[Medication overuse headache]

Medication overuse headache (MOH) is a globally prevalent and debilitating condition that results from excessive use of acute therapies and can significantly affect quality of life, despite the fact that simple information about the causes and consequences of the condition can help prevent or stop MOH. In recent years, many new insights have been gained into headaches caused by medication overuse. In addition, the diagnostic criteria and guideline recommendations have changed considerably. This article provides a comprehensive overview of the clinic, definition/classification, epidemiology, risk factors, pathophysiology, controversies, prevention, and treatment of MOH.

Association between Body Mass Index and Medication-Overuse Headache among Individuals with Migraine: A Cross-Sectional Study

INTRODUCTION

Medication-overuse headache (MOH) is a secondary chronic headache disorder that occurs in individuals with a pre-existing primary headache disorder, particularly migraine disorder. Obesity is often combined with chronic daily headaches and is considered a risk factor for the transformation of episodic headaches into chronic headaches. However, the association between obesity and MOH among individuals with migraine has rarely been studied. The present study explored the association between body mass index (BMI) and MOH in people living with migraine.

METHODS

This cross-sectional study is a secondary analysis of data from the Survey of Fibromyalgia Comorbidity with Headache study. Migraine and MOH were diagnosed using the criteria of the International Classification of Headache Disorders, 3rd Edition. BMI (kg/m2) is calculated by dividing the weight (kg) by the square of the height (m). Multivariable logistic regression analysis was used to evaluate the association between BMI and MOH.

RESULTS

A total of 2,251 individuals with migraine were included, of whom 8.7% (195/2,251) had a concomitant MOH. Multivariable logistic regression analysis, adjusted for age, sex, education level, headache duration, pain intensity, headache family history, chronic migraine, depression, anxiety, insomnia, and fibromyalgia, demonstrated there was an association between BMI (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.11; p = 0.031) and MOH. The results remained when the BMI was transformed into a category. Compared to individuals with Q2 (18.5 kg/m2 ≤ BMI ≤23.9 kg/m2), those with Q4 (BMI ≥28 kg/m2) had an adjusted OR for MOH of 1.81 (95% CI, 1.04-3.17; p = 0.037). In the subgroup analyses, BMI was associated with MOH among aged more than 50 years (OR, 1.13; 95%, 1.03-1.24), less than high school (OR, 1.08; 95%, 1.01-1.15), without depression (OR, 1.06; 95%, 1.01-1.12), and without anxiety (OR, 1.06; 95%, 1.01-1.12). An association between BMI and MOH was found in a sensitivity analysis that BMI was classified into four categories according to the World Health Organization guidelines.

CONCLUSION

In this cross-sectional study, BMI was associated with MOH in Chinese individuals with migraine.

Medication-overuse headache: A pharmacovigilance study in France

BACKGROUND

Overusing medication for primary headaches or other medical conditions can lead to dependency and medication-overuse headache (MOH) as an adverse drug reaction (ADR).

OBJECTIVES

To analyse reports of ADRs associated with MOH recorded in the French national pharmacovigilance database (FPVD).

METHODS

This retrospective study selected all MOH cases reported in the FPVD from January 2000 to June 2023. A search of the High-Level Group Term "headache" was performed for drugs classified under ATC codes for the musculoskeletal and nervous systems. Specific keywords were searched in report narratives to further reduce their number. Voluntary intoxication reports were excluded. Only MOH cases according to the International Classification of Headache Disorders or with a medical diagnosis of MOH were considered.

RESULTS

Among the 2674 reports associated with the HLGT "headache", for 649 ATC drug codes, only 234 reports correspond to MOH, primarily notified by physicians. The median age was 45 years (IQR: 32-56), with 74.4% females and approximately 61.0% having pre-existing primary headaches. In all, 53.4% of the reports were classified as serious. Among patients, 84.2% had an isolated "headache" as the ADR. One drug was suspected in 47.4% of cases, two drugs in 29.1%, and three or more in 23.5%. In total, 473 suspected drugs, corresponding to 104 active ingredients, were involved, including analgesics (63.0%), in particular, acetaminophen-containing drugs, opioids, triptans and ergots, and non-steroidal anti-inflammatory drugs (12.7%). Antiepileptics and psycholeptics were found in 6.6% and 6.1% of cases, respectively. Drug withdrawal was successful in 84.6% of drug-discontinuation cases. Warnings about MOH are mentioned in the summary of product characteristics (SmPCs) for triptans, ergots, and certain acetaminophen-containing drugs, but not other drug classes.

CONCLUSIONS

Certain drug classes show a high reporting rate of MOH and caution should be exercised when prescribing these drugs. Notably, warnings about MOH must be mentioned in the SmPC of all concerned drug classes.

Burden of Medication Overuse in Migraine: A Cross-sectional, Population-Based Study in Five European Countries Using the 2020 National Health and Wellness Survey (NHWS)

INTRODUCTION

Overuse of medication to treat migraine attacks can lead to development of a new type of headache or significant worsening of pre-existing headache, known as medication overuse headache. However, data concerning the burden of medication overuse (MO) in migraine are limited. This study aimed to assess the humanistic burden of MO in individuals with migraine from five European countries.

METHODS

Data are from the 2020 National Health and Wellness Survey-a cross-sectional, population-based survey conducted in France, Germany, Italy, Spain, and the UK. Data were included from adults (≥ 18 years) with a self-reported diagnosis of migraine and at least one migraine attack and one headache in the past 30 days. MO was defined as (i) use of simple analgesics/over-the-counter medications on ≥ 15 days/month; or (ii) use of migraine medication, including combination analgesics, on ≥ 10 days/month. Humanistic burden of MO was assessed using the 12-Item Short-Form Health Survey (SF-12v2), EuroQol 5-Dimensions 5-Levels (EQ-5D), Short-Form 6-Dimensions (SF-6D), and Migraine Disability Assessment (MIDAS). The association of MO with humanistic burden was evaluated using generalized linear models adjusted for potential confounders in the full migraine population and in subgroups defined by headache frequency (monthly headache days [MHDs] 1-3, 4-7, 8-14, or ≥ 15).

RESULTS

Among individuals with migraine, humanistic burden (SF-12v2, SF-6D, EQ-5D, and MIDAS) was higher in individuals who reported MO (n = 431) versus no MO (n = 3554), even after adjustment for confounding variables (p < 0.001 for all measures). MIDAS and EQ-5D scores were higher in individuals with MO than without, at all levels of headache frequency. For SF-12v2 and SF-6D, differences between groups with/without MO were seen only at lower levels of headache frequency (MHD 1-3 and 4-7).

CONCLUSION

Among people with migraine, those who report MO face a greater humanistic burden than those without MO, irrespective of headache frequency.

Update of Gepants in the Treatment of Chronic Migraine

PURPOSE OF REVIEW

Despite the unmet therapeutic needs of patients with chronic migraine (CM) and/or medication overuse, available treatment options are limited. Recently, four calcitonin gene-related peptide receptor antagonists, known as gepants, have been approved for the treatment of migraine. This review focuses on the preventive treatment of CM with gepants and highlights recent findings.

RECENT FINDINGS

Two randomized controlled trials (RCTs) have shown promising results for rimegepant and atogepant as preventive treatments for CM. In an RCT targeting patients with CM, atogepant demonstrated a significant reduction in the mean monthly migraine days, irrespective of acute medication overuse. Moreover, the patients reported no significant safety concerns and exhibited good tolerance to treatment. These findings highlight the potential of gepants as a new and effective therapeutic option for patients with CM and/or medication overuse. Gepant use will help improve the management and quality of life of individuals with this debilitating condition.

Evaluation of Headache Trends among Undergraduate First Responders for Medical Emergencies at Saudi University in Riyadh, Saudi Arabia

Background and objective: Headache is more common among students and may be a crucial indication of mental health; it can have a detrimental impact if left untreated, especially on students, and may affect their academic performance. Thus, this study aimed to assess the headache trends among undergraduate first responders for medical emergencies at Saudi University in Riyadh, Saudi Arabia. Method: A cross-sectional study was undertaken over three months in 2023 to analyze headache patterns among emergency medical services (EMS) students using prevalidated questionnaires. The data were collected via convenience sampling and processed with the IBM SPSS Statistics 26 program (IBM Inc., Chicago, IL, USA). Results: The current findings show that the majority 90.6% (n = 164) of the participants had at least one episode of headache in the last week. With regard to the number of days students had a headache during the last week, 21.5% (n = 39) of them reported 2 days, while 18.8% (n = 34) reported 1 day only. About slightly less than half (48.6% (n = 88)) of students reported that the usual site of the headache was frontal, followed by temporal 27.1% (n = 49), and 23.3% (n = 42) reported orbital. When students were asked whether a headache aggravates their routine activity, 40.3% agreed with this statement, and 44.2% of students reported that a headache causes them to avoid their routine activity (reading writing, attending college). The majority of the students considered taking analgesics (60.8%), followed by sleeping (26.5%), caffeine (14.4%), and herbal and alternative remedies (7.7%) for the relief of headaches. Although headache episodes were significantly associated with routine activities (reading writing, attending college) (p = 0.018, t = 2.282) daily activities (walking, running) (p = 0.022, t = 2.307). The findings showed that fourth-year EMS students were found to have higher headache pain intensity scores compared to other students (p = 0.046). Similarly, the pain intensity was significantly higher among the students between 1-3 and >7 episodes of headaches (p = 0.001) Conclusion: The findings of this study revealed that Saudi emergency medical services students suffer from headaches. However, the current findings revealed variation in the headache pain intensity scores concerning the year of study.

