Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life

Outcome of Medication Overuse Headache after Abrupt in-Patient withdrawal

One hundred and one patients suffering from chronic daily headache (CDH) and medication overuse were treated, in an in-patient setting, with abrupt discontinuation of the medication overused, intravenous hydrating, and intravenous administration of benzodiazepines and ademetionine. The mean time to CDH resolution was 8.8 days. The in-patient withdrawal protocol used was effective, safe and well tolerated. There was a trend for a shorter time to CDH resolution in patients who overused triptans ( P = 0.062). There was no correlation between time to CDH resolution and either the type of initial primary headache or duration of medication abuse, whereas time to CDH resolution was related to daily drug intake ( P = 0.01). In multiple regression analysis, daily drug intake, age and type of medication overused were independent predictors of time to CDH resolution. At 3-months' follow-up, no patient had relapsed and was again overusing symptomatic medications.

One-Year Prevalence and Socio-Cultural Aspects of Chronic Headache in Turkish Immigrants and German Natives

The aim of this research was to study the prevalence of chronic headache (CH) and associated socio-cultural factors in Turkish immigrants and native Germans. Five hundred and twenty-three Turkish and German company employees were screened using a standard questionnaire. Those who suffered from headaches were also examined by a neurologist. Complete data were available for 471 (90%) subjects. Thirty-four participants (7.2%) had CH. Two independent factors for association with CH could be identified: overuse of acute headache medication (OR = 72.5; 95% CI 25.9-202.9), and being a first-generation Turkish immigrant compared with native Germans (OR = 4.4; 95% CI 1.4-13.7). In contrast, the factor associated with chronic headache was not increased in second-generation Turkish immigrants. Medication overuse was significantly more frequent in first-generation Turkish immigrants (21.6%) compared with second-generation Turkish immigrants (3.3%) and native Germans (3.6%; X2 = 38.0, P < 0.001). First-generation Turkish immigrants did not contact headache specialists at all, compared with 2.8% of second-generation Turkish immigrants and 8.8% of native Germans ( X2 = 118.4, P < 0.001). Likewise no first-generation Turkish immigrant suffering from CH received headache preventive treatment, compared with 6.6% of native Germans ( X2 = 19.1, P = 0.014). The data from this cross-sectional study reveal a high prevalence of chronic headache as well as a very low utilization of adequate medical care in first-generation Turkish immigrants in Germany.

Chronic Frequent Headache in the General Population: Comorbidity and Quality of Life

We studied the nature and extent of comorbidity of chronic frequent headache (CFH) in the general population and the influence of CFH and comorbidity on quality of life. Subjects with CFH (headache on >14 days/month) were identified in a general health survey. We sent a second questionnaire including questions on comorbidity and quality of life to subjects with CFH and subjects with infrequent headache (IH) (1-4 days/month). We recoded comorbidity by using the Cumulative Illness Rating Scale (CIRS) and measured quality of life with the RAND-36, a Dutch version of Short Form-36. CFH subjects ( n = 176) had higher comorbidity scores than the IH subjects ( n = 141). Mean CIRS scores were 2.94 for CFH and 1.55 for IH [mean difference 1.40, 95% confidence interval (CI) 0.91, 1.89]. The mean number of categories selected was 1.92 in CFH and 1.10 in IH (mean difference 0.82, 95% CI 0.54, 1.11). Fifty percent of CFH subjects had a comorbidity severity level of at least 2, indicating disorders requiring daily medication, compared with 28% of IH subjects (mean difference 22%, 95% CI 12, 33). CFH subjects had more musculoskeletal, gastrointestinal, psychiatric and endocrine/breast pathology than IH subjects. Quality of life in CFH subjects was lower than that of IH subjects in all domains of the RAND-36. Both headache frequency and CIRS score had a negative influence on all domains. We conclude that patients with CFH have more comorbid disorders than patients with infrequent headaches. Many CFH patients have a comorbid chronic condition requiring daily medication. Both high headache frequency and comorbidity contribute to the low quality of life in these patients.

Medication Overuse Headache: Clinical Features Predicting Treatment Outcome at 1-Year Follow-Up

We present a prospective study of 240 patients with medication overuse headache (MOH) treated with drug withdrawal and prophylactic medications. At 1-year follow-up, 137 (57.1%) patients were without chronic headache and without medication overuse, eight (3.3%) patients did not improve after withdrawal and 95 (39.6%) relapsed developing recurrent overuse. Age at time of MOH diagnosis, regular use of benzodiazepines, frequency and Migraine Disability Assessment (MIDAS) score of chronic headache, age at onset of primary headache, frequency and MIDAS score of primary headache, ergotamine compound overuse and daily drug intake were significantly different between successfully and unsuccessfully treated patients. Multivariate analysis determined the frequency of primary headache disorder, ergotamine overuse and disability of chronic headache estimated by MIDAS as independent predictors of treatment efficacy at 1-year follow-up.

Activation of dura-sensitive trigeminal neurons and increased c-Fos protein induced by morphine withdrawal in the rostral ventromedial medulla

Aims

Overuse of medications used to treat migraine headache can increase the frequency of headaches. Sudden abstinence from migraine medication can also lead to a period of withdrawal-induced headaches. The aim of this study was to examine the effect of morphine withdrawal localized to the rostral ventromedial medulla (RVM) on the activity of dura-sensitive spinal trigeminal nucleus caudalis (Vc) neurons.

