Medication overuse headache

The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice

OBJECTIVE

To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults.

BACKGROUND

The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline.

METHODS

This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement.

RESULTS

Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation).

CONCLUSIONS

The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.

The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice

OBJECTIVE

To provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults.

BACKGROUND

The principles of preventive and acute pharmacotherapy for patients with migraine have been outlined previously, but the emergence of new technologies and treatments, as well as new formulations of previously established treatments, has created a need for an updated guidance on the preventive and acute treatment of migraine.

METHODS

This statement is based on a review of existing guidelines and principles for preventive and acute treatment of migraine, as well as the results of recent clinical trials of drugs and devices for these indications. Input was sought from health insurance providers, employers, pharmacy benefit service companies, device manufacturers, pharmaceutical and biotechnology companies, patients, and patient advocates. Expert clinicians and researchers in the field of headache medicine from across North America and the European Union provided input and feedback.

RESULTS

The principles of pharmacologic preventive treatment of migraine with oral treatments have been as follows: use evidence-based treatments when possible and appropriate; start with a low dose and titrate slowly; reach a therapeutic dose if possible; allow for an adequate treatment trial duration; establish expectations of therapeutic response and adverse events; and maximize adherence. Newer injectable treatments may work faster and may not need titration. The principles of acute treatment include: use evidence-based treatments when possible and appropriate; treat early after the onset of a migraine attack; choose a nonoral route of administration for selected patients; account for tolerability and safety issues; consider self-administered rescue treatments; and avoid overuse of acute medications. Neuromodulation and biobehavioral therapy may be appropriate for preventive and acute treatment, depending on the needs of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy.

CONCLUSIONS

This statement updates prior recommendations and outlines the indications for initiating, continuing, combining, and switching preventive and acute treatments of migraine.

Integrated care for chronic migraine patients: epidemiology, burden, diagnosis and treatment options

Migraine is a common neurological disorder, characterised by severe headaches. Epidemiological studies in the USA and Europe have identified a subgroup of migraine patients with chronic migraine. Chronic migraine is defined as ≥15 headache days per month for ≥3 months, in which ≥8 days of the month meet criteria for migraine with or without aura, or respond to treatment specifically for migraine. Chronic migraine is associated with a higher burden of disease, more severe psychiatric comorbidity, greater use of healthcare resources, and higher overall costs than episodic migraine (<15 headache days per month). There is a strong need to improve diagnosis and therapeutic treatment of chronic migraine. Primary care physicians, as well as hospital-based physicians, are integral to the identification and treatment of these patients. The latest epidemiological data, as well as treatment options for chronic migraine patients, are reviewed here.

Proposal of a model for multidisciplinary treatment program of chronic migraine with medication overuse: preliminary study

The treatment of patients with chronic migraine associated with medication overuse is challenging in clinical practice; different strategies of treatment have been recently developed, multidisciplinary treatment approaches have been developed in academic headache centers. Education and support of patients are necessary to improve patients' adherence to pharmacological treatments as well as to non-pharmacological therapies. This study reports a clinical experience conducted at our Headache center with a group of female patients, suffering from chronic migraine complicated by medication overuse, treated by a multidisciplinary approach and followed for a period of 1 year after withdrawal. Results confirm the efficacy of a multifaceted treatment to manage this problematic category of 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.

Latin American consensus on guidelines for chronic migraine treatment

Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine.

Reduction of current migraine headache pain following neck massage and spinal manipulation

BACKGROUND

Migraine headache significantly impacts the health of individuals and of society. The application of simple physical nonpharmacological techniques could greatly reduce the therapeutic costs and side effects in acute onset of such headaches.

METHODS

Ten male patients (mean age was 32.0 ± 10.59 years) with acute onset of a migraine headache according to IHS-2004 diagnostic criteria were enrolled in the study. Neck and upper thoracic spine massage and manipulation technique was performed. Headache pain intensity was assessed before and after the intervention by means of a verbal analog scale.

