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

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

Disclosures

J Child Neurol. 2006;21(1):45-48. 

In This Article

Discussion

In this small, retrospective study, discontinuation of analgesics alone was equally likely to result in significant improvement at 1 month as discontinuation combined with the administration of daily preventive medications. In fact, even with the small sample size, the likelihood of a > 90% headache reduction was higher for those who did not receive daily prophylaxis. The outcomes for both groups were favorable; in about half of the children, headaches were reduced from once a day to once a week. Our patient population is similar to that used in the other studies of medication-overuse headache in children in age, gender, headache frequency, and follow-up.[12,14] The significant difference between this study and the others is the ability to compare the two therapeutic options. Age, gender, caffeine use, and previous headache duration did not appear to be important factors in predicting a better outcome by starting preventive therapy initially, although a longer previous headache duration was somewhat negatively correlated with a favorable outcome overall.

It is reasonable to delay initiation of a course of daily preventive medications when children with medication-overuse headache are first identified. All patients should be educated about basic lifestyle modifications (eg, regular sleep, exercise, stress reduction) and recommendations to discontinue the analgesics. The child should then be seen after 1 month. This might also allow for a possible, and occasionally high, placebo effect from simply being seen by a physician. Triptans can also be prescribed for episodes of intense headache, although at the time of this publication, they are not approved by the US Food and Drug Administration for children under age 18 years. Withdrawal symptoms were infrequent in this study. This approach avoids a potentially confusing message of discontinuing analgesics while beginning another medication on a daily basis. Moreover, this regimen might permit general pediatricians to treat such patients and avoid the need for referral. Patients with a headache duration over 2 years can be more intractable and perhaps should be referred to a neurologist, although they do not necessarily require initial preventive therapy.

This study has several limitations. For one, in this retrospective study, choices of abortive rescue agents and even specific prophylactics were not consistent or random. The decision to start or not to start a preventive therapy was made conjointly with input from the patient, his or her family, and the physician and subject to biases owing to this preference. A larger, prospective, placebo-controlled trial design would be more definitive in assessing the relative efficacy of a preventive medication compared with analgesic discontinuation alone.

In conclusion, medication-overuse headache in children and adolescents is a difficult problem, but once it is recognized, the prognosis is generally favorable. Preliminary information from this small, retrospective study indicates that discontinuation of analgesics appears to be the key factor leading to improvement, and both referrals to pediatric neurology and starting preventive medications might not be necessary. If follow-up is ensured, prophylactic therapy can always be started after 1 month if no improvement is seen.


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