Medication overuse headache: a review of current evidence and management strategies

The third edition of the International Classification of Headache Disorders (ICHD-3) defines medication-overuse headache (MOH) as a headache that develops when a person regularly uses acute or symptomatic headache medications excessively (10 or more, or 15 or more days per month, depending on the medication) for a period of time longer than 3 months. Even though it may not be reported as frequently as it actually is, it affects about 5% of the general population on average. It typically happens following repeated anti-pain medication use for pre-existing headache disorders, such as migraines. Anti-pains can also be used frequently in patients with pre-existing headache disorders for reasons other than treating headaches, such as psychological drug attachment. MOH is linked to a number of illnesses, such as anxiety, depression, and obsessive compulsive disorder (OCD). Both simple and complex types are possible. Additionally, there is no universal consensus on how to treat MOH, but drug discontinuation is the best course of action. Using the medical subject headings "Medication Overuse Headache," "Migraine Headache," "Tension Headache," "Chronification of Headache," and "Antipains," an all-language literature search was done on PubMed, Google Scholar, and Medline up until March 2023. We looked into the epidemiology, risk factors, pathophysiology, clinical characteristics, comorbidities, diagnosis, management, and preventative measures of MOH in the literature. This article focuses on the MOH research themes.

The prevalence and burden of medication overuse headache in Greece

OBJECTIVE

To estimate the prevalence and burden of medication overuse headache in a representative sample of the Greek population, aged 18-70 years old.

METHODS

This is a cross-sectional descriptive observational study performed by quantitative computer-assisted telephone interviews, using a standardized 37-item questionnaire for headaches. The prevalence of medication overuse headache was estimated in the general population and compared within the groups formed by factors such as age, gender, diagnosis of headache type, prophylactic treatment used, geographical regions, social class, workdays lost and loss of productivity.

RESULTS

1197 (12.0%) participants reported headaches affecting performance out of 10,008 interviewees. The estimated prevalence of medication overuse headache in the general population was 0.7% (95% CI: 0.5-0.9). The female to male ratio was 3.6:1. The proportion of medication overuse headache was largest in the 35-54 age group, followed by the over 55 group. The Aegean islands and Crete were the regions with the highest proportion of medication overuse headache. Among participants with headaches, the proportion of medication overuse headache was 5.8% (95% CI: 4.4%-7.1%); 6.3% (95% CI: 4.7%-7.9%) among females and 4.4% (95% CI: 2.2%-6.6%) among males. In the same headache group, the proportion of medication overuse headache by prophylactic treatment for headache was 19.0% (95% CI: 9.5%-29.1%) for recipients and 5.0% (95% CI: 3.8-6.3) for non-recipients. The mean absenteeism in people with medication overuse headache was 1.0 days/month (95% CI: 0.4-1.6) and the mean presenteeism 6.3 days/month (95% CI: 3.9-8.7). The social class stratification showed a significant effect between the medication overuse headache in the sample of the general population and the C2 class, corresponding to skilled manual labour (OR: 0.7, CI: 0.5-0.9). In people with chronic migraine, and chronic tension type headache, as differentiated by the 37-item questionnaire, the proportion of medication overuse headache in the headache group estimated to be 50.5% (95% CI: 40.8%-60.1%) and 45.9%, (95% CI: 29.9%-62.0%) respectively. The group of people with acute headache medication overuse fulfilling the rest of the diagnostic criteria for medication overuse headache, except from the number of headache days per month (≥15 days/month), had a prevalence of 2.0% (95% CI: 1.75-2.30) and a proportion of 17.0% (95% CI: 14.8%-19.1%) among people with headache. In the episodic types of headache, the proportion of acute headache medication overuse was higher in the subgroup of people with high frequency episodic migraine, 24.9% (95% CI: 18.8%-31.0%), while it was 10.8% (95% CI: 8.2%-13.5%), for the low frequency episodic migraine and 8.5% (95% CI: 5.5%-10.4%), for the episodic tension type headache.

CONCLUSION

The prevalence of medication overuse headache in the general population in Greece and its proportion among the people with headache belongs to the lower part of the range of the reported literature, while the 3.6:1 female to male ratio is in agreement with it. In the same line, the impact of absenteeism and presenteeism on the workplace renders the condition alarming socio-economic health problem demanding immediate health policy planning.

[Headache in the general practice]

Headaches are one of the most frequent causes of consultations in general practice. Of more than 350 known headache tendencies, tension-type headache and migraine are particularly common in general practice. Medication overuse headache (MOH) is also common but rarely diagnosed. The medical consultation with a targeted anamnesis is the cornerstone of the diagnosis and correct classification. A detailed neurological examination completes the basic diagnosis. Additional laboratory and instrumental diagnostics follow in cases of atypical headache or clinical suspicion of secondary headache. This article focuses on the diagnosis and treatment of Tension-type Headache, migraine and Medication Overuse Headache.

Effects of Botulinum Toxin Type A on the Nociceptive and Lemniscal Somatosensory Systems in Chronic Migraine: An Electrophysiological Study

(1) Background: OnabotulinumtoxinA (BoNT-A) is a commonly used prophylactic treatment for chronic migraine (CM). Although randomized placebo studies have shown its clinical efficacy, the mechanisms by which it exerts its therapeutic effect are still incompletely understood and debated. (2) Methods: We studied in 15 CM patients the cephalic and extracephalic nociceptive and lemniscal sensory systems using electrophysiological techniques before and 1 and 3 months after one session of pericranial BoNT-A injections according to the PREEMPT protocol. We recorded the nociceptive blink reflex (nBR), the trigemino-cervical reflex (nTCR), the pain-related cortical evoked potential (PREP), and the upper limb somatosensory evoked potential (SSEP). (3) Results: Three months after a single session of prophylactic therapy with BoNT-A in CM patients, we found (a) an increase in the homolateral and contralateral nBR AUC, (b) an enhancement of the contralateral nBR AUC habituation slope and the nTCR habituation slope, (c) a decrease in PREP N-P 1st and 2nd amplitude block, and (d) no effect on SSEPs. (4) Conclusions: Our study provides electrophysiological evidence for the ability of a single session of BoNT-A injections to exert a neuromodulatory effect at the level of trigeminal system through a reduction in input from meningeal and other trigeminovascular nociceptors. Moreover, by reducing activity in cortical pain processing areas, BoNT-A restores normal functioning of the descending pain modulation systems.

Real-World Evaluation of the Tolerability to Onabotulinum Toxin A: The RETO Study

Onabotulinumtoxin A (onabotA) has shown efficacy in chronic migraine (CM), with good tolerability and a low rate of adverse effects, most of them not severe. The aim of this study is to evaluate tolerability and adverse effects of onabotA in clinical practice and to analyze if there is a relationship between tolerability to treatment administration, adverse effects' (AEs) occurrence and clinical response. We included patients with CM that received treatment with onabotA for the first time. Tolerability to treatment was evaluated by a 0-10 numeric rating scale (0: worst possible, 10: optimal tolerability). We assessed the presence of AEs by using a standardized questionnaire. Treatment response was based on the 50 and 75% responder rate between weeks 20 and 24, compared with the baseline, according to headache diaries. We analyzed whether the tolerability was associated with a higher frequency of AEs or a higher probability of clinical response. We included 105 patients, 87.7% female, with an age of 43.9 ± 10.7 years. Mean tolerability was 7.8/10 and 7.2/10 in the first and second onabotA administration, respectively. AEs were reported by (first-second) 71.4-68.6% patients. The percentage of patients with a 50% response was 56.3%. There was no association between tolerability and AEs' occurrence or clinical response.

Management of medication overuse (MO) and medication overuse headache (MOH) S1 guideline

Introduction

Chronic headache due to the overuse of medication for the treatment of migraine attacks has a prevalence of 0.5–2.0%. This guideline provides guidance for the management of medication overuse (MO) and medication overuse headache (MOH).

