Management of medication-overuse headache

Medication-overuse headache-a review of different treatment strategies

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.

A Descriptive Review of Medication-Overuse Headache: From Pathophysiology to the Comorbidities

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is an important problem worldwide, with different areas of controversy regarding its entity. This article reviews the risk factors, comorbidities, pathophysiology, clinical presentation, effective management, and prognosis of MOH by summarizing and integrating the results and findings from previously performed more than 15,000 studies (from 2010 to 2023) available from the scientific database of the University Medical Library in the University Clinical Center of Niš, which aimed to investigate and define the complexity of this type of headache.

RECENT FINDING

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 triptans and other painkillers 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

Although it is likely that MOH does occur, restricting the number 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. Further research needs to be developed to identify more precise mechanisms for effective MOH management and its evolution.

Chiropractic student diagnosis and management of headache disorders: A survey examining self-perceived preparedness and clinical proficiency

OBJECTIVE

To explore the self-perceived preparedness and clinical proficiency in headache diagnosis and management of Australian chiropractic students in senior years of study.

METHODS

Australian chiropractic students in the 4th (n = 134) and 5th year (n = 122) of 2 chiropractic university programs were invited to participate in an online cross-sectional survey. Descriptive analyses were conducted for all variables. Post hoc analyses were performed using simple linear regression to evaluate the relationship between self-perceived preparedness and correctness of headache diagnosis and management scores.

RESULTS

Australian chiropractic students in senior years demonstrated moderate overall levels of self-perceived preparedness and proficiency in their ability to diagnose and manage headache disorders. Final-year students had a slightly higher self-perceived preparedness and proficiency in headache diagnosis and management compared to those students in the 4th year of study. There was no relationship between self-perceived preparedness and correctness of headache diagnosis and management for either 4th- or 5th-year chiropractic students.

CONCLUSION

Our findings suggest that there may be gaps in graduate chiropractic student confidence and proficiency in headache diagnosis and management. These findings call for further research to explore graduate chiropractic student preparedness and proficiency in the diagnosis and management of headache disorders.

The Many Faces of Medication-Overuse Headache in Clinical Practice

The management of medication-overuse headache (MOH) is multifaceted and headache experts have different views on the optimal strategy to tackle this type of secondary headache. The purpose of this review is to provide an overview of the literature on the management of MOH, and to highlight important considerations in the clinical evaluation of the MOH patient. Managing MOH in clinical practice starts by evaluating the headache patient with medication overuse, determining the overused drug(s), assessing the impact of headaches on the patient and assessing comorbid conditions and disorders. Withdrawal of the overused medication is the cornerstone of treatment. An inpatient or outpatient setting is chosen based on the clinical profile of the patient. There is evidence for abrupt withdrawal combined with headache preventive treatment. Bridging therapy to bring relief to withdrawal headaches and/or symptoms should be offered. Education and motivational work through multidisciplinary assessment show benefits in sustaining withdrawal and preventing relapse. Although the reversal of chronic headache after cessation of overused acute medication has been noticed worldwide, different aspects of the management of MOH, such as complete or gradual withdrawal, or preventive treatment with or without withdrawal are still debated.

The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey

BACKGROUND

Headache management is common within chiropractic clinical settings; however, little is yet known about how this provider group manage headache sufferers. The aim of this study is to report on the prevalence of headache patients found within routine chiropractic practice and to assess how chiropractors approach key aspects of headache management applicable to primary care settings.

METHODS

A 31-item cross-sectional survey was distributed to a national sample of chiropractors (n = 1050) to report on practitioner approach to headache diagnosis, interdisciplinary collaboration, treatment and outcome assessment of headache patients who present with recurrent headache disorders.

RESULTS

The survey attracted a response rate of 36% (n = 381). One in five new patients present to chiropractors with a chief complaint of headache. The majority of chiropractors provide headache diagnosis for common primary (84.6%) and secondary (90.4%) headaches using formal headache classification criteria. Interdisciplinary referral for headache management was most often with CAM providers followed by GPs. Advice on headache triggers, stress management, spinal manipulation, soft tissue therapies and prescriptive neck exercises were the most common therapeutic approaches to headache management.

CONCLUSION

Headache patients make up a substantial proportion of chiropractic caseload. The majority of chiropractors managing headache engage in headache diagnosis and interdisciplinary patient management. More research information is needed to understand the headache types and level of headache chronicity and disability common to chiropractic patient populations to further assess the healthcare needs of this patient population.

Economic benefits of treating medication-overuse headache – results from the multicenter COMOESTAS project

Background

Medication-overuse headache is a costly disease for individuals and society.

Objective

To estimate the impact of medication-overuse headache treatment on direct and indirect headache-related health care costs.

Methods

This prospective longitudinal study was part of the COMOESTAS project (COntinuous MOnitoring of Medication Overuse Headache in Europe and Latin America: development and STAndardization of an Alert and decision support System). Patients with medication-overuse headache were included from four European and two Latin American headache centers. Costs of acute medication, costs of health care services, and measurements of productivity were calculated at baseline and at 6-month follow-up Treatment consisted of overused drug withdrawal with optional preventive medication.

Results

A total of 475 patients (71%) completed treatment and were followed up for 6 months. Direct health care costs were on average reduced significantly by 52% ( p < 0.001) for the total study population. Significant reductions were seen in both number of consumed tablets (−71%, p < 0.001) and number of visits to physicians (−43%, p < 0.001). Fifty percent of patients reduced their number of consumed tablets ≥ 80%. Headache-related productivity loss, calculated either as absence from work or ≥ 50% reduction of productivity during the workday, were reduced by 21% and 34%, respectively ( p < 0.001).

