John DiNardo 137studies typically ignore serious selection bias due to non-random attrition and
regression to the mean.- In one of the few published critiques of the theory, it was noted that millions of
users of analgesics, for reasons other than headache, do not develop migraine. In
response, the theory evolved to state that only those individuals “predisposed”
to migraine get MOH. - When a definition of the diagnosis that required improvement in pain after
cessation of the offending medication was proposed it was strongly criticized.
The definition was revised to empty it of potentially refutable content.
Every challenge to the theory that pain medication causes pain has been met by
“accommodating” the evidence. Rather than reject the theory, at every turn the
theory has accommodated the new evidence by making it more difficult to test.
Furthermore, there is a complete absence of “severe testing.”
3.6.1 What is medication overuse headache? Nosology and
dubious ontology
The essence of “medication overuse headache” as a term for a certain class of
chronic headache pain^42 is the idea that the patientcauseshis/her pain by taking
pain (or other headache) medication in excess of arbitrary norms (set by researchers
in the area) of appropriate use. The “offending” medication, as it is often referred
to, can be any of a very diverse set with very different effects and mechanisms
of action. These include ergotamine, caffeine, morphine, sumatriptan, and many
other drugs. Opioids (morphine and related medications) are generally thought to
be more of a problem than the other medications (Saper and Lake, 2006a).^42 Ober-
mann and Katsarava (2007) cite a global prevalence rate of 1% and describe it as the
“third most frequent headache type after tension-type headaches and migraine.”^43
There are two ways to account for this phenomenon. The obvious one is that
these people take chronic daily analgesics because they have chronic daily
headaches. This is the explanation embraced by our patients and, until recently,
by most physicians [who are not headache specialists]. (Edmeads, 1990)^44I believe this case study is illuminating because it suggests that the problem isnot
one of failing to view probability as epistemic, but is because researchers in the
area have systematicallynotconfronted their long-held views with severe testing.
3.6.2 Some salient background
3.6.2.1 Early history
In a recent review of the subject, Obermann and Katsarava (2007) date the first
clear identification of MOH to a 1951 study, without a control group or ran-
domization, which described 52 patients who took daily amounts of ergotamine
and improved after “the ergotamine was withdrawn. A recommendation of the
first withdrawal program followed and was introduced in 1963.” The view that