Methods

Rats were implanted with either morphine or placebo pellets for six to seven days before the microinjection of naloxone methiodide or phosphate-buffered saline into the RVM in urethane-anesthetized animals. Dura-sensitive neurons were recorded in the Vc and the production of c-Fos-like immunoreactivity was quantified.

Results

In chronic morphine-treated animals, naloxone methiodide microinjections produced a significant increase both in ongoing and facial heat-evoked activity and an increase in Fos-positive neurons in the Vc and in the nucleus reticularis dorsalis, a brainstem region involved in diffuse noxious inhibitory controls.

Conclusions

These results indicate that activation of pronociceptive neurons in the RVM under conditions of morphine withdrawal can increase the activity of neurons that transmit headache pain. Modulation of the subnucleus reticularis dorsalis by the RVM may explain the attenuation of conditioned pain modulation in patients with chronic headache.

Medication overuse headache in Europe and Latin America: general demographic and clinical characteristics, referral pathways and national distribution of painkillers in a descriptive, multinational, multicenter study

BACKGROUND

Medication overuse headache (MOH) is a very disabling and costly disorder due to indirect costs, medication and healthcare utilization. The aim of the study was to describe general demographic and clinical characteristics of MOH, along with the national referral pathways and national painkillers distribution in several European and Latin American (LA) Countries.

METHODS

This descriptive cross-sectional observational study included 669 patients with MOH referred to headache-centers in Europe and LA as a part of the COMOESTAS project. Information about acute medication and healthcare utilization were collected by extensive questionnaires, supplemented with structured patient interviews.

RESULTS

Triptans were overused by 31 % European patients and by 6 % in LA (p < 0.001), whereas ergotamines were overused by 4 % in Europe and 72 % in LA (p < 0.001). Simple analgesics were overused by 54 % in Europe and by 33 % in LA (p < 0.001), while combination-analgesics were more equally overused (24 % in Europe and 29 % in LA). More European patients (57 %) compared with LA patients (27 %) visited general practitioners (p < 0.001), and 83 % of European patients compared to 38 % in LA consulted headache specialists (p < 0.001). A total of 20 % in Europe and 30 % in LA visited emergency rooms (p = 0.007).

CONCLUSION

There are marked variations between LA and Europe in healthcare pathways and in acute medication overuse regarding patients with MOH. This should be considered when planning prevention campaigns against MOH.

GPs' experiences with brief intervention for medication-overuse headache: a qualitative study in general practice

Background

Medication-overuse headache (MOH) is common in the general population, and most patients are managed in primary health care. Brief Intervention (BI) has been used as a motivational technique for patients with drug and alcohol overuse, and may a have role in the treatment of MOH.

Aim

To explore GPs’ experiences using BI in the management of patients with MOH.

Design and setting

Qualitative study in Norwegian general practice.

Method

Data were collected through four focus group interviews with 22 GPs who participated in an intervention study on BI for MOH. Systematic text condensation was used to analyse transcripts from the focus group interviews.

Results

The GPs experienced challenges when trying to convince patients that the medication they used to treat and prevent headache could cause headache, but labelling MOH as a diagnosis opened up a space for change. GPs were able to use BI within the scope of a regular consultation, and they thought that the structured approach had a potential to change patients’ views about their condition and medication use. Being diagnosed with medication overuse could bring about feelings of guilt in patients, and GPs emphasised that a good alliance with the patient was necessary for successful change using BI to manage MOH.

Conclusion

GPs experience BI as a feasible strategy to treat MOH, and the technique relies on a good alliance between the doctor and patient. When using BI, GPs must be prepared to counter patients’ misconceptions about medication used for headache.

Prevalence of primary headache disorders in Fayoum Governorate, Egypt

Background

There is abundance of epidemiological studies of headache in developed and western countries; however, data in developing countries and in Egypt are still lacking. This study aims to detect the prevalence of primary headache disorders in both urban and rural sectors in Fayoum governorate, Egypt.

Methods

A total of 2600 subjects were included using multi-stage stratified systematic random sampling, with respondent rate of 91.3 %. A pre-designed Arabic version, interviewer-administered, pilot tested structured questionnaire was developed according to The International Classification of Headache Disorders, 3rd edition (beta version), and this questionnaire was validated and the strength of agreement in headache diagnosis was good.

Results

The 1-year headache prevalence was 51.4 %, which was more prevalent in urban dwellers. The most common primary headache type was episodic tension type headache (prevalence; 24.5 %), followed by episodic migraine (prevalence; 17.3 %), both types peaked in midlife. Headache disorders were more common in females with exception of cluster headache that showed the expected male dominance. The risk of chronic headache increased more than one fold and half when the participants were females, married, and in those with high education. More than 60 % of our participants did not seek medical advice for their headaches problem; this percentage was higher in rural areas.

Conclusions

Primary headache disorders are common in Egypt; prevalence rate was comparable with western countries with exception of episodic tension headache. Still headache is under-estimated and under-recognized in Egypt and this problem should be targeted by health care providers.

Psychopathological comorbidities in medication-overuse headache: a multicentre clinical study

BACKGROUND AND PURPOSE

In medication-overuse headache (MOH) patients, the presence of psychopathological disturbances may be a predictor of relapse and poor response to treatment. This multicentre study aimed to assess the occurrence of psychopathological disorders in MOH patients by comparing the incidence of psychopathological disturbances with episodic migraine (EM) patients and healthy controls (HC).

