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Universidad industrial de Santander.

Sede socorro.

Tecnología en regencia de farmacia.

Estudio de los problemas relacionados con el uso de los medicamentos


(PRUM) analgésicos en las cefaleas de rebote.

Diana Chávez.

María Paola Silva Rojas.

Socorro Colombia

2019
Contenido
1. TITULO. ............................................................................................................................................ 3
2. INTRODUCCION. .............................................................................................................................. 4
3. JUSTIFICACION: ............................................................................................................................... 6
4. PLANTEAMIENTO DEL PROBLEMA: ................................................................................................. 6
5 OBJETIVOS ........................................................................................................................................ 7
5.1 OBJETIVO GENERAL ................................................................................................................... 7
5.2. OBJETIVOS ESPECIFICOS. .......................................................................................................... 7
6. MARCO TEORICO ............................................................................................................................. 8
7. METODOLOGÍA................................................................................................................................ 9
8. RESULTADOS: ................................................................................................................................ 10
8. 1. SALUD PUBLICA ................................................................................................................... 10
8. 2. ADMINISTRACION EN FARMACIA ........................................................................................ 12
8. 3 SERVICIOS FARMACEUTICOS ................................................................................................ 13
8.4 FRAMACIA MAGISTRAL ......................................................................................................... 17
9. Análisis de resultado ..................................................................................................................... 20
10. CONCLUSIONES: .......................................................................................................................... 22
11.Bibliografía ................................................................................................................................... 23
12. ANEXOS ....................................................................................................................................... 24
12.1Cefalea crónica diaria con Abuso de Analgésicos .................................................................. 24
12.2Consumo excesivo de medicamentos para el dolor de cabeza ............................................. 24
12.3 Headache Management ........................................................................................................ 24
12.4 Medication Overuse Headache ............................................................................................. 24

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1. TITULO.

ESTUDIO DE LOS PROBLEMAS RELACIONADOS CON EL USO DE LOS


MEDICAMENTOS (PRUM), EN CEFALEAS DE REBOTE CON
ACETAMINOFEN, IBUPROFENO, COMBINACION DE CAFEÍNA CON
ACIDO ACETIL SALICILICO Y ACETAMINOFEN,

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2. INTRODUCCION.

Este proyecto colaborativo se desarrolla con el fin de cumplir con nuestro proceso
académico de quinto semestre de Regencia de Farmacia, y también para conocer,
indagar e investigar sobre los problemas relacionados con el uso de los
medicamentos en la cefalea primaria.

La definición de los PRUM en el decreto 2200 de 2005 nos dice:“ PROBLEMAS


RELACIONADOS CON LA UTILIZACIÓN DE MEDICAMENTOS (PRUM).-
Corresponden a causas prevenibles de problemas relacionados con medicamentos,
asociados a errores de medicación incluyendo los fallos en el Sistema de Suministro
de Medicamentos, relacionados principalmente a la ausencia en los servicios de
procesos administrativos y técnicos que garanticen la existencia de medicamentos
que realmente se necesiten, acompañados de las características de efectividad,
seguridad, calidad de la información y educación necesaria para su utilización
correcta.” (1)

con base a lo anterior las fases en las que se pueden presentar y el error en la
medicación se pueden caracterizar en: disponibilidad: esto relacionado con el stock
reducido por cualquier razón, la calidad, garantizar las condiciones técnicas de los
medicamentos adquiriéndolos de proveedores reconocidos, la prescripción
incorrecta por un medicamento innecesario, interacción con otros medicamentos,
mal diagnostico o no preciso, claridad y exactitud de la formula entre otras.

En cuanto a la dispensación, estos pueden ser por dispensación del medicamento


equivocado, cantidad diferente del medicamento, incompleto en su totalidad, no
informar sobre su uso adecuado, la administración errónea del paciente o del
cuidador. (2),el uso por medio de la automedicación irresponsable o no terminar el
tratamiento.

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Sabemos que los medicamentos se usan para diagnosticar curar y prevenir
enfermedades, su mala utilización puede causar problemas en la salud del
individuo, no logrando los efectos terapéuticos deseados o la aparición de otros
efectos no deseados, aumentando el costo de la atención en salud.

En un gran porcentaje en el mundo se prescriben se dispensan o se venden en


forma incorrecta, y aún no hay acceso total a los medicamentos esenciales y otra
parte los individuos los toman de forma incorrecta, es por esto la importancia de
fomentar el uso racional de los medicamentos aplicando estrategias para cambiar
estos hábitos del uso inadecuado de los medicamentos.

En conformidad con lo anterior, es importante que nosotros como futuros regentes


de farmacia, seamos conscientes de la participación en el equipo de salud,
educando y dirigiendo a pacientes, usuarios y personal de la salud en los problemas
relacionados con el uso de los medicamentos.

Los analgésicos son medicamentos de venta con o sin receta médica, utilizados
para controlar el dolor, incluyendo las migrañas y otros tipos de dolores de cabeza.
Estos analgésicos pueden contribuir al proceso que causa el dolor de cabeza.
Aunque los analgésicos disminuyen la intensidad del dolor de cabeza durante
algunas horas, parecen alimentar el dolor. Si el paciente no deja de usar los
analgésicos del todo, es probable que la cefalea crónica continúe, a pesar de
cualquier otro tratamiento que se administre. Usualmente, cuando se interrumpe el
uso de analgésicos, el dolor de cabeza puede empeorar durante varios días y el
paciente puede sentir nauseas o vómitos. Dicho abuso se ha definido como la
administración regular de analgésicos simples -o de combinaciones analgésicas

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3. JUSTIFICACION:

La presente investigación se enfocará en estudiar las cefaleas de rebote


(clasificación internacional de enfermedades) CIE 10 (G44.4) y los problemas
relacionados con el uso de los medicamentos en la cadena de los mismos
(adquisición, recepción, almacenamiento, distribución, prescripción médica, formas
magistrales entre otras).

Es tarea de nosotros como futuros regentes de farmacia contribuir con la labor diaria
y los esfuerzos para lograr la educación de la comunidad y de muchos profesionales
de salud en este tema, para de esta forma garantizar el bienestar del paciente, igual
mente la importancia de la correcta conservación, y uso racional de los
medicamentos.

4. PLANTEAMIENTO DEL PROBLEMA:

“Aunque parezca increíble, siete de cada diez personas sufren cada vez más dolor
de cabeza por el uso excesivo de los analgésicos con los que, precisamente, buscan
alivio día tras día.” (3), las cefaleas no solo son dolorosas sino también tienen un
impacto en la calidad de vida ya que son causales de discapacidad, y afectan la
vida social del paciente pues esta predispuesto a padecer un nuevo episodio, por lo
que esto conlleva a que aparezcan enfermedades secundarias por estos episodios,
los problemas relacionados con el uso de los medicamentos en cefaleas como
acetaminofén, ibuprofeno y combinación de cafeína con aspirina y acetaminofén se
pueden producir por la automedicación, el uso inapropiado de los mismos, ya que
las personas con cefalea no creen que esta patología sea una enfermedad grave
por el poco conocimiento que tiene sobre la misma, por lo que ellos mismos se tratan
con medicamentos sin receta.

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5 OBJETIVOS

5.1 OBJETIVO GENERAL

Conocer los factores asociados a los problemas relacionados con el uso de los
medicamentos (PRUM), en la cefalea de rebote y en la cadena del medicamento.

5.2. OBJETIVOS ESPECIFICOS.

 Describir los problemas relacionados con el uso de los medicamentos


(PRUM).
 Identificar los medicamentos más utilizados en la cefalea de rebote o
medicamentosa.
 Identificar algunos de los factores que influyen al mayor impacto de aparición
de problemas relacionados con el uso de los medicamentos como
acetaminofén, ibuprofeno, combinación de cafeína con ácido acetil salicílico
y acetaminofén

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6. MARCO TEORICO

Según la OMS:” las cefaleas (dolores de cabeza) son uno de los trastornos más
comunes del sistema nervioso. son trastornos primarios dolorosos e incapacitantes
como la jaqueca o migraña, la cefalea tensional y la cefalea en brotes. también
pueden ser causadas por muchos otros trastornos, por ejemplo, el consumo
excesivo de analgésicos” (4)

Las cefaleas o dolores de cabeza se dividen en dos grandes grupos: Cefaleas


primarias, El dolor de cabeza es el único o principal síntoma de la enfermedad. Es
decir, donde no hay datos que indiquen que el dolor forma parte de otra enfermedad
entre ellos la migraña, la cefalea de tensión, la cefalea en racimos etc. Las Cefaleas
secundarias El dolor de cabeza es un síntoma de otra enfermedad.

“Se calcula que la prevalencia mundial de la cefalea (al menos una vez en el último
año) en los adultos es de aproximadamente 50%. Entre la mitad y las tres cuartas
partes de los adultos de 18 a 65 años han sufrido una cefalea en el último año, y el
30% o más de este grupo ha padecido migraña. La cefalea que se presenta 15 días
o más cada mes afecta de un 1,7% a un 4% de la población adulta del mundo. A
pesar de las variaciones regionales, las cefaleas son un problema mundial que
afecta a personas de todas las edades, razas, niveles de ingresos y zonas
geográficas”. (5)

“La cefalea es un síntoma prevalente, el 90% de los adultos ha referido cefalea


alguna vez en su vida y de estos hasta el 60% la presenta con una periodicidad
variable, el diagnóstico debe orientarse de acuerdo a la Clasificación Internacional
de Cefaleas dentro de las causas primarias y secundarias.

La edad de presentación más común es de los 30 a 39 años, dentro de los tipos de


migraña, la migraña sin aura es la más común afectando aproximadamente al 75%
de los casos” (6)

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7. METODOLOGÍA

La metodología utilizada es de investigación documental definida como “Puede


definirse la investigación documental como una estrategia de comprensión y análisis
de realidades teóricas o empíricas mediante la revisión, cotejo, comparación o
comprensión de distintos tipos de fuentes documentales referentes a un tema
específico, a través de un abordaje sistemático y organizado (7). Según Baena
(1985), la investigación documental es una técnica que consiste en la selección y
compilación de información a través de la lectura y crítica de documentos y
materiales bibliográficos, bibliotecas, bibliotecas de periódicos, centros de
documentación e información. (8)

Se consulto en las siguientes bases de datos seleccionadas: como MEDLINE,


EMBASE, DYNAMED, CLINCALKEY, para poder extraer la información relevante
para nuestro caso.

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8. RESULTADOS:

8. 1. SALUD PUBLICA

1. Asignar el Código CIE-10 para cada una de las patologías o enfermedades


trazadoras relacionadas con cada Grupo Terapéutico asignado.

R51 cefalea y (G44.4) Cefalea inducida por medicamentos, no clasificada en otra


parte

2.Definir y describir de manera resumida, la fisiopatología de la entidad clínica


seleccionada Presentar mediante un esquema la historia natural de la
enfermedad (HNE).

