Chronic Daily Headache Triggers: It’s Not What You Take but How Often That Counts

In his article on chronic daily headache (CONSULTANT,  July 2005, page 871), Dr Gary Ruoff mentions benzodiazepines as one of the classes of agents that can be responsible for these headaches. I have seldom seen this association in the literature. However, I take 0.5 mg of alprazolam nightly and have for years—and I have chronic daily headaches. Could my alprazolam regimen be considered “excessive use”? I understand that the frequency of using an offending medication is more important than the dose. — Hector A. Prestera, MD   Dr Prestera’s question is an important one. First, he is absolutely correct that the medical literature contains much more information about the role of barbiturates and opiates in chronic daily headache than it does on benzodiazepines. Other analgesics, benzodiazepines (such as alprazolam), and over-the-counter medications are only occasionally linked to daily headaches by case studies or anecdotal reports. However, there is a great deal of research—which Dr Prestera alludes to—to show that in a sensitive, susceptible person, frequency of use over an extended period is a more important factor than dose in the development of chronic daily headache or the exacerbation of a headache already present.1-3 Episodic headaches can be transformed into daily headaches when any analgesic (including those that contain butalbital, ergotamine, or a triptan) is taken more than 2 times per week. It is also important to keep in mind that the risk factors or triggers for migraine are cumulative. One trigger alone might not provoke a headache response, whereas a combination would. Regular ingestion of alprazolam might, by itself, trigger or exacerbate a headache. However, the development or exacerbation of headache would be more likely if regular alprazolam use occurred in conjunction with other risk factors, such as the ingestion of certain foods (eg, ripened cheeses, artificial sweeteners, chocolate [and other caffeine sources], nuts, monosodium glutamate, or red wine).4 These foods and others have been demonstrated to be migraine stimuli. Avoiding them may ameliorate or resolve both migraine and chronic daily headache. — Gary E. Ruoff, MD Clinical Professor of Family Medicine Michigan State University Lansing REFERENCES: 1. Mathew NT, Kurman R, Perez F. Drug induced refractory headache—clinical features and management. Headache. 1990;30:634-638. 2. Diener HC, Katasarva Z. Analgesic/abortive overuse and misuse in chronic daily headache. Curr Pain Headache Rep. 2001;5:545-550. 3. Zed PJ, Loewen PS, Robinson G. Medication-induced headache: overview and systematic review of therapeutic approaches. Ann Pharmacother. 1999;33:61-72. 4. National Headache Foundation. Diet and headache. Available at: www.headaches.org/consumer/topicsheets/diet_headache.html. Accessed December 29, 2004.