European Journal of Clinical Pharmacology

, Volume 71, Issue 7, pp 851–860 | Cite as

Prescription pain medications and chronic headache in Denmark: implications for preventing medication overuse

  • Maria Lurenda Westergaard
  • Ebba Holme Hansen
  • Charlotte Glümer
  • Rigmor Højland Jensen
Pharmacoepidemiology and Prescription



The aim of the present paper is to study which prescription pain medications are most commonly dispensed to people with chronic headache (CH), particularly those with medication-overuse headache (MOH).


This cross-sectional study analysed prescription pain medications dispensed within 1 year to 68,518 respondents of a national health survey. Participants with headache ≥15 days per month for 3 months were classified as having CH. Those with CH and over-the-counter analgesic use ≥15 days per month or purchase of ≥20 or ≥30 defined daily doses (DDDs) of prescription pain medication per month (depending on the drug) were classified as having MOH. Associations between CH and other chronic pain conditions were analysed by logistic regression.


Among those with CH (adjusted prevalence 3.3 %, CI 3.2–3.5 %), pain medications most commonly dispensed were paracetamol, tramadol, ibuprofen and codeine. CH was associated with osteoarthritis, back pain, and rheumatoid arthritis. Among those with MOH, 32.4 % were dispensed an opioid at least once within 1 year. Only 5.1 % of people with CH were dispensed triptans.


High prevalence of opioid use among people with CH may be due to inappropriate headache treatment or development of MOH among those treated for other pain conditions. While there were cases of triptan overuse, triptans remain underutilized among those with CH, suggesting that migraine may be under-recognized and inappropriately treated, leading to overuse of other medications. Education of physicians on appropriate headache management is essential for MOH prevention. There is a need to increase universal awareness about MOH as an adverse effect of long-term analgesic use.


Pharmacoepidemiology Analgesics Triptans Opioids Chronic headache Secondary headache disorders Medication-overuse headache 



The authors thank the Research Centre for Prevention and Health, especially data manager Carsten Agger, and the team responsible for the Danish National Health Survey; Inger Helt Poulsen for facilitating use of data from Region Zealand; and Statistics Denmark for management of the raw data. Furthermore, we thank everyone who responded to the surveys.


This study did not receive corporate sponsorship. The Region Zealand Health Profile 2010 and The Capital Region Health Profile 2010 were funded by The Region Zealand and The Capital Region of Denmark. MW received research grants from IMK Almene Fond and the patient organization Migræne og Hovedpineforeningen in connection with this study.

Conflict of interest statement

MW received travel grants from Pfizer, Lundbeck Fund, and Allergan to attend international conferences. RJ has given lectures for Pfizer, Berlin-Chemie, Allergan, Merck, and Autonomic Technologies; is a member of the advisory boards of Autonomic Technologies, Medotech, and Neurocore; and is co-director of Lifting The Burden and EHMTIC. EHH and CG declare that they have no conflict of interest.

Author’s contributions

MLW preformed the drafting and revising the manuscript, study concept, statistical analysis, and interpretation of data; EHH for revising the manuscript, study concept, interpretation of data, and study supervision; CG for revising the manuscript, study design, acquisition and interpretation of data, obtaining funding, study supervision, and coordination; and RHJ for revising the manuscript, study concept and design, interpretation of data, obtaining funding, study supervision, and coordination.