La cefalea o dolor de cabeza representa una de las formas más comunes de dolor
en la raza humana. Generalmente el dolor de cabeza se presenta de forma
intermitente. Las formas más frecuentes corresponden a la migraña o jaqueca y a
la cefalea de tensión.

PERIODO PRE PATOGÉNICO:

AGENTE:

HTA, Estrés (y relajación después de un periodo de estrés). Ciertas comidas


(alcohol, queso, cítricos, chocolate). Omitir comidas. Un exceso o muy pocas horas
de sueño. Cambios hormonales (algunas mujeres pueden ser más susceptibles a
presentar migraña durante la menstruación), fármacos.

HUESPED:

Hombre y mujeres de cualquier edad, teniendo una mayor prevalencia en las


mujeres.

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MEDIO AMBIENTE:

Luces intensas. Ruidos Fuertes. Falta O Exceso De Sueño, Etnia Caucásico,


Factores Genéticos, Estatus Socioeconómico Bajo

PATOGÉNICO
SIGNOS Y SÍNTOMAS
SIGNOS Y SÍNTOMAS
ESPECÍFICOS:
INESPECÍFICOS:
Dolor punzante
Dolor
Dolor terebrante (como taladro)
Irritabilidad
Dolor opresivo
Vértigo
Dolor eléctrico
Nauseas
Enrojecimiento de ojos
COMPLICACION:
Lagrimeo
Erupciones cutáneas
Mareos e inestabilidad
SIGNOS Y SÍNTOMAS
Fiebre
ESPECÍFICOS:
Sensación de hormigueo en brazo y
Espasmos faciales
piernas
Parpados caídos
Alteraciones de visión
Dolor explosivo

SECUELAS:
Migraña episodios recurrentes de
dolor de cabeza

3. En el tema de HNE, se deben presentar estrategias de promoción de la salud


y prevención primaria, con base en el análisis de los determinantes sociales
de la salud.

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PREVENCIÓN PREVENCIÓN PREVENCIÓN
PRIMARIA SECUNDARIA TERCIARIA
PRIMER NIVEL DE SEGUNDO NIVEL DE TERCER NIVEL DE
ATENCIÓN ATENCIÓN ATENCIÓN
Darle Evaluación de paciente Terapia física: ejercicios
información necesaria al Tratamiento adecuados para la
paciente sobre su farmacológico para hta movilidad
enfermedad Indicar al paciente como
Situal al paciente en un debe manejar su edad o
área segura y observable realizar diferentes
Evitar alcohol y tabaco actividades con ayudad
de familiares o terceras
personas

8. 2. ADMINISTRACION EN FARMACIA

Desde su rol como regente de farmacia y director técnico de un servicio


farmacéutico de primer nivel, ¿cómo implementaría un sistema fácil de
entender, que evite los PRUM en las áreas de recepción, almacenamiento y
dispensación? Explique muy bien cada paso que quiera usar para entender el
proceso.

RECEPCIÓN: inspeccionando visualmente todo lo relacionado los aspectos


técnicos de los medicamentos (cantidad de unidades, el número de lote, fechas de
vencimiento, registro sanitario, laboratorio fabricante, condiciones de
almacenamiento durante el transporte, manipulación, embalaje, material de
empaque y envase), contar con la ficha técnica del medicamento (tiempo de vida
útil, condiciones de almacenamiento y la información que la institución considere
necesaria. Todo lo que tiene que ver con sus propiedades Organolépticas.

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ALMACENAMIENTO: Teniendo en cuenta las cadenas de frio las áreas
demarcadas y señalizadas, las condiciones de temperatura y humedad, la
ventilación la infraestructura física, el recurso humano competente, documentación;
Kardex, informes, formatos, dotación, en óptimas condiciones

DISPENSACION: Se tiene que dar la información correcta al paciente, ya que


nuestra profesión implica un compromiso con el paciente en cuanto a manejo del
medicamento, como usarlo correctamente y cuidado, su almacenamiento,
Asesorándolo para prevenir incompatibilidades frente a otros medicamentos y/o
alimentos, para lograr el objetivo terapéutico buscado, junto a la entrega del
medicamento al paciente.

8. 3 SERVICIOS FARMACEUTICOS

1. Identifique las diferentes etapas de Buenas Prácticas de


Abastecimiento que se deben cumplir para los medicamentos que
fueron asignados a su CIPA.

las buenas prácticas de abastecimiento es el conjunto de normas destinadas


a garantizar el almacenamiento transporte y distribución adecuada de
productos farmacéuticos y materiales después del proceso de fabricación,
para conservar la naturaleza y calidad para su llegada al destino final, el
usuario. Comprende 3 etapas:

SELECCIÓN: medicamentos esenciales en función de las enfermedades


prevalentes, el proveedor que cumpla con toda la documentación legal y
vigente, garantía de buenas prácticas del almacenamiento transporte y
distribución. para asegurar que no se adquieran medicamentos de baja
calidad, adulterados, sin licencia, de etiquetado engañoso, falsificados o de
imitación, y que estos no entren en la cadena de suministro. La segunda

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ALMACENAMIENTO: asegurar que haya espacio suficiente, limpiar el área,
inspeccionar los paquetes recibidos, rotular FIFO (primero en entrar primero
en salir) establecer planes de contingencia para situaciones de escasez de
medicamentos y para compras en casos de emergencia. Por último,
DISTRIBUCIÓN: entrega de unidades, dispensación a pacientes o usuarios
y realizar informe diario de despacho,

2. Que actividades se llevarían a cabo para implementar las Buenas


prácticas de dispensación a los medicamentos que le han sido
asignado a su CIPA.

SEMAFORIZACIÓN: Es una herramienta que permite identificar y determinar


en el momento oportuno que medicamentos están próximos a vencer,
ejercerciendo un control sobre estos, esta semaforización se efectúa de
acuerdo a la rotación de los medicamentos, en el almacén central, en el carro
de paro y en donde se utilicen medicamentos.

El color rojo indica que tiene menos de un mes de vida útil. El color amarillo
indica que tiene hasta 3 meses de vida útil. El color verde indica que tiene de
cuatro meses en adelante de vida útil.

Evitando los errores LASA (Looks A Like Sound A like) medicamentos con
apariencia o nombre similar, por similitudes ortográficas, fonéticas o de
empaquetamiento.

Información al paciente mejora los conocimientos generales sobre el uso de los


medicamentos y modificar positivamente su conducta respecto al cumplimiento
de la terapia prescrita por el médico. Las instrucciones deben ser claras y
simples, en un lenguaje adecuado, Hacer un resumen de toda la información
aportada. Comprobar si el paciente ha asimilado la información implicándolo en
el tratamiento. Explicar los pros y los contras de tomar o no la medicación.

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Utilizaríamos la técnica de los 5 correctos:
Paciente correcto, hora correcta, medicamento correcto dosis correcta, vía de
administración correcta

3. Desde el Componente Inspección, Vigilancia y Control de


Medicamentos:

a) ¿Si el medicamento sufre alguna adecuación, se requiere la


Certificación INVIMA en BPE?

“Cuando en estos establecimientos farmacéuticos realicen elaboración,


adecuación, preparaciones, mezclas, adecuación y ajuste de concentraciones
de dosis, reenvase o reempaque de medicamentos, deberán obtener el
Certificado de Cumplimiento de Buenas Prácticas de Elaboración (BPE),
otorgado por el Instituto Nacional de Vigilancia de Medicamentos y Alimentos -
INVIMA y su dirección técnica estará a cargo exclusivamente del Químico
farmacéutico.” los dispuesto en la resolución 0444 de 2008. (9)

b) Si el medicamento es de Control especial, ¿cuáles son los requisitos


para obtener la resolución por parte de la Secretaria de Salud
Departamental, Oficina Fondo Rotatorio de Estupefacientes, ¿para la
distribución y dispensación de este medicamento?

Para nuestros medicamentos no aplica ya que son medicamentos de venta libre


se puede adquirir sin formula médica, sirven para aliviar el dolor leve a
moderado, Son tan comunes y corrientes que la gente los toma con frecuencia
y sin darles gran importancia, mientras que los de control especial su principio
se debe vender con formula médica y formato de control especial.

c) Realizar Auditoria Farmacéuticas a sus proveedores de medicamentos:


si un externo realiza las actividades de preparación de fórmulas magistrales y

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la realización de Auditorías Internas del Sistema de Gestión de Calidad del
Servicio Farmacéutico.

1. En caso que los medicamentos asignados son de Control Especial


como sería Manejo técnico de los mismos.

No aplica.

2. ¿Como se previenen los Problemas Relacionados con el Uso de los


Medicamentos (PRUM) en los componentes del Servicio Farmacéutico?

Ya que los PRUM son problemas prevenibles estos se pueden evitar por
medio de:

DISPONIBILIDAD: de medicamentos adecuados para cada tratamiento.


Dispensar los medicamentos y sus cantidades completos concentración y
forma farmacéutica indicada. Prescripción de medicamentos del plan
obligatorio de salud.

PRESCRIPCION: Elección e indicación correcta en su forma farmacéutica,


concentración, principio activo de los medicamentos, dosis correcta. Brindar
las instrucciones necesarias y correctas al paciente sobre el medicamento y
su uso correcto. Las prescripciones deben ser legibles. Reconocer las
reacciones adversas.

DISPENSACION: Medicamento correcto (principio activo, forma


farmacéutica, concentración)

Cantidad correcta, Hora o día correcto Monitorización correcta, información


correcta para la administración o para el uso del medicamento.

USO: No Automedicación cumplimiento del tratamiento en su totalidad., no


omitir dosis.

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CALIDAD: Entrega de un producto de calidad, en especial en la
concentración, desintegración o disolución de principio activo, que
contenga la presencia de sustancias extrañas que pueden generar
problemas de seguridad con la utilización del medicamento

ADMINISTRACION: INTERPRETACION DE LA PRESCRIPCION


CORRECTAMENTE, Medicamento correcto, Medicamento autorizado, Dosis
correcta, Vía incorrecta, Hora correcta, Forma farmacéutica correcta Técnica
correcta, Tiempo correcto. Interpretación correcta de las instrucciones
suministradas por el personal médico o farmacéutico.

8.4 FRAMACIA MAGISTRAL

Según los medicamentos asignados a su CIPA, escoja uno de ellos y diga en


que formas farmacéuticas se encuentra dicho medicamento en el mercado.

Ibuprofeno, su presentación en el mercado se encuentra en capsulas


comprimidos, comprimidos recubiertos supositorios, ampollas.

“IBUPROFENO
Código ATC: M01AE01 Venta libre

CLASE TERAPÉUTICA: analgésico, antipirético, antiinflamatorio no esteroideo


AINEs.
Indicación del medicamento

 Pertenece a una clase de medicamentos llamados antiinflamatorios no esteroideos


AINEs, que funciona al detener la producción de una sustancia que causa dolor,
fiebre e inflamación.