Recommendations

Treatment of headache due to overuse of analgesics or specific migraine medications involves several stages. Patients with medication overuse (MO) or medication overuse headache (MOH) should be educated about the relationship between frequent use of symptomatic headache medication and the transition from episodic to chronic migraine (chronification), with the aim of reducing and limiting the use of acute medication. In a second step, migraine prophylaxis should be initiated in patients with migraine and overuse of analgesics or specific migraine drugs. Topiramate, onabotulinumtoxinA and the monoclonal antibodies against CGRP or the CGRP-receptor are effective in patients with chronic migraine and medication overuse. In patients with tension-type headache, prophylaxis is performed with amitriptyline. Drug prophylaxis should be supplemented by non-drug interventions. For patients in whom education and prophylactic medication are not effective, pausing acute medication is recommended. This treatment can be performed in an outpatient, day hospital or inpatient setting. Patients with headache due to overuse of opioids should undergo inpatient withdrawal. The success rate of the stepped treatment approach is 50–70% after 6 to 12 months. A high relapse rate is observed in patients with opioid overuse. Tricyclic antidepressants, neuroleptics (antiemetics) and the administration of steroids are recommended for the treatment of withdrawal symptoms or headaches during the medication pause. Consistent patient education and further close monitoring reduce the risk of relapse.

Refractory Headaches

Medication overuse headache (MOH), new daily persistent headache (NDPH), and persistent refractory headache attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection represent a significant burden in terms of disability and quality of life, and a challenge in terms of definition, pathophysiology, and treatment. Regarding MOH, prevention without withdrawal is not inferior to prevention with withdrawal. Preventive medications like topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP) monoclonal antibodies improve chronic migraine with MOH regardless of withdrawal. The differential diagnosis of NDPH is broad and should be carefully examined. There are no guidelines for the treatment of NDPH, but options include a short course of steroids, nerve blocks, topiramate, nortriptyline, gabapentin, CGRP monoclonal antibodies, and onabotulinumtoxinA. The persistence of headache 3 months after SARS-CoV2 infection is a predictor of poor prognosis.

A Digital Therapeutic Allowing a Personalized Low-Glycemic Nutrition for the Prophylaxis of Migraine: Real World Data from Two Prospective Studies

Migraine is a headache disorder associated with a high socioeconomic burden. The digital therapeutic sinCephalea provides an individualized low-glycemic diet based on continuous glucose measurement and is intended to provide a non-pharmacological migraine prophylaxis. We performed two prospective studies with migraine patients who used sinCephalea over a period of 16 weeks. The patients used a headache diary and recorded their migraine-related daily life impairments using the assessment tools HIT-6 and MIDAS for a pre versus post comparison. In addition, continuous glucose data of patients were compared to healthy controls. In both studies, patients reported a reduction of headache and migraine days as well as reductions in HIT-6 and MIDAS scores. More specifically, migraine days decreased by 2.40 days (95% CI [−3.37; −1.42]), HIT-6 improved by 3.17 points (95% CI [−4.63; −1.70]) and MIDAS by 13.45 points (95% CI [−22.01; −4.89]). Glucose data suggest that migraine patients have slightly increased mean glucose values compared to healthy controls, but drop into a glucose range that is below one’s individual standard range before a migraine attack. In conclusion, sinCephalea is a non-pharmacological, digital migraine prophylaxis that induces a therapeutic effect within the range of pharmacological interventions.

Prevention of medication overuse and medication overuse headache in patients with migraine: a randomized, controlled, parallel, allocation-blinded, multicenter, prospective trial using a mobile software application

Background

Overall, 55% of the German population suffers from primary episodic headaches according to recent studies. Inadequate management of headache disorders is a significant medical problem. The prevalence of medication overuse headache (MOH) is about 1% with an estimated number of 800,000 people in Germany. Medication overuse (MO) and MOH are usually managed through a complex process of medication withdrawal and initiating of prophylaxis. However, patients who were successfully treated for MO or MOH have a high relapse rate in the following 2 years. Previously, continued monitoring of self-reported medication intake demonstrated lower relapse rates. The prevalence and burden of MO and MOH are high, and effective strategies to prevent the development of a relapse into MOH or de novo MOH are still missing. Therefore, the MOH trial was designed to assess the effects of combining self-reported medication intake with daily monitoring of the entered data and a personalized patient-specific medication intake feedback system in an easy-accessible app-based platform in order to prevent the development and relapse of MO(H).

Methods

The MOH trial is a randomized, controlled, parallel, multicenter, prospective trial. A total of 624 migraine patients with frequent migraine attacks and 336 patients who underwent treatment for MO(H) will be randomly allocated to use either a customized app with or without individual feedback regarding their self-reported medication intake for 12 months. The primary outcome will be the proportion of patients developing MO or MOH for at least 3 consecutive months between baseline and end of study visits.

Discussion

This trial will assess the effects of providing patients with feedback regarding their self-reported use of migraine medications and migraine days using a mobile software on the development or prevention of MO(H). We hypothesize that the development of MO(H) in patients with frequent episodic migraine (EM) or chronic migraine (CM) and relapse after treatment of MO(H) can be reduced by a feedback system. If this trial proves that using an app with specific and unspecific messaging to the patient is successful, this method, which is now investigated mainly in specialized headache centers, could later be extended to primary care, thus providing benefits for a broader patient group.

Trial registration

German Clinical Trials Register DRKS00025961. Registered on 04 August 2021.

HIT-6 and EQ-5D-5L in patients with migraine: assessment of common latent constructs and development of a mapping algorithm

OBJECTIVE

The aims of this study were to assess whether there is a conceptual overlap between the questionnaires HIT-6 and EQ-5D and to develop a mapping algorithm allowing the conversion of HIT-6 to EQ-5D utility scores for Germany.

METHODS

This study used data from an ongoing randomised controlled trial for patients suffering from migraine. We assessed the conceptual overlap between the two instruments with correlation matrices and exploratory factor analysis. Linear regression, tobit, mixture, and two-part models were used for mapping, accounting for repeated measurements, tenfold cross-validation was conducted to validate the models.

RESULTS

We included 1010 observations from 410 patients. The EQ-5D showed a substantial ceiling effect (47.3% had the highest score) but no floor effect, while the HIT-6 showed a very small ceiling effect (0.5%). The correlation between the instruments' total scores was moderate (- 0.30), and low to moderate among each domain (0.021-0.227). The exploratory factor analysis showed insufficient conceptual overlap between the instruments, as they load on different factors. Thus, there is reason to believe that the instruments' domains do not capture the same latent constructs. To facilitate future mapping, we provide coefficients and a variance-covariance matrix for the preferred model, a two-part model with the total HIT-6 score as the explanatory variable.

CONCLUSION

This study showed that the German EQ-5D and the HIT-6 lack the conceptual overlap needed for appropriate mapping. Thus, the estimated mapping algorithms should only be used as a last resort for estimating utilities to be employed in economic evaluations.

The evolving classifications and epidemiological challenges surrounding chronic migraine and medication overuse headache: a review

Changes in diagnostic criteria, for example, the various International Classification of Headache Disorders criteria, would lead to changes in the outcomes of epidemiological studies. International Classification of Headache Disorders-1 was based mainly on expert opinion, yet most of the diagnostic criteria were reliable and valid, but it did not include chronic migraine. In its second version, the classification introduced chronic migraine, but this diagnosis resembled more a high-frequency migraine rather than the actual migraine transformation process. It also introduced medication overuse headache, but it necessitated analgesic withdrawal and subsequent headache improvement to be diagnosed as such. Hence patients having medication overuse headache could only be diagnosed in retrospect, which was an awkward situation. Such restrictive criteria for chronic migraine and medication overuse headache omitted a high proportion of patients. International Classification of Headache Disorders-3 allows a diagnosis of medication overuse headache due to combination analgesics if taken for at least 10 days per month for more than three months. Hence the prevalence rate of medication overuse headache and chronic migraine can increase compared to the previous version of the headache classification. Different criteria have been used across studies to identify chronic migraine and medication overuse headache, and therefore the information acquired from previous studies using earlier criteria becomes uncertain. Hence much epidemiological research would need to be interpreted cautiously or repeated with the most updated criteria, since the subjects in studies that apply the latest criteria may be phenotypically different from those in older studies.

Comprehensive approach for the treatment of medication-overuse headache

Background: Medication-overuse headache (MOH) is defined by the International Classification of Headache Disorders as a headache in patients with a pre-existing primary headache disorder that occurs on 15 or more days per month for more than 3 months. It is caused by overuse of medication for acute or symptomatic headache treatment. Regular and frequent use of acute or symptomatic medications can worsen headaches and lead to chronic headache or MOH. MOH is a burdensome medical condition that is difficult to treat, and the frequent recurrence of headaches may result in disability in individuals and impair socioeconomic outcomes.Current Concepts: Awareness of MOH and the education of patients, the general population, and healthcare providers are important for the first step of treatment. Scientific research regarding the treatment of MOH has been published in the past few years.Discussion and Conclusion: Physicians should educate and counsel patients to stop or at least reduce the intake of acute or symptomatic medications that can be discontinued abruptly or tapered slowly. During the period after the discontinuation of the overused medications, some withdrawal symptoms including headache might be manageable with bridging therapy. Evidence-based preventive therapies including anticonvulsants (topiramate and divalproex sodium), botulinum toxin A, and medications acting by antagonism of the calcitonin generelated peptide pathway might be helpful in patients with MOH for both avoiding the overused medication and preventing the relapse of overuse. A comprehensive and multidisciplinary approach may improve the outcomes of patients with MOH.

