Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Sede socorro.
Diana Chávez.
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
P á g i n a 2 | 60
1. TITULO.
P á g i n a 3 | 60
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.
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.
P á g i n a 4 | 60
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.
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
P á g i n a 5 | 60
3. JUSTIFICACION:
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.
“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.
P á g i n a 6 | 60
5 OBJETIVOS
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.
P á g i n a 7 | 60
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)
“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)
P á g i n a 8 | 60
7. METODOLOGÍA
P á g i n a 9 | 60
8. RESULTADOS:
8. 1. SALUD PUBLICA
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.
AGENTE:
HUESPED:
P á g i n a 10 | 60
MEDIO AMBIENTE:
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
P á g i n a 11 | 60
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
P á g i n a 12 | 60
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
8. 3 SERVICIOS FARMACEUTICOS
P á g i n a 13 | 60
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,
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.
P á g i n a 14 | 60
Utilizaríamos la técnica de los 5 correctos:
Paciente correcto, hora correcta, medicamento correcto dosis correcta, vía de
administración correcta
P á g i n a 15 | 60
la realización de Auditorías Internas del Sistema de Gestión de Calidad del
Servicio Farmacéutico.
No aplica.
Ya que los PRUM son problemas prevenibles estos se pueden evitar por
medio de:
P á g i n a 16 | 60
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
“IBUPROFENO
Código ATC: M01AE01 Venta libre
P á g i n a 17 | 60
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
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 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.
P á g i n a 18 | 60
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).
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
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.
P á g i n a 20 | 60
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:
10.5. 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.
P á g i n a 22 | 60
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.
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/.
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/.
P á g i n a 23 | 60
12. ANEXOS
https://www.mayoclinic.org/es-es/diseases-conditions/medication-overuse-
headache/symptoms-causes/syc-20377083
Stephen D. Silberstein
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?
P á g i n a 25 | 60
and triptans, the threshold was placed at 10 days per month. These quantities were
determined by expert consensus.
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.
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.
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.
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
P á g i n a 28 | 60
1. Headache greater than 15 days per month that has developed or markedly
worsened during medication overuse
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.
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
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.
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.
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.
P á g i n a 32 | 60
and it cites analgesics, ergotamines, caffeine, and triptans as all being associated
with this phenomenon.
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
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.)
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.
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.
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.
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.
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.
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.
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.
The following questions may assist the provider in determining if medication overuse
is a likely component of a chronic headache pattern:
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?
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.
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.
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.
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.
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.
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.
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.
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
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
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.)
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.
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.
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
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
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