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 Se utiliza para aliviar el dolor, sensibilidad, inflamación y la rigidez causada por la
osteoartritis y la artritis reumatoide. También se usa para aliviar el dolor menstrual,
cefaleas, dolor de muelas, resfrío común, dolores musculares, dolor de espaldas y
para reducir la fiebre (5).

No tome ibuprofeno de venta libre con ningún otro analgésico (IECA) como
benazepril, captopril, enalapril, Antidepresivos

ACETAMINOFÉN + ÁCIDO ACETIL SALICÍLICO + CAFEÍNA


Código ATC: N02BE51 Financiado con recursos de la UPC para el tratamiento de
episodios agudos de migraña en adultos Venta libre

CLASE TERAPÉUTICA: analgésicos y antipiréticos.


Indicación del medicamento

 Analgésico, antipirético.
 Este medicamento se usa para aliviar temporalmente dolores fuertes y dolores leves
como: cefalea, resfrío, artritis, dolores musculares, sinusitis, dolor de dientes, dolor
premenstrual y menstrual (1).

Evite tomar otro AINE (antiinflamatorio no esteroideo) como aspirina, ibuprofeno,


naproxeno, celecoxib, diclofenaco, indometacina, meloxicam entre otros.

Evite el café, té, gaseosas, bebidas energéticas u otras fuentes de cafeína mientras
toma este medicamento

ACETAMINOFÉN
Código ATC: N02BE01 Venta libre CLASE TERAPÉUTICA: analgésico, antipirético.

OTROS NOMBRES: paracetamol.


Indicación del medicamento

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 El acetaminofén pertenece a una clase de medicamentos llamados analgésicos
(que alivian el dolor) y antipiréticos (reducen la fiebre).
 Funciona al cambiar la forma en que el cuerpo siente el dolor y enfriando el cuerpo.
 Se utiliza para aliviar el dolor de intensidad leve a moderada (dolores de cabeza,
dolores musculares, cólicos menstruales, dolor de garganta, dolor de muelas, dolor
de espalda, reacciones dolorosas a las vacunas) y para reducir la fiebre (5).

Tomar otros medicamentos que contengan acetaminofén puede hacer que su


hígado falle no deben utilizarse en niños menores de 2 años de edad Si usted bebe
tres o más bebidas alcohólicas al día, no tome acetaminofén.” (10)

Si un paciente necesita el medicamento, pero en una forma farmacéutica


diferente, por algún problema, como la deglución, etc., según lo estudiado en
Farmacia Magistral, ¿cómo cambiaría la forma farmacéutica y cual elige?

Ya que el ibuprofeno cuenta con amplias formas farmacéuticas y teniendo en cuenta


las preparaciones magistrales la modificación la haríamos en gel analgésico

Exponga un caso de un paciente y cuál sería la mejor forma de


administrar el medicamento escogido. ¿Como haría la preparación?

Paciente con cefalea de rebote que se le va quitar de golpe todos los


medicamentos, para que no sienta tanto dolor ya que este tratamiento le va a
producir más dolor, este no tendrá que consumir los medicamentos y de manera
externa se bajara la intensidad del dolor.

almidón de maíz, almidón pregelatinizado, celulosa microcristalina, dióxido de sílicio


coloidal, estearato magnésico, derivado de celulosa/ polioxil 40 estearato, dióxido

P á g i n a 19 | 60
de titanio (E-171), hidroxipropilmetilcelulosa (E-464), propilenglicol y polietilenglicol
8000, c.s. incorporándolo a la base de gel.

9. Análisis de resultado

Con la realización de este proyecto se puede deducir que los medicamentos de


venta libre, son medicamentos de nueva generación elaborados por la necesidad
de obtener medicamentos más efectivos, menos químicos, para que actúen de
forma específica y con una reacción directa para atacar la enfermedad, suprimirla,
prevenir o retrasar su evolución disminuyendo los efectos adversos que los
químicos producen en nuestro cuerpo.

la tendencia para los próximos años deberá ser el desarrollo y aplicación cada vez
más frecuente de procesos enzimáticos que permitan integrarse a diferentes etapas
de procesos de la química tradicional e incluso sustituirlos en su totalidad, un alto
porcentaje de los fármacos que saldrán al mercado serán medicamentos biológicos
que darán respuesta a pacientes que en este momento no tienen un tratamiento
adecuado.

Todo tipo de medicamentos debe contar con su protocolo de seguridad en cuanto


elaboración, dispensación, almacenamiento medidas orientadas a impedir, reducir,
prever controlar fenómenos peligrosos y de contaminación en los mismos.

Es importante recordar que debemos tener una manipulación de dichos


medicamentos muy eficaz y eficiente y sobre todo responsable ya que son
medicamentos de alto costo que se manejan en su mayoría en centros médicos y
muy pocos en el hogar por lo que se deben concientizar a los pacientes para que
los manipulen correctamente y evitar complicaciones a futuro.

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Las farmacias y las droguerías son la puerta más importante de entrada al sistema
de salud, ya que es el sitio de consulta más usado, por lo que el personal a cargo
de las mismas (regentes de farmacia) debe reforzar y estar en continuo aprendizaje
para garantizar el uso adecuado, pero principalmente para prevenir, detectar y
notificar al personal correspondiente para corregir las fallas previniendo así los
problemas relacionados con el uso de los medicamentos (PRUM).

P á g i n a 21 | 60
10. CONCLUSIONES:

10.1 la tarea que realizan los profesionales farmacéuticos es fundamental en el


sistema de atención de la salud, la cual se ocupa de la necesidad, seguridad y
efectividad de los medicamentos

10.2 El regente de farmacia cumple un papel importante y fundamental ayudando


desde la prevención y el uso adecuado de los medicamentos.

10.3. El personal de salud como personal experto en los medicamentos a través de


la atención farmacéutica (dispensación, indicación farmacéutica promoción, etc.)
debe identificar con prioridad los PRUM para evitar más RNM (resultados negativos
asociados a la medicación) y mejorar la calidad de vida de los pacientes

10.4. la falta de dirección por parte de los profesionales de salud encargados en el


proceso de mejoría, en este caso de la cefalea, por la falta de análisis de los
problemas relacionado con el uso de los medicamentos, lo que podría producir el
efecto terapéutico no deseado y la no calidad de vida del paciente.

10.5. El exceso de fármacos utilizados para aliviar cualquier tipo de cefalea primaria,
pero principalmente de migraña o cefalea tensional ocasión la cefalea por abuso de
medicamentos o de rebote.

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11.Bibliografía

1. SOCIAL MDLP. INVIMA. [Online].; 2005 [cited 2019 SEPTIEMBRE 01. Available from:
https://www.invima.gov.co/documents/20143/453029/Decreto-2200de-2005.pdf/272bc063-
41bd-7094-fc8f-39e5e8512d95?t=1541014861533.

2. rodriguez ami. diccionario farmaceutico. [Online].; 2013 [cited 2019 septiembre 02. Available
from: http://auramilenainsuastyrodriguez.blogspot.com/2013/05/prum-corresponden-
causas-prevenibles-de.html.

3. Czubaj F. intramed. [Online].; 2010 [cited 2019 11 05. Available from:


https://www.intramed.net/contenidover.asp?contenidoid=64125.

4. ORGANIZACION MUNDIAL DE LA SALUD. [Online]. [cited 2019 SEPTIEMBRE 01. Available


from: https://www.who.int/topics/headache_disorders/es/.

5. Ghebreyesus DTA. organizacion mundial de la salud. [Online]. [cited 2019 septiembre 21.
Available from: https://www.who.int/es/news-room/fact-sheets/detail/headache-disorders.

6. Paredes SJR. bdigital repositorio institucional UN. [Online].; 2018 [cited 2019 octubre 01.
Available from: http://bdigital.unal.edu.co/70484/1/1085260373.2018.pdf.

7. Uriarte. JM. "Investigación Documental". [Online].; 2018 [cited 2019 11 05. Available from:
https://www.caracteristicas.co/investigacion-documental/.

8. Robles D. investigacion cientifica. [Online]. [cited 2019 11 06. Available from:


https://investigacioncientifica.org/que-es-la-investigacion-documental-definicion-y-
objetivos/.

9. ministerio de proteccion social. alr sura. [Online].; 2008 [cited 2019 octubre 02. Available
from: https://www.arlsura.com/images/stories/documentos/res444_08.pdf.

10. minsalud. medicamentos a un clip. [Online]. [cited 2019 noviembre 28. Available from:
http://www.medicamentosaunclic.gov.co/.

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12. ANEXOS

12.1Cefalea crónica diaria con Abuso de Analgésicos


http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1699-695X2009000300005

12.2Consumo excesivo de medicamentos para el dolor de cabeza

https://www.mayoclinic.org/es-es/diseases-conditions/medication-overuse-
headache/symptoms-causes/syc-20377083

12.3 Headache Management

 Stephen D. Silberstein

Practical Management of Pain, 30, 408-423.e4

12.4 Medication Overuse Headache

 Roger Cady , Curtis P. Schreiber y Kathleen Farmer Pain Management,


Chapter 49, 453-463

Most intriguing, yet often frustrating, are patients with daily or near-daily headaches
who insist they need daily analgesic in order to function. The quantity of analgesic
they require is often staggering, and they frequently are seeking medical advice in
hopes of being prescribed an even more potent analgesic medication. There is often
a history spanning years to decades of increasingly frequent severe, disabling
headaches and a concomitant history of escalating analgesic use. Confounding this
clinical scenario is that patients assure the medical provider that they only seek
medication in order to function effectively and that they have had experiences where

P á g i n a 24 | 60
the medication was unavailable and have endured severe, unrelenting headaches
that often result in repeated visits to the emergency department. Reviewing these
patients' histories, one frequently finds that they have multiple medical providers.

The clinical dilemmas are obvious. Are these patients overtly seeking drugs? Are
they accurately conveying to us that without their daily use of medications, headache
would prevent them from functioning? Or is the medication itself maintaining the
headache? What are the therapeutic and management options for these chronic
headache patients?

Definition of Medication Overuse

The underlying premise of medication overuse headache is that acute medication


used to treat migraine or tension-type headache can over time in susceptible
individuals escalate and maintain the frequency and disability of the headache
pattern. Essentially, episodic primary headache is transformed into a chronic
headache pattern with acute medication being the primary catalyst for this process.
The science supporting this phenomenon is weak at best, but the clinical observation
that frequent use of acute medication associates with frequent episodes of headache
is obvious. Further, numerous clinical studies have observed that withdrawal of the
offending medication results in improvement of the underlying headache pattern.
Rarely, however, is medication withdrawal the only intervention provided to these
patients.

In 2004 the International Headache Society (IHS) defined medication overuse


headache as a pattern of greater than or equal to 15 days of primary headache per
month for at least 3 months associated with predefined quantities of specific acute
medication usage. In the IHS taxonomy, overuse of acute medications was divided
into medication usages of greater than 15 days a month for 3 months for simple
analgesics and caffeine-containing combination analgesics. For opioids, butalbital,

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and triptans, the threshold was placed at 10 days per month. These quantities were
determined by expert consensus.