METHODS

The psychopathological assessment of patients and HC involved the administrations of the Beck Depression Inventory, the Beck Anxiety Inventory, the Modified Mini International Neuropsychiatric Interview (M-MINI), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Leeds Dependence Questionnaire.

RESULTS

The MOH, EM and HC groups (88, 129 and 102 subjects, respectively) differed significantly from each other for the presence of moderate/severe anxiety, whereas mood disorder and depression were revealed in similar proportions for both MOH and EM patients. By stratifying the M-MINI questionnaire results according to the number of psychiatric disorders, it was found that MOH patients had a more complex profile of psychiatric comorbidity. Furthermore, clinically relevant obsessive-compulsive disturbances for abused drugs assessed by Y-BOCS appeared to be more represented in the MOH group, whilst the prevalence of this trait in the EM group was comparable to that of HC (12.5%, 0.8% and 0%, respectively).

CONCLUSIONS

Our study indicates the multiple presence of psychopathological comorbidities in patients with MOH. In light of this, it is recommended that the assessment of the psychopathological profile be included in an evaluation of MOH patients, allowing the clinician to more rapidly start an appropriate behavioural treatment, which would greatly improve MOH management.

Medication overuse headache

Medication overuse headache (MOH) is a common and disabling headache disorder. It has a prevalence of about 1-2 % in the general population. The International Classification of Headache Disorders 3rd edition (beta version) has defined MOH as a chronic headache disorder in which the headache occurs on 15 or more days per month due to regular overuse of medication. These headaches must have been present for more than 3 months. The pathophysiology is complex and not completely known. It involves genetic and behavioural factors. There is evidence that cortical spreading depression, trigeminovascular system and neurotransmitters contribute to the pain pathway of MOH. The treatment of MOH includes patient education, stopping the offending drug(s), rescue therapy for withdrawal symptoms and preventative therapy. Relapse rates for MOH are high at 41 %. MOH can severely impact quality of life, so it is important to identify patients who are at risk of analgesic overuse.

Migraine-specific quality of life questionnaire and relapse of medication overuse headache

BACKGROUND

The management of Medication overuse headache (MOH) represents a difficult challenge for clinicians and headache experts, particularly for the responder rate after a successful withdrawal treatment. The purpose of this study was to investigate the role of demographic and clinical characteristics as well as the score of Migraine-Specific Quality of Life Questionnaire (MSQ), Migraine Disability Questionnaire and Leeds Dependence Questionnaire in predicting a response after a successful withdrawal treatment in patients with MOH.

METHODS

This ancillary study is part of a randomized trial that demonstrated the safety and the efficacy of a 3-month treatment with sodium valproate (VPA) (800 mg/day vs placebo) in MOH. Demographic and clinical characteristics and questionnaire results were obtained from the entire sample.

RESULTS

A significant correlation was found only between MOH relapse and the total MSQ score, the Role Preventive sub-scale and the Emotional Function sub-scale, suggesting a poorer quality of life in non responders.

CONCLUSION

A high MSQ score could be associated with a poor short-term outcome in MOH patients after a successful treatment with detoxification followed by a new treatment.

Brief intervention for medication-overuse headache in primary care. The BIMOH study: a double-blind pragmatic cluster randomised parallel controlled trial

BACKGROUND

Medication-overuse headache (MOH) is common in the general population. We investigated effectiveness of brief intervention (BI) for achieving drug withdrawal in primary care patients with MOH.

METHODS

The study was double-blind, pragmatic and cluster-randomised controlled. A total of 25,486 patients (age 18-50) from 50 general practitioners (GPs) were screened for MOH. GPs defined clusters and were randomised to receive BI training (23 GPs) or to continue business as usual (BAU; 27 GPs). The Severity of Dependence Scale was applied as a part of the BI. BI involved feedback about individual risk of MOH and how to reduce overuse. Primary outcome measures were reduction in medication and headache days/month 3 months after the intervention and were assessed by a blinded clinical investigator.

RESULTS

42% responded to the postal screening questionnaire, and 2.4% screened positive for MOH. A random selection of up to three patients with MOH from each GP were invited (104 patients), 75 patients were randomised and 60 patients included into the study. BI was significantly better than BAU for the primary outcomes (p<0.001). Headache and medication days were reduced by 7.3 and 7.9 (95% CI 3.2 to 11.3 and 3.2 to 12.5) days/month in the BI compared with the BAU group. Chronic headache resolved in 50% of the BI and 6% of the BAU group.

CONCLUSIONS

The BI method provides GPs with a simple and effective instrument that reduces medication-overuse and headache frequency in patients with MOH.

TRIAL REGISTRATION NUMBER

NCT01314768.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults

BACKGROUND

This is an updated version of the original Cochrane review published in 2005 on selective serotonin reuptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards migraine prevention. Another updated review is under development to cover tension-type headache.Migraine is a common disorder. The chronic forms are associated with disability and have a high economic impact. In view of discoveries about the role of serotonin and other neurotransmitters in pain mechanisms, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of migraine.

OBJECTIVES

To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic migraine in adults.

SEARCH METHODS

For the original review, we searched MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), and Headache Quarterly (1990 to 2003). For this update, we applied a revised search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10), MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older of either sex with migraine.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data (migraine frequency, index, intensity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement; cost-effectiveness; and adverse events) and assessed the risk of bias of trials. The primary outcome of this updated review is migraine frequency.

