156 Metastatistics for the Non-Bayesian Regression Runner
outside of the MOH literature it is generally viewed that opioids are under-prescribed
because of (sometimes irrational) fears of promoting addiction, censure by police, and
so on (Lipman, 2004). “The history of opioid use (or nonuse) in neuropathic pain is
instructive. The natural reluctance to prescribe opioids to patients with neuropathic pain
of benign cause was, for many years, reinforced by the received wisdom that opioids
were ineffective in neuropathic pain [such as headache], based on weak evidence. It took
many years before this ‘truth’ was questioned. Reexamination in the later 1980s was
followed by controlled studies that clearly substantiated an important analgesic action
of morphine and fentanyl and, later, other opioids in neuropathic pain” (Scadding,
2004).
- Medication overuse headache has gone by several different names, includinganalgesic
rebound,ergotamine rebound,medication induced headache,transformed migraine,chronic
migraine,daily headache,drug-induced headache,painkiller headache,medication-misuse
headache,analgesic-dependent headache(Obermann and Katsarava, 2007; Silbersteinet al.,
1994, and so on).
- As is widely recognized, severe chronic daily migraine occurred before the use of offend-
ing medications was common or even possible. The most widely cited example comes
from the important neurologist Thomas Willis (1683), who recorded his treatment of
Viscountess Anne (Finche) Conway in the seventeenth century.
- Even current scholars in the field are negative about early developments in the field of
headache. “Prior to the 1980s, the field of headache was rarely influenced by what would
be generally accepted as scholarly, credible research” (Saper, 2005).
- In describing the work as “representative,” however, the view among experts in the field
is considerably more favorable. Ward (2008) describes it as “his favorite article” in a recent
review. Mathew (2008) responds by noting: “The impact of this article on the American
and European headache communities was substantial. Until then, the Europeans had not
appeared to appreciate the clinical significance of medication overuse or the existence of
chronic daily headache...One enduring fact continues to disappoint me. In spite of
the extensive effort made to emphasize the importance of medication overuse in manag-
ing the headache population, many practitioners – including neurologists – continue to
overprescribe symptomatic medications, thereby condemning their patients to treatment
failure.” For a more recent systematic review, see Zedet al.(1999).
- No randomization appears to be involved. The patients were merely “grouped.”
- The measurement of “improvement” is not clear, but it appears to have been asymmetric.
Improvement was measured as a percentage change in a headache index if the patient
improved, and was given a value of zero if the patient did not improve.
- One definition of MOH is:
- Occurs in a patient with a primary headache disorder who uses symptomatic
or immediate relief medications very frequently (daily), often in excessive
quantities.
- Tolerance to symptomatic medications develop and headaches become worse on
continuing the treatment.
- The patient may show symptoms of withdrawal on discontinuing the medication,
with increased headache lasting for a variable period of time, as long as three to four
weeks.
- Headache ultimately improves after stopping the offending medications even though
the primary headache disorder needs continuing prophylactic treatment.
- The only other criticism I have been able to locate are letters to the editors (Gupta, 2004a,
2004b, 2004c).
- Using language evocative of severe testing, Fisher remarked that “Claude Bernard, in
speaking of an hypothesis, said that it is not sufficient to merely gather all the facts that
support it but even more importantly, one must go out of one’s way to find every means
of refuting it.”
