Analgesic Overuse May Fuel Persistent Headache After Concussion

Megan Brooks

November 04, 2013

AUSTIN, Texas — Overuse of analgesics after concussion may exacerbate concussion-related headaches or make them chronic, a new study suggests.

The researchers advise minimizing analgesics or discontinuing them when headaches continue several weeks after the concussion.

Geoffrey L. Heyer, MD, and Syed A. Idris, MD, from Nationwide Children's Hospital in Columbus, Ohio, reported their findings here at the Child Neurology Society (CNS) 2013 Annual Meeting.

Nationwide Children's Hospital is developing a complex concussion clinic through the pediatric neurology division, Dr. Heyer told Medscape Medical News. "Over the past 3 years, sports medicine doctors and pediatricians/primary care doctors have been sending us their concussion patients who have persistent postconcussion symptoms, often lasting several months," he said.

"We began noticing that a lot of these adolescents and young adults had been instructed to take analgesics during their acute concussion management, but the medicines were never decreased or stopped as the headaches became chronic," Dr. Heyer explained.

By the time patients reached the clinic, many had been taking over-the-counter analgesics 2 to 3 times daily for many months for their daily or near-daily headaches, Dr. Heyer said. "As frequent and prolonged use of headache medicines (including simple analgesics) can cause a medication overuse headache, we decided to look back at patient outcomes once the analgesics were stopped," he noted.

Headaches Ease When Medication Stopped

In reviewing 104 adolescent patients with concussion, the researchers found that 77 had chronic post-traumatic headache lasting between 3 and 12 months. Fifty-four of these patients (70.1%) met criteria for probable medication-overuse headache.

Patients with medication overuse were more likely to have daily headaches (P = .006), to be female (P = .02), to have nausea (P < .001), or to have throbbing associated with their headaches (P = .001).

More than two thirds of the patients with medication overuse (37 of 54 [68.5%]) saw their headaches subside or improve to preconcussion patterns within 2 months of stopping analgesics. Seven patients (13%) had no change in headache status or worsening of headaches after going off analgesics. Ten (18.5%) patients did not discontinue analgesics or were lost to follow-up.

"When daily headaches following concussion (post-traumatic headaches) continue for several weeks, clinicians should consider stopping analgesics or restricting their use to no more than 2 days weekly as medication-overuse headache can develop," Dr. Heyer said.

Tough to Draw Firm Conclusions

"We need to remember that this is a poster with limited information," cautioned Rosemarie Scolaro Moser, PhD, board-certified neuropsychologist and director of the Sports Concussion Center of New Jersey, Lawrenceville. "This research is a beginning, an initial look at an important issue, but not conclusive, as more controlled research needs to be conducted. The study documents correlations, not causation," added Dr. Moser, who wasn't involved in the study.

The fact that 68.5% of patients with medication-overuse headache had resolution of headaches or return to their preconcussion headache after discontinuing the medication "could also be explained by spontaneous healing; concussions do resolve and get better on their own, so I am not sure if taking the patients off the analgesics was what made them get better over a 2-month period," Dr. Moser told Medscape Medical News.

She cautioned that it's hard to make clinical conclusions based on this preliminary study. "I would recommend that parents and adolescents work with physicians and headache specialists who understand concussion and are careful about monitoring the use of any medications during the recovery period," Dr. Moser said.

"In addition, aside from medication, for chronic headaches, working with a neuropsychologist, psychotherapist, and biofeedback specialist may offer additional interventions to help alleviate the symptoms of headache," she added.

The authors and Dr. Moser have disclosed no relevant financial relationships.

Child Neurology Society (CNS) 2013 Annual Meeting. Abstract #113.

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