Twelve Cases of Analgesic Headache Arch Dis Child: First Published As 10.1136/Adc.78.6.555 on 1 June 1998

Arch Dis Child 1998;78:555–556 555

Twelve cases of analgesic headache Arch Dis Child: first published as 10.1136/adc.78.6.555 on 1 June 1998. Downloaded from

D N K Symon

Abstract (nine girls and three boys) ranged in age from Analgesic headache occurs when drugs 6 to 16.5 years (mean 12.5, median 13.7). The given for the treatment of headache children had a history of headaches that aggravate symptoms. The condition is well became increasingly frequent. The history of recognised in adults but has not been headaches ranged from three months to 10 described before in children in whom it years. These children comprised about a quar- may be induced by mild analgesics such as ter of all referrals with headache to the outpa- paracetamol used alone. Twelve children tient clinic during this period. (nine girls and three boys, aged 6 to 16.5 All 12 children were using at least one dose years) with analgesic headache (from of an analgesic drug for each headache and three months to 10 years) are reported. eight were using analgesic drugs daily. Many of Five children were taking paracetamol the children and their parents initially denied alone, six were taking paracetamol with drug treatment, and only admitted to analgesic codeine, and one child was taking ibupro- use when direct leading questions were asked. fen. The abrupt withdrawal of analgesic Most did not consider mild analgesics, avail- drugs was successful in eight of the able without prescription, to be drug treat- children; two had episodic migraine head- ment. Five were taking paracetamol alone, six aches; one had headaches but with re- were taking combinations of paracetamol and duced frequency; and one returned to codeine, and one child, even in the absence of analgesic abuse. symptoms, was taking ibuprofen daily to try to (Arch Dis Child 1998;78:555–556) prevent the onset of headache, with extra doses of the drug being taken when the headache Keywords: headache; migraine; analgesic; paracetamol actually occurred. Interestingly, many of the children felt that the drugs were not of beneﬁt but continued to take them anyway. Physicians treating headaches in adult patients In all cases, clinical examination including a are aware that drugs given for the treatment of full neurological examination, proved unre- headache may aggravate the symptoms. Anal- markable. Seven of the children had computed gesic abuse headache is listed as a separate cat- tomography of the head, which showed no egory in the International Headache Society abnormalities. http://adc.bmj.com/ classiﬁcation of headache disorders.1 In a recent review Olesen2 noted that analgesic headache is a common treatable condition that deserves further attention. Despite widespread Treatment and outcomes knowledge of the condition in adults, analgesic Initial treatment in all children consisted of an headache has not been described in children. abrupt withdrawal of all analgesic drugs. It was The condition has been described as head- explained to the children and their parents that

ache occurring during daily intake of this was necessary as the drug treatment was on September 29, 2021 by guest. Protected copyright. medication for symptomatic headache. The causing an increased frequency of headaches. headache occurs daily or almost daily but No alternative drug treatment was given during disappears within a few weeks after withdrawal the analgesic withdrawal period. Many parents of medication.3 were initially reluctant to accept this advice, as Analgesic headache may be caused by a wide they felt they were denying their children range of drugs. Headache caused by chronic essential symptomatic relief. ergotamine use is well known, but narcotics Drug withdrawal produced complete resolu- and even mild analgesics may aggravate tension tion of all headache symptoms in six patients headaches as well as migraine when taken daily. (50%). In a further two patients the daily Studies in adults show that abuse of single headache resolved but the children continued preparations of aspirin, phenacetin, or para- to have intermittent episodic migraine head- cetamol is rare. Most cases of analgesic aches that were not suYciently frequent to jus- Department of headache are caused by compound prepara- tify regular prophylactic treatment. The re- Paediatrics, tions of a simple analgesic with caVeine, maining four patients all showed some Hartlepool General 4 Hospital, Holdforth codeine, benzodiazepines, or barbiturates. In reduction in the frequency of headaches but Road, Hartlepool, some of these cases the headache may be continued to have recurrent troublesome Cleveland TS24 9AH, caused by excessive use of the “non-analgesic” symptoms. UK drug in the compound, particularly caVeine.5 Sodium valproate has been reported to be of D N K Symon beneﬁt in adults with chronic tension 6 Correspondence to: Patients and clinical ﬁndings headache, and has been used in adult patients Dr Symon. Over 10 months, I saw 12 children referred to with analgesic headache. Three of the patients email: david.symon@ a general paediatric clinic at a district general with continuing symptoms were prescribed virgin.net hospital with a complaint of headache occur- sodium valproate in the doses recommended Accepted 17 February 1998 ring on at least four days a week. The children by the manufacturers for epilepsy treatment. 556 Symon

