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


Of the 43 children available for evaluation, 35 had headaches daily and 8 had events 3 to 5 times per week. The initial mean headache frequency was 6.4 per week. The mean duration of prior headaches at the time of evaluation was 27.5 months. Twenty (46%) were honor-roll students according to the families. A history of migraines was present in 21 (49%). Additional diagnoses included concussion (n = 3), epilepsy (n = 2), Chiari I malformation (n = 2), and surgically resected temporal astrocytoma (n = 1). Headaches were described by the patients as frontal or temporal in all but two (occipital) and unilateral in 14 (33%). The analgesics being overused were nonsteroidal anti-inflammatory drugs in 36 patients (ibuprofen in 32, naproxen in 4); acetaminophen (n = 3); acetaminophen with codeine (n = 1); aspirin, butalbital, and caffeine (Fiorinal) (n = 1); butalbital and acetaminophen (Phrenilin Forte) (n = 1); and sumatriptan (n = 1). Caffeine overuse (either as a combination agent or in soft drinks) occurred in 11 patients.

A 50% headache reduction was noted at 1 month in 32 (74.4%) and 90% reduction in 23 (53.5%), regardless of the choice of initial preventive therapy or no initial preventive therapy. All patients were compliant with their therapy regimen. The mean headache frequency decreased from 6.4 to 2.9 per week (P <.001). Increased improvement was not observed during the summer months.

There was no significant difference when age was examined as a risk factor. Children aged 12 years and over were equally likely to achieve 90% improvement at 1 month (11 of 24, 46%) as those 11 years of age or younger (12 of 19, 63%) (P = .26). Gender did not influence outcome, with 10 of 18 (56%) male children having a 90% improvement compared with 13 of 25 (52%) female children (P = .82). The overuse of caffeine was not detrimental to outcome, with 6 of 11 children (54.5%) having a 90% reduction in headaches by 1 month compared with 17 of 32 without caffeine use (53.1%) (P = .92). Triptans were provided as rescue agents in 15 patients, and there was also no difference in 1-month outcomes, with 9 of 15 (60%) having a 90% improvement compared with 14 of 28 (50%) (P = .53).

The presence of a shorter previous headache duration showed a trend toward improved outcomes. In the 19 patients with a median headache duration of more than 24 months, 7 (36.8%) had 90% or greater improvement. Sixteen (66.7%) of those with less than 24 months' duration had similar improvement (P = .05).

Twenty-three children (53%) were not started on daily preventive medication at the initial clinic visit, with parents choosing to wait 1 month to assess outcomes after discontinuation of analgesics. Twenty children (47%) were treated at the initial clinic visit with prophylactic therapy, including amitriptyline (n = 13), topiramate (n = 4), gabapentin (n = 1), verapamil (n = 1), and valproate (n = 1). The choices of preventive agents were individualized, and based on patient comorbidity, side-effect profile, and parent preferences, there was no difference in outcome among these medications. The details of each group are shown in Table 1 . Only three children reported withdrawal symptoms during the month after analgesics were stopped, lasting 14, 14, and 28 days each before resolving. In the 12 patients who were not available for follow-up, 10 were not started on preventive medications at the initial (and only) clinic visit.

There was no difference in headache reduction outcome at 1 month between those started and those not started on initial preventive medications in the likelihood of achieving a 50% headache improvement, 15 of 20 (75%) versus 17 of 23 (74%) respectively (P = .91). No difference was seen in the percentage of 90% improved, 10 of 20 (50%) versus 13 of 23 (57%) (P = .67). There was also no difference between the groups in the total number of headaches per week at 1 month, 3.0 versus 2.7 (P = .75).

Seven of 23 patients in the no-preventive medication group had no change in their headaches at 1 month and chose after that time to then start daily preventive therapy. Medications included amitriptyline (n = 2), valproate (n = 2), fluoxetine (n = 1), topiramate (n = 1), and propranolol (n = 1). Five of these patients were available for follow-up afterward, with patients on amitriptyline, valproate, and topiramate having a subsequent 90% reduction in headaches within 1 month.

In comparing treatment groups based on patient demographics (age, gender, caffeine overuse, and previous headache duration), no differences were found ( Table 2 ). No significant differences in outcomes were identified based on the decision to use triptans as a rescue agent as well.


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