Chronic pain in the 11th revision of the International Classification of Diseases: users' questions answered

ABSTRACT

The upcoming 11th revision of the International Classification of Diseases (ICD-11) will include a comprehensive classification of chronic pain for the first time, which is based on the biopsychosocial definition of chronic pain. This presents a great opportunity for pain research and clinical practice. The new classification consists of seven main diagnostic categories of chronic pain, which are further divided into increasingly specific levels of diagnoses. Each diagnosis is characterized by clearly defined operationalized criteria. Future users will need to familiarize themselves with the new system and its application. The aim of the present publication is to provide users of the ICD-11 chronic pain classification with answers to frequently asked questions regarding the ICD-11 as a whole, the ICD-11 chronic pain classification, and its application to common pain syndromes. The questions compiled here reached the International Association for the Study of Pain Task Force via different routes (e.g., at conferences, by letter, or during field testing). Furthermore, the authors collected questions posted to the ICD-11 browser and contacted early users of the classification to enquire about their most frequent difficulties when applying the new diagnoses. The authors of the present publication prepared answers to these frequently asked questions. This publication intends to act as a guide for the future users of the new ICD-11 chronic pain classification, hence facilitating its implementation.

Interim analysis of the Registry for Load and Management of Medication Overuse Headache (RELEASE): A multicenter, comprehensive medication overuse headache registry

BACKGROUND

Characteristics, disabilities, and optimal management of medication overuse headache remain uncertain. This study aimed to elucidate the clinical characteristics of patients with medication overuse headache enrolled in a medication overuse headache registry in Korea.

METHODS

The Registry for Load and Management of MEdicAtion OveruSE Headache (RELEASE), a cross-sectional prospective observational study including seven referral headache centers in Korea, started enrolling adult patients with medication overuse headache in April 2020. Data included information on headache characteristics, burden on daily function, depression, anxiety, history of acute and preventive medications, and treatment strategies.

RESULTS

A total of 229 patients (85.6% females; mean age, 45.5 ± 13.5 years) were enrolled by June 2021. The average durations of chronic headaches and medication overuse were 6.5 and 4.3 years, respectively. In the past month before enrollment, patients had headaches for 25 days and severe headaches for 12 days, and used acute medications for 20 days. Patients were disabled in 66.8 days in the past 3 months and had moderate/severe depression and anxiety in 56% and 35%, respectively. The proportion of patients on preventive treatments increased from 38% to 93% during the study period.

CONCLUSIONS

RELEASE study reflects the current management status and opportunities to improve the quality of care in patients with medication overuse headache.

Over-the-counter analgesics use is associated with pain and psychological distress among adolescents: a mixed effects approach in cross-sectional survey data from Norway

BACKGROUND

Over-the-counter analgesics (OTCA) such as Paracetamol and Ibuprofen are frequently used by adolescents, and the route of administration and access at home allows unsupervised use. Psychological distress and pain occur simultaneously and are more common among females than among males. There is a dynamic interplay between on-label pain indications and psychological distress, and frequent OTCA use or misuse can exacerbate symptoms. No studies have to date provided an overview of frequent OTCA use in a larger population-based study. The current study used survey data to explore associations between and the relative predictive value of on-label pain indication and measures of psychological distress, together with sex differences for weekly OTCA use.

METHODS

This study included 349,528 adolescents aged 13-19. The data was collected annually between January 2014 and December 2018 as part of the Norwegian Young Data survey. Performance analysis was conducted to explore the relative roles and associations between on-label pain indication and psychological distress in weekly OTCA use. A mixed-effects logistic regression model was used to explore the unique contributions from four domains of on-label pain indication and psychological distress as measured by a combined measure of anxiety and depression (HSCL-10) and peer-bullying involvement as victims or bullies.

RESULTS

Thirty percent of females and 13 % of males use OTCA weekly. Headache is the strongest on-label pain predictor of weekly OTCA use, followed by abdominal pain. Depression and anxiety are the strongest psychological predictor of weekly OTCA use, and higher symptom levels and being female increase the strength of this association. Anxiety and depression also predict weekly OTCA use after controlling for physiological pain.

CONCLUSIONS

Sex, pain and anxiety and depression are inter-correlated and strong predictors of frequent OTCA use. Frequent OTCA use in the context of psychological distress may be a form of self-medication that can exacerbate symptoms and decrease psychosocial function. Longitudinal studies that explore causal trajectories between frequent on-label OTCA use and psychological distress are required. OTCA use among adolescents, and particularly among females, with anxiety and depression should be administered with caution and closely monitored.

Analgesic abuse headache: risk factors and causes of poor adherence in the detox process

BackgroundMedication overuse headache (MOH) is characterized by a pre-existing primary or secondary headache associated with medication overuse.AimsTo identify the clinical, epidemiological, and therapeutic profiles associated with MOH and poor adherence to treatment.MethodsA cross-sectional, comparative, descriptive, analytical study was carried out to assess the characteristics of patients with MOH treated at the Hospital Geral de Fortaleza (HGF).Results103 patients participated, 95 (92.2%) women and 8 (7.8%) men. Of these, 55 (53.4%) patients answered that had already been instructed about the MOH, however they continue to abuse medication for many reasons i.e.: difficulty in bearing pain, and fear of worsening the pain. When asked about what could be done to improve adherence to treatment, in a general way, 28 (27.2%) were unable to inform, 37 (35.9%) answered that most frequent consultations could help. Furthermore, 19 (18.4%) believe that psychological counseling wound bring benefits.ConclusionThe lack of guidance or interest in the guidelines provided are real and important obstacles to treat MOH. Changes in the care model that include effective communication, more frequent return, family and psychotherapy support and close monitoring by the physician or nurses are factors that should be considered in headache clinics.  

Candidate Genes and Proteomic Biomarkers of Serum and Urine in Medication-Overuse Headache

Chronic headache is a topical problem of neurology, psychiatry and general practice. The medication-overuse headache (MOH) is one of the leading pathologies in the structure of chronic headache. However, early diagnosis of the MOH is challenging. We analyzed potential proteomic biomarkers of serum and urine in patients with MOH.

METHODS

We searched PubMed, Springer, Scopus, Web of Science, ClinicalKey, and Google Scholar databases for English publications over the past 10 years using keywords and their combinations.

RESULTS

We found and analyzed seven studies that met the search criteria for the purpose of the review, including 24 serum proteomic biomarkers and 25 urine proteomic biomarkers of MOH. Moreover, the candidate genes and locus of the studied serum (vitamin D-binding protein, lipocalin-type prostaglandin D2 synthase, apolipoprotein E, etc.) and urine proteomic biomarkers (uromodulin, alpha-1-microglobulin, zinc-alpha-2-glycoprotein, etc.) of MOH are presented in this review.

CONCLUSIONS

The serum and urine proteomic biomarkers of MOH can potentially help with the identification of patients with MOH development. Due to the relevance of the problem, the authors believe that further investigation of the MOH proteomic biomarkers in different ethnic and racial groups of patients with primary headache is necessary. In addition, it is important to investigate whether medications of different drug classes influence the levels of serum and urine proteomic biomarkers.

Effects of greater occipital nerve block with local anesthetic and triamcinolone for treatment of medication overuse headache: an open-label, parallel, randomized, controlled clinical trial

AIM

There is a paucity of evidence and consensus on exactly how to carry out the detoxification process. To examine the effect of a greater occipital nerve block (GONB) in the detoxification process, we conducted an open-label, parallel, randomized, controlled clinical trial.

MATERIALS AND METHODS

In order to conduct this study, 54 medication-overuse headache (MOH) patients were recruited and allocated randomly to group A (n = 27) or B (n = 27). In both groups, patients underwent detoxification processes without any acute migraine medication or analgesics. During the run-in period, all patients in both groups received the same education, managed by a neurologist and nutritionist. All patients were offered maximally 300 mL of promethazine syrup (5 mg/5 mL) to be taken 10 mg every 8 h during the first 10 days of the study. A 2-mL syringe containing 1 mL of lidocaine 2% and 1 mL of triamcinolone 40 mg/mL was prepared for each patient of group A for conducting GONB. Characteristics of headache attacks, including headache severity, frequency, and duration, were assessed at baseline and after 3 months of intervention.

