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Low-Dose Tizanidine With Nonsteroidal Anti-inflammatory Drugs for Detoxification From Analgesic Rebound Headache


Address all correspondence to Dr. Timothy R. Smith, Mercy Health Research and Ryan Headache Center, Suite 200, 1585 Woodlake Drive, St. Louis, MO 63017.


Objective.—To describe an outpatient regimen for analgesic detoxification and resolution of analgesic rebound headache.

Background.—Frequent analgesic use is believed to promote the transformation of episodic migraine into a chronic, pervasive headache syndrome. Management of pain precipitated by analgesic withdrawal is crucial to treatment success. Outpatient treatment protocols designed to achieve successful withdrawal will reduce costs and potentially lead to more widespread implementation of therapy.

Methods.—Patients with appropriate histories were managed on an outpatient basis for detoxification by discontinuation of the offending analgesic and initiation of treatment with tizanidine and a long-acting nonsteroidal anti-inflammatory drug. Patients kept diaries of pain and medication use. Results were evaluated at 6 and 12 weeks. Patients able to tolerate no or trivial analgesic use (ie, 4 or fewer doses in each 2-week period) were considered responders.

Results.—At 6 weeks, 36 patients (65%) were responders. At 12 weeks, 38 patients (69%) were responders. The chronic daily headache pattern had resolved at 12 weeks in 34 patients (62%).

Conclusions.—This treatment protocol was well tolerated and yielded a high degree of efficacy, demonstrating that outpatient management can be effective for achieving analgesic withdrawal and resolution of analgesic rebound headache.