  1. 1.
    Paulose-Ram R, Hirsch R, Dillon C, Losonczy K, Cooper M, Ostchega Y (2003) Prescription and non-prescription analgesic use among the US adult population: results from the third National Health and Nutrition Examination Survey (NHANES III). Pharmacoepidemiol Drug Saf 12:315–326. doi: 10.1002/pds.755 PubMedCrossRefGoogle Scholar
  2. 2.
    Saper JR, Sa Silva AN (2013) Medication overuse headache: history, features, prevention and management strategies. CNS Drugs 27:867–877. doi: 10.1007/s40263-013-0081-y PubMedCrossRefGoogle Scholar
  3. 3.
    Munksgaard SB, Jensen RH (2014) Medication overuse headache. Headache 54:1251–1257. doi: 10.1111/head.12408 PubMedCrossRefGoogle Scholar
  4. 4.
    Kristoffersen ES, Lundqvist C (2014) Medication-overuse headache: a review. J Pain Res 7:367–368. doi: 10.2147/JPR.S46071 PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Westergaard ML, Glumer C, Hansen EH, Jensen RH (2014) Prevalence of chronic headache with and without medication overuse: associations with socioeconomic position, and physical and mental health status. Pain 155:2005–2013. doi: 10.1177/0333102413512033 PubMedCrossRefGoogle Scholar
  6. 6.
    Lanteri-Minet M, Duru G, Mudge M, Cottrell S (2011) Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: a systematic review. Cephalalgia 31:837–850. doi: 10.1177/0333102411398400 PubMedCrossRefGoogle Scholar
  7. 7.
    Steiner TJ, Stovner LJ, Katsarava Z, Lainez JM, Lampl C, Lantéri-Minet M, Rastenyte D, de la Torre ER, Tassorelli C, Barré J, Andrée C (2014) The impact of headache in Europe: principal results of the Eurolight project. J Headache Pain 15:31. doi: 10.1186/1129-2377-15-31 PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Russell MB, Lundqvist C (2012) Prevention and management of medication overuse headache. Curr Opin Neurol 25:290–295. doi: 10.1097/WCO.0b013e328352c431 PubMedCrossRefGoogle Scholar
  9. 9.
    Headache Classification Committee of the International Headache Society (2013) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33:629–808. doi: 10.1177/0333102413485658 CrossRefGoogle Scholar
  10. 10.
    Jonsson P, Hedenrud T, Linde M (2011) Epidemiology of medication overuse headache in the general Swedish population. Cephalalgia 31:1015–1022. doi: 10.1177/0333102411410082 PubMedCrossRefGoogle Scholar
  11. 11.
    Da Silva AN, Lake AE III (2014) Clinical aspects of medication overuse headaches. Headache 54:211–217. doi: 10.1111/head.12223 PubMedCrossRefGoogle Scholar
  12. 12.
    Nielsen MW, Søndergaard B, Kjøller M, Hansen EH (2008) Agreement between self-reported data on medicine use and prescription records vary according to method of analysis and therapeutic group. J Clin Epidemiol 61:919–924. doi: 10.1016/j.jclinepi.2007.10.021 PubMedCrossRefGoogle Scholar
  13. 13.
    Hagen K, Lind M, Steiner TJ, Stovner LJ, Zart J-A (2012) Risk factors for medication-overuse headache: an 11-year follow-up study. The Nord-Trøndelag health studies. Pain 153:56–61. doi: 10.1016/j.pain.2011.08.018 PubMedCrossRefGoogle Scholar
  14. 14.
    Christensen AI, Ekholm O, Glümer C, Andreasen AH, Hvidberg MF, Kristensen PL, Larsen FB, Ortiz B, Juel K (2012) The Danish National Health Survey 2010. Study design and respondent characteristics. Scand J Public Health 40:391–397. doi: 10.1177/1403494812451412 PubMedCrossRefGoogle Scholar
  15. 15.
    Kildemoes HW, Sørensen HT, Hallas J (2011) The Danish national prescription registry. Scand J Public Healt 39(Suppl 7):38–41. doi: 10.1177/1403494810394717 CrossRefGoogle Scholar
  16. 16.
    WHO Collaborating Centre for Drug Statistics Methodology (2011) Use of ATC/DDD, (accessed 11 February 2015)
  17. 17.
    Pedersen CB (2011) The Danish civil registration system. Scand J Public Health 39(Suppl 7):22–25. doi: 10.1177/1403494810387965 PubMedCrossRefGoogle Scholar
  18. 18.
    Gaist D (1999) Use and overuse of sumatriptan. Pharmacoepidemiological studies based on prescription register and interview data. Cephalalgia 19:735–761PubMedCrossRefGoogle Scholar
  19. 19.
    Von Euler M, Keshani S, Baatz K, Wettermark B (2014) Utilization of triptans in Sweden; analyses of over the counter and prescription sales. Pharmacoepidemiol Drug Saf 23:1288–1293. doi: 10.1002/pds.3681 CrossRefGoogle Scholar
  20. 20.
    20 Bendtsen L, Birk S, Kasch H, Aegidius K, Sørensen PS, Thomsen LL, Poulsen L, Rasmussen MJ, Kruuse C, Jensen R (2012) Danish Headache Society. Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition. J Headache Pain 13 Suppl 1: S1–29. doi:  10.1007/s10194-011-0402-9
  21. 21.
    Franklin GM (2014) Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology 83:1277–1284. doi: 10.1212/WNL.0000000000000839 PubMedCrossRefGoogle Scholar
  22. 22.
    Marmura MJ, Silberstein SD, Schwedt TJ (2015) The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache 55(1):3–20. doi: 10.1111/head.12499 PubMedCrossRefGoogle Scholar
  23. 23.