RESULTS

Twenty-six patients in group A (96.3%) and twenty-three in group B (85.2%) completed detoxification, and were thus cured of MOH (P = 0.351). The present study revealed that GONB with local anesthetic and triamcinolone significantly improved the characteristics of headache, including frequency (- 13.66 in group A and - 7.55 in group B), duration (- 7.92 in group A and - 5.88 in group B), and severity (- 3.44 in group A vs. - 1.33 in group B) in group A compared to control (all P value < 0.05).

CONCLUSIONS

Although both detoxification programs were effective, detoxification with GONB resulted in better outcomes.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (registration number; IRCT20150906023922N2).

Medication overuse headache

PURPOSE OF REVIEW

Medication overuse headache (MOH)is a disabling problem worldwide with areas of controversy regarding its cause. This article reviews the recent ideas regarding the development of this disorder and its effective management.

RECENT FINDINGS

It has been proposed that all acute migraine medications can lead to MOH, with differences in the propensity of different agents to cause the problem. Early data suggests that gepants, which are small-molecule calcitonin gene-related peptide antagonists used for the acute treatment of migraine, may be an exception. Recent studies show that practitioners and the general public are still largely unaware of the problem of medication overuse and its damaging effects.

SUMMARY

MOH is an accepted concept of an increase in headaches driven by the frequent administration of acute antimigraine drugs. The impressions of providers, and studies documenting the concept may be flawed. Although it is likely that MOH does occur, and restricting the amount of acute medications is necessary to prevent it, it is also possible that increasing amounts of acute medications are simply a reflection of poorly controlled headaches, rather than a cause. Objective markers need to be developed to identify those who have MOH, which does not include all with chronic migraine, and to use these markers in diagnosis and management, particularly in those patients where the frequent acute drugs might only be a reflection of frequent headaches, rather than a cause.

Triptanophobia in migraine: A case-control study on the causes and consequences of the nonuse of triptans in chronic migraine patients

Background: Triptanophobia is the excessive and inadequately justified concern about potential risks of triptans. We evaluated causes and consequences of nonuse of triptans in chronic migraine (CM) Methods: Case-control study. We included CM patients firstly referred to aheadache unit. Patients were cases or controls depending on whether they were triptan naïve, or not. We analyzed if nonuse of triptans was justified by formal contraindications or adverse events. We assessed if triptan naïve patients had higher frequency of vascular risk factors (VRF), contraceptive drugs or older age. Results: We included 941 patients, 247 (26.2%) triptan users. Triptans had been discontinued due to tolerability in 116 patients (12.3%), being 578 patients (61.4%) triptan naïve. Formal contraindications were found in 23 patients (2.4%). Frequency of VRF, contraceptive drugs or age did not differ between the groups (p > 0.1). Triptan users consumed symptomatic medications fewer days/month (13.9 vs 17.1, p < 0.001), were under prophylactic treatment more frequently (79.4% vs 34.8%, p < 0.001) and had medication overuse headache less frequently (55.1% vs. 63.0%, p = 0.03). Conclusion: Triptans were not used by three-quartersof CM patients. Nonuse of triptans was not justified by tolerability, frequency of contraindications, or frequency of VRF. Expert opinion: In the present study, we evaluated causes and consequences of the nonuse of triptans in CM sufferers. We analyzed frequency of triptan use in CM patients. We compared, between triptan users and triptan naïve patients, the presence of contraindications, frequency of vascular risk factors, and differences in management prior to the referral to a headache unit.

Migraine and tension-type headache in Germany. Prevalence and disease severity from the BURDEN 2020 Burden of Disease Study

Headache disorders are widespread among women and men in Germany and are primarily associated with restrictions on quality of life. The two most common types of headache disorders are migraine and tension-type headache. In order to gain valid estimates of the prevalence of these conditions, a cross-sectional telephone-based survey was conducted among adults in Germany (N=5,009) between October 2019 and March 2020. The frequency, duration, the characteristics and comorbidities associated with headache were measured using the diagnostic criteria defined in the International Classification of Headache Disorders. 57.5% of women and 44.4% of men in Germany stated that they had had a headache in the last twelve months. 14.8% of women and 6.0% of men meet all of the diagnostic criteria for migraine. Tension-type headache affects 10.3% of women and 6.5% of men. Migraine and tension-type headache are predominantly found among people of working age and steadily decrease with age. Migraine is often accompanied by comorbidities such as depressive symptoms and anxiety disorders. People affected by headache disorders tend to receive very little professional medical care, with only a minority seeking treatment within a year. These results provide a comprehensive picture of the population-related impact of headache disorders and are used in the BURDEN 2020 study to quantify key indicators for burden of disease assessment.

Secondary headache attributed to exposure to or overuse of a substance

BACKGROUND

Secondary headaches attributed to exposure to or the overuse of a substance are classified under chapter eight in the International Classification of Headache Disorders 3rd edition. Three distinct sub-chapters consider: 1. Headache attributed to exposure to a substance, 2. Medication overuse headache, and 3. Headache attributed to substance withdrawal. Headache attributed to exposure to a substance refers to a headache with onset immediately or within hours after the exposure, while medication overuse headache is a headache occurring on 15 or more days per month that has developed as a consequence of regular usage of acute headache medication(s) for more than three consecutive months in a patient with a pre-existing primary headache disorder. The withdrawal of caffeine, oestrogen, and opioids is most often associated with the development of headache.

DISCUSSION

Despite the current headache classification, there is no certainty of a causal relationship between the use of any substance and the development of headache. Some substances are likely to provoke headache in patients that suffer from a primary headache disorder like migraine, tension-type headache or cluster headache, while others were described to cause headache even in people that generally do not get headaches. Toxic agents, such as carbon monoxide (CO) are difficult to investigate systematically, while other substances such as nitric oxide (NO) were specifically used to induce headache experimentally. If a patient with an underlying primary headache disorder develops a headache, in temporal relation to exposure to a substance, which is significantly worse than the usual headache it is considered secondary. This is even more the case if the headache phenotype is different from the usually experienced headache characteristics. Medication overuse headache is a well-described, distinct disease entity with only marginally understood pathophysiology and associated psychological factors. Managing medication overuse headache patients includes education, detoxification, prophylactic treatments and treating comorbidities, which is reflected in available guidelines. Viewing medication overuse headache as a separate entity helps clinicians and researchers better recognise, treat and study the disorder.

CONCLUSION

Identification of substances that may cause or trigger secondary headache is important in order to educate patients and health care professionals about potential effects of these substances and prevent unnecessary suffering, as well as deterioration in quality of life. Treatment in case of medication overuse and other chronic headache should be decisive and effective.

Medication overuse headache in 787 patients admitted for inpatient treatment over a period of 32 years

BACKGROUND

Definitions of medication overuse headache have changed over time.

OBJECTIVE

To evaluate the clinical characteristics of medication overuse headache patients admitted for inpatient withdrawal therapy over a period of 32 years.

METHODS

We included all patients with medication overuse headache treated from 1 January 1984 to 31 December 2015. We obtained all data from the medical reports and defined three periods, P1 (1984-1993), P2 (1994-2003), and P3 (2004-2015). The p-value adjusted for multiple comparisons was set to 0.005.

RESULTS

Within 32 years, a total of 787 patients accounted for 904 admissions for MOH. From P1 to P3, the proportion of patients with preexisting migraine increased from 44.3% to 53.3% (chi² = 9.0, p = 0.01) and that with preexisting tension-type headache decreased from 47.9% to 34.6% (chi² = 9.3, p < 0.01). The median time since onset of headache and medication overuse headache decreased from 20 to 15 years (p < 0.001) and from 3 to 2 years (p < 0.001). The median cumulative number of single doses decreased from 120 to 90 per month (p = 0.002). Overuse of triptans, non-opioid analgesics, and opioids increased, whereas overuse of ergotamines decreased over time (p < 0.001 for all tests). The use of prophylactic medication before admission increased from 8.3% to 29.9% (chi² = 89.5, p < 0.001).

CONCLUSION

This retrospective study in a large number of patients with medication overuse headache admitted for inpatient withdrawal therapy over a period of 32 years shows a trend towards changes in the preexisting headache type, a decrease in the time since onset of headache and medication overuse headache, a decrease in the number of drug doses used per month, changes in the type of drugs overused, and an increase in, but still low rate, of prophylactic medication prior to admission.

Eighty years of Medication-Overuse Headache: what about Medication-Overuse Backpain?

INTRODUCTION

Although chronic low back pain (CLBP) is one of the most common pain syndromes, up to now, clear pathophysiological causes or specific treatment options are missing. Medication-overuse has been associated with chronic headache, but never with CLBP.

HYPOTHESIS

Based on several similarities between CLBP and Medication-Overuse Headache (MOH), we hypothesized that medication-overuse might contribute to CLBP as well, maybe even as an own entity. Might there be something like Medication-Overuse Backpain (MOB)?

