A Response


  • Ninan T. Mathew MD

This article was based entirely on clinical observations of patients presenting with increasingly refractory headaches who were referred to me after I branched off into headache medicine from general neurology and established the Houston Headache Clinic in 1976. The first striking observation was the report by many patients who presented with daily or near daily headache that their headaches had been less frequent and more manageable in earlier years. That led us to publish our first article, “Transformation of Episodic Migraine Into Daily Headache; Analysis of Factors. Headache 22:66-68, 1982.” That article identified medication overuse, particularly of combination analgesics (caffeine/acetaminophen/butalbital) or opioids, as a major factor contributing to what has come to be termed migraine “chronification.” An expanded series on “transformed migraine” subsequently was published in 1987.1 After a decade of observing these patients, I was convinced that a major factor contributing to their resistance to treatment intervention was the continuing use of certain acute medications. We then carefully analyzed 200 patients, recorded their clinical features, and in 1990 published the article to which Dr. Ward refers.

The impact of this article on the American and European headache communities was substantial. Until then, the Europeans had not appeared to appreciate the clinical significance of medication overuse or the existence of chronic daily headache, but now I am gratified to report that the medication overuse headache is included as an important component of the International Classification of Headache Disorders, 2nd edition.

It seems clear that there are differences between triptan overuse and overuse of butalbital-containing compounds or opioids. For one, it is easier to withdraw patients from triptan overuse than from those compounds or opioids, and patients overusing one or the other of the latter 2 classes also appear to have more psychiatric or behavioral comorbidity.

One enduring fact continues to disappoint me. In spite of the extensive effort made to emphasize the importance of medication overuse in managing the headache population, many practitioners – including neurologists – continue to overprescribe symptomatic medications, thereby condemning their patients to treatment failure.