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ENGLISH VERSION: TREATMENT OF ABUSE HEADACHE IN PATIENTS WITH CHRONIC MIGRAINE AND TENSION HEADACHE
Fysun Yu. O, Fysun S.. Yu.
Ukrainian Medical Stomatological Academi, Poltava
Drug headache ranks third in the structure of headaches, and second only to tension headaches and migraines. According to information from US and European researchers in speciaiized clinics abuse headache is diagnosed in 40% of patients. Nowadays, the problem of this headache is actively interested doctors all over the world. This is particuiaryy an issue becomes in countries where painkillers can be bought without a prescription. In this article, the authors offer a modern treatment regimen abuse headache.
Key words: abuse headache, chronic migraine, tension headache, antidepressants and anticonvulsants
Name of the pain originating from the English word «to abuse" - abused, that generally reflects the cause of this type of headache. Previously, the following terms: "rebound headache", "drug-induced headache", "analgesic-dependent headache", "withdrawal headache". Ironically, even drugs used to treat pain and directly headaches at their misuse can trigger headaches [1, 3].
For the first time abuse headache (AH) was reported at the abuse of Phenatcytin drug used to relieve headaches. The next drug in the chain of provocateurs of AH was ergotamine. Ergotamine is very slowly excreted, with frequent use up to 3 times a week can accumulate and cause medical headaches. One of the leading places in the AH occurrence be longs to triptans. The most common cause of headache is chronic abuse of analgesics to relieve headaches of various origins. Virtually all drugs of NSAIDs are characterized by the ability to cause this condition. The analysis of 300 case histories of patients Headache Clinic (Russia) indicates that more often AH is triggered by excessive use of Tcitramon (17%), Sedalhin (13%), Pentalhin (10%), Solpadeyin (7%) a combination of several analgesics (38%) [2, 5].
We can trace the history of typical diseases of our patients for months or years to develop AH. The basis is an episodic headache, migraine or more tension headache that troubles patients and for what they take painkillers. Over time, headache, as well as frequent use of analgesics and become almost daily. A key factor in the development of abuse headache is preventive use of the drug waiting for the next headache attack. AH has many variable and heterogeneous characteristics and significantly troubles patients.
It is necessary to note that at AH the following comorbid disorders occur: depression, dysthymia, anxiety, somatoform disorders, sleep disorders, myofascial pain syndromes, etc. [4, 6].
The aim is a comprehensive comparison of AH flowing of patients with chronic migraine and patients with tension headache during treatment with antidepressants and anticonvulsants.
Materials and methods
In our work, we studied patients with chronic migraine complicated by AH in 41 people (31 women and 10 men, age of the patients ranged from 20 to 51 years) and patients with tension headache with manifestations of AH total of 28 people (20 women and 8 men, age of the patients ranged from 23 to 48 years). Patients's AH was associated with excessive and uncontrolled use of NSAIDs and their combination with codeine and barbiturates. Patients had to be subject to diagnostic criteria of abuse headache:
- Headache, which was present for more than 15 days a month;
- Excessive and uncontrolled use of combined analgesics more than 3 months;
- Headache that occurs or is significantly enhanced by excessive use of analgesics [1].
All patients underwent selection criteria, which allow for outpatient treatment of AH, this includes:
a) a high level of self-discipline and motivation as the main method of treatment of AH is categorical cancellation of drug abuse;
b) the absence of other typical symptoms of side effects of drug abuse (peptic ulcer, Ergotism, dyssomniya);
c) patients's anxiety and depression caused by AH under outpatient care [3, 4].
For medical treatment, patients were divided into four groups.
The first group of 20 people - patients with chronic migraine + AH treated with antidepressant escitalopram "Estsytam" 20 mg daily in combination with an anticonvulsant pregabalin "Neohabin" 75 mg twice daily. Duration of is treatment 12 weeks.
The second group of 21 people - patients with chronic migraine + AH treated with antidepressant escitalopram "Estsytam" 20 mg daily in combination with an anticonvulsant carbamazepine 200 mg twice daily. Duration of treatment 12 weeks.
The third group of 16 people - patients with tension headache + AH treated with antidepressant escitalopram "Estsytam" 20 mg daily in combination with an anticonvulsant pregabalin "Neohabin" 75 mg twice daily. Duration of treatment is 12 weeks.
