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

Correspondence to:

ARTICLES: R. Colás, P. Muñoz, R. Temprano, C. Gómez, and J. Pascual Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life Neurology 2004; 62: 1338-1342 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Reply to Gupta

Julio Pascual, Rafael Colás, and Pedro Muñoz   (20 May 2004)

Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life

Vinod K. Gupta   (20 May 2004)

Reply to Gupta 20 May 2004
Julio Pascual, MD Service of Neurology, University Hospital Marqués de Valdecilla (UC), 39008 Santander, Spain, Rafael Colás, and Pedro Muñoz Send Correspondence to journal: Re: Reply to Gupta juliopascual{at}telefonica.net Julio Pascual, et al.	We thank Dr. Gupta for his interest in our paper and for his sensible arguments regarding the necessity to reconsider the theory that chronic analgesic consumption is the reason to transform primary headaches into CDH. We carefully used the term chronic daily headache “with” analgesic overuse both in the title and throughout the manuscript because we are not convinced that analgesic overuse is the true reason for CDH development, but a precipitating or aggravating factor. After studying the prevalence of CDH in the general population, we realized that one-third of these cases fulfilling CDH criteria did not show analgesic overuse. [6] In our view, the extreme and widespread contention supporting that analgesics are a necessary reason to suffer from CDH is untenable. That would imply that CDH did not exist before the analgesic era and the traditional literature is full of accurate descriptions fully compatible with a CDH diagnosis. We do believe that we will witness the description of a specific genetic background as the hidden reason for “spontaneous” CDH development. A variety of “environmental” factors, such as analgesic misuse or others, would possibly be involved in some or many of these genetically predisposed cases to eventually develop CDH. We do not think that the call for public health intervention in CDH patients with analgesic overuse should be necessarily preceded by better mechanistic comprehension. Patients at risk of developing disturbing CDH, usually middle-aged women with an increasing frequency of migraine attacks, should be treated with preventatives at an early stage and instructed to avoid symptomatic medications with a high incidence of rebound. References 6. Castillo J, Muñoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache 1999; 39: 190-196.
Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life 20 May 2004
Vinod K. Gupta, Dubai Police Medical Services, Dubai, United Arab Emirates P.O. Box 12005, Dubai, United Arab Emirates Send Correspondence to journal: Re: Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life docgupta{at}emirates.net.ae Vinod K. Gupta	Colás et al found chronic daily headache (CDH) with analgesic overuse common in the general population. [1] With 70% of CDH patients in the general population not overusing analgesics, [1] it is essential to reconsider the theory that chronic analgesic consumption can transform episodic migraine or tension-type headache (TTH) into CDH. Evidence for the role of analgesics in the development of CDH is purely circumstantial: [2] 1.) There is no evidence to support the suggestion [1] that analgesics interfere with the efficacy of prophylactic headache medications. 2.) We know of no central neuronal process possibly relevant to migraine or TTH pathophysiology that might be affected by chronic analgesic consumption. Since drugs that do not cross the blood- brain barrier also remit migraine, a primary involvement of central neuronal processes in idiopathic headaches is arguable. [3] 3.) Improvement of headache following analgesic withdrawal is regarded as the principal basis of this causal assumption. [4] While analgesic abuse is a self-determined unsupervised activity, analgesic withdrawal is a medically controlled activity; every therapeutic intervention -- including supervised analgesic withdrawal -- involves a placebo effect. [2] 4.) Analgesic withdrawal in clinical practice is commonly accompanied by other interventions undertaken simultaneously. [5] 5.) No particular temporal pattern has emerged between regular analgesic use and development of daily headache in migraine patients. [2] 6.) A mean of 5.4 years (range, 2 to 10 years) of analgesic consumption preceded onset of daily headache in 62.5% (5 of 8) of migraine patients; [4] a very tardy speculative pathogenetic mechanism needs to be invoked. [2] 7.) Relevance of the tendency of headache-prone patients to develop daily headaches if put on analgesics for a non-headache indications1 must be considered in the context of the inevitable pain-stress nexus as stress frequently precipitates migraine. 8.) The subtle semantic distinction between CDH and transformed migraine is based entirely on phenomenology. [2,3] 9.) We do not know why only very few patients regularly using analgesics develop CDH. [2] Natural transformation of an episodic primary headache into CDH1 appears to be an uncommon but logical outcome of primary headache disorders. [2,5] A small subset of primary headache (migraine or tension- type) patients – over-represented in subspecialty clinics -- might progress spontaneously from episodic headaches of lower frequency to episodic headaches of a higher frequency up to daily recurrences. The call for public health interventions in CDH patients with analgesic overuse [1] must be preceded by better mechanistic comprehension. References 1. Colás R, Muñoz P, Temprano R, et al. Chronic daily headache with analgesic overuse. Epidemiology and impact on quality of life. Neurology 2004;62:1338-1342. 2. Gupta VK. De novo headache and analgesic consumption: pathophysiological insights from nosologic complexity? Headache 2004;44:375. 3. Gupta VK. Classification of primary headaches: pathophysiology versus nosology? Published electronic response to: Peatfield R. A revised classification of headache disorders. Available at:http://bmj.com/cgi/content/full/328/7432/119?etoc (22 January 2004). 4. Bahra A, Walsh M, Menon S, Goadsby PJ. Does chronic daily headache arise de novo in association with regular use of analgesics? Headache 2003;43:179-190. 5. Lipton RB, Bigal ME. Chronic daily headache. Is analgesic overuse a cause or a consequence? Neurology 2003;61:154-155.