METHODS

We substantiate our hypothesis with a preliminary case-series analyzing five patients suffering from CLBP with a marked medication-overuse. In these patients, a stepwise analgesic withdrawal was recommended.

RESULTS

Within 6 months of recruitment, five patients fulfilled the inclusion criteria and successfully completed discontinuation of their medication. All patients reported noticeable pain relief, despite the discontinuation of their analgesics. Withdrawal was well tolerated in all cases.

CONCLUSIONS

Considering our results, the described withdrawal method seems to be a simple and safe method to achieve pain reduction while simultaneously preventing organ damage. Despite the preliminary character of our results, our hypothesis might stimulate a new understanding of CLBP's pathophysiology.

More Attacks and Analgesic Use in Old Age: Self-Reported Headache Across the Lifespan in a German Sample

Background: Reliable population-based data on the prevalence and characteristics of primary headache across the lifespan are essential. However, robust data are lacking.

Methods: We utilized questionnaire data from a random general population sample in Germany, that comprised 2,478 participants aged ≥14 years. A standardized questionnaire addressing headache and headache treatment was filled in during the face-to-face survey.

Results: The 6-month prevalence of self-reported headache in the total sample amounted to 39.0% (known diagnosis of migraine 7.2%; tension-type headache 12.4%; another diagnosis or unknown diagnosis 23.4%). Age-specific prevalence rates were 37.9% (14–34 years), 44.6% (35–54 years), 38.5% (55–74 years), and 26.9% (≥75 years). Compared to age group 14–34, participants aged 35–54 were more (OR = 1.29, 95%-CI 1.05–1.60, p = 0.018) and those aged ≥75 were less (OR = 0.55, 95%-CI 0.40–0.76, p < 0.001) likely to have any headache. Of the participants with headache, 79.5% reported headache on <4 days per month, 15.6% on 4–14 days per month and 4.9% on >14 days per month. The frequency of headache did not differ significantly between age groups in men [χ(3, N = 384)2 = 1.45, p > 0.05], but in women [χ(3, N = 651)2 = 21.57, p < 0.001]: women aged ≥75 years were over-represented in the group reporting 4–14 headache days per month. The analgesic use (days per month) differed significantly between age groups among participants with headache on <4 days per month and on >14 days per month: 1.8 (14–34 years), 2.5 (35–54 years), 3.2 (55–74 years), and 3.4 (≥75 years), respectively 7.9 (14–34 years), 11.4 (35–54 years), 18.4 (55–74 years), and 22.8 (≥75 years).

Conclusions: In general, the prevalence of headache decreases with age. However, older women suffer from more frequent attacks and older participants take analgesics on more days per month than younger participants. This might put them at risk of medication overuse which may lead to medication overuse headache. More research is needed to understand these specifics in headache frequency and treatment behavior in older people.

Monitoring chronic headache and medication-overuse headache prevalence in Denmark

Objectives

To study chronic headache and medication-overuse headache (MOH) prevalence; to identify groups with high prevalence of these conditions; and to identify the most frequently used pain medications among respondents with chronic headache.

Background

Chronic headache and MOH prevalence in Denmark were last estimated in 2010.

Methods

In this cross-sectional study, 104,950 individuals aged ≥16 years were randomly sampled for the 2017 Danish Capital Region Health Survey. Responses to questions about headache and use of acute pain medications were linked to demographic registries. MOH was defined as headache ≥15 days/month plus self-report of use of pain medications ≥10 or 15 days/month, in the last three months. Weighted prevalence proportions were calculated.

Results

Among 55,185 respondents, chronic headache prevalence was 3.0% (95% CI: 2.3–3.2) and MOH prevalence was 2.0% (95% CI: 1.8–2.1). Both conditions were more common among females and the middle-aged. Respondents on social welfare or receiving early retirement pensions had the highest prevalences. Among those with chronic headache, 44.7% overused over-the-counter analgesics for headache; paracetamol 41.5%; a combination of different pain relievers 25.3%; ibuprofen 21.9%; opioids 17.0%; combination preparations 14.3%; and triptans 9.1%.

Conclusions

The highest prevalence of chronic headache and MOH was seen among people with low socioeconomic position. Overuse of paracetamol was most common. Reported opioid use was higher than expected. Groups with high prevalence of MOH should be the focus of public health interventions on rational use of OTC and prescription pain medications.

Primary headache and migraine in headache specialists – does personal history of doctors matter?

Objective

Migraine is a common disorder affecting more than 10% of the population. The prevalence of migraine among physicians and, in particular, among headache specialists is widely unknown as is the impact of suffering from migraine on the attitudes towards migraine and on treatment recommendations of physicians. We designed a survey among headache specialists and neurologists and compared the results to general pain specialists and general practitioners.

Methods

A standardized interview in randomly selected samples of these four groups of physicians was performed. The interview included data on the prevalence of migraine and other primary headache disorders in the physician groups, self-report on their own treatment, attitudes towards migraine, and treatment recommendations for migraine. The prevalence rates were also compared to an age- and sex-matched German general population sample.

Results

The lifetime prevalence of migraine was higher in headache specialists (53.0%) than in general neurologists (43.0%), pain specialists (21.7%), general practitioners (19.3%), and in the general age- and sex-matched population (16.8%). Cluster headache prevalence was high in neurologists (1.9%) and in headache specialists (1.3%); episodic tension-type headache prevalence was significantly lower in general practitioners (19.5%). One reason, among others, was that being a migraine (or cluster headache) patient more often prompted the sufferers to become a specialist in neurology. Physicians with migraine rated the biopsychosocial concept of lower importance for migraine than did physicians without migraine. The self-treatment of migraine in physicians differs from the treatment recommendations to the patients. For example, only 36.4% of the headache specialists with migraine take triptans whereas 94.4% recommend triptans to their patients.

Conclusions

We conclude that being a headache specialist or a neurologist is associated with an increased migraine or cluster headache prevalence. This personal history of migraine leads to a more somatic view of migraine as a disorder and to different treatment recommendations as compared to self-treatment.

Impact of Medical Care on Symptomatic Drug Consumption and Quality of Life in Headache: A One-Year Population Study

Background: Chronic headache is one of the most common pain conditions, often leading to symptomatic drug overuse. The aim of this study was to provide data on symptomatic drug consumption in an Italian outpatient population and to describe how the clinical picture of headache may change after headache experts take charge of the care of affected individuals.

Methods: A total of 199 adults complaining of chronic headache were recruited through 32 pharmacies in the Pavia health district. Participants underwent four evaluations: a baseline assessment (T0) and three follow-up evaluations performed by a neurologist at 3, 6, and 12 months (T3, T6, and T12, respectively). On each occasion, they underwent a complete neurological assessment and received therapeutic adjustments to achieve better management of their headache.

Results: On the basis of a preliminary telephone interview, the prevalence rates of chronic headache and medication overuse headache (MOH) were 16 and 12%, respectively. At 12 months of follow-up, we observed a significant decrease in the frequency of attacks (T0: 9 ± 9/month vs. T12: 2 ± 2/month; p < 0.001), in the number of days/month with headache (T0: 11 ± 9 vs. T12: 4 ± 4; p < 0.001) and in single attack duration (T0: 34 ± 30 h vs. T12: 10 ± 19 h; p < 0.001). Careful headache management resulted in a significant decrease in analgesic consumption (T0: 12 ± 16 vs. T12: 4 ± 6 doses/month; p = 0.014) and a significant increase in quality of life, measured using the Migraine Disability Assessment Scale (MIDAS) and Headache Under-Response to Treatment (HURT) scales (p < 0.001).

Conclusions: Headache management by a specialist is more effective than self-treatment, resulting in an overall benefit for headache patients.

Comparison of chronic daily headache with and without medication overuse headache using ICHD II R and ICHD 3 beta criteria

OBJECTIVE

To evaluate the frequency of Medication Overuse Headache (MOH) in the patients with Chronic Daily Headache (CDH) using International Classification of Headache Disorder II Revision (ICHD II R) and International Classification of Headache Disorder 3 Beta (ICHD-3 beta) criteria. We also compare the CHD patients with and without MOH using both the criteria.

PATIENTS AND METHODS

Consecutive CDH patients from neurology service between 2014 and 2015 were included. The patients with CDH was categorised to MOH was based on ICHDIIR and ICHD-3 beta criteria. Their demographic and headache characteristics including frequency, duration, severity and disability were noted. Severity of headache was assessed using Visual Analogue Scale (VAS). Predictors of MOH were evaluated by multivariate analysis. Demographic and headache characteristics of CDH patients without MOH were compared with those with MOH.