The fourth group of 12 people - patients with tension headache + AH treated with antidepressant escitalopram "Estsytam" 20 mg daily in combination with an anticon-vulsant carbamazepine 200 mg twice daily. Duration of treatment is 12 weeks.
To evaluate the intensity of pain Visual analogue scale (VAS) was used, which is a mechanical device in the form of a segment length of 10 cm, the cursor moves on the interval. The patient moves the cursor from 0 points (no pain) to 10 points (unbearable pain) and notes the figure that in his opinion is responsible for intensity of pain. 1 and 3 points - the pain of low intensity, 4 and 6 -medium intensity, 7 and 9 - severe pain [7].
Qualitative and quantitative characteristics of pain were assessed using McGill pain questionnaire which is by far the most objective. The descriptors used in the questionnaire and determining the quality characteristics of pain are divided into three classes: sensory scale characterizes pain in accordance with the terms of the mechanical impact of spatial and temporal perception; affective scale reflects the emotional component of pain and its vegetative manifestations; quantitative scale, allows for subjective assessment of pain. Rank index of pain (RIP) was calculated in amount of sequence numbers in all subscales descriptors and index number of selected descriptors (INSD).
Also, patients were evaluated for the degree of depressive disorder using psychometric Montgomery-
Tom 18. N 5-6 2014 p.
Asberg (MADRS) scales, which can detect depressive disorder, from the smallest to the most severe. It is evaluated on a scale from 0 to 60. When the level of the total score is from 0 to 16 - no depression, 16 to 25 - mild depression, 26 to 30 - the average degree of depression of 30 and above - severe depression [7]. The level of reactive and personal anxiety was assessed on a scale of Spielberger - Hanin. Reactive anxiety the patient is considered at the time of the survey. The low level of reactive anxiety on a scale of 0 to 30 points, from 31 to 44 -average, more than 45 - a high level. Personal anxiety indicates the willingness of the patient to anxious reactions characteristic of his personality. 30 points or less -low level of personal anxiety, from 31 to 44 - the average level, 45 and above - high [7].
Results and discussion
The main clinical manifestation in patients of all four groups is AH. Most episodes of AH begin immediately after waking, headache is bilateral, or of compressive arching nature, there are expressed increases with physical or intellectual work. Examination using VAS
shows that in the first group of patients before treatment pain rated as moderate in 5 patients (25.0%), as expressed in 15 patients (75.0%) and averaged 7,72 ± 0,22 points; in the second group of patients pain rated as moderate in 8 patients (38.1%), as expressed in 13 patients (61.9%) and averaged 7,66 ± 0,12 points; in the third group of patients pain rated as moderate in 7 patients (43.7%), as expressed in 9 patients (56.3%) and averaged 7,62 ± 0,11 points; in the fourth group of patients pain rated as moderate in 3 patients (25.0%), as expressed in 9 patients (75.0%) and averaged 7,83 ± 0,31 points.
After treatment in patients of all four groups the decrease of active clinical symptoms such as AH was observed (Table 1).
According to the data presented in Table 1, antide-pressant therapy in combination with an anticonvulsant leads to near extinction of AH. More pronounced it was observed in patients of first and third groups treated with escitalopram in combination with pregabalin.
Table 1
Indicators of pain intensity on a visual analogue scale patients before and after treatment (%)
Patients with chronic migraine + AH Patients with tension headache + AH
The first group, n = 20 The second group, n = 21 The third group, n = 16 The fourth group, n = 12
Indicators (escitalopram 20 mg daily and pregabalin 75 mg twice daily) (escitalopram 20 mg daily and carbamazepine 200 mg twice daily) (escitalopram 20 mg daily and pregabalin 75 mg twice daily) (escitalopram 20 mg daily and carbamazepine 200 mg twice daily)
Before treatment After treatment Before treatment After treatment Before treatment After treatment Before treatment After treatment
Pain intensity on VAS:
- missing 0 67 0 49 0 54 0 43
- light 0 33 0 48 0 46 0 45
- temperate 25 0 38 3 44 0 25 12
- intense 75 0 62 0 56 0 75 0
- unbearable 0 0 0 0 0 0 0 0
Among the many comorbus symptoms, which are an integral part of the clinical picture of AHB, 100% of patients had anxiety and depressive disorders, which we assessed by tests of Spielberger-Hanin and scale MADRS. The evolution of anxiety and depression in patients four groups is listed in the table. 2
According to the data displayed in the Table.2, after antidepressant and anticonvulsant treatment the level of
reactive anxiety in patients of second and fourth groups quite significantly decreased, and in patients of first and third groups reactive anxiety was reduced to a minimum. Depressive disorders in patients of all four groups was significantly reduced with moderate to low and even complete disappearance of depression.
