Medication overuse headache

Medication overuse in a subgroup analysis of phase 3 placebo-controlled studies of galcanezumab in the prevention of episodic and chronic migraine

INTRODUCTION

Acute medication overuse is prevalent in patients with migraine.

METHODS

In three phase 3, double-blind, randomized, placebo-controlled studies, patients with episodic migraine (EVOLVE-1 and EVOLVE-2) or chronic migraine (REGAIN) were randomized 2:1:1 to monthly subcutaneous injections of placebo or galcanezumab 120 or 240 mg for 3 or 6 months. This subgroup analysis evaluated mean changes in the number of monthly migraine headache days in each treatment among patients with versus without baseline acute medication overuse via mixing modelling with repeated measures.

RESULTS

The percentages of patients with baseline medication overuse in placebo, galcanezumab 120-mg and 240-mg groups, respectively, were 19.4%, 17.3%, and 19.3% for EVOLVE-1/-2 (pooled; post hoc), and 63.4%, 64.3%, and 64.1% for REGAIN (a priori). Both galcanezumab doses demonstrated significant improvement compared with placebo for overall least squares mean change in monthly migraine headache days in patients with baseline medication overuse in both the episodic and chronic migraine studies (p ≤ 0.001). Furthermore, both galcanezumab doses reduced average monthly medication overuse rates compared to placebo (p < 0.001) in both patient populations with medication overuse at baseline.

CONCLUSIONS

Galcanezumab appears to be effective for the preventive treatment of episodic and chronic migraine in patients who overuse acute medications.Trial registration: ClinicalTrials.gov Identifiers: NCT02614183, NCT02614196, and NCT02614261.

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.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.

Analysis of risk factors for medication-overuse headache relapse: a clinic-based study in China

Background

Medication overuse headache (MOH) is the third most prevalent headache type after migraine and tension-type headache. A large number of studies on the long-term prognosis have shown that MOH has a high relapse rate after treatment. Although MOH relapse-related risk factors have been reported, no related research has been performed in China. Therefore, the purpose of this study was to analyze and evaluate the risk factors for MOH relapse in China.

Methods

Eighty-six out-patients of Shandong Provincial Hospital who were initially diagnosed with MOH, and who had successful withdrawal treatment within 2 months, were chosen from March 2012 to July 2013. All subjects were followed up by the investigators of this study. Of the 86 subjects, 27 who had relapsed were compared with 59 who had not relapsed (i.e. the controls). Based on a standardized questionnaire, a database was created (with Microsoft Excel 2010). The data, which included 38 indexes, were analyzed by univariate analysis with chi-square test, Fisher’s exact test, t-test, or paired rank test. The statistically correlated (P < 0.05) variables were chosen as the independent variables, thereby enabling the calculation of the non-conditional multivariate stepwise logistic regression.

Results

The independent risk factors for medication-overuse headache relapse were determined as headache frequency before drug withdrawal, duration of primary headache, and headache frequency after drug withdrawal.

Conclusion

Headache frequency before drug withdrawal, duration of primary headache, and headache frequency after drug withdrawal may be the independent risk factors for MOH relapse in China.

Combined analgesics in (headache) pain therapy: shotgun approach or precise multi-target therapeutics?

BACKGROUND

Pain in general and headache in particular are characterized by a change in activity in brain areas involved in pain processing. The therapeutic challenge is to identify drugs with molecular targets that restore the healthy state, resulting in meaningful pain relief or even freedom from pain. Different aspects of pain perception, i.e. sensory and affective components, also explain why there is not just one single target structure for therapeutic approaches to pain. A network of brain areas ("pain matrix") are involved in pain perception and pain control. This diversification of the pain system explains why a wide range of molecularly different substances can be used in the treatment of different pain states and why in recent years more and more studies have described a superior efficacy of a precise multi-target combination therapy compared to therapy with monotherapeutics.

DISCUSSION

In this article, we discuss the available literature on the effects of several fixed-dose combinations in the treatment of headaches and discuss the evidence in support of the role of combination therapy in the pharmacotherapy of pain, particularly of headaches. The scientific rationale behind multi-target combinations is the therapeutic benefit that could not be achieved by the individual constituents and that the single substances of the combinations act together additively or even multiplicatively and cooperate to achieve a completeness of the desired therapeutic effect.As an example the fixed-dose combination of acetylsalicylic acid (ASA), paracetamol (acetaminophen) and caffeine is reviewed in detail. The major advantage of using such a fixed combination is that the active ingredients act on different but distinct molecular targets and thus are able to act on more signalling cascades involved in pain than most single analgesics without adding more side effects to the therapy.

