Ergotamine and triptans induced medication-overuse headache: a real-world population-based comparative study from the Northern Thai headache registry

Abstract

Background: Medication-overuse headache (MOH) remains a leading cause of chronic daily headache globally. Although triptans are the predominant implicated in high-income countries, ergotamine continues to be widely used in many low- and middle-income settings. Comparative data on ergotamine- versus triptan-induced MOH remain limited. Methods: We analyzed prospective data from the Northern Thai Headache Registry, enrolling patients with ergotamine-MOH, triptan-MOH, or dual-MOH. Demographic and clinical characteristics, treatment outcomes, recurrence rates, and withdrawal symptoms were evaluated over 12 months. Outcomes included changes in Headache Impact Test (HIT-6) scores, recurrence-free survival, and adverse events during withdrawal. Results: A total of 117 MOH patients were included: 61 (52.1%) with ergotamine-MOH, 44 (37.6%) with triptan-MOH, and 12 (10.3%) with dual-MOH. Patients with ergotamine-MOH experienced significantly more withdrawal symptoms compared to those with triptan-MOH (P < 0.01). In contrast, recurrence rates were highest among dual-MOH patients (P < 0.01). Improvement in HIT-6 scores was observed across all groups, though ergotamine-MOH patients showed slower recovery trajectories. Kaplan–Meier analysis demonstrated a higher risk of recurrence in dual-MOH compared to single-agent MOH. Conclusions: Ergotamine-induced MOH is linked to more severe withdrawal symptoms, whereas dual-MOH carries the greatest risk of recurrence. These findings highlight the importance of tailored withdrawal strategies and close monitoring, particularly in resource-limited settings where ergotamine remains widely available. They also support policy initiatives aimed at restricting over-the-counter ergotamine and expanding access to safer acute treatment options.