Tfelt-Hansen, P., Welch, K. M. A., editors. The Headaches, 2nd edition, Lippincott, Williams & Wilkins, Philadelphia 1999:871-878. 3. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8:1-96. 4. Silberstein S, Lipton R. Chronic daily headache. In: Goadsby P, Silberstein S (eds.). Headache. Boston: Butterworth-Heinemann, 1997:201- 225. 5. Silberman 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.
Clinical features of withdrawal headache following overuse of triptans and other headache drugs 19 December 2001
Alexander Mauskop New York Headache Center New York Send Correspondence to journal: Re: Clinical features of withdrawal headache following overuse of triptans and other headache drugs NYHeadache{at}aol.com Alexander Mauskop	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.