SUMMARY

Multitarget therapeutics like combined analgesics broaden the array of therapeutic options, enable the completeness of the therapeutic effect, and allow doctors (and, in self-medication with OTC medications, the patients themselves) to customize treatment to the patient's specific needs. There is substantial clinical evidence that such a multi-component therapy is more effective than mono-component therapies.

Long-term evolution of chronic daily headache with medication overuse in the general population

OBJECTIVE

To investigate long-term efficiency of an intervention protocol for chronic daily headache with medication overuse (CDHwMO) in the general population.

METHODS

The 72 subjects meeting CDHwMO criteria coming from an epidemiological study in the general population (Neurology 2004; 62: 1338-42) were offered follow-up and treatment for 1 year and then discharged to their general practitioner with treatment recommendations. Four years later, they were interviewed again. They filled in a diary for 1 month and the SF-12 test.

RESULTS

After 1 year, 46 (64%) did not fulfill MO criteria while 26 (36%) did. After 4 years, 68 subjects were contacted. Of those, 38 (58%) did not have CDHwMO, while 30 (44%) still had MO. Among those 38 subjects without MO criteria, 6 still met CDH criteria. Remission at year 1 was a significant predictor for sustained remission at year 4. Age, gender, civil status, socioeconomic situation, and CDH type were not different in the group with MO vs those without MO. Consumption of nonsteroidal anti-inflammatory drugs and/or triptans was significantly higher in subjects without CDH and MO, while the use of ergotics and/or opioids was significantly higher in those patients who still met CDHwMO criteria. Quality of life (QoL) was significantly better at 4 years for the whole group.

CONCLUSIONS

After 4 years, almost 60% of subjects did not fulfill CDHwMO criteria and their QoL was also improved. This justifies public health interventions that should include recommendations on a judicious use of symptomatic medications together with an early use of preventatives.

Utility of Topiramate for the Treatment of Patients with Chronic Migraine in the Presence or Absence of Acute Medication Overuse

Chronic migraine has been linked to the excessive use of acute headache medications. Medication overuse (MO) is commonly considered the most significant risk factor for the progression of migraine from an episodic to a chronic condition. Managing MO is a challenge. Discontinuation of the acute medication can result in withdrawal headache, nausea, vomiting and sleep disturbances. This review summarizes the results from two similarly designed, randomized, placebo- controlled, multicentre studies of chronic migraine conducted in the USA and European Union. Both studies demonstrate the efficacy and safety of the migraine preventive medication, topiramate, for the treatment of chronic migraine in patient populations both with and without MO. These studies may have important implications for the future of chronic migraine management, suggesting that detoxification prior to initiating prophylactic therapy may not be required in all patients if MO is present.

Is there hope for chronic pain and headache?

Currently the clinical needs for pain and headache management are not met. Despite the numerous and exciting recent advances in understanding the molecular and cellular mechanisms that originate pain, we cannot yet fully explain the mechanism underlying the biology of chronic pain. Pain is a natural mechanism preserving our species survival; however, when the protective quality is lost, physiologic changes to the peripheral and central nervous systems result in the formation of chronic pain states. Once we understand how this chronic pain state is created, either through genetic, environmental, therapeutic, or other triggers we may be able to enhance our species existence, limiting maladaptive pain and suffering. The future therapeutic targets will need to address the genetics, neurophysiologic changes of the neurons and brain as well as help control immune systems including the glia. The key to successful headache and pain therapy is research aimed at prevention and minimizing the plastic changes triggering chronic pain.

Pharmacokinetics and interactions of headache medications, part I: introduction, pharmacokinetics, metabolism and acute treatments

Recent progress in the treatment of primary headaches has made available specific, effective and safe medications for these disorders, which are widely spread among the general population. One of the negative consequences of this undoubtedly positive progress is the risk of drug-drug interactions. This review is the first in a two-part series on pharmacokinetic drug-drug interactions of headache medications. Part I addresses acute treatments. Part II focuses on prophylactic treatments. The overall aim of this series is to increase the awareness of physicians, either primary care providers or specialists, regarding this topic. Pharmacokinetic drug-drug interactions of major severity involving acute medications are a minority among those reported in literature. The main drug combinations to avoid are: i) NSAIDs plus drugs with a narrow therapeutic range (i.e., digoxin, methotrexate, etc.); ii) sumatriptan, rizatriptan or zolmitriptan plus monoamine oxidase inhibitors; iii) substrates and inhibitors of CYP2D6 (i.e., chlorpromazine, metoclopramide, etc.) and -3A4 (i.e., ergot derivatives, eletriptan, etc.), as well as other substrates or inhibitors of the same CYP isoenzymes. The risk of having clinically significant pharmacokinetic drug-drug interactions seems to be limited in patients with low frequency headaches, but could be higher in chronic headache sufferers with medication overuse.