RESULTS

Following treatment, headache pain intensity was significantly reduced compared to the pretreatment values (1.85 ± 1.11 vs. 5.80 ± 2.25, p = .005). As a percentage, this represents a mean pain reduction of 68.77% ± 18.56. No side effects were observed, and all of the patients reported satisfaction with the intervention.

CONCLUSION

Our results show that the applied cervical and upper thoracic massage and manipulation technique could reduce the headache attack pain intensity in patients with migraine headaches, though further testing, including study designs that make use of control groups, is needed.

Dependence scores predict prognosis of medication overuse headache: a prospective cohort from the Akershus study of chronic headache

Medication overuse headache (MOH) is a chronic headache that is common in the general population. It has characteristics similar to drug dependence, and detoxification is established as the main treatment. The majority of MOH cases are in contact with general practitioners. Our objective was to investigate whether the Severity of Dependence Scale (SDS) score could be used as predictor for the prognosis of MOH in the general population. In a cross-sectional epidemiological survey, an age- and gender-stratified sample of 30,000 persons 30 to 44 years of age was recruited via a posted questionnaire. Those individuals with self-reported chronic headache (≥15 days per month) were interviewed by neurological residents at Akershus University Hospital, Oslo. The International Classification of Headache Disorders was used. Those with MOH were re-interviewed by telephone 2 to 3 years after the initial interview. SDS scores and medication information were collected at baseline and follow-up. The main outcomes were SDS scores, termination of MOH and chronic headache from baseline to follow-up. We found the predominant overused analgesics in this sample to be simple analgesics. At follow-up, 65% of participants no longer had medication overuse, and 37% had changed to episodic headache (<15 days per month). The SDS score at baseline successfully predicted improvement for primary MOH, but not secondary MOH. The SDS scores decreased slightly from baseline to follow-up in those who stopped medication overuse, but were still significantly higher than in subjects with chronic headache without medication overuse at baseline. We conclude that the SDS score can predict successful prognosis related to detoxification of primary MOH but not in secondary MOH.

Proteomic analysis of urine in medication-overuse headache patients: possible relation with renal damages

Medication-overuse headache (MOH) is a chronic disorder associated with overuse of analgesic drugs, triptans, non-steroidal anti-inflammatory drugs (NSAIDs) or other acute headache compounds. Various epidemiologic investigations proved that different drug types could cause nephrotoxicity, particularly in chronic patients. The aim of the present work was to analyze, by a proteomic approach, the urinary protein profiles of MOH patients focusing on daily use of NSAIDs, mixtures and triptans that could reasonably be related to potential renal damage. We selected 43 MOH patients overusing triptans (n = 18), NSAIDs (n = 11), and mixtures (n = 14), for 2–30 years with a mean daily analgesic intake of 1.5 ± 0.9 doses, and a control group composed of 16 healthy volunteers. Urine proteins were analyzed by mono-dimensional gel electrophoresis and identified by mass spectrometry analysis. Comparing the proteomic profiles of patients and controls, we found a significantly different protein expression, especially in the NSAIDs group, in which seven proteins resulted over-secreted from kidney (OR = 49, 95% CI 2.53–948.67 vs. controls; OR = 11.6, 95% CI 0.92–147.57 vs. triptans and mixtures groups). Six of these proteins (uromodulin, α-1-microglobulin, zinc-α-2-glycoprotein, cystatin C, Ig-kappa-chain, and inter-α-trypsin heavy chain H4) were strongly correlated with various forms of kidney disorders. Otherwise, in mixtures and in triptans abusers, only three proteins were potentially associated to pathological conditions (OR = 4.2, 95% CI 0.33–53.12, vs. controls). In conclusion, this preliminary proteomic study allowed us to define the urinary protein pattern of MOH patients that is related to the abused drug. According with the obtained results, we believe that the risk of nephrotoxicity should be considered particularly in MOH patients who abuse of NSAIDs.

