Medication-Overuse Headache in Children: Is Initial Preventive Therapy Necessary?

Eric H. Kossoff, MD; Dhwani N. Mankad, MPH, MBBS


J Child Neurol. 2006;21(1):45-48. 

In This Article

Abstract and Introduction

Chronic daily headaches can be a difficult problem in children as well as adults. Over half of the cases of chronic daily headaches in adults are thought to be due to medication-overuse headache, and treatment consists of discontinuation of these analgesics. Since many patients are also treated with preventive agents at the time of analgesic withdrawal, it is difficult to determine whether discontinuation alone is the most effective treatment. A retrospective study was performed to evaluate the outcomes of 43 children (ages 6–17 years) with medication-overuse headache 1 month after withdrawal of analgesics: 20 children received daily doses of a preventive medication, and 23 received no preventive medication. Headache reduction was assessed 1 month later. There was no difference in the percentage, with 90% or greater headache reduction at 1 month between children treated by withdrawal of analgesic drugs only and those receiving preventive medications (57% vs 50%, respectively). There was no influence of age, gender, use of triptans as rescue agents, or caffeine use on outcomes. A previous duration of headaches over 2 years was negatively correlated with overall outcome. We advise discontinuation of analgesics in all children with medication-overuse headache, without the necessity for starting daily preventive agents concurrently. Should headaches persist after 1 month, such agents can be added.

Chronic daily headache is a common problem afflicting as many as 3% to 4% of the adult population.[1,2] It is also common in children.[3,4,5] Chronic daily headache can be due to chronic migraine, chronic tension-type headache, or new persistent daily headache. In the first two groups, there can be a "rebound" effect from daily or near-daily use of analgesics.[6] In fact, in 50% to 82% of adults, chronic daily headache is thought to be secondary to overuse of analgesics.[7] Several names have been given to this syndrome, including analgesic withdrawal headache, rebound headache, and medication-overuse headache.[8] Medication-overuse headache is defined as refractory daily or near-daily headache in a patient who uses analgesic medications daily, often excessively (more than five times per week), in whom the headache becomes worse but eventually subsides with discontinuation.[6] According to two recent large surveys from Norway and Spain, this condition is believed to occur in 1% to 1.4% of the general population.[9] Nearly all abortive medications can induce medication-overuse headache, including acetaminophen, aspirin, ibuprofen, naproxen, ergotamine, triptans, and caffeine.[7,10]

This "unrecognized epidemic" is even less recognized in children.[11,12,13,14,15,16] Although withdrawal of the offending analgesic is a well-established treatment for medication-overuse headache, many pediatric neurologists also often concurrently begin a prophylactic medication, such as amitriptyline. In one study, 22 of 24 children aged 5 to 17 years were started on 10 mg of amitriptyline as analgesics were discontinued.[12] Outcomes were generally favorable, with a 73% decrease in the total headaches seen after 1 month.

It is unclear from this study whether amitriptyline was required to achieve improvement.[12] The two patients who were not treated showed similar improvement so that the authors concluded that amitriptyline might not have been the primary factor in reducing headaches. However, as most patients were started on amitriptyline at the same time as analgesic discontinuation, it was believed to be "difficult to discern the beneficial effect of discontinuing analgesics from the introduction of amitriptyline."[12] Another study of children found that 20 of 26 were headache free at 12 weeks without the need for prophylactics.[14] In two previous studies evaluating discontinuation of analgesics in adults, 45% to 60% were improved with medication withdrawal alone, with only small additional benefit from amitriptyline in one study.[16,17] Since amitriptyline and all other preventive medications have potential side effects, this decision is not trivial.

In our clinical practice, medication-overuse headache is universally treated by withdrawing analgesics, but not always by starting prophylactics concurrently. Many children appear to improve within days of medication discontinuation alone. We hypothesized that medication-overuse headache could be effectively treated at 1 month equally with medication withdrawal alone and in combination with preventive medications.


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