In its original construct of medication overuse headache the concept of improvement


after withdrawal of medication was a critical component of diagnosis. However, this
criterion has been dropped in favor of the clinical observation that the underlying
headache pattern has worsened since the use of the offending medication was
initiated. Thus the term probable medication overuse headache, which was used
until improvement was documented, has been dropped and quantity limits of various
medications imposed in its place.

Complicating matters has been the evolving definition of chronic migraine and the
newer concept of intractable migraine. At the heart of this debate is the fact that there
is not clear agreement on what constitutes either of these diagnostic constructs.
Thus it is difficult to quantity which IHS-defined headache is worsening and whether
or not this is related to medication or the disease of headache itself or both.

Classification of Chronic Headache

The 2004 edition of The International Classification of Headache Disorders of the


IHS for the first time acknowledged chronic migraine.

Chronic forms of tension-type headache and cluster had been included in the 1988
classification system. Chronic migraine was defined as headaches fulfilling IHS
criteria for episodic migraine on 15 or more days per month over a period of at least
3 months and without evidence of medication overuse. Since 2004 several attempts
have been made to refine the diagnostic criteria since it was quickly realized that the
original definition was overly restrictive and would preclude research of chronic
migraine.

In 2006 an appendix definition of chronic migraine was introduced suggesting a


headache frequency of 15 or greater days of “headache”

P á g i n a 26 | 60
but only 8 or more needed to fulfill IHS criteria for migraine. In addition, response to
migraine-specific medication (triptan or ergotamine) used by the patient before
development of all necessary IHS diagnostic symptoms was considered evidence of
the treated headache being a migraine. Zeeberg et al

recently published a study comparing these two diagnostic definitions with a third
requiring only 4 days of IHS-defined migraine and concluded that the 2006 appendix
diagnosis was the most applicable to clinic populations.

Chronic tension-type headache was defined as headaches fulfilling criteria for


tension-type headache occurring more than 15 days per month for greater than 3
months without evidence of analgesic overuse. This diagnosis is complicated, and
the Spectrum study demonstrated that tension-type headache responded to triptan
medication, at least in migraine patients, and suggested that common biologic
mechanisms were shared in both primary headache types.

Arguably, the most significant advancement in the latest IHS revision was the
inclusion of chronic migraine and medication overuse headache in the diagnostic
taxonomy ( Table 49.1 ) . In acknowledging chronic migraine, the IHS indirectly
supported clinical observations that episodic migraine can evolve into chronic
headache, thus lending credibility to a potential transformational process for
migraine. Further, symptomatic medications were considered a possible factor in
maintai-ning chronic primary headache patterns. The IHS taxonomy expanded the
association of chronic headache and medication overuse by providing a diagnosis
for each headache syndrome that is related to a specific medication that is being
overused ( Table 49.2 ) . However, because many patients overuse multiple
medications and different quantities each month, it makes this aspect of the
classification cumbersome in clinical practice. Even more confusing, the
classification system also continued to recommend independent diagnosis of each
episode of headache a patient experiences—thus necessitating the use of multiple
diagnoses when more than one type of primary headache can be defined in an

P á g i n a 27 | 60
individual patient. Patients are the source of historical information, and their belief
(often fostered by past misunderstandings of primary headaches) in unique
etiologies to different clinical presentations of primary headache clearly influences
symptom description provided to clinicians and consequently the diagnostic labels
medical providers give to patients. This diagnostic confusion often made clinical
application of the IHS criteria burdensome in clinical practice. Further, the IHS
taxonomy continued to state that clinicians should use the criteria to diagnose each
attack of headache and not use the diagnostic labels provided by the IHS to define
patients.

Table 49.1
International Headache Society Diagnostic Criteria for Chronic Migraine and
Medication Overuse Headache
MIGRAINE
 1.Migraine headache occurring on 15 or more days per month for more than
3 months in the absence of medication overuse and not attributable to other
disorder

 2. Headache has at least two of the following four characteristics:


o Unilateral location
o Pulsating quality
o Moderate-to-severe intensity
o Aggravated with activity

 3. During the headache, at least one of the following:


o Nausea and/or vomiting
o Photophobia and phonophobia

MEDICATION OVERUSE HEADACHE

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 1. Headache greater than 15 days per month that has developed or markedly
worsened during medication overuse

 2. Headache resolves or reverts to its previous pattern with 2 months of


discontinuing the overused medication

Table 49.2
Quantities of Selected Medications Associated with Medication Overuse Headaches
Ergotamine intake 10 or more days a month for >3 months
Triptan intake on 10 or more days a month for >3 months
Simple analgesic intake on 15 or greater days per month for >3 months
Opioid intake on 10 or more days a month for >3 months
Combination medications on 10 or more days a month for >3 months
Headache Classification Committee of the International Headache Society: The
international classification of headache disorders, Cephalalgia 24(suppl 1):8, 2004.

In 2006 diagnostic criteria provided as an appendix to the 2004 classification defined


chronic migraine as 15 or greater days of headache per month with at last 8 fulfilling
IHS criteria for migraine 1.1 or 1.2 or responding to migraine-specific therapies used
before all IHS symptoms have developed.

The other days of headache can fulfill diagnostic criteria for probable migraine or
tension-type headache. This represents a clear departure from the operational rules
of earlier taxonomy schemes as it defines patients with a pattern of headache rather
than dissecting out individual headache diagnoses. This was necessitated by the
restrictive nature of the original criteria and concern that research could not be
conducted on chronic migraine unless the criteria were more clinically relevant. The
need for medication overuse headache to be excluded continues to be required,
although recent studies suggest that some preventive medications may be effective
without discontinuation of overused acute medications.

P á g i n a 29 | 60
Complicating diagnostic issues is the developing concept of intractable migraine.
This diagnostic concept is not a formal part of the IHS criteria, but considerable
interest has recently developed in an attempt to define a group of patients refractory
to pharmacologic treatment. Thus when evaluating a patient with chronic migraine,
physicians are confronted with several operational dilemmas. Medication overuse
headache is defined based on frequent headaches associated with defined
quantities of medication use per month, such as 10 days of triptan use or 15 days of
combination analgesics. These quantities were established by consensus criteria,
and there is no scientific basis for the quantities that the IHS determined to define
medication overuse. Nor is there any recognition of biologic differences in patient
populations. This is akin to defining alcoholism solely on the basis of quantity of
alcohol consumed and holding the entire population to this definition; there is no
requirement for improvement with medication withdrawal. This makes it nearly
impossible to differentiate a patient with intractable primary headache from
medication overuse headache if that patient has a history of “overusing” acute
medication in the past. It is hoped that these diagnostic inconsistencies will be
corrected as sound science emerges.

The Debate Over the Role of Analgesics in Patients with Analgesic Overuse

The idea that substances or withdrawal of substances may complicate or provoke


headaches has been suggested for many years. In 1940 Dreisbach

reported caffeine withdrawal headache; in 1949 Wolfson and Graham reported


ergotamine tolerance and withdrawal headache; and in 1951 Peters and Horton
coined the term rebound headache referring to the severe headache that occurred
when “vasoactive substances” were withdrawn from patients with underlying
headache disorders. However, it was not until 1982 that Kudrow and concurrently
Isler

P á g i n a 30 | 60
published studies implicating overuse of commonly employed analgesics used in
treating primary headache disorders as a factor in maintaining primary headache
patterns. Further, withdrawal of the offending analgesic resulted in rebound
headache and, with time, a reduction in headache frequency after the offending
medications were discontinued.

In Kudrow's study, a population of 200 patients with daily headaches was divided
into two groups. Group 1 was prescribed amitriptyline in addition to daily
symptomatic medication; group 2 discontinued daily symptomatic medication before
using amitriptyline for prophylaxis. The mean improvement of group 1 was 20% as
compared with a mean improvement of 72% for group 2. This study noted that it
could take up to 3 months for improvement to occur. Isler's study of 235 patients,
many of whom were overusing ergotamine, reported that those using more than 30
tablets a month suffered twice as many headaches as those using less than 30
tablets a month.

Mathew et al, in a retrospective analysis, expanded the concept of chronic headache


significantly by characterizing a clinical transformation or “evolutive” process by
which patients with primary headaches transitioned from an episodic to a chronic
headache condition. This landmark study noted the frequently associated analgesics
overused by the chronic headache population and it described several important
comorbid conditions observed to be associated with this patient population. In
addition, the different medications and the quantities of use of these various
analgesics were reported. Thus an important paradigm shift occurred: from the
current IHS approach of clinical analysis of each episode of headache to an
approach of making diagnoses based on the evolution of the headache pattern over
time. This transition, although intuitive to many clinicians, remains an enigma to the
academic community that was sought to provide to regulatory agencies worldwide a
diagnostic classification system for use in clinical trials of medications.

P á g i n a 31 | 60
Later, Mathew et al observed that patients with analgesic-dependent headache
patterns were less responsive to both preventive medications and other abortive
medications unless the offending medications were first discontinued. He used the
terms evolutive and transformational migraine to describe the observed changes in
the headache pattern in this patient population.

In 1985 Rapoport et al published findings on 70 patients with daily headaches using


14 or more analgesics per week. They reported that with discontinuation of the
offending analgesic, 66% had improved significantly within 1 month and that 81%
had improved within 2 months. The use of either amitriptyline or cyproheptadine
significantly added to the success reported in this patient population. These studies
demonstrated that successful patient responses were attained by withdrawing
frequently used analgesics. This research expanded the concept that symptomatic
medications were mechanistically an important component in the etiology of chronic
headaches.

Despite these important studies, the fact that few effective nonanalgesic options
were available for treating migraine until the advent of the triptans in the early 1990s
prevented the concept of analgesic rebound headache from being widely
disseminated outside the headache community. With the advent of triptan
medications, it was hoped that these migraine-specific medications would provide
an option for reducing and perhaps preventing analgesic-maintained headaches.
However, reports of triptan overuse headaches began to appear in the literature
soon after the regulatory approval of sumatriptan, being formally reported in 1996 by
Gobel et al.

Today, triptan rebound is considered a potential consequence of all triptans. Thus it


appears that a diverse group of symptomatic medications are implicated in
maintaining chronic primary headache disorders. This prompted the IHS
nomenclature committee to include the diagnosis of medication overuse headache

P á g i n a 32 | 60
and it cites analgesics, ergotamines, caffeine, and triptans as all being associated
with this phenomenon.

Medication Overuse: Cause or Consequence of Headache?

Chronic primary headaches are common, affecting an estimated 2% to 4% of the


American population.