Clinical outcome of a headache-specific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study

This study investigated the outcome of a 5-day headache-specific multidisciplinary treatment program (MTP) and the adherence to treatment recommendations in 295 prospectively recruited consecutive headache patients [210 migraine, 17 tension-type headache (TTH), 68 combination headache, including 56 medication-overuse headache (MOH)]. Headache frequency decreased from 13.4 (±8.8) to 8.8 (±8.0) days per month after 12–18 months. Forty-three percent of the participants fulfilled the primary outcome (reduction of headache frequency of ≥50%), which was less likely in patients with combination of migraine and TTH compared to migraine (OR = 3.136, p = 0.002) or TTH (OR = 1.029, n.s.). Increasing number of headache days per month (OR = 1.092, p ≤ 0.0001) and adherence to lifestyle modifications (OR = 1.269, p = 0.004) predicted primary outcome. 51 of 56 MOH patients were treated successfully. Thirty-five percent of the patients were adherent to pharmacological prophylaxis, 61% to relaxation therapy, and 72% to aerobic endurance sports. MTP is effective in headache treatment. Adherence to therapy was associated with better outcome.

Effectiveness of aripiprazole for medication overuse headache: a case report

Aripiprazole, a dopamine D2 receptor partial agonist, has been used to treat schizophrenia and might be effective for alcohol dependence and craving. We treated a 53-year-old woman with refractory medication overuse headache, which was successfully treated with aripiprazole. Our experience suggests that aripiprazole may be effective for patients with medication overuse headache.

Prevalence of parafunctional habits and temporomandibular dysfunction symptoms in patients attending a tertiary headache clinic

OBJECTIVE

To investigate the most prevalent forms of headache in a tertiary outpatient service, and to assess the frequency of associated parafunctional habits and temporomandibular dysfunction symptoms (TMD).

METHOD

All new patients referred to the Headache Outpatient Service in UNIMES during 2008 were prospectively assessed by the neurologist and the dental surgeon.

RESULTS

Eighty new patients were assessed; chronic migraine and episodic migraine without aura were the most prevalent conditions, accounting for 66.3% of all cases. There was significantly higher use of analgesics/days for the chronic migraine patients. The prevalence of parafunctional habits was 47.5% and the prevalence of TMD symptoms was 35%.

CONCLUSION

The high prevalence of primary headaches, parafunctional habits and TMD symptoms and the inadequate use of analgesic drugs suggest that primary healthcare units need further training in the field of headache and orofacial pain.

Genomic expression patterns in medication overuse headaches

BACKGROUND

Chronic daily headache (CDH) and chronic migraine (CM) are one of the most frequent problems encountered in neurology, are often difficult to treat, and frequently complicated by medication-overuse headache (MOH). Proper recognition of MOH may alter treatment outcome and prevent long term disability.

OBJECTIVE

This study identifies the unique genomic expression pattern MOH that respond to cessation of the overused medication.

METHODS

Baseline occurrence of MOH and typical pattern of response to medication cessation were measured from a large database. Whole blood samples from patients with CM with or without MOH were obtained and their genomic profile was assessed. Affymetrix human U133 plus2 arrays were used to examine the genomic expression patterns prior to treatment and 6-12 weeks later. Headache characterisation and response to treatment based on headache frequency and disability were compared.

RESULTS

Of 1311 patients reporting daily or continuous headaches, 513 (39.1%) reported overusing analgesic medication. At follow-up, 44.5% had a 50% or greater reduction in headache frequency, while 41.6% had no change. Blood genomic expression patterns were obtained on 33 patients with 19 (57.6%) overusing analgesic medication with a unique genomic expression pattern in MOH that responded to cessation of analgesics. Gene ontology of these samples indicated a significant number were involved with brain and immunological tissues, including multiple signalling pathways and apoptosis.

CONCLUSIONS

Blood genomic patterns can accurately identify MOH patients that respond to medication cessation. These results suggest that MOH involves a unique molecular biology pathway that can be identified with a specific biomarker.