None of the patients showed any improvement sic drugs. There has been no double blind pla- in headache symptoms and the drug was with- cebo controlled study of analgesic withdrawal Arch Dis Child: first published as 10.1136/adc.78.6.555 on 1 June 1998. Downloaded from drawn. but many papers have reported substantial Three patients with continuing symptoms improvement in the frequency or severity of were referred for psychiatric treatment. The headaches after daily analgesics are stopped.2 parents of one child refused to attend. The This approach also seems appropriate for chil- remaining two children showed complete reso- dren. We do not know if those children in lution of symptoms. whom drug withdrawal appeared to produce The final outcome in the 12 patients was no benefit complied with the advice given, complete resolution of all symptoms in eight although all claimed to have done so. Some children; episodic migraine headaches in two; children may benefit from psychological assist- reduced headache frequency but continuing ance. Sodium valproate, however, does not troublesome symptoms in one; and complete appear to be of benefit. failure to respond with return to analgesic There is no information on the prevalence of abuse in one. analgesic headache in children. Abu-Arafeh Children with analgesic headache are a par- and Russell8 found that migraine was by far the ticularly diYcult group to treat. Six of the 12 most common cause of severe recurrent head- patients failed to attend clinic appointments, ache in childhood. Children with analgesic including patients in whom treatment was suc- headache were probably included among the cessful. Follow up to measure outcome re- 10% of children with severe recurrent head- quired contact by telephone and through gen- ache classified as tension headache. The eral practitioners. condition is more important than these small numbers would suggest as the frequency of Discussion symptoms results in considerable disability for Analgesic headache does occur in children and those aVected. Recognition of analgesic head- is not restricted to adults. It should be ache in children makes possible successful suspected in any child with a history of treatment of its disabling symptoms. headache on four or more days a week. A history of analgesic use should be sought in all such children. I did not see any other children 1 Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for with such frequent headaches but without headache disorders, cranial neuralgias and facial pain. excessive analgesic use during the study period. Cephalalgia 1988;8(suppl7):1–96. In adults, analgesic headache has been 2 Olesen J. Analgesic headache. BMJ 1995;310:479–80. 3 Diener HC, Tfelt-Hansen P. Headache associated with reported mainly with the frequent use of ergot- chronic use of substances. In: Olesen J, Tfelt-Hansen P, amine or of compound analgesic preparations. Welch KMA, eds. The headaches. New York: Raven Press, 1993:721–7. It seems likely that this merely reflects the pat- 4 Wallasch T-M. Medikamentös induzierter Kopfschmerz. tern of drug use for headaches in adults7 rather Fortschr Neurol Psychiat 1992;60:114–18. 5 Mathew NT, Stubits E, Nigam MP. Transformation of epi-

than being a necessary part of the syndrome. In sodic migraine into daily headache: analysis of factors. http://adc.bmj.com/ this study half of the children were using a sin- Headache 1982;22:66–8. 6 Mathew NT, Ali S. Valproate in the treatment of persistent gle simple analgesic; clearly paracetamol alone chronic daily headache. An open-label study. Headache is suYcient to induce analgesic headache. 1991;31:71–4. 7PfaVenrath V, Niederberger U. What kind of drugs are taken The mechanism of analgesic headache is by patients with primary headaches? In: Diener HC, unknown. Possibly it may be no more than a Wilkinson M, eds. Drug-induced headache. Berlin: Springer- Verlag, 1988:44–62. withdrawal phenomenon. The main treatment 8 Abu-Arafeh, I, Russell G. Prevalence of headache and for analgesic headache is withdrawal of analge- migraine in school children. BMJ 1994;309:765–9. on September 29, 2021 by guest. Protected copyright.