Although several headache specialists report near-epidemic proportions of


analgesic-maintained headache patients in their specialty-based practices, not all
patients with chronic headache appear to overuse symptomatic medications.
Several large epidemiologic studies conducted outside the United States where
over-the-counter analgesics are not commonly available suggest that factors other
than medication overuse may be involved in initiating and maintaining chronic
headaches. Ravishankar reported that less than 5% of a population of 1000 patients
in India with chronic migraine had concomitant medication overuse. Although many
studies report that discontinuation of overused symptomatic medications resulted in
the chronic headache reverting to an episodic headache pattern, rarely did any of
these studies assess the discontinuation of symptomatic medication isolated from
other interventions, such as education and the use of preventive medications. For
example, the study by Mathew et al of 200 patients found that 20% improved over 2
months by discontinuing overused symptomatic medications only. However, 80%
improved over 2 months by discontinuing medication and using preventive
medications. Further, the benefits of analgesic withdrawal appear in many studies to
be short-lived. Pini et al

reported that, after 4 years, only one third of treated patients still refrained from daily
analgesics. In addition, those who returned to daily analgesic use had better quality-
of-life scores than those who no longer used daily analgesics.

P á g i n a 33 | 60
Given the significant rate of analgesic relapse of nearly 60%, the debate has become
whether analgesics are a cause or consequence of chronic daily headaches. Dodick

has suggested that, whereas symptomatic medication can be associated with


rebound headache, chronic migraine itself may be a progressive brain disorder that
leads to overuse of symptomatic medication and that this may be a more common
reason for chronic headache than overuse of medication. This debate has
crystallized given research by Welch et al documenting iron deposition in the
periaqueductal gray area (PAG) in migraineurs with histories of long-standing,
frequent migraine. The authors hypothesized that this may reflect oxidative damage
in this important pain inhibitory nucleus secondary to long-standing uncontrolled
migraine. More recently, Kruit et al reported that subclinical cerebellar white matter
lesions are noted on magnetic resonance imaging (MRI) scans of individuals with
long-standing histories of frequent migraine. These results suggest that for some
patients, migraine may indeed be a progressive neurologic disease.

Proposed Mechanisms of Chronic Headache and Analgesic Rebound


Headache

Over the preceding three decades, the pathophysiology of migraine has changed
significantly and has evolved from a stress to a vascular and now into a neurologic
disorder. In addition, the notion that tension-type headache is a disorder of muscular
etiology has been largely dispelled and a more unified model of primary headache
appears to be emerging. The once-popular notion that migraine and tension-type
headache are distinct pathophysiologic diseases has little scientific support—at least
in the portion of the population capable of having migraine.

(The Spectrum Study found that migraine sufferers have various presentations of
headaches that respond equally to migraine-specific medication.)

In 1980 Raskin and Appenzeller

P á g i n a 34 | 60
proposed a continuum model of migraine with migraine with aura on one end of the
spectrum of headache activity and chronic tension-type headache on the other.
Between these two extremes fell the different clinical phenotypes of primary
headache disorders observed in clinical practice. This model also suggested that, as
migraine became more chronic, the threshold for the next migraine was lowered and
that analgesics and ergotamine expedited this change in the threshold to migraine.
Mathew observed that, when migraine was an episodic condition, patients
complained of associated neurovascular and gastrointestinal symptoms but as it
transformed into a more chronic condition, there was a greater association of
myogenic and psychological symptoms. This original observation may have found
recent support in the American Migraine II study, with the population screening
positive for migraine reporting the greatest frequency of primary headaches also
reporting the greatest number of physician diagnoses of primary headaches. In 2002
Cady et al expanded this concept by proposing the “convergence hypothesis,” which
suggested that primary headaches, at least in the migraine population, evolved from
a single pathophysiologic mechanism. This model correlated the clinical phases of
migraine with presumed underlying pathophysiologic mechanisms of the evolving
process of migraine ( Fig. 49.1 ) . Different clinical diagnoses common to the
migraine population were explained by the level of pathophysiologic disruption
associated with a specific migraine attack. Later, expanding this model to explain the
evolution of episodic into chronic headache, it was suggested that the threshold to
activating the migraine process was influenced by several factors beyond analgesics
including genetics, biology, trauma (both physical and psychologic), and
uncontrolled headaches, and that uncontrolled migraine can become a progressive
neurologic disease in a subset of primary headache sufferers ( Fig. 49.2 ) .
Fig. 49.1
Model of convergence hypothesis, which suggests that primary migraine headaches
evolve from a single pathophysiologic mechanism. In this model, the clinical phases
of migraine correlate with presumed underlying pathophysiologic mechanisms.
Fig. 49.2

P á g i n a 35 | 60
Evolution of migraine from attacks to disease.

Mechanisms of Medication Overuse Headache

The mechanism of analgesic rebound or medication overuse headache is unknown,


but data suggest that this phenomenon is more common and perhaps unique to
those individuals with migraine. Lance et al

reported that analgesic overuse did not increase the frequency of headaches in
those without a history of migraine. Based on a study of individuals taking daily
analgesics for arthritis, the authors postulated suppression or down-regulation of
already suppressed nociceptive mechanisms caused by excessive use of
symptomatic medications as a possible explanation for analgesic rebound
headaches. Later, Hering et al reported a reduction of serotonin in the blood of
patients with chronic headaches and that these levels increased significantly when
the offending symptomatic medication was discontinued.

Fields and Heinricher proposed increased nociception resulting in activation of “on


cells” in the ventromedial medulla as a possible mechanism of analgesic rebound.
Mathew reported that stimulation of 5-HT-1 receptors was abortive for acute
episodes of migraine but that activation of 5-HT-2 receptors increased pain
transmission. Srikiatkochorn found an increase of 5-HT-2A receptors on platelets in
patients with chronic migraine and analgesic overuse that decreased once the
offending medication was withdrawn. Current theories suggest that, with medication
overuse, there is a decrease in central serotonin and up-regulation of 5-HT-2A
receptors leading to central hyperalgesia. Recent work by Ossipov et al and Mao et
al has suggested that prolonged used of opioids can produce a state of hyperalgesia.

Thus, the debate continues as to whether escalating headache attacks lead to more
frequent medication use or whether escalating medication use leads to increases in
headache frequency. Suffice it to say that once patients are caught in a web of

P á g i n a 36 | 60
chronic primary headaches and using acute medications frequently, they have
significant treatment needs and will undoubtedly find greater benefit from
discontinuing the offending medication than continuing a pattern of failure.

Clinical Features of Medication Overuse Headache

Medication overuse headache or analgesic-rebound headache is characterized by


a sustained pattern of headaches—medication—headaches—and more medication.
Typically, headaches occur on a daily or near-daily basis and the offending
medication often appears to be the only medication capable of bringing relief, albeit
temporary. The primary headache is low grade, waxing and waning, with pain
varying in intensity, location, and severity. Superimposed on this headache pattern
are periods of more intense headache activity. These headaches generally occur
with characteristics suggestive of migraine. Often even mild physical and mental
perturbations in daily activities trigger severe headaches.

Complicating this clinical scenario is the fact that this population of patients also
exhibit psychologic disruptions such as depression and symptoms such as irritability
and memory difficulties. Commonly, the patient complains of sleep disturbance and
predictable early morning headaches that often necessitate pharmacologic
intervention. A detailed history often reveals the need for dose escalation of the
medication(s) being overused. In addition, patients will frequently use medication in
anticipation of headaches. Patients caught in the web of medication overuse
generally believe that their medication is not as effective as it once was but also
believe it is a lifeline for preventing severe disabling headaches. Further, they
frequently have experienced severe withdrawal headaches when they have been
without medication or medication use has been delayed. Consequently, the stage is
set for a strong belief in their need for symptomatic medications.

Clinical Evaluation of the Headache Patient with Suspected Medication


Overuse

P á g i n a 37 | 60
It is paramount that clinicians have a high index of suspicion when evaluating chronic
or transforming headache disorders associated with frequent use of symptomatic
medications.

Several factors in a patient's history are suggestive of medication overuse headache.


Patients caught in this web often begin treatment efforts early in the morning
because presumably overnight the blood levels of the offending analgesic may have
decreased to the point of causing a mini–withdrawal syndrome, including the
symptom of headache. Thus a history of early morning headache is common.
Further, the history of having stopped the potentially offending analgesics at some
point for several days resulted in a severe “rebound” headache. Patients often
interpret this as evidence that they “need” their medication but, in fact, it may be
evidence that withdrawal of medication caused the headache and that medication
overuse is maintaining the headache condition.

Several investigators have attempted to ascertain the threshold quantity of different


analgesics that can result in chronic medication-induced headache patterns. Others
have suggested that the time period of exposure is also critical. These studies,
although interesting, are retrospective evaluations of patients from tertiary headache
centers. Consequently, therapeutic efforts to manage these patients are frequently
beyond simply discontinuing an offending medication. Given these limitations, the
IHS has proposed a list of substances, including several symptomatic medications,
that by consensus appear to relate to chronic headache disorders.

Recently, Limmroth et al looked at duration of exposure to various therapeutic acute


agents and the development of chronic daily headache. In their study, they suggest
that duration of triptan therapy of 1.7 years using 18 doses per month could result in
medication overuse headache. Using ergots for 2.7 years with an average of 37
doses per month or analgesics 4.8 years using 114 doses per month was also
considered to result in medication overuse headaches. Combination analgesics
were not evaluated in this study. The limitations of this study reside in the different

P á g i n a 38 | 60
study populations in that those patients selected by medical providers for triptan
therapy may have had more severe migraine or have been suffering migraine for a
longer duration than those using analgesics.

Taking a Headache History of a Patient with Medication Overuse

When patients have frequent headaches it is critical to determine the frequency and
quantity of symptomatic medications the patient is using. Determining how many
days a week the patient requires acute treatment is often challenging because
patients often provide answers that are vague or reveal that the amount of
medication being used is difficult to determine because its use varies depending on
therapeutic need. It is critical that providers press for accurate, quantifiable answers
about all symptomatic medications being used by the patient including over-the-
counter medications.

Medication overuse headaches should be suspected when there is a daily or near-


daily pattern of headache and the patient uses any symptomatic medication on an
average of more than 2 days a week. In addition, medication overuse should be
suspected whenever patients report that their usual symptomatic medication is less
effective than it had been in the past. Frequently, patients will convey the fact that
medication controls their headache reasonably well unless there is a delay in
administration. It is vital to determine the use of both prescription and nonprescription
medications because many patients fail to realize that over-the-counter preparations
are, in fact, medications.

The following questions may assist the provider in determining if medication overuse
is a likely component of a chronic headache pattern:

 1. Is the patient using analgesics to treat other types of pain or medical


conditions?
 2. How does the patient determine when to treat?

P á g i n a 39 | 60
 3. Is medication used in anticipation of headache?
 4. Is there fear of developing a severe disabling headache if medications are
not taken?
 5. Are the medications used for headache treatment effective (i.e., do they
get a pain-free response or only partial relief)?
 6. What is the duration of effective relief that a dose of medication provides?
 7. How long does a specific quantity of symptomatic medication typically last?

These questions provide a framework for assessing the role of medication as a


contributing factor for chronic headache. In addition, they allow the patient and the
provider to communicate about the relationship of chronic primary headaches and
symptomatic medications. It is essential that these questions are explored in a
nonjudgmental manner and that the provider is in alliance with the patient to solve
this vexing clinical situation.

