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Tramadol for Tension Headache
Lawrence Robbins, M.D.
Posted: November 2003  
Department of Neurology, Rush Medical College, Chicago, IL  

Tramadol is a relatively mild opioid-like analgesic. Many of the analgesics currently used for tension headache contain caffeine, or are anti-inflammatories. Tramadol avoids the problems inherent with these compounds.

My retrospective assessment of the efficacy and safety of tramadol use in tension headache yielded 245 patients (treated from 1996 to 2003). The analysis revealed that 55% of patients initially felt that tramadol relieved their tension headache. However, over time only 28% of patients remained on the medication. The majority of the patients discontinued the medication due to declining efficacy. The most common adverse advents were: dizziness, fatigue, and increased headache.

Three patients reported withdrawal upon discontinuation of tramadol, with no indication of abuse. Four patients overused tramadol, while one overused tramadol plus acetaminophen (Ultracet). These patients were withdrawn off of tramadol, and none were felt to be addicted.

Tramadol has been marketed as relatively nonaddicting. I have heard, from various members of the Ortho-McNeil marketing team, that tramadol addiction ranges from "1 in 10,000 to 1 in 100,000". We have witnessed erroneous aggressive marketing of addictive medications in the past. Examples of this include the marketing of butorphanol (Stadol) nasal spray by Bristol-Myers Squibb Company in the early 1990’s,¹ and more recently the marketing of Oxycontin by Purdue Pharma L.P.. These were more powerful medications than tramadol, with a significant incidence of serious adverse advents. (In the case of butorphanol, the drug was released by the FDA as non-scheduled, and instructions were issued to the company to perform thorough postmarketing follow-up. This was not accomplished.)

One 1999 postmarketing study did address tramadol abuse.² It revealed that 97% of abuse cases occurred among individuals with a history of substance abuse. However, further follow-up on tramadol abuse has been very limited. In my current study, 7 patients had a withdrawal syndrome, or overused tramadol. An internet search revealed a number of law offices advertising for patients who have become addicted to tramadol. If even one or two percent of patients overuse or abuse tramadol, it is much more than what Ortho-McNeil acknowledges.

I have raised the addiction issue with Ortho-McNeil representatives, regional scientists, and the medical information department. The representatives and regional scientists have responded to my questions in a very appropriate manner. They do indicate that they realize the potential for addiction is far greater with tramadol than the company will allow them to officially state. My calls to the medical information department at Ortho- McNeil have met with resistance. They should be more forthcoming about the true addiction potential of tramadol.

1. Robbins L. Stadol Nasal Spray- Treatment for Migraine? Letter in Headache.1999;33.
2. Cicero TJ, Adams EH, Geller A, Inciardi JA, Munoz A, Schnoll SH, Senay ED, Woody GE.
A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Drug and Alcohol Dependence 1999;57:7-22.

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