Table 2
The evolution of anxiety and depression in patients at pre- and post-treatment scores (M ± m)
Indicators Patients with chronic migraine + AH Patients with tension headache + AH
The first group, n = 20 (escitalopram 20 mg daily and pregabalin 75 mg twice daily) The second group, n = 21 (escitalopram 20 mg daily and carbamazepine 200 mg twice daily) The third group, n = 16 (escitalopram 20 mg daily and pregabalin 75 mg twice daily) The fourth group, n = 12 (escitalopram 20 mg daily and carbamazepine 200 mg twice daily)
Before treatment After treatment Before treatment After treatment Before treatment After treatment Before treatment After treatment
Test Spielberger-Hanin: - reactive anxiety - personal anxiety 46,31±0,23 44,76±1,72 29,61±1,15* 28,98±1,11 45,28±1,44 44,53±1,81 31,08±0,76 32,09±0,32 45,23±1,65 43,83±1,21 30,13±0,80* 29,12±0,41 46,01±0,89 42,22±1,09 32,52±0,41* 31,15±0,77
MADRS scale 21,01±0,33 9,31±1,75 19,69±1,91 10,73±0,59 20,09±0,68 8,58±0,34* 20,64±0,88 10,90±75
Note: * - statistically significant differences between the indices (p <0,05)
Проблеми екологц та медицини
In evaluating the qualitative and quantitative charac- teristics of pain McGill questionnaire was used (Table. 3).
Table 3
The evolution of pain on McGill questionnaire before and after treatment scores (M ± m)
Indicators Patients with chronic migraine + AH Patients with tension headache + AH
The first group, n = 20 (escitalopram 20 mg daily and pregabalin 75 mg twice daily) The second group, n = 21 (escitalopram 20 mg daily and carbamazepine 200 mg twice daily) The third group, n = 16 (escitalopram 20 mg daily and pregabalin 75 mg twice daily) The fourth group, n = 12 (escitalopram 20 mg daily and carbamazepine 200 mg twice daily)
Before treatment After treatment Before treatment After treatment Before treatment After treatment Before treatment After treatment
The index number of the selected descriptors: - Touch Scale - Affective scale - Evalyuatyvna scale 3,75±0,11 3,41±0,13 2,71±0,06 3,02±0,13* 3,06±0,22* 2,03±0,32 3,98±0,21 3,55i0,54 2.42±0,53 3,01±0,51 3,11±0,23* 2,08±0,01 4,01±0,05 3,67±0,40 2,89±0,03 3,22±0,07* 3,20±0,11 2,45±0,30 3,88±0,66 3,56±0,39 2,97±0,40 3,07i0,37* 3,11i0,24 2,48i0,08
Total INSD 7,16±0,38 6,08±0,28* 6,53±0,21 6,12±0,60 7,68±0,35 6,42±0,09* 7,44±0,59 6,18i0,42*
Total RIP 16,03±0,41 14,19±0,34* 15,48±0,44 14,32±0,40 18,25±0,77 15,29±0,64 17,85i0,53 14,84±0,22*
Note: * - statistically significant differences between the int
According to the data presented in Table. 3, during treatment in all four groups the total number of allocated words decreased. After treatment with carbamazepine and estsytalopramom total INSD and total RIP decreased primarily due to sensory scale. During the treatment with pregabalin and estsytalopram reduce of total RIP and INSD happened both in sensory, and afferent scales, which may indicate the impact on the emotional component of pain.
Conclusions
The use of a combination of antidepressants and anticonvulsants drugs in the treatment of patients with AH resulted in a decrease of pain, level of reactive and personal anxiety, pain intensity and its quality indicators, reduce of depression and improving the quality of life of patients.
The use of a combination of estsytolopram 20 mg and pregabalin 75 mg twice daily in patients with AH and different primary headache indicates a more effective reduction of pain, level of personal and reactive anxiety, pain intensity and its quality characteristics, the disap-
(p <0,05)
pearance of depressive symptoms and improving the quality of life of patients.
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MaTepian HagitiiuoB go pegamn28.01.2015