Psychologic Evaluation of the Patient with Medication Overuse Headache

The evolution of episodic headaches into daily ones usually occurs over time,
perhaps more than a decade.

During this evolutionary time period, individuals have maintained their ability to
function through self-management and by following the advice of well-meaning
friends, relatives, and medical providers. Today more than ever patients have access
to a myriad of treatment ideas. They find advice on the Internet and from talk shows,
books, and many different health care practitioners. Often the message for headache
sufferers is that their headaches should be something they are able to control on
their own through lifestyle and adequate stress management.

Often, by the time headache sufferers seek medical consultation, they have failed
with multiple self-treatment attempts. They are fearful that headaches will continue
to worsen to the point of ultimately taking away their ability to function. Specifically,

P á g i n a 40 | 60
they may fear the loss of a scholarship, job, or marriage. At this juncture, patients
often feel psychologically and physically vulnerable, worrying that headaches are an
expression of physical and mental inadequacy. A recent study found that, before
symptoms of depression or anxiety appear, there is an increase in somatic pain
complaints. As the impact of headaches reaches severe (60+ on the Headache
Impact Test [HIT-6] or 21+ on the Migraine Disability Assessment [MIDAS]), the
number of somatic complaints increases to a significant degree, from an average of
5.0 at no or mild headache impact to 7.5 at severe headache impact. In fact, in this
study of 93 individuals with disabling headaches, 71% complained of back pain and
54% were bothered by pain in arms, legs, joints, or lower abdomen.

From the patient's perspective, headache is but one of several medical conditions
that is affecting the patient's life.

Another study measured the link between 391 pain patients and their analgesic
medication using the Leeds Dependence Questionnaire. The researchers found that
those with migraine (both episodic and chronic) were more profoundly linked to
analgesics than were those with rheumatic disease.

Clearly, the fear of an attack of migraine intensifies the importance of analgesics.


This finding was confirmed in another study utilizing the Severity of Dependence
Scale among 405 Norwegians with chronic migraine. A third study found that 66.8%
of medication overuse headache patients were considered dependent on acute
treatments of headaches according to the DSM-IV criteria, the majority of whom
overused opioid analgesics. Interestingly, affective symptoms did not appear to
predict dependence. The authors concluded that medication overuse among
headache patients appears to belong to the spectrum of addictive behaviors. For this
reason, behavioral management should augment pharmacologic intervention.
Another group of researchers found a significantly increased familial risk for chronic
headache, drug overuse, and substance abuse, suggesting that a genetic factor may
be involved.

P á g i n a 41 | 60
Psychologic Assessment Tools

Several objective measurements have been devised to help clinicians to assess and
define the headache sufferer with chronic primary headaches. These tools, although
not specifically designed to define the population overusing medication, are valuable
in defining the psychologic and medical needs of this population. Headache impact
tools are simple to use even in a busy clinical setting and should be considered an
invaluable way to document therapeutic efficacy of management efforts in this
population of patients:

1. HIT-6 or MIDAS to assess the impact of the headaches on the individual's life.
These tests can also be used to follow the progress of patients over time.

2.Visual analog scale (VAS) of pain severity to measure pain levels before and after
interventions. It is presented graphically with a 10 cm line and end point adjective
descriptors (“the worst imaginable pain” on one end and “no pain” on the other). The
patient is asked to place a mark along the line to indicate the current pain level. A
difference of 13 mm between consecutive ratings of pain is the minimum change in
a pain rating that is clinically significant.
3. Symptom index to record somatic symptoms associated with headaches. As
mentioned, chronic daily headache is often one of several pain complaints.
4. Zung Depression Inventory to measure the level of depression and suicide
potential of the patient, which is a measure of the psychologic effect that headaches
are having on the individual.
5. State Trait Anxiety Scale to indicate the level of anxiety both at the present time
and throughout the person's life. High anxiety generally implies that the individual is
using medication to anticipate headaches and lessen the anxiety over not being able
to perform in a certain setting because of headaches.
6. Minnesota Multiphasic Personality Inventory-2 (MMPI-2) to appraise an
individual's behavioral adaptation to the current life situation. It consists of 567
true/false statements, which usually takes a patient 11/2 to 2 hours to complete. It is

P á g i n a 42 | 60
an objective, valid, and reliable instrument that uncovers significant psychopathology
that may complicate management and serve as a basis for referral.

Psychologic testing of patients with chronic headache reflects a greater incidence of


behavioral abnormalities. The MMPI-2 profile may be a 3-1 or 1-3, often called
“Conversion V,” that may also be interpreted as a call for help. After treatment, when
headaches return to episodic, the MMPI-2 usually normalizes.

Using the MMPI-2, researchers compared the personality profiles of patients with
medication overuse headaches and episodic headaches. They found that both
groups exhibited very similar patterns. Scale 1 (Hypochondriasis) and Health
Concerns were the only significantly differing scales. There were no significant
differences in the scores of the scales measuring dependence-related behavior. The
authors concluded that “pseudo-addiction” may better explain their findings, that is,
headache patients use medications to relieve pain that enables them to function and
maintain a normal lifestyle.

In addition, a history of substance abuse, especially alcoholism, or physical and/or


mental abuse appears more frequently in the chronic headache population,
particularly among those who are refractory to treatment.

Management of Medication Overuse Headache

Perhaps the most critical aspect of managing a patient who is suffering from
medication overuse headache is for the clinician to avoid being overly judgmental.
In many instances, medication overuse begins subtly and symptomatic medications
are prescribed to the patient without knowledge of the risks. At times, patients may
present for evaluation unsuspecting that medications are actually maintaining their
headache pattern. Others may be aware of their reliance on medication but see no
alternative. They fear discontinuing the medication instead of understanding the
potential benefits of freeing themselves from medication dependency. Still other

P á g i n a 43 | 60
patients may view their reliance on medication as addiction and feel angry and guilty.
Rarely, patients approach the clinician with the intent of using the complaint of
headache to surreptitiously acquire specific medications. Thus managing
medication-maintained headache requires time, clinical skills, and clear
communication between the medical provider and the patient. It is important to
approach the patient with medication overuse headache confidently and with
compassion.

Education

Education is the cornerstone of effective management for patients caught in the trap
of medication overuse headache. From patients' perspective, it is often difficult to
understand that discontinuing the only medication that provides relief, albeit
temporary, will be beneficial. Clinicians are often met with considerable skepticism
and fear when they recommend to their patients that the medication must be
stopped. Likewise, clinicians can offer no guarantee that discontinuing medication
will improve the underlying headache pattern. However, they can convey that there
is good evidence suggesting that most patients do, in fact, improve after stopping
overused abortive migraine medications and that not stopping the medication will
likely perpetuate and worsen the cycle of daily headaches.

The key component of education includes a clear explanation of medication overuse


headache and the spiral of ever-escalating headache that occurs with this medical
condition. It is also valuable to explain that uncontrolled migraine may evolve into a
progressive neurologic disease that can impair the patient's ability to perform in all
aspects of life.

Designing a Treatment Plan

Historically, analgesic withdrawal was often performed in the hospital setting. This is
still a reasonable and preferred treatment approach for the more complicated

P á g i n a 44 | 60
spectrum of this patient population. However, in an era of managed care, most often
patients will be managed in an outpatient setting. If patients agree to detoxification,
it is critical to be frank and honest about the benefit of discontinuing an overused
medication whether detoxification is done on an inpatient or outpatient basis. This
education includes the fact that improvement might not be realized for 2 to 3 months
(or not at all) and that in all likelihood there will be a period of increased headache,
a fact that many patients already know. Regardless, it is critical that clinicians
establish a clear rationale for medication withdrawal and provide a plan for its
implementation.

The Initial Visit

During the initial visit, many clinicians choose to provide education and do not
discontinue the offending medication at that time. Instead the patient is instructed to
change the use of the offending medication from symptom-based to time-based
administration. This has the advantage of allaying a patient's fear and permits the
patient to be open about the quantities of medication being consumed. During that
same visit the patient is advised to withdraw from dietary caffeine and other potential
dietary factors that may exacerbate the underlying headache pattern, such as
tyramine and nitrates. The patient is given a date for discontinuing the medication
that is generally not more than 2 weeks away from the first visit. This provides an
opportunity for the patient to arrange a short leave of absence from work or family
commitments when the withdrawal is commenced. A prophylactic medication can be
provided, although it is unlikely to provide its full pharmacologic benefit until the acute
medication withdrawal has been completed. Finally, the patient is provided a
headache diary in which headaches and all medication usage are recorded. Many
clinicians insist that the patient sign a medication contract with the “rules” clearly
defined. Finally, whenever possible, behavioral therapy with a psychologist skilled in
pain and headache management should be strongly recommended.

P á g i n a 45 | 60
During the initial visit, a strategy for medication withdrawal should be improvised.
Several factors should be considered in determining which approach is most
appropriate for a specific patient. If patients are using significant quantities of opioid
or butalbital combination products, the risk of withdrawal seizure should be
assessed. Phenobarbital with its longer half-life can be substituted for butalbital as
a convenient and effective withdrawal strategy. Generally, patients are started on 90
mg and the dose is adjusted up or down based on the presence of agitation or
sedation. Each week the phenobarbital dose can be reduced by 30 mg. A similar
strategy can be employed with opioids, as a short-acting medication is converted to
a long-acting formulation and then slowly withdrawn over several weeks. When
these strategies are employed, it is critical to communicate to the patient that this
medication is not being used as an acute treatment for headache and that the patient
is provided with an appropriate abortive for acute intervention. In addition, a clonidine
patch can be prescribed to diminish the intensity of some of the withdrawal
symptoms. Typically the 0.1 mg patch is used. Dose is patient dependent, but a
typical regimen is to apply two patches for 1 week followed by one patch for 1 week,
then discontinued.

In general, the authors recommend that withdrawal of overused symptomatic


medications be done rapidly rather than using a slow taper. It is valuable to include
the patient in these decisions and provide a realistic structure wherein both provider
and patient have clear input into the decision-making process. Abrupt withdrawal
may result in an intense rebound headache of shorter duration, whereas tapering
may buffer withdrawal headache but may prolong the symptomatic time period. If
withdrawal is done too slowly, undoubtedly migraine triggering events will ensue and
a severe breakthrough headache will occur. This may result in a desperate patient
using more medication than the withdrawal schedule permits. Although a temporary
worsening of headache often occurs with rapid withdrawal, many patients are able
to discontinue medications and have improvement in the headache pattern without
an escalation in headaches. It is difficult to predict which patient will have a difficult

P á g i n a 46 | 60
time. Regardless of the method employed, patients need to be assured that they will
not be abandoned and that several bridge therapies exist that can attenuate,
although not necessarily prevent, all headaches.

