Prof. Dr. Hartmut Göbel
September 5th, 2012, is International Headache Day. On this occasion, we remind you of the most important rule for the medication-based treatment of headaches: the "10-20 rule." Taking painkillers too frequently for headaches can itself trigger headaches – a vicious cycle.
This could be prevented, explains Professor Dr. Hartmut Göbel, Director of the neurological-behavioral medicine pain clinic in Kiel, in an interview with Dr. Ulrike Maronde.
How can one distinguish in practice whether a headache patient has chronic migraine, chronic tension headache, or chronic headache due to painkiller overuse?
HG It is crucial to ask specific questions during the pain history: What is the course of the headaches? On how many days a month do they occur? And very importantly: What does the patient do to alleviate their headaches? Some people simply endure their headaches because they don't want to take painkillers every day. However, a patient with medication-overuse headache has crossed a significant threshold: They take acute medication – a triptan, an analgesic, or both – on more than ten days a month. In this case, it can be assumed that the frequent use of these medications has increased the frequency of the headaches.
Until this potential risk factor for chronic pain is clarified, preventative measures cannot be effectively implemented. A medication break provides clarity. This is the first therapeutic step when acute painkillers are taken on more than ten days per month. The goal of this break is to allow the pain-processing system to recover.
How long should such a medication break last?
Migraine and self-medication
HG That depends on which medications were taken. With triptans, a break of five to seven days is usually sufficient. No acute painkillers should be administered for the adjustment headache that occurs during this time. Adjunctive therapy is advisable, for example, an antiemetic for nausea and vomiting or a neuroleptic for restlessness and insomnia. Prednisolone administered over several days can also significantly reduce the pain.
And how long is the break with other painkillers?
HG With other medications, treatment is more complex. In these cases, the switch-off headaches often last three to four weeks. This frequently affects patients taking two or three medications or combination analgesics with psychotropic substances such as caffeine or codeine. Once the switch-off headache has subsided and the affected individuals remain headache-free for five to ten days, the chronic headache has become episodic. Then, if headaches recur, acute medication can be used again.
It is important to start effective and sustainable prophylaxis after the medication break so that the headache frequency remains low and the "rule of ten" is adhered to, taking acute painkillers on a maximum of ten days per month.
Inpatient treatment offers the greatest success for headaches caused by medication overuse. What is the long-term success rate?
inpatient conditions and with on-site follow-up care by local headache specialists, a sustained improvement of approximately 95 percent is still observed after one year. Outpatient treatments lead to lasting improvement in at best 30 percent of those affected.
How can this difference be explained?
this therapy is education, which provides information about headaches and how those affected can prevent them through lifestyle changes. Daily routines, regular breaks, diet, exercise, and relaxation techniques are important elements of this behavioral medicine intervention. Therefore, inpatient treatment is significantly more effective than outpatient treatment that only involves medication changes.
The 10-20 rule in headache treatment
Could early prophylaxis prevent the overuse of painkillers from the outset?
With effective, timely prophylaxis, chronicity and thus the development of overuse headache could be avoided to a much greater extent. One approach is prophylactic medication. However, the crucial components are education about the possible causes of headaches and behavioral therapy measures. It is important to identify unfavorable situations such as stressors in everyday life, within the family, or at work, and to offer those affected appropriate advice on possible solutions to these problems .
Do you think it makes sense to make it more difficult for patients to access over-the-counter painkillers, for example by reducing package sizes?
HG Limiting pack sizes won't solve the problem. Triptans, for example, are limited to two tablets per pack over the counter, while prescription packs contain six. And yet, these are currently the medications with the highest rates of overuse. I believe it's far more important to educate the public about the proper use of painkillers and to communicate the "10-20 rule": Acute medications are acceptable on ten days of the month, and 20 days should be pain-free. This should really be printed on every package. I repeatedly find that very few patients are aware of this limit.