MAIN RESULTS

The original review included eight studies on migraine. Overall, we now include 11 studies on five SSRIs and one SNRI with a total of 585 participants. Six studies were placebo-controlled, four compared a SSRI or SNRI to amitriptyline, and one was a head-to-head comparison (escitalopram versus venlafaxine). Most studies had methodological or reporting shortcomings (or both): all studies were at unclear risk of selection and reporting bias. Follow-up rarely extended beyond three months. The lack of adequate power of most of the studies is also a major concern.Few studies explored the effect of SSRIs or SNRIs on migraine frequency, the primary endpoint. Two studies with unclear reporting compared SSRIs and SNRIs to placebo, suggesting a lack of evidence for a difference. Two studies compared SSRIs or SNRIs versus amitriptyline and found no evidence for a difference in terms of migraine frequency (standardised mean difference (SMD) 0.04, 95% confidence interval (CI) -0.72 to 0.80; I(2) = 72%), or other secondary outcomes such as migraine intensity and duration.SSRIs or SNRIs were generally more tolerable than tricyclics. However, the two groups did not differ in terms of the number of participants who withdrew due to adverse advents or for other reasons (one study, odds ratio (OR) 0.39, 95% CI 0.10 to 1.50 and OR 0.42, 95% CI 0.13 to 1.34).We did not find studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. antiepileptics and anti-hypertensives).

AUTHORS' CONCLUSIONS

Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine as preventive drugs for migraine. There is no evidence to consider SSRIs or venlafaxine as more effective than placebo or amitriptyline in reducing migraine frequency, intensity, and duration over two to three months of treatment. No reliable information is available at longer-term follow-up. Our conclusion is that the use of SSRIs and SNRIs for migraine prophylaxis is not supported by evidence.

Opioid-induced central immune signaling: implications for opioid analgesia

Despite being the mainstay of pain management, opioids are limited in their clinical utility by adverse effects, such as tolerance and paradoxical hyperalgesia. Research of the past 15 years has extended beyond neurons, to implicate central nervous system immune signaling in these adverse effects. This article will provide an overview of these central immune mechanisms in opioid tolerance and paradoxical hyperalgesia, including those mediated by Toll-like receptor 4, purinergic, ceramide, and chemokine signaling. Challenges for the future, as well as new lines of investigation will be highlighted.

Psychometric properties of the stagnation scale in medication overuse headache patients

Background

Medication-overuse headache (MOH) is often comorbid with emotional disturbances, contributing to poorer outcomes. The aims of the present study were to assess the psychometric properties of the Stagnation Scale in a sample of MOH patients, and to compare two factor models: a three-factor model reported in previous studies and a proposed bi-factor model.

Methods

Consecutive adult outpatients (N = 310) admitted to the Regional Referral Headache Centre of the Sant’Andrea Hospital in Rome (Italy) were administered the Stagnation Scale and two questionnaires measuring depression and perceived disability.

Results

The original three-factor model demonstrated an adequate fit to the data (χ²₁₀₁ = 238.70; p < 0.001; Root Mean Square Error of Approximation [RMSEA] = 0.07; 90% CI of RMSEA = 0.06 / 0.08; Comparative Fit Index [CFI] = 0.98; Weighted Root Mean Square Residual [WRMR] = 0.75). However, the bi-factor model had a comparable or even better fit, with a RMSEA of 0.05 (90% CI: 0.04 / 0.07), providing strong evidence for an absolute fit to the data (χ²₈₈ = 161.43; p < 0.001; RMSEA = 0.05; 90% CI of RMSEA = 0.04 / 0.07; CFI = 0.99; WRMR = 0.56). The stagnation general factor and all the group factors correlated significantly and positively with convergent measures.

Conclusions

There is support for the use of the Stagnation Scale in MOH patients, with the goal of better understanding the role of psychological factors in the evolution and course of the disorder.

Long term headache duration is a factor predicting nonresponse to detoxification and advice in medication overuse headache

Background

Medication overuse headache (MOH) is a very heterogeneous disorder for which a recommended treatment is not yet available. The purpose of this study was to investigate any possible roles of demographic and clinical characteristics of MOH patients that might predict a response to detoxification and advice with or without preventive treatment.

Findings

This ancillary study is part of the Sodium vAlproate in the treatment of Medication Overuse HeadAche (SAMOHA) study that randomized 88 MOH patients for 3-month treatment period with sodium valproate (VPA) (800 mg/day) or placebo after a 6-day outpatient detoxification regimen. Demographic and clinical characteristics obtained on patients from both study arms were analyzed to point out an association with the response to the treatment. While for patients from VPA arm no significant results were obtained, comparing responders to non-responders to detoxification and advice to withdraw from MOH, a significant difference in headache duration was observed. Specifically, the efficacy of such treatment resulted ineffective in headache lasting longer than 30 years.

Conclusions

Our findings suggest that the benefit from detoxification and advice can be excluded in MOH of long duration. Therefore, a preventive treatment is suggested particularly for these patients.

Medication-overuse headache in China: clinical profile, and an evaluation of the ICHD-3 beta diagnostic criteria

BACKGROUND

Although medication-overuse headache (MOH) is common in China, its clinical profile is not yet fully established. Meanwhile, ICHD-3 beta has been published, but its diagnostic criteria require further validation.

