The duration and severity of withdrawal headache after overuse of various headache drugs, including analgesics, ergots, and triptans, were determined in a prospective study of 95 patients (mean age 45+/-12 years; 80 women, 15 men) at the University Hospital Essen, Germany. Sixty-nine (73%) had migraine, 12 (12%) tension-type, and 14 (15%) a combination of headaches. Withdrawal headache is often associated with nausea, vomiting, and sleep disturbance. lasting up to 10 days or longer. The intensity of withdrawal headache typically increases between the second and fourth days and decreases by the sixth and eighth days. After standard inpatient withdrawal therapy over 14 days, the duration of withdrawal headache was shorter in patients overusing triptans (4.1 days) than in those overusing ergots (6.7 days) or analgesics (9.5 days, p<.002). Duration was also shorter in patients with migraine (6.7 days) than in patients with tension-type (9.6 days) and combination headache (8.5 days, p<.02), but only patients with migraine had overused triptans and none with tension-type headache. Mean headache intensity was the same on the first day of withdrawal for all medications but by day 14, it was lower in patients overusing triptans than in those on ergots or analgesics (p<.005). Of triptan overusers, 85% were headache-free by 14 days compared to only 23% of analgesic overusers, and the need for rescue medication was less in triptan withdrawal patients. [1]

COMMENT. The treatment of choice for medication-overuse headache (MOH) is complete withdrawal of headache medication. Most studies of MOH have involved ergots and analgesics. The increased use of triptans has been associated with an increase in prevalence of MOH and the need to withdraw triptan treatment. The duration and intensity of withdrawal headache are less following triptan withdrawal than that following analgesic or ergot withdrawal. Withdrawal headache is dependent on the type of overused drug and pharmacological mechanisms, including specificity for 5-HT receptors or other enzyme systems. The milder withdrawal headache in migraineurs reflects the overuse of triptans, whereas the more severe withdrawal symptoms in tension headache patients is associated with overuse of analgesics. A similar study involving adolescents with migraine would be of interest. The safety and effectiveness of sumatriptan in children has not been established by controlled study. A beneficial response is reported in two open label studies of subcutaneously administered sumatriptan in patients <18 years (Cited by Maytal J. Overview of recent advances in migraine and other headaches. In Millichap JG ed. Progress in Pediatric Neurology III, PNB Publ, 1997).