    Scher AI, Lipton RB, Stewart WF, Bigal M (2010) Patterns of medication use by chronic and episodic headache sufferers in the general population: results from the frequent headache epidemiology study. Cephalalgia 30:321–328. doi: 10.1111/j.1468-2982.2009.01913.x PubMedCrossRefGoogle Scholar
  24. 24.
    Bigal ME, Lipton RB (2008) Excessive acute migraine medication use and migraine progression. Neurology 71:1821–1828. doi: 10.1212/01.wnl.0000335946.53860.1d PubMedCrossRefGoogle Scholar
  25. 25.
    Limmroth V, Katsarava Z, Fritsche G, Przywara S, Diener HC (2002) Features of medication overuse headache following overuse of different acute headache drugs. Neurology 59:1011–1014PubMedCrossRefGoogle Scholar
  26. 26.
    Orr SL, Aubé M, Becker WJ, Davenport WJ, Dilli E, Dodick D, Giammarco R, Gladstone J, Leroux E, Pim H, Dickinson G, Christie SN (2015) Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 35:271–284. doi: 10.1177/0333102414535997 PubMedCrossRefGoogle Scholar
  27. 27.
    Kelley NE, Tepper DE (2012) Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post-discharge medications. Headache 52:467–482. doi: 10.1111/j.1526-4610.2012.02097.x PubMedCrossRefGoogle Scholar
  28. 28.
    Robbins L (2004) Tramadol for tension-type headache. Headache 44(2):192–193PubMedCrossRefGoogle Scholar
  29. 29.
    Ekholm O, Kurita GP, Højsted J, Juel K, Sjøgren P (2014) Chronic pain, opioid prescriptions, and mortality in Denmark: a population-based cohort study. Pain 155(12):2486–2490. doi: 10.1016/j.pain.2014.07.006 PubMedCrossRefGoogle Scholar
  30. 30.
    Fredheim OMS, Skurtveit S, Moroz A, Breivik H, Borchgrevink PC (2009) Prescription pattern of codeine for non-malignant pain: a pharmacoepidemiological study from the Norwegian Prescription Database. Acta Anaesthesiol Scand 53:627–633PubMedCrossRefGoogle Scholar
  31. 31.
    Le H, Tfelt-Hansen P, Skytthe A, Kyvik KO, Olesen J (2012) Increase in self-reported migraine prevalence in the Danish adult population: a prospective longitudinal population-based study. BMJ Open 2. doi: 10.1136/bmjopen-2012-000962 Google Scholar
  32. 32.
    Antonaci F, Dumitrache C, De Cillis I et al (2010) A review of current European treatment guidelines for migraine. J Headache Pain 11:13–19. doi: 10.1007/s10194-009-0179-2 PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Bigal ME, Borucho S, Serrano D, Lipton RB (2009) The acute treatment of episodic and chronic migraine in the USA. Cephalalgia 29:891–897. doi: 10.1111/j.1468-2982.2008.01819.x PubMedCrossRefGoogle Scholar
  34. 34.
    Wells RE, Markowitz SY, Barton EP, Hentz JG, Kalidas K, Mathew PG, Halker R, Dodick DW, Schwedt TJ (2014) Identifying the factors underlying discontinuation of triptans. Headache 54:278–289. doi: 10.1111/head.12198 PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Lipton RB, Fanning KM, Serrano D, Reed ML, Cady R, Buse DC (2015) Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. Neurology 84:688–695. doi: 10.1212/WNL.0000000000001256 PubMedCrossRefGoogle Scholar
  36. 36.
    Tfelt-Hansen PC, Koehler PJ (2008) History of the use of ergotamine and dihydroergotamine in migraine from 1906 onward. Cephalalgia 28:877–886. doi: 10.1111/j.1468-2982.2008.01578.x PubMedCrossRefGoogle Scholar
  37. 37.
    Bahra A, Walsh M, Menon S, Goadsby PJ (2003) Does chronic headache arise de novo in association with regular use of analgesics? Headache 43:179–190. doi: 10.1046/j.1526-4610.2003.03041.x PubMedCrossRefGoogle Scholar
  38. 38.
    Yoon MS, Manack A, Schramm S, Fritsche G, Obermann M, Diener HC, Moebus S, Katsarava Z (2013) Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: results of the German Headache Consortium Study. Pain 154(3):484–492. doi: 10.1016/j.pain.2012.12.010 PubMedCrossRefGoogle Scholar
  39. 39.
    Johnson JL, Hutchinson MR, Williams DB, Rolan P (2013) Medication-overuse headache and opioid-induced hyperalgesia: a review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment. Cephalalgia 33(1):52–64. doi: 10.1177/0333102412467512 PubMedCrossRefGoogle Scholar
  40. 40.
    Langhammer A, Krokstad S, Romundstad P, Heggland J, Holmen J (2012) The HUNT study: participation is associated with survival and depends on socioeconomic status, diseases and symptoms. BMC Med Res Methodol 12:143. doi: 10.1186/1471-2288-12-143 PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Maria Lurenda Westergaard
    • 1
  • Ebba Holme Hansen
    • 2
  • Charlotte Glümer
    • 3
    • 4
  • Rigmor Højland Jensen
    • 1
  1. 1.Danish Headache Center, Department of Neurology, Glostrup Hospital, Faculty of Health and Medical SciencesUniversity of CopenhagenGlostrupDenmark
  2. 2.Department of Pharmacy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
  3. 3.Research Center for Prevention and Health, Glostrup HospitalUniversity of CopenhagenCopenhagenDenmark
  4. 4.Department of Health Science and TechnologyUniversity of AalborgAalborgDenmark

Personalised recommendations