RESULTS

202 patients were included whose median age was 32 (range 18-65) years, and 151(74.8%) were females. 12.3% patients fulfilled ICHDIIR criteria for MOH and 46.5% fulfilled ICHD-3 beta criteria. The predictors of MOH were female gender (OR = 3.72; 95% CI 1.72-8.02, p = 0.001), low education level (OR = 1.07, 95%CI 1.02-1.13; p = 0.007) and higher VAS score (OR = 0.67, 95%CI 0.51-0.88; p = 0.004). MOH patients as per ICHD-3 beta criteria had higher education (p = 0.02) and consumed lesser abortive drugs (p = 0.03) as compared with ICHDIIR criteria.

CONCLUSION

The frequency of MOH increases by four-fold when using ICHD-3 beta criteria instead of ICHDIIR criteria. Females with lower education level predispose to MOH.

Cognitive Decline in Chronic Migraine with Nonsteroid Anti-inflammation Drug Overuse: A Cross-Sectional Study

Background

Chronic migraine with medication overuse headache (CM-MOH) is the most common type of chronic migraine, and it increases risk of stroke and white matter lesions. These pathologic changes could induce cognitive decline. However, the alteration of cognitive function in CM-MOH patients is not established. Therefore, we took this study to reveal the cognitive performances in CM-MOH.

Methods

This cross-sectional study was conducted between December 2015 and January 2017. Patients were divided into CM-MOH, CMwoMOH (chronic migraine without medication overuse), and MO (migraine without aura) groups. Cognitive function was assessed in all cases during interictal periods using Addenbrooke's Cognitive Examination Test (ACE-R), Trail Making Test A/B (TMT A/B), and Digit Symbol Test (DST). Detailed headache characteristics and evaluation of anxiety, depression, and living and sleep quality were collected.

Results

116 patients were included in this study. There were 21 CM-MOHs, 20 CMwoMOHs, 35 MOs, and 40 controls. Age and education were the independent risk factors of cognitive decline (P < 0.05). After adjusting, the risk of cognitive decline was higher in CM compared with control in ACE-R score and language fluency (P < 0.05). In addition, CM-MOH sufferers were in higher risk of memory and executive dysfunction (P < 0.05). The cognitive function had no difference between CM-MOH and CMwoMOH (P > 0.05). Meanwhile, CM-MOH got significantly higher scores than MO in anxiety and depression, with poorer performances in sleep and life quality (P < 0.05).

Conclusion

The risk of cognitive decline increased in chronic migraine patients. Nonsteroid anti-inflammatory drugs overuse had no influence on cognitive performances among chronic migraine sufferers.

High Achievement Motivation is Not Related to Increased Use of Acute Headache Medication in Migraine: A Cross-sectional Observational Cohort Study

OBJECTIVE

To determine if migraine patients with high achievement motivation have an increased use of acute headache medication.

BACKGROUND

It has been hypothesized that high achievement-motivated migraine patients have an increased use of acute headache medication to be able to perform at work and during daily life, putting them at risk for medication overuse headache (MOH).

METHODS

The Achievement Motivation Inventory and use of acute headache medication were assessed in 117 migraine patients (60 episodic, 57 chronic) at their first appointment at our tertiary headache center.

RESULTS

Patients with low vs high achievement motivation were not significantly different in acute headache medication days per month (10.8 ± 6.9 vs 10.9 ± 7.8, P = .98), in acute headache medication use in the absence of headache (to prevent occurrence of headache later that day: 51.8% vs 48.2%, P = .38), in having a diagnosis of MOH (37.9 vs 23.7%, P = .12), or in reduction of acute headache medication days at 3 and 6 months follow-up (both P > .20).

CONCLUSIONS

High achievement motivation in migraine patients was not associated with increased acute headache medication use or more frequent diagnosis of MOH.

Medication-overuse headache: a widely recognized entity amidst ongoing debate

Medication overuse in primary headache disorders is a worldwide phenomenon and has a role in the chronification of headache disorders. The burden of disease on individuals and societies is significant due to high costs and comorbidities. In the Third Edition of the International Classification of Headache Disorders, medication-overuse headache is recognized as a separate secondary entity next to mostly primary headache disorders, although many clinicians see the disease as a sole complication of primary headache disorders. In this review, we explore the historical background of medication-overuse headache, its epidemiology, phenomenology, pathophysiology and treatment options. The review explores relevant unanswered questions and summarizes the current debates in medication-overuse headache.

Chronic Headache Due to Overuse of Analgesics and Anti-Migraine Agents

BACKGROUND

The frequent or regular use of analgesics and anti-migraine drugs can make headache more frequent and induce the transformation of episodic to chronic headache. Chronic headache due to medication overuse is defined as headache that is present on ≥ 15 days per month for at least three months in a patient who previously suffered from primary headaches, and who takes analgesics on ≥ 15 days per month or anti-migraine drugs (triptans or ergot alkaloids), opioid drugs, or combined analgesics on ≥ 10 days per month.

METHODS

This review is based on pertinent articles published up to December 2017 that were retrieved by a selective search in PubMed employing the terms "medication overuse AND headache" and "medication overuse headache."

RESULTS

The prevalence of medication overuse headache in the general population in Germany is 0.7% -1%. This disorder is more common in women and in persons suffering from comorbid mental disorders or other painful conditions. The treatment of medication overuse headache consists of three steps. Patient education and counseling are given with the goal of reducing the intake of medication for acute headache treatment. The ensuing headache prophylaxis is with topiramate, amitriptyline, or onabotulinum toxin A. If these treatment strategies fail, a drug holiday is recommended. This can be in the outpatient, day clinic, or inpatient setting, depending on the severity of the condition and its comorbidities.

CONCLUSION

Patients who frequently take acute medication to treat headache episodes must be identified early in order to avoid headache chronification and medication overuse headache. The suggested treatment algorithm is still in need of validation by randomized trials.

Obesity and Migraine: Effect Modification by Gender and Perceived Stress

BACKGROUND

The association between obesity and migraine has been established; however, it is unclear whether it varies by perceived stress within each gender.

METHODS

This cross-sectional study used data from the ongoing NutriNet-Santé e-cohort with enrollees from the general population. Anthropometric and migraine data were provided via self-report questionnaires (2013-2016). Migraine was defined using established criteria. Perceived stress was assessed with Cohen's Perceived Stress Scale-10. Associations were estimated via gender- and stress-stratified multivariable polytomous logistic regression models.

RESULTS

Among 32,835 participants with complete data (75% women; mean age = 51.9 ± 13.8 years), 34% reported no headache, 44% non-migraine headache, and 22% migraine with or without aura during one's lifetime. In these groups, obesity was present in 8.6, 9.9, and 11.6%, respectively. Stress was a significant moderator of the obesity-migraine association only among women. The largest significant adjusted odds ratio (aOR) was found between obesity and migraine in women with high stress (aOR 1.61, 95% CI 1.35-1.91).

CONCLUSIONS

We found support for gender- and stress-dependent associations between obesity and migraine using a large, heterogeneous adult sample. This underscores the need for evidence-based strategies for weight loss and stress reduction for female migraineurs.

Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study

Background

The MAST Study is a longitudinal, cross-sectional survey study of US adults with migraine. These analyses were conducted to estimate rates of acute medication overuse (AMO) and determine associations of AMO with individual and headache characteristics.

Methods

Eligible respondents had ICHD-3-beta migraine, reported ≥3 monthly headache days (MHDs) in the past 3 months, ≥1 MHD in the past 30 days, and currently took acute headache medication. AMO was defined according to ICHD-3-beta thresholds for monthly days of medication taking when diagnosing medication overuse headache.

Results

Eligible respondents (N = 13,649) had a mean age of 43.4 ± 13.6 years; most were female (72.9%) and Caucasian (81.9%). Altogether, 15.4% of respondents met criteria for AMO. Compared with those not overusing medications, respondents with AMO were significantly more likely to be taking triptans (31.3% vs 14.2%), opioids (23.8% vs 8.0%), barbiturates (7.8% vs 2.7%), and ergot alkaloids (3.1% vs 0.6%) and significantly less likely to be taking NSAIDs (63.3% vs 69.8%) (p < 0.001 for all comparisons). Respondents with AMO had significantly more MHDs (12.9 ± 8.6 vs 4.3 ± 4.3, p  <  0.001); higher migraine symptom severity (17.8 ± 2.7 vs 16.4 ± 3.0, p  <  0.001), higher pain intensity scores (7.4 vs 6.5, p  <  0.001); and higher rates of cutaneous allodynia (53.7% vs 37.5%, p  <  0.001). Adjusted for MHDs, the odds of AMO were increased by each additional year of age (OR 1.02, 95% CI 1.02, 1.03); being married (OR 1.19, 95% CI 1.06, 1.34); smoking (OR 1.54, 95% CI 1.31, 1.81); having psychological symptoms (OR 1.62, 95% CI 1.43, 1.83) or cutaneous allodynia (OR 1.22, 95% CI 1.08, 1.37); and greater migraine symptom severity (OR 1.06, 95% CI 1.04, 1.09) and pain intensity (OR 1.27, 95% CI 1.22, 1.32). Cutaneous allodynia increased the risk of AMO by 61% in males (OR 1.61, 95% CI 1.28, 2.03) but did not increase risk in females (OR 1.08, 95% CI 0.94, 1.25).