METHODS

We retrospectively classified the clinical features of 240 consecutive patients with MOH (55 males, 185 females), whose demographic data, headache features, overused medications (type, quantity, frequency and duration of use), headache-attributed burden, and outcomes were reviewed. We then applied the criteria of the several versions of ICHD (II, IIR and 3-beta) to these patients.

RESULTS

Compared with those with other headaches, patients with MOH were more likely to be less well educated (64.6% vs 42.0% for secondary school or lower, p < 0.0001), and on lower annual incomes (72.3% vs 56.0% for an income of Chinese yuan (CNY) 30,000 or less, p < 0.0001). Combination analgesics were the most commonly overused medications, and, caffeine (89.9%), aminopyrine (70.0%), phenacetin (53.9%) and phenobarbital (48.8%) were the most commonly used specific components of these. Only two patients (0.8%) had previously been given the diagnosis of MOH; accordingly, the median time to diagnosis after the estimated onset of the disorder was 4.0 years. The majority of patients (83.7%) improved with treatment. All 240 patients fulfilled the diagnostic criteria for MOH according to ICHD-3 beta; only 134 (55.8%) satisfied the diagnostic criteria for definite MOH according to ICHD-II, while 195 (81.2%) met those of ICHD-IIR.

CONCLUSIONS

MOH in China is associated with lower educational level and annual income. MOH has rarely been diagnosed and correctly treated in China. ICHD-3 beta appears to be more appropriate for the diagnosis of MOH than previous versions.

Development of persistent headache following stroke: A 3-year follow-up

Background

Headache following stroke has been described in previous studies with an incidence of 23%–54%, but a clear description of headache developing after stroke onset is still lacking. The aim of this study was to determine the incidence and characteristics of persistent novel headache after stroke and to describe the use of medication, including dipyridamole.

Methods

As a follow-up to a prospective study, a standardized questionnaire about characteristics of novel headache and medication use was sent out to surviving patients three years after their stroke.

Results

The questionnaire was sent to 256 patients and returned by 222, of whom 12% (26/222) of patients reported persistent novel headache. Dipyridamole had no significant influence on the incidence. Stroke-attributed headache according to predefined criteria was reported in 7.2% (16/222) of patients, with tension-type-like headache in 50.0%, migraine-like in 31.3% and medication overuse in 6.25% of patients. More than half of patients experienced moderate to severe pain and had a score of 55 or above on the Headache Impact Test-6 scale.

Conclusion

Novel headache after stroke affects one in 10 patients and seems to be unrelated to dipyridamole use. Persistent headache attributed to stroke is similar to tension-type headache for half of patients.

Medication overuse headache - An under-diagnosed problem in shunted idiopathic intracranial hypertension patients

PURPOSE

Management of headache in a subgroup of shunted idiopathic intracranial hypertension (IIH) patients is a well- described and difficult task. We present our series of shunted IIH patients with medication overuse headache (MOH) and discuss the role of careful pain management in this group of patients.

MATERIALS AND METHODS

A retrospective review of shunted IIH patients with headache, who had their shunt function assessed by monitoring their intracranial pressure and were subsequently diagnosed with MOH.

RESULTS

A total of 15 patients were identified. The mean time between the diagnosis of IIH and the diagnosis of medication overuse headache was 6 years (standard deviation 4.9, range 2-18 years). The majority of patients in this group (12/15) had undergone multiple shunt revisions.

CONCLUSIONS

Medication overuse headache in shunted IIH patients can lead to the requirement of hospital admission, investigations and procedures. We suggest that opiates and non-steroidal anti-inflammatory analgesics (NSAIDs) are used for a specified duration post-operatively and reviewed regularly. We suggest that patients are counselled regarding medication overuse headache in a multidisciplinary setting.

Predictive factors of self-medicated analgesic use in Spanish adults: a cross-sectional national study

Background

Analgesics are among the most commonly consumed drugs by the world populations. Within the broader context of self-medication, pain relief occupies a prominent position. Our study was to ascertain the prevalence of self-medication with analgesics among the Spanish population and to identify predictors of self-medication, including psychological disorders, psychological dysfunction, mental health status, and sociodemographic and health-related variables.

Methods

We used individualized secondary data retrieved from the 2009 European Health Interview Survey (EHIS) for Spain to conduct a nationwide, descriptive, cross-sectional pharmacoepidemiology study on self-medication with analgesics among adults (individuals aged at least 16 years) of both genders living in Spain. A total of 7,606 interviews were analysed. The dichotomous dependent variables chosen were the answers “yes” or “no” to the question In the last 2 weeks have you taken the medicines not prescribed for you by a doctor for joint pain, headache, or low back pain?” Independent variables were sociodemographic, comorbidity, and healthcare resources.

Results

A total of 7,606 individuals reported pain in any of the locations (23.7%). In addition, analgesic consumption was self-prescribed in 23.7% (1,481) of these subjects. Forty percent (40.1%) of patients self-medicated for headache, 15.1% for low back pain, and 6.7% for joint pain. The variables significantly associated with a greater likelihood of self-medication of analgesics, independently of pain location were: age 16–39 years (2.36 < AOR < 3.68), higher educational level (1.80 < AOR <2.21), psychological disorders (1.56 < AOR < 1.98), and excellent/good perception of health status (1.74 < AOR < 2.68). In subjects suffering headache, self-prescription was associated with male gender (AOR 2.13) and absence of other comorbid condition (AOR 4.65).

