Neurology -- Correspondence for Zwart et al., 61 (2) 160-164

Correspondence published:

Analgesic use: A predictor of chronic pain and medication overuse headache: The Head–HUNT Study: John-Anker Zwart, Grete Dyb, Knut Hagen, Sven Svebak, and Jostein Holmen (6 August 2003)

Analgesic use: a predictor of chronic pain in medication overuse headache.: Fred D Sheftell, Fred Sheftell, Stewart Tepper, and Alan Rapoport (6 August 2003)

Analgesic use: A predictor of chronic pain and medication overuse headache: The Head–HUNT Study 6 August 2003

John-Anker Zwart,
Department of Clinical Neuroscience
Faculty of Medicine, NTNU, 7006 Trondheim, Norway,
Grete Dyb, Knut Hagen, Sven Svebak, and Jostein Holmen
Send Correspondence to journal:
Re: Analgesic use: A predictor of chronic pain and medication overuse headache: The Head–HUNT Study

john-anker.zwart{at}medisin.ntnu.no John-Anker Zwart, et al.

In response to our article of analgesic use as a predictor of chronic pain and medication overuse headache, we are grateful to Drs. Sheftell, Tepper and Rapoport for drawing the attention to the pioneer work of the Swiss neurologist Hansreudi Isler and Dr. Lee Kudrow from California, both having conducted important clinical studies on chronic headache and medication overuse. We do agree that their work should be acknowledged and will take a note of this in our future work within this field.

Analgesic use: a predictor of chronic pain in medication overuse headache. 6 August 2003

Fred D Sheftell,
New England Center for Headache
778 Long Ridge Road, Stamford, CT 06902,
Fred Sheftell, Stewart Tepper, and Alan Rapoport
Send Correspondence to journal:
Re: Analgesic use: a predictor of chronic pain in medication overuse headache.

ninotores1{at}aol.com Fred D Sheftell, et al.

July 22, 2003
Editor Journal of Neurology
Analgesic use: a predictor of chronic pain in medication overuse headache. The Head-HUNT Study
To the EDITOR:
We were delighted by the inclusion of both the article by Zwart J.- A., et al. [1], and the accompanying editorial by Lipton RB and Bigal ME. [2] on the clinical issues of both chronic daily headache and rebound. However, we believe that any article exploring the role of analgesic overuse and chronic daily headache should acknowledge the pioneering work which appeared in 1982 that first laid out the paradoxical effects of frequent analgesic use and the clinical benefits of discontinuation of these medications. Two studies appeared at around the same time that year by two giants in headache care who simultaneously reported similar results. Alphabetically ordered, the first study was by the Swiss neurologist Hansreudi Isler [3]. Dr. Isler coined the term “Chronic Migraine” to describe patients who transformed from episodic to chronic daily headache with overuse of relief medications. He identified 235 patients between 1978 and 1981 whom he felt had this syndrome. He detoxified the patients from the acute medications and noted, “ withdrawal of attack drugs alone led to marked reduction of frequency of headache, indicating that excessive intake of these drugs is much more a cause than a consequence of frequent and chronic migraine.” Interestingly, he also reported that “Of the 87 patients who showed improvement [after detoxification] by a decreased frequency of attacks, 51 had one or more relapses into their former medication habit, always leading to a higher frequency of headaches. Their relapses were induced by dental procedures [and] by common respiratory infections,” and their treatment was with analgesics., thus suggesting that overuse alone led to daily headache, not use of analgesic medications as a consequence of headache. The California internist and Headache journal editor Dr. Lee Kudrow’s study, was equally important and prescient. In that study Dr. Kudrow reviewed a group of patients with chronic daily headache and divided them first into two groups, withdrawing one group from their analgesics and allowing the second group to remain on their analgesics. He then divided each of those groups randomly to receive amitriptyline as preventive treatment or non-amitriptyline treatment. His results showed that the group with the best outcome was the one withdrawn from analgesics and taking amitriptyline preventively. . The second best outcome was achieved in the group who simply was taken off their analgesics. The group that remained on analgesics and given amitriptyline did modestly better than the group that simply remained on analgesics and received no preventive treatment. He thus described the relationship of analgesic overuse and rebound headache and laid out an appropriate treatment algorithm. The clinical application of Dr.Kudrow’s research has withstood the test of time for more than 20 years and has become the cornerstone and template for successful treatment of refractory headache all over the world. Given the frequency and difficulty of chronic daily headache, seen everyday in neurologists’ offices worldwide, a tip of our respectful hats to our mentors and their pioneering work, is always in order.
1. Zwart JA, Dyb G, Hagen K, Svebak S, Holmen J. “Analgesic use: A predictor of chronic pain and medication overuse headache, the Head-HUNT study. Neurology 2003; 61:160-164. 2. Lipton RB and Bigal ME. Chronic daily headache: Is analgesic overuse a cause or consequence? Neurology 2003; 61:154-155. 3. Isler H.. Migraine Treatment as a Cause of Chronic Migraine. in Advances in Migraine Research and Therapy, Rose FC, Editor, NY: Raven Press. Pp 159-164, 1982. 4. Kudrow L. Paradoxical Effects of Frequent Analgesic Use. Advances in Neurology 1982;33:335-341.
Fred D. Sheftell, M.D., Stewart J. Tepper, MD, and Alan M. Rapoport, MD,
Stamford, CT