Bridge or Transition Therapies

The concept of bridge therapy is to provide a short-term treatment that will attenuate
the rebound headache and other symptoms of medication withdrawal through the
time period when the nervous system is most vulnerable. Although commonly
employed by headache specialists, these therapies have not been rigorously
evaluated in large, placebo-controlled, randomized studies. The first of these was
described by Tfelt-Hansen

in 1981. Patients were hospitalized and treated with sedatives for an average of 9
days and three fourths were reported improved. In 1986 Raskin

reported on the use of repetitive doses of intravenous dihydroergotamine (DHE) in


hospitalized patients. Patients received nine doses of DHE 0.5 to 1 mg over a 5-day
period in a tapering schedule. This protocol has been occasionally modified by
several other headache specialists but still remains the standard for detoxification of
patients in analgesic rebound. Generally, antidopaminergic medications such as
metoclopramide are given with the DHE as an antiemetic agent. Subcutaneous
sumatriptan has also been used in management of analgesic rebound with 6 mg
given twice daily for 5 days.

More recently, oral triptans have been used as bridge therapies and are especially
attractive in an outpatient setting. Triptans with longer half-lives, such as naratriptan
and frovatriptan, appear particularly suited for this role. Typically, naratriptan 1 mg
(or half of a 2.5 mg tablet) twice daily for 5 to 7 days with 2.5 mg as a rescue dose
for breakthrough headaches, with a total daily dose not to exceed 5 mg, is commonly
used by headache specialists. Frovatriptan 2.5 mg daily with an additional 2.5 mg

P á g i n a 47 | 60
for breakthrough migraine, with a daily dose not exceeding 5 mg, is an alternative.
Many specialists also have recommended a burst of prednisone 60 to 80 mg tapered
over 7 to 14 days as adjunctive therapy or a short tapering course of dexamethasone
(12 mg, 8 mg, 4 mg) for three consecutive mornings

( Table 49.3 ) .

Table 49.3
Bridge (Transition) Therapies for Medication Withdrawal Headache
Dihydroergotamine (DHE): 0.5–1 mg IV, IM, or SC q8hr for 1 day, then q12hr for 2
days, then qd for 2 days. Metoclopramide 10 mg can be given 30 min before DHE
for prevention of nausea. Common adverse events include nausea, vomiting,
muscle cramps. Avoid in patient with coronary disease or significant risk factors,
peripheral vascular disease, gastric ulcer, sepsis.
Naratriptan: 1–1.25 mg bid for 5 days with an additional 2.5 mg within any 24-hour
time period provided for breakthrough headache. Adverse events are uncommon
but may include triptan sensations. Avoid in patients with coronary heart disease or
significant coronary risk factors, hypertension, hemiplegic or basilar migraine.
Diphenhydramine: 25–50 mg IM or IV tid.
Various neuroleptics (e.g., chlorpromazine): 6.25–12.5 mg IV q 8–12hr.
Magnesium sulfate: 1–2 g IV qd for 3–5 days or 1 g bid for 3–5 days.
Steroids: rapid tapering dose of oral or parenteral steroids such as prednisone 60
mg q am for 3 days then 40 mg q am for 2 days; 30 mg q am for 2 days; 20 mg q
am for 2 days; 10 mg q am for 2 days; 5 mg q am for 2 days; then discontinue.
Occipital and cervical epidural nerve blocks with local anesthetics (such as 0.25%
bupivacaine). Some physicians add long-acting steroids to the bupivacaine.
bid, twice a day; IM, intramuscularly; IV, intravenously; qd, every day; SC,
subcutaneously; tid, three times a day.

Psychologic Support

P á g i n a 48 | 60
In today's health care environment it is often difficult to convince third-party payers
or patients that effective management of chronic medical conditions requires more
than a prescription and 10 minutes of time. However, successfully managing patients
with chronic debilitating headaches and associated medication overuse is one
clinical situation in which psychologic support is critical. There are several levels of
support to consider, including individual psychotherapy, biofeedback, group therapy,
and patient support organizations. Integrating psychologic therapy into a medical
treatment plan early on improves treatment response. A group of researchers

studied the effects of short-term psychotherapy on the therapeutic response of 26


patients with medication overuse headaches. At 12 months into the study, the group
with psychotherapy had a significantly greater decrease in headache frequency and
medication intake. The relapse rate was also significantly lower in the group with
psychotherapy (15.3%) compared to the group without psychotherapy (23%).

The biopsychosocial treatment model integrates medical, physical, psychological,


and spiritual therapy into the treatment plan ( Fig. 49.3 ) . In other words, medication
overuse headache is more than an acute episode of headache that has become
chronic. During this transformational process, it becomes a health problem that
affects the patient's entire life and, likewise, factors other than analgesics may be
affecting the patient's chronic headache, such as biologic, behavioral, and social
factors. Physical problems, such as the diagnosis of a medical disease other than
headaches, may short-circuit the system that is expressed by chronic headaches.

Fig. 49.3
Biopsychosocial model of chronic pain.
(Adapted from Keefe FJ, Bonk V: Psychosocial assessment of pain in patients
having rheumatic diseases, Rheum Dis Clin North Am, 25:81, 1999.)

Trauma, whether psychologic or physical, such as an automobile accident or a


burglary of one's home, can be fodder for chronic headaches. Social factors, such

P á g i n a 49 | 60
as divorce, separation, loss of job, or relocation, are high-impact events that affect
the chronic headache condition, as well as responsiveness to treatment.

These individuals desire the opportunity to discuss these issues in a supportive


environment, either with a therapist or within a support group. Once they realize they
are not alone, that others may be attempting to cope with as many problems as they
are, they are encouraged to follow the treatment plan and venture into the realm of
being a doer rather than a victim. For chronic problems, there is no linear relationship
between cause and effect. By recognizing that the chronic headache has progressed
over time, even years, patients see therapy as a process of healing the nervous
system by several avenues, not just medication. This realization is at times essential
for patients to respond to a treatment strategy.

What if Medication Withdrawal Does Not Result in Patient Improvement?

As previously discussed, withdrawal from medication does not always result in an


improvement in the underlying daily headache pattern. If a patient persists in a
debilitating chronic headache pattern, decisions about chronic maintenance with
symptomatic medications should be discussed. Few data are available, but in a
study by Saper et al,

the clinical outcome of a population of patients with chronic headache using


maintenance opioids found that only 25% responded. The obvious difficulty is
predicting which patients will respond to a stable dose of opioids without escalation
and concomitant reduction in efficacy over time. If analgesic maintenance is
recommended, it is critical that patients be followed regularly and that providers
document objective improvement in functional status.

Far more difficult is the patient frequently using non-opioid abortive medications such
as triptans and presumably controlling disabling headaches but requiring medication
more than three times a week. In this scenario, clinicians are often triangulated

P á g i n a 50 | 60
between the needs of their patient and the restrictions of the payer of the
pharmaceutical benefits. Managed care concerns often revert to tactics that imply
clinicians are outside of normative prescription behavior standards, although the
reality is that this patient population has never been studied by the stringent
regulatory standards used to establish accepted evidence. Ironically, patients in this
clinical scenario may have daily headaches but report that if they use a triptan early
in the headache process, they can abort the impending headache and maintain
normal function. For this reason, patients do not want to alter this management
strategy. In truth, we do not know the long-term consequences of using abortive
medications, such as triptans, on a chronic basis. But once the medications have
been appropriately withdrawn without benefit and there has been documented
deterioration in the patient's functional status, the question then becomes, Should
symptomatic medications be used on a chronic basis? Without scientific proof to
guide decisions, one can decide this based only on individual assessment with risks
and benefits fully discussed with the patient. Hopefully, over time, as more migraine
sufferers develop the need for frequent abortive medication, pharmaceutical and
regulatory agencies will see the need to evaluate this question more completely.

Long-Term Care Needs

Patients in medication overuse headache patterns almost always require long-term,


ongoing headache management that will span decades of their lives. Through the
lifetime of episodic migraine there is a significant chance that patients will, at some
point, develop chronic headache. It is important for providers and patients to realize
that, although it is convenient to blame medication overuse, there is a significant
chance of developing chronic headache even after medication withdrawal has been
successful.

The evolution from episodic to chronic primary headache is clearly about more than
the headaches patients experience. Often, disruptions of sleep or mood are the first
signal that a migraine patient is transitioning to a chronic daily headache pattern.

P á g i n a 51 | 60
Physiologic and neurologic function between headaches becomes abnormal in that
symptoms such as irritability, fatigue, lethargy, and a sense of feeling “blue” or
hypervigilant occur. These characteristics may become the basis for diagnosis of
several disorders considered comorbid with migraine. Ironically, medication overuse
can be a catalyst that signals the transformation of episodic migraine into a chronic
headache pattern. Therefore it is essential that patients understand the risks of
migraine transformation, which may become a progressive neurobiologic disorder
that leads to a chronic pain syndrome. Because overly zealous pharmacologic
interventions can be a catalyst for this process, it is critical to set limits on the use of
symptomatic medications early in the management of headache patients.

Maintaining medical care that optimizes treatment response can also potentially
circumvent daily headache patterns associated with medication overuse. This often
appears as a paradox because treatment failure or partial treatment responses often
encourages use of additional medication. A treatment diary is invaluable in
assessing response to treatment and medication use. The hallmark of quality
headache care is to provide these tools for episodic headaches, thereby preventing
the development of chronic headaches and the subsequent need to rescue patients
from them.

Conclusion

Medication overuse headache can be a challenging clinical syndrome to manage. It


is far easier to prevent than to treat. Clinicians should be mindful of medication
overuse headache in all headache patients they manage. Central to preventing this
medical condition is to provide clear guidelines on frequencies and quantities of
medication used as abortive. Further, clear goals defining treatment success should
be provided to all patients when prescribed migraine therapies. Patients should be
advised to seek reevaluation whenever the goals of treatment are not being met,
which includes reviewing the effectiveness of acute therapy, as well as the institution
of preventive measures.

P á g i n a 52 | 60
Once patients are having chronic headaches associated with medication overuse it
is paramount to discontinue the potentially offending medication for at least 2
months. Providing effective education, psychologic support, preventive medications,
and a bridge therapy for acute care are invaluable components of successful
management of this condition. With a cogent approach to medication overuse
headache, most patients can be successfully managed and clinicians often find the
condition of analgesic rebound headache rewarding to manage.