Conclusions

This pharmacoepidemiology study constitutes an adequate approach to analgesic self-medication use in the Spanish population, based on a representative nationwide sample. Self-prescribed analgesic consumption was higher in young people with higher educational level, higher income, smoker, and with psychological disorders and with a good perception of their health status independently of the location of pain.

Medication overuse headache

BACKGROUND

Medication overuse headache (MOH) affects between 1% and 2% of the general population but is present in up to 50% of patients seen in headache centers. There are currently no internationally accepted guidelines for treatment of MOH.

METHODS

A review of the current literature on MOH treatment and pathophysiology.

RESULTS

We conclude that headache frequency can be reduced to episodic headache in more than 50% of the patients by simple detoxification and information. Approximately half the patients will not have need for prophylactic medication after withdrawal. Pain perception is altered in patients with MOH but can be restored to a baseline pattern, indicating a reversible mechanism in the central sensitization leading to chronic pain. The great comorbidity with depression and anxiety could be a consequence of the altered serotonin metabolism indicating a reversible and potentially treatable condition.

CONCLUSION

Increased focus on MOH is extremely important, as MOH both can and should be treated and prevented. MOH is thus a diagnosis that should be considered in all chronic headache patients as the very first step in their management strategy. In the general population, prevention campaigns against MOH are essential to minimize chronic pain disability.

Medication-overuse headache: a review

Medication-overuse headache (MOH) is a worldwide health problem with a prevalence of 1%–2%. It is a severe form of headache where the patients often have a long history of headache and of unsuccessful treatments. MOH is characterized by chronic headache and overuse of different headache medications. Through the years, withdrawal of the overused medication has been recognized as the treatment of choice. However, currently, there is no clear consensus regarding the optimal strategy for management of MOH. Treatment approaches are based on expert opinion rather than scientific evidence. This review focuses on aspects of epidemiology, diagnosis, pathogenesis, prevention, and treatment of MOH. We suggest that information and education about the risk of MOH is important since the condition is preventable. Most patients experience reduction of headache days and intensity after successful treatment. The first step in the treatment of MOH should be carried out in primary care and focus primarily on withdrawal, leaving prophylactic medication to those who do not manage primary detoxification. For most patients, a general practitioner can perform the follow-up after detoxification. More complicated cases should be referred to neurologists and headache clinics. Patients suffering with MOH have much to gain by an earlier treatment-focused approach, since the condition is both preventable and treatable.

Migraine in health workers: working in a hospital can be considered an advantage?

Migraine is the most common form of headache, and is one of the most diffused pathologies in the world. Moreover, patients often lose years before obtaining a correct diagnosis. The aim of this study was to evaluate whether diagnostic delay differs between hospital workers, in theory more sensible to health problems, and common people. We compared our cohort of patients attending the headache center on which we put a diagnosis of migraine with and without aura with a sample of hospital workers investigated about headache presence and characteristics. Particularly, hospital workers were evaluated by ID-migraine test, a three-question test validated to formulate a migraine diagnosis. Continuous variables (age and diagnostic delay) were compared with t test for independent samples. Dichotomous and categorical variables were compared with Chi squared test. The mean difference between in-hospital workers and outpatients was analyzed with a GLM/multivariate model accounting for age and sex. The difference between the single subcategory of workers affected by migraine was explored with a GLM/multivariate model accounting of age and sex. Five hundred and ninety-nine patients affected by migraine with and without aura were enrolled. Demographical characteristics were comparable in the two study populations. In-hospital workers (99 patients) had a mean longer diagnostic delay (14.89 years; 95 % CI: 7.85-21.93 years) with respect to the outpatients (12.13 years; 95 % CI: 5.37-18.89 years). The difference resulted statistically significant at the multivariate model (p < 0.05). Single subpopulations of in-hospital workers did not have a statistically significant different delay in diagnosing migraine. Diagnostic delay was significantly longer in hospital workers with respect to outpatients. Then, we can conclude that our population of hospital workers did not present a particular attention to their headache, probably because of a tendency to self-treating. Moreover, we did not find differences among different typology of workers, underlining that different job experience and education did not contribute to a best management of headache. More information and informative initiatives are necessary to sensitize people about migraine, especially among hospital workers.

Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients?

BACKGROUND

The causes of persistent headache following concussion are poorly understood. The objective of this study is to explore analgesic overuse as a potential cause of chronic post-traumatic headache among adolescents referred to a headache clinic following concussion.

METHODS

A retrospective chart review was conducted of all adolescent concussion patients referred to our pediatric headache clinic over the 16-month period between August 1, 2011, and November 30, 2012. Those patients with chronic post-traumatic headaches of 3-12 months' duration who also met International Headache Society criteria for probable medication-overuse headache were identified. Demographic data, concussion symptoms, and headache features were characterized from the initial evaluation and from follow-up visits.

RESULTS

Of 104 adolescent concussion patients referred during the study period, 77 had chronic post-traumatic headache of 3-12 months' duration. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache. Only simple analgesics were overused. Thirty-seven patients (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics; seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up.

CONCLUSION

Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents. Management of patients with chronic post-traumatic headache should include analgesic detoxification when medication overuse is suspected.

