Katsarava Z.& Diener H-C.
Department of Neurology, University of Essen, Essen, Germany

Medication overuse headache in Germany

This study, supported by the Federal Ministry of Education, investigates the prevalence and incidence of chronic headache (CH) and medication overuse in adults, adolescents and children. 1- Adults Currently preliminary data of the study in approximately 6.000 adults are available. The prevalence of CH (> 14 days per month) was 4%. Half of the patients with CH took acute headache drugs on > 14 days per month. During a prospective 1-year follow-up, 2% of the headache patients with episodic headache at baseline developed CH. Frequent intake of acute headache drugs (> 10 days per month), intake of two or more different acute headache drugs and concomitant low back pain have been identified as the main risk factors for developing CH. The 1-year follow-up of patients with CH at baseline revealed that almost 70% of them improved spontaneously. Risk factors for the persistence of CH were similar to those for the transition of episodic to chronic headache: 1. overuse of acute headache medication; 2. intake of two or more different acute headache drugs; 3. concomitant chronic low back pain. 2- Children and adolescents The study on the prevalence of CH in children and adolescents approached 8800 households. The 6-month prevalence of paediatric headache was 53.2%. The prevalence was lowest in children aged 7 years and increased with age reaching 63% at age 14 years. Overall, recurrent headache (> 1/week) was experienced by 6.5% of the total sample and was significantly more common among older girls (>11 years) than their male counterparts. Boys and girls did not differ markedly from one another regarding headache occurrence and frequency until the age of 11 years Mean age of headache onset was 7.5 years, with onset occurring at a significantly younger age among boys than among girls. In accordance with International Classification of Headache Disorders-II criteria, migraine was diagnosed in 7.5% and TTH in 18.5% of cases Paediatric headache was strongly associated with other health problems, including other pain symptoms and history of parental headache. Treatment Abrupt drug withdrawal is the treatment of choice for MOH. Anyway there are still some questions under extensive debate: what is the best methodology (in-patient programmes, out-patient setting or a day clinic)? When is it indicated to start preventive treatment (immediately, during or after withdrawal)? When is it necessary to give patients a replacement therapy? The German Migraine and Headache Society recommends in its guidelines out-patient withdrawal for patients who do not overuse opioids or tranquillizers and are highly motivated. In-patient treatment should be performed in patients who take opioids, fail to withdraw the drugs as out-patients or who have a high depression score. Withdrawal symptoms usually last for 2–10 days and include withdrawal headache, nausea, vomiting, arterial hypotension, tachycardia, sleep disturbances, restlessness, anxiety and nervousness. The withdrawal phase is much shorter when patients are abusing only triptans. All the patients are treated by a multidisciplinary team including neurologists, psychologists and physiotherapists. Treatment usually starts with abrupt withdrawal from the overused drug. An important part of the treatment is education, which includes basic information about clinical features, pathophysiology and treatment principles of migraine, TTH and MOH. Patients receive training to improve their pain coping strategies and learn several non-drug-based treatment strategies. The lack of uniform medical and psychological follow-up programmes after discharge is an obvious challenge of the common treatment performance in Germany. (summary of the original article by H. Duyver)

Cephalalgia, 2008, 28, 1221-1222 (© Blackwell Publishing Ltd)