References

Referencias

1. 1. Headache Classification Committee of the International Headache Society


: The international classification of headache disorders. Cephalalgia 2004; 24:
pp. 8
Ver en el Artículo
2. 2. Olesen J., Bousser M.G., Diener H.C., et al: New appendix criteria open
for a broader concept of chronic migraine. Cephalalgia 2006; 26: pp. 742
Ver en el Artículo | Cross Ref
3. 3. Zeeberg P., Olesen J., and Jensen R.: Medication overuse headache and
chronic migraine in a specialized headache centre: field-testing proposed new
appendix criteria. Cephalalgia 2008; 29: pp. 214
Ver en el Artículo | Cross Ref
4. 4. Diener H.C., Dodick D.W., Goadsby P.J., et al: Utility of topiramate for the
treatment of patients with chronic migraine in the presence or absence of
acute medication overuse. Cephalalgia 2009; 29: pp. 1021
Ver en el Artículo | Cross Ref
5. 5. Dreisbach R.H.: Experimental caffeine withdrawal headache. J Pharmacol
Exp Ther 1940; 69: pp. 283
Ver en el Artículo

P á g i n a 53 | 60
6. 6. Wolfson W.Q., and Graham J.R.: Development of tolerance to ergot
alkaloids in a patient with unusually severe migraine. N Engl J Med 1949; 241:
pp. 296
Ver en el Artículo | Cross Ref
7. 7. Peters G.A., and Horton B.T.: Headache: with special reference to the
excessive use of ergotamine preparations and withdrawal effects. Mayo Clin
Proc 1951; 26: pp. 153
Ver en el Artículo
8. 8. Kudrow L.: Paradoxical effects of frequent analgesic use. Adv Neurol 1982;
33: pp. 335
Ver en el Artículo
9. 9. Isler H.: Migraine treatment as a cause of chronic migraine. In Rose F.C.
(eds): Advances in migraine research and therapy. New York: Raven Press,
1982. pp. 159
Ver en el Artículo
10. 10. Mathew N.T., Stubits E., and Nigam M.P.: Transformation of episodic
migraine into daily headache: analysis of factors. Headache 1982; 22: pp. 66
Ver en el Artículo | Cross Ref
11. 11. Mathew N.T., Reuveni U., and Perez F.: Transformed or evolutive
migraine. Headache 1987; 27: pp. 102
Ver en el Artículo | Cross Ref
12. 12. Rapoport A.M., Weeks R.E., Sheftell F.D., et al: Analgesic rebound
headache: theoretical and practical implications. Cephalalgia 1985; 5: pp. 448
Ver en el Artículo
13. 13. Gobel H., Stolze H., Heinze A., et al: Easy therapeutic management of
sumatriptan-induced daily headache. Neurology 1996; 47: pp. 297
Ver en el Artículo | Cross Ref
14. 14. Newman L.C., Lipton R.B., Solomon S., et al: Daily headache in a
population sample: results from the American Migraine Study. Headache

P á g i n a 54 | 60
1994; 34: pp. 295
Ver en el Artículo
15. 15. Ravishankar K.: Headache patterns in India—a headache clinic analysis
of 1000 patients [abstract]. Cephalalgia 1997; 17: pp. 316
Ver en el Artículo
16. 16. Mathew N.T., Kurman R., and Perez F.: Drug induced refractory
headache: clinical features and management. Headache 1990; 30: pp. 270
Ver en el Artículo
17. 17. Pini L.A., Cicero A.F., and Sandrini M.: Long-term follow up of patients
treated for chronic headache with analgesic oveuse. Cephalalgia 2001; 21:
pp. 878
Ver en el Artículo | Cross Ref
18. 18. Dodick D.W.: Debate: analgesic overuse is a cause, not consequence, of
chronic daily headache. Headache 2002; 42: pp. 543
Ver en el Artículo | Cross Ref
19. 19. Welch K.M., Nagesh V., Aurora S.K., et al: Periaqueductal gray matter
dysfunction in migraine: cause or the burden of illness? Headache 2001; 41:
pp. 629
Ver en el Artículo | Cross Ref
20. 20. Kruit M.C., van Buchem M.A., Hofman P.A., et al: Migraine as a risk factor
for subclinical bra in lesions. JAMA 2004; 291: pp. 427
Ver en el Artículo | Cross Ref
21. 21. Lipton R.B., and Pan J.: Is migraine a progressive brain disease? JAMA
2004; 291: pp. 493
Ver en el Artículo | Cross Ref
22. 22. Lipton R.B., Stewart W., Cady R.K., et al: Lessons learned from the
Spectrum study. Neurology 2002; 58: pp. S57
Ver en el Artículo | Cross Ref

P á g i n a 55 | 60
23. 23. Raskin N.H., and Appenzellar O.: Headache. Philadephia: Saunders,
1980.
Ver en el Artículo
24. 24. Mathew N.T.: Migraine transformation and chronic daily headache. In
Cady R.K., and Fox A.W. (eds): Treating the headache patient, New York. ,
Marcel Dekker, 1994. pp. 75
Ver en el Artículo
25. 25. Lipton R.B., Diamond S., Reed M.L., et al: Migraine diagnosis and
treatment: results of the American Migraine Study II. Headache 2001; 41: pp.
538
Ver en el Artículo
26. 26. Cady R., Schreiber C., Farmer K., et al: Primary headaches: a
convergence hypothesis. Headache 2002; 42: pp. 204
Ver en el Artículo | Cross Ref
27. 27. Cady R.K., Schreiber C.P., and Farmer K.U.: Understanding the
headache patient: the evolution from episodic to chronic migraine. A
proposed classification of patients with headache. Headache 2004; 44: pp.
426
Ver en el Artículo | Cross Ref
28. 28. Lance J., Parkes C., and Wilkinson M.: Does analgesic abuse cause
headaches de novo? Headache 1988; 28: pp. 61
Ver en el Artículo | Cross Ref
29. 29. Hering R., Catarci T., Glover V., et al: 5-HT in migraine patients with
analgesic-induced headache. London: Ninth Migraine Trust International
Symposium, 1992.
Ver en el Artículo
30. 30. Fields H.L., and Heinricher M.M.: Brainstem modulation of nociceptor-
driven withdrawal reflexes. Ann N Y Acad Sci 1989; 563: pp. 34
Ver en el Artículo | Cross Ref

P á g i n a 56 | 60
31. 31. Mathew N.T.: Serotonin 1D (5-HT1D) agonists and other agents in acute
migraine. Neurol Clin 1997; 15: pp. 61
Ver en el Artículo
32. 32. Srikiatkhachorn A., Puangniyom S., and Govitrapong P.: Plasticity of 5-
HT serotonin receptor in patients with analgesic-induced transformed
migraine. Headache 1998; 38: pp. 534
Ver en el Artículo
33. 33. Ossipov M.H., Lai J., Vanderah T.W., et al: Induction of pain facilitation
by sustained opioid exposure: relationship to opioid antinociceptive tolerance.
In (eds): American Headache Society Conference.
Ver en el Artículo
34. 34. Mao J., Price D.D., and Mayer D.J.: Mechanisms of hyperalgesia and
morphine tolerance. A current view of their possible interactions. Pain 1989;
62: pp. 259
Ver en el Artículo | Cross Ref
35. 35. Limmroth V., Katsarava Z., Fritsche G., et al: Features of medication
overuse headache following overuse of different acute headache drugs.
Neurology 2002; 59: pp. 1011
Ver en el Artículo | Cross Ref
36. 36. Spierings E.L., Ranke A.H., Schroevers M., et al: Chronic daily headache:
a time perspective. Headache 2000; 40: pp. 306
Ver en el Artículo | Cross Ref
37. 37. Cady R.K., Farmer K.U., and Schreiber C.P.: Evaluation of disease
burden in subjects with migraine. Rancho, Mirage, CA: National Headache
Foundation. 1st Annual Headache Research Summit, 2004.
Ver en el Artículo
38. 38. Ferrari A., Leone S., Tacchi R., et al: The link between pain patient and
analgesic medication is greater in migraine than in rheumatic disease
patients. Cephalalgia 2009; 29: pp. 31
Ver en el Artículo | Cross Ref

P á g i n a 57 | 60
39. 39. Grande R.B., Aaseth K., Saltyte Benth J., et al: The Severity of
Dependence Scale detects people with medication overuse: the Akershus
study of chronic headache. J Neurol Neurosurg Psychiatry 2009; 80: pp. 784
Ver en el Artículo | Cross Ref
40. 40. Radat F., Creac'h C., Guegan-Massardier E., et al: Behavioral
dependence in patients with medication overuse headache: a cross-sectional
study in consulting patients using the DSM-IV criteria. Headache 2008; 48:
pp. 1026
Ver en el Artículo | Cross Ref
41. 41. Cevoli S., Sancisi E., Grimaldi D., et al: Family history for chronic
headache and drug overuse as a risk factor for headache chronification.
Headache 2009; 49: pp. 412
Ver en el Artículo | Cross Ref
42. 42. Kosinski M., Bayliss M.S., Bjorner J.B., et al: A six-item short-form survey
for measuring headache impact: the HIT-6. Qual Life Res 2003; 12: pp. 963
Ver en el Artículo | Cross Ref
43. 43. Stewart W.F., Lipton R.B., Kolodner K., et al: Reliability of the migraine
disability assessment scores in a population-based sample of headache
sufferers. Cephalalgia 1999; 19: pp. 107
Ver en el Artículo | Cross Ref
44. 44. Gallagher E.J., Liebman M., and Bijur P.E.: Prospective validation of
clinically important changes in pain severity measured on a visual analog
scale. Ann Emerg Med 2001; 38: pp. 633
Ver en el Artículo | Cross Ref
45. 45. Zung W.K.: A self-rating depression scale. Arch Gen Psychiatry 1965; 12:
pp. 63
Ver en el Artículo | Cross Ref
46. 46. Zung W.K.: From art to science: the diagnosis and treatment of
depression. Arch Gen Psychiatry 1973; 29: pp. 328
Ver en el Artículo | Cross Ref

P á g i n a 58 | 60
47. 47. Spielberger C.D., Gorsuch R.L., Lushene R., et al: Manual for the State-
Trait Anxiety Inventory (form Y). Palo Alto, CA: Consulting Psychologists
Press, 1983.
Ver en el Artículo
48. 48. Butch J.N., Dahlstrom W.G., Graham J.R., et al: MMPI-2: manual for
administration and scoring. Minneapolis: University of Minnesota Press,
1989.
Ver en el Artículo
49. 49. Sances G., Galli F., Anastasi S., et al: Medication-overuse headache and
personality: a controlled study by means of the MMPI-2. Headache 2010; 50:
pp. 198
Ver en el Artículo | Cross Ref
50. 50. Tfelt-Hansen P., and Æbelholt Krabbe A.: Ergotamine abuse. Do patients
benefit from withdrawal? Cephalalgia 1981; 1: pp. 29
Ver en el Artículo | Cross Ref
51. 51. Raskin N.: Repetitive intravenous dihydroergotamine as therapy for
intractable migraine. Neurology 1986; 36: pp. 995
Ver en el Artículo | Cross Ref
52. 52. Rozen T.D.: Migraine headache: immunosuppressant therapy. Curr Treat
Options Neurol 2002; 4: pp. 395-401
Ver en el Artículo | Cross Ref
53. 53. Altieri M., Di Giambattista R., Di Clemente L., et al: Combined
pharmacological and short-term psychodynamic psychotherapy for probable
medication overuse headache: a pilot study. Cephalalgia 2009; 29: pp. 293
Ver en el Artículo | Cross Ref
54. 54. Saper J.R., Hammel R.L., Lake A.E., et al: Long-term scheduled opioid
treatment for refractory headache: second interim outcome report. Headache
1998; 38: pp. 401
Ver en el Artículo

P á g i n a 59 | 60
P á g i n a 60 | 60

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