Medication-overuse headache: epidemiology, diagnosis and treatment

Medication-overuse headache (MOH) is one of the most common chronic headache disorders and a public health problem with a worldwide prevalence of 1-2%. It is a condition characterized by chronic headache and overuse of different headache medications, and withdrawal of the overused medication is recognised as the treatment of choice. However, the strategy for achieving withdrawal is, at present, based on expert opinion rather than scientific evidence, partly due to the lack of randomised controlled studies. This narrative review investigates different aspects of epidemiology, diagnosis, risk factors and pathogenesis as well as management for MOH. We suggest that the first step in the treatment of MOH should be carried out in general practice and should focus primarily on detoxification. For most patients, both prevention and follow up after detoxification can also be performed in general practice, thus freeing resources for referral of more complicated cases to headache clinics and neurologists. These suffering patients have much to gain by an earlier treatment-focused approach lower down on the treatment ladder.

Feasibility of a brief intervention for medication-overuse headache in primary care--a pilot study

Background

Medication-overuse headache (MOH) is a common problem in primary care. Brief intervention (BI) has successfully been used for detoxification from overuse of alcohol and drugs. The aim of this pilot study was to develop and test methodology, acceptability and logistics for a BI for MOH in primary care.

Findings

Observational feasibility study of an intervention in a Norwegian general practice population.

Six general practitioners (GPs) were recruited. A screening questionnaire for MOH was sent to all 18–50 year old patients on these GPs` list. GPs were taught BI, which was applied to MOH patients as follows: Severity of dependence scale (SDS) scores were collected and individual feedback was given of the relationship between the SDS, medication overuse and headache. Finally, advice to reduce medication was given. Patients were invited to a headache interview three months after the BI. Main outcomes were feedback from GPs/patients about the feasibility and logistics of the study design, screening/recruitment process, BI and headache interviews. Efficacy and patient-related outcomes were not focused. The patients reported a high degree of acceptability of the methodology. The GPs reported the BI to be feasible to implement within a busy practice and to represent a new and improved instrument for communication with MOH patients. The BI requires further testing in a randomised controlled trial (RCT) in order to provide evidence of efficacy.

Conclusion

This feasibility study will be used to improve the BI for MOH and the design of a cluster-RCT.

Trial registration

ClinicalTrials.gov: NCT01078012 (Initially registered as controlled efficacy trial but changed to observational study).

A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study

INTRODUCTION

The management of medication-overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. In this study we defined and tested a consensus protocol for the management of MOH on a large population of patients distributed in different countries.

SUBJECTS AND METHODS

The protocol was based on evidence from the literature and on consolidated expertise of the members of the consensus group. The study was conducted according to a multicentric interventional design with the enrolment of 376 MOH subjects in four centres from Europe and two centres in Latin America. The majority of patients were treated according to an outpatient detoxification programme. The post-detoxification follow-up lasted six months.

RESULTS

At the final evaluation, two-thirds of the subjects were no longer overusers and in 46.5% of subjects headache had reverted back to an episodic pattern of headache. When comparing the subjects who underwent out-patient detoxification vs those treated with in-patient detoxification, both regimens proved effective, although the drop-out rate was higher in the out-patient approach.

CONCLUSIONS

The present findings support the effectiveness and usability of the proposed consensus protocol in different countries with different health care modalities.

Should we educate about the risks of medication overuse headache?

BACKGROUND

Medication-overuse headache (MOH) is caused by the regular use of medications to treat headache. There has been a lack of research into awareness of MOH. We distributed an electronic survey to undergraduate students and their contacts via social networking sites. Analgesic use, awareness of MOH, perceived change in behaviour following educational intervention about the risks of MOH and preferred terminology for MOH was evaluated.

FINDINGS

485 respondents completed the questionnaire (41% having received healthcare training). 77% were unaware of the possibility of MOH resulting from regular analgesic use for headache. Following education about MOH, 80% stated they would reduce analgesic consumption or seek medical advice. 83% indicated that over the counter analgesia should carry a warning of MOH. The preferred terminology for MOH was painkiller-induced headache.

CONCLUSIONS

This study highlights the lack of awareness of MOH. Improved education about MOH and informative packaging of analgesics, highlighting the risks in preferred lay terminology (i.e., painkiller-induced headache), may reduce this iatrogenic morbidity and warrants further evaluation.

Management of medication-overuse headache

Medication-overuse headache (MOH) has developed into the third most common type of headache after tension-type headache and migraine. The prevalence reaches approximately 1% of the world's population and shows an increasing trend. Many important studies on MOH have been published in the last year, some of which investigated the pathophysiology of headache chronicity, with others focusing on the evaluation of risk factors. The International Headache Society revised its classification criteria on MOH. Several large population-based longitudinal studies clearly demonstrated that overuse of any kind of acute headache medication is the main risk factor leading to the development of chronic headache. Management of MOH remains difficult; the only effective treatment concept is consequent withdrawal therapy.

Instrumental exams performance can be a contributing factor to the delay in diagnosis of migraine

BACKGROUND

Diagnostic delay is a recognized drawback for a correct management of migraine patients. The aim of this study was to investigate the possible relationship among number and type of examinations performed and diagnostic delay in migraine diagnosis.

METHODS

We enrolled 500 subjects referred to our Headache Center for a migraine without aura. We analyzed the relationship among diagnostic delay, number of examinations performed and performance of each single test by a Cox regression model and an ordinal logistic regression model.

