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Cluster Headache Patients Are Not Immune to Medication-Overuse Headaches

Those with overuse headaches also had migrainous headache features, and most had family histories of migraine.

It is widely believed that patients with cluster headache do not develop medication overuse headaches (MOH), although they have multiple headaches and, therefore, often consume large amounts of analgesics and triptans. In this study, investigators assessed whether cluster headache is in fact associated with MOH. They reviewed data from 430 patients with cluster headache and examined in detail data from the 17 people (7 with episodic and 10 with chronic cluster headache) who also had chronic daily headaches associated with medication overuse.

The medications overused included simple analgesics, nonsteroidal anti-inflammatory drugs, opiates, ergots, and triptans. More than half of these patients were not using adequate preventive therapy. The striking feature in all 17 patients was a migrainous biology: 15 had clear personal histories or family histories of migraine, or both; the other 2 had family histories of "headaches." In an unusually large proportion (8 of 17), the cluster attacks incorporated migrainous features. Medication withdrawal was attempted in all patients, and it was successful in 13.

The authors conclude that MOH is an under-recognized and treatable problem in patients with cluster headache and that these patients, especially those with a personal or family history of migraine, should be monitored for this problem.

Comment: Cluster headache appears to be "contaminated" by MOH in about 4% of patients — about the same incidence as in migraine. This study does not tell us how many of the 430 cluster headache patients were overusing medications and did not develop MOH, and how many of these "MOH-immune" patients had a migrainous biology.

Is a migrainous biology sufficient to cause MOH in individuals who overuse medications? Evidence from other studies is conflicting (N Engl J Med 2006; 354:158). Of patients with migraine who take large regular doses of analgesics for rheumatic disease, only about one in four developed MOH in one study (Headache 2003; 43:179). But in a study of patients taking opiates for control of bowel motility, of eight patients overusing opiates, MOH developed only in the two patients with histories of migraine (Headache 2001; 41:303).

When prescribing analgesics for any indication, it seems prudent to be especially careful in people with migraine.

— John Edmeads, MD

Dr. Edmeads is Professor of Medicine (Neurology), University of Toronto, and Neurologist, Sunnybrook and Women's Health Sciences Center, Toronto, Ontario, Canada.

Published in Journal Watch Neurology October 3, 2006

Citation(s):

Paemeleire K et al. Medication-overuse headache in patients with cluster headache. Neurology 2006 Jul 11; 67:109-13.

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