Conclusions

AMO was present in 15% of respondents with migraine. AMO was associated with higher symptom severity scores, pain intensity, and rates of cutaneous allodynia. AMO was more likely in triptan, opioid, and barbiturate users but less likely in NSAID users. Cutaneous allodynia was associated with AMO in men but not women. This gender difference merits additional exploration.

Migraine

Migraine is a chronic paroxysmal neurological disorder characterised by multiphase attacks of head pain and a myriad of neurological symptoms. The underlying genetic and biological underpinnings and neural networks involved are coming sharply into focus. This progress in the fundamental understanding of migraine has led to novel, mechanism-based and disease-specific therapeutics. In this Seminar, the clinical features and neurobiology of migraine are reviewed, evidence to support available treatment options is provided, and emerging drug, device, and biological therapies are discussed.

Factors Associated With Medication-Overuse Headache in Patients Seeking Treatment for Primary Headache

BACKGROUND

Although risk factors for medication-overuse headache have been identified within the general population, most studies have neglected clinical samples. The present study examined the relative and combined associations of these factors with medication-overuse headache in a sample of US adults seeking treatment for primary headache disorders.

METHODS

Treatment-seeking headache patients provided data on demographics, headache variables, psychiatric variables, use of headache medications, and use of other prescription medications and substances. A classification tree selection strategy was utilized within this cross-sectional study to differentiate between those with and without medication-overuse headache, and a final multivariable model assessed their combined utility.

RESULTS

Forty-three of 164 participants (26.2%) met diagnostic criteria for medication-overuse headache. Relative to non-medication-overuse headache participants, participants with medication-overuse headache reported greater headache-related disability (odds ratio = 1.09, 95% confidence interval = 1.01-1.18), escape and avoidance responses indicative of fear of pain (odds ratio = 1.07, 95% confidence interval = 1.00-1.15), and use of combination medications for headache (odds ratio = 3.10, 95% confidence interval = 1.51-6.36). The final multivariable model differentiated well between the 2 groups (area under the receiver operating characteristic curve = .78; 95% confidence interval = .71-.86).

CONCLUSIONS

Items that assess headache-related disability, use of combination medications, and fear of pain help identify patients who are currently overusing acute headache medications and may serve as indicators of treatment progress. Future studies should apply similar analytic approaches longitudinally to identify headache sufferers at risk for medication-overuse headache prior to headache progression.

Lifestyle factors and risk of migraine and tension-type headache. Follow-up data from the Nord-Trøndelag Health Surveys 1995-1997 and 2006-2008

AIMS

The aim of this population-based historical cohort study was to investigate the influence of lifestyle factors on the risk of developing migraine or tension-type headache (TTH).

METHODS

Data from the Nord-Trøndelag Health Study performed in 1995-1997 and 2006-2008 was used. A total of 15,276 participants without headache at baseline were included. A Poisson regression was used to evaluate the associations between lifestyle factors and risk ratios (RRs) of migraine and TTH 11 years later. Precision of the estimates was assessed by 95% confidence interval (CIs).

RESULTS

Increased risk of migraine (RR 1.30, 95% CI 1.11-1.52) was found in smokers (past or current) compared to those who had never smoked. Hard physical exercise 1-2 hours per week reduced the risk of migraine (OR 0.71, 95% CI 0.54-0.94) compared to inactivity, and the risk of migraine was also lower among those who consumed alcohol (RR 0.73, 95% CI 0.57-0.94) compared to abstainers. No association was found between smoking, physical activity, alcohol use and risk of TTH.

CONCLUSIONS

The main finding was that current and previous smoking was associated with increased risk of migraine, but not of TTH.

Longitudinal assessment of gray matter volumes and white matter integrity in patients with medication-overuse headache

Background Medication-overuse headache is a common clinical entity, but neuroimaging studies investigating volumetric and microstructural alterations of the brain in medication-overuse headache are rare. Therefore, in the current longitidunal study we evaluated gray matter volume and white matter integrity in patients with medication-overuse headache before and after drug withdrawal. Methods A prospective study evaluated 27 patients with medication-overuse headache and 27 age-, sex-, and education-matched healthy adults. High-resolution T1-weighted magnetic resonance imaging and diffusion tensor imaging were obtained from the control group and medication-overuse headache patients before and six months after drug withdrawal. Tract-based spatial statistics of multiple diffusivity indices and voxel-based morphometry were employed to investigate white and gray matter abnormalities. Results No correlation was found between age, gender, education and smoking status in both groups. The most commonly overused medications were simple analgesics (96.3%) and combined analgesics (3.7%). The mean duration of the history of medication overuse and headaches was 56.7 ± 63.5 months. White matter diffusional and gray matter morphological alterations including volume, fractional anisotropy, radial diffusivity, and axial diffusivity analyses showed no significant relationship in the patients before and six months after withdrawal of analgesics. Also no difference was observed between the patients versus controls. Conclusion Our data demonstrated no structural alterations within the brain in medication-overuse headache.

Headache in Resource-Limited Settings

PURPOSE OF REVIEW

This review summarizes the unmet need of headache burden and management in resource-limited settings. It provides a general overview of the nuances and peculiarities of headache disorders in resource-limited settings. The review delivers perspectives and explanations for the emerging burden of both primary and secondary headache disorders. Important discussion on demographic and epidemiologic transition pertinent to low-resource settings is included. A critical analysis of headache disorders is made within the context of growing burden non-communicable disorders in low-resource countries. Challenges are examined and prospective feasible solutions tailored to existing resources are provided to address headache disorders in resource-limited settings.

RECENT FINDINGS

Many low-resource countries are entering into the third epidemiological transition featuring increasing burden of non-communicable disorders of which headache disorders contribute a significant proportion. Exponential population growth involving youthful demographic and massive rural-urban migration is taking place in low-resource countries. Youthful demographic is the natural cohort for primary headache such as migraine. Socioeconomic mobility and lifestyle changes are leading to higher levels of physical inactivity and obesity, both of which are related to headache. Life expectancy is rising in some resource-restricted countries; this increases prevalence of secondary headache attributed to neurovascular causes. Many low-resource countries are still burdened with tropical infectious causes of secondary headache. Health care facilities are primarily designed to respond to infectious epidemic and not to chronic burden such as headache. Many low-resource-restricted settings are plagued by poor and corrupt governance, ill-equipped regimes with malfunctioning health policies, war, and poverty. Many low-resource settings do not have access to generic headache medications such as triptans. Headache training and expertise is low. Healthy lifestyle changes emphasizing on improving regular exercise can be inexpensive method to reducing primary headache burden and its comorbidities (e.g. obesity). Addressing the increasing burden of headache disorders in resource-limited settings is important to avert accrued disability which in turn lowers productivity and socioeconomic performance in a young booming population.

Health and quality of life in patients with medication overuse headache syndrome after standardized inpatient rehabilitation: A cross-sectional pilot study

The aim of this pilot study was to determine health-related quality of life (HRQoL) in patients with history of medication overuse headache (MOH) after detoxification and a headache-specific inpatient rehabilitation program and to receive necessary information for future prospective studies.HRQoL and headache-related disability were cross-sectionally measured by Short Form 36 (SF-36), Hospital Anxiety and Depression Scale (HADS), Migraine Disability Score (MIDAS), Coping Strategies Questionnaire (CSQ), and Symptom Checklist 90 revised (SCL-90-R). SF-36, HADS, and SCL-90-R data were compared to German population norms, stratified by age, sex, and comorbidities.Fifty-one patients (72.5% females, mean age 47.3 years) were included with an average headache duration of 25.3 years. Moderate to high levels of headache were reported on the MIDAS VAS at 6.51 (range 0-10); SF-36 bodily pain was 40.3 (norm = 59.0, P < .001, 100 = best). Impaired functioning averaged at 78.4 (100 = no impairment) on the MIDAS. In contrast, SF-36 physical functioning was comparable to the norm (mean: 78.4, norm = 81.8, P = .63). All other SF-36 scales were significantly lower than expected from the norm (all P < .001). The scales depression, anxiety, obsessive-compulsive, and interpersonal sensitivity were significantly affected, whereas the levels of SCL-90-R schizophrenia nuclear and schizotypia were not lower than the norm. Coping with pain was moderate.This pilot study is the first that presents a comprehensive and simultaneously specific assessment of health and quality of life of MOH patients after detoxification and inpatient rehabilitation. Moderate to high levels of pain and self-reported disability owing to headache were observed, whereas physical function on the SF-36 was not different from the expected level of the norm. Mental health was substantially affected in several dimensions, which had been described to reduce the ability to cope with pain. MOH patients seem to have high expectations of functionality, low symptomatology, and intact well-being.