RESULTS

Each individual exam increased a diagnostic delay of at least 12 months (p < 0.05, Cox regression model). Brain CT as the first diagnostic approach had a reduced risk of delay of more than 5 years (OR 0.632, 95% CI 0.71-0.56, p < 0.05, ordinal regression model).

CONCLUSIONS

The number of instrumental examinations seems to significantly influence the diagnostic delay. This aspect contributes to increase health care costs, the risk of pain chronicization and pharmacological treatment misuse.

Medication-overuse headache

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is a well described clinical entity. There is a growing body of knowledge on the epidemiology of MOH, risk factors, and treatment strategies.

RECENT FINDINGS

The International Headache Society updated the classification criteria for MOH. Population-based studies provided an insight into the prevalence and peculiarities of MOH patients in eastern Europe and Asia. Large-scaled population-based longitudinal studies made it possible to analyze risk factors leading to the development of MOH. Imaging studies helped to better understand the pathophysiology of headache chronicity. New treatment strategies have been suggested.

SUMMARY

MOH is a common headache disorder and a serious public health problem all over the world. Although the treatment regimen for MOH patients is straightforward and the outcomes are favorable, it is time now to move forward and establish a predictive model for early recognition of patients at high risk, to intervene early and avoid development of chronic headache.

Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review

BACKGROUND

Case definitions of medication-overuse headache (MOH) in population-based research have changed over time. This study aims to review MOH prevalence reports with respect to these changes, and to propose a practical case definition for future studies based on the ICHD-3 beta.

METHODS

A systematic literature search was conducted to identify MOH prevalence studies. Findings were summarized according to diagnostic criteria.

RESULTS

Twenty-seven studies were included. The commonly used case definition for MOH was headache ≥15 days/month with concurrent medication overuse ≥3 months. There were varying definitions for what was considered as overuse. Studies that all used ICHD-2 criteria showed a wide range of prevalence among adults: 0.5%-7.2%.

CONCLUSIONS

There are limits to comparing prevalence of MOH across studies and over time. The wide range of reported prevalence might not only be due to changing criteria, but also the diversity of countries now publishing data. The criterion "headache occurring on ≥15 days per month" with concurrent medication overuse can be applied in population-based studies. However, the new requirement that a respondent must have "a preexisting headache disorder" has not been previously validated. Exclusion of other headache diagnoses by expert evaluation and ancillary examinations is not feasible in large population-based studies.

Improving quality in population surveys of headache prevalence, burden and cost: key methodological considerations

Population-based studies of headache disorders are important. They inform needs assessment and underpin service policy for a set of disorders that are a public-health priority. On the one hand, our knowledge of the global burden of headache is incomplete, with major geographical gaps; on the other, methodological differences and variable quality are notable among published studies of headache prevalence, burden and cost. The purpose here was to start the process of developing standardized and better methodology in these studies. An expert consensus group was assembled to identify the key methodological issues, and areas where studies might fail. Members had competence and practical experience in headache epidemiology or epidemiology in general, and were drawn from all WHO world regions. We reviewed the relevant literature, and supplemented the knowledge gathered from this exercise with experience gained from recent Global Campaign population-based studies, not all yet published. We extracted methodological themes and identified issues within them that were of key importance. We found wide variations in methodology. The themes within which methodological shortcomings had adverse impact on quality were the following: study design; selection and/or definition of population of interest; sampling and bias avoidance; sample size estimation; access to selected subjects (managing and reporting non-participation); case definition (including diagnosis and timeframe); case ascertainment (including diagnostic validation of questionnaires); burden estimation; reporting (methods and results). These are discussed.

Probable medications overuse headaches: validation of a brief easy-to-use screening tool in a headache centre

BACKGROUND

To validate a rapid questionnaire as a screening tool, because application of the diagnostic revised criteria of the ICHD-II for medication overuse headache (MOH) requires experience for the physician and is time-consuming.

METHODS

ICHD-II criteria for probable MOH (pMOH) were transformed in questions formulated in such a way that they could be self-administered, easily understood, and quickly filled out. We compared this questionnaire to the gold standard: the diagnosis made by headache specialists, based on the the ICHD-II criteria. Patients who were consulting for pMOH or migraine for the first time were consecutively included. As validity indicators, we calculated sensitivity, specificity, positive and negative predictive values of the items.

RESULTS

Seventy-nine patients were screened, 77 included, 2 female patients excluded. Forty-two patients have been considered as suffering from pMOH, 35 patients suffered from migraine without medication overuse. The association of the question "do you take a treatment for attacks more than 10 days per month" and the question "is this intake on a regular basis?" had a sensitivity of 95.2% and a specificity of 80%.

CONCLUSION

This screening tool can detect pMOH with a sensitivity that could be of interest to screen patients in clinical practice and to pre-include patients for research as epidemiological studies.

Medication Overuse Headache: The Reason of Headache That Common and Preventable

Medication overuse headache (MOH) is well-defined clinically and is one of the common reasons of chronic daily headache, but its pathophysiology has not been elucidated yet. MOH has varying clinical features in regard to regional, psychosocial, medical and economic factors. Even though, the studies have shown that many factors may play a role, MOH is likely to occur in patients who are prone to primary headaches. Mainstay of the treatment is to withdraw the excessively used analgesic drugs. The primary prevention with education of the patients as well as early diagnosis and treatment of MOH will reduce its increasing financial burden on both patients and countries. Meticulous and multifactorial evaluation of the disease besides the diagnosis and treatment of the comorbid diseases will reduce the risk of recurrences.