Conclusion

Standardized treatment of medication-overuse headache in six countries significantly reduced direct health care costs and increased productivity. This emphasizes the importance of increasing awareness of the value of treating medication-overuse headache.

Trial registration

The trial was registered at ClinicalTrials.gov (no. NCT02435056)

Chronic Daily Headache: Mechanisms and Principles of Management

Primary headache is a common malady that is often under-recognized and frequently inadequately managed in spite of the fact that it affects up to 95 % of the population in a lifetime. Many forms of headache, including episodic tension and migraine headaches, if properly diagnosed, are reasonably amenable to treatment, but a smaller, though not insignificant, percent of the population suffer daily from a chronic, intractable form of headache that destroys one's productivity and quality of life. These patients are frequently seen in neurological practices at a point when treatment options are limited and largely ineffective. In the following review, we will discuss mechanisms drawn from recent studies that address the transition from acute to chronic pain that may apply to the transformation from episodic to chronic daily headaches which may offer opportunities for preempting headache transformation.

Update on Medication-Overuse Headache and Its Treatment

OPINION STATEMENT

Medication-overuse headache-i.e., a too-frequent consumption of acute headache medications leading to increased headache frequency and reduced effectiveness of acute and preventive treatments-is a serious medical condition whose pathophysiology still remains incompletely known, which is reflected into a lack of mechanism-based treatments. The first mandatory step in the therapeutic strategy remains withdrawal of the abused drug, preferably abrupt, in concomitance with a detoxification pharmacological regimen to lessen withdrawal symptoms. Intravenous hydration, antiemetics, corticosteroids (prednisone), tranquilizers (benzodiazepine), neuroleptics, and rescue medication (another analgesic than the overused) should be delivered in various combinations, on an inpatient (hospitalization and day hospital) basis or outpatient basis, depending on the characteristics of the specific patient and type of overuse. Inpatient withdrawal should be preferred in barbiturate and opioid overuse, in concomitant depression, or, in general, in patients who have difficulty in stopping the overused medication as outpatients. In contrast, in overuse limited to simple analgesics in highly motivated patients, without high levels of depression and/or anxiety, home detoxification should be chosen. Re-prophylaxis should immediately follow detoxification, ideally with local injections of onabotulinumtoxinA every 3 months or topiramate orally for at least 3 months. Adequate information to patients about the risks of a too-frequent consumption of symptomatic headache medications is essential and should constantly parallel treatment to help preventing relapse after detoxification and re-prophylaxis.

Latin American consensus on guidelines for chronic migraine treatment

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

Advice alone versus structured detoxification programmes for complicated medication overuse headache (MOH): a prospective, randomized, open-label trial

Background

The aim of this study was to compare the effectiveness of an educational strategy (advice to withdraw the overused medication/s) with that of two structured pharmacological detoxification programmes in patients with complicated medication overuse headache (MOH) plus migraine.

Methods

One hundred and thirty-seven complicated MOH patients participated in the study. MOH was defined as complicated in patients presenting at least one of the following: a) a diagnosis of co-existent and complicating medical illnesses; b) a current diagnosis of mood disorder, anxiety disorder, eating disorder, or substance addiction disorder; c) relapse after previous detoxification treatment; d) social and environmental problems; e) daily use of multiple doses of symptomatic medications. Group A (46 patients) received only intensive advice to withdraw the overused medication/s. Group B (46 patients) underwent a standard detoxification programme as outpatients (advice + steroids + preventive treatment). Group C (45 patients) underwent a standard inpatient withdrawal programme (advice + steroids + fluid replacement and antiemetics preventive treatment). Withdrawal therapy was considered successful if, after two months, the patient had reverted to an intake of NSAIDs lower than 15 days/month or to an intake of other symptomatic medication/s lower than 10 days/month.

Results

Twenty-two patients failed to attend follow-up visits (11 in Group A, 9 in Group B, 2 in Group C, p < 0.03). Overall, we detoxified 70% of the whole cohort, 60.1% of the patients in Group A and in Group B, and 88.8% of those in Group C (p < 0.01).

Conclusions

Inpatient withdrawal is significantly more effective than advice alone or an outpatient strategy in complicated MOH patients.

Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition, 2012

Headache and facial pain are among the most common, disabling and costly disorders in Europe. Correct diagnosis and treatment is important for achieving a high quality of care. As a national organisation whose role is to educate and advocate for the needs of patients with primary headaches, the Danish Headache Society has set up a task force to develop a set of guidelines for the diagnosis, organisation and treatment of the most common types of headaches and for trigeminal neuralgia in Denmark. The guideline was published in Danish in 2010 and has been a great success. The Danish Headache Society decided to translate and publish our guideline in English to stimulate the discussion on optimal organisation and treatment of headache disorders and to encourage other national headache authorities to produce their own guidelines. The recommendations regarding the most common primary headaches and trigeminal neuralgia are largely in accordance with the European guidelines produced by the European Federation of Neurological Societies. The guideline provides a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organised in Denmark. This description is followed by individual sections on the characteristics, diagnosis, differential diagnosis and treatment of each of the major headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular problems regarding headache in children and headache in relation to female hormones and pregnancy are described.

Study protocol: brief intervention for medication overuse headache--a double-blinded cluster randomised parallel controlled trial in primary care

Background

Chronic headache (headache ≥ 15 days/month for at least 3 months) affects 2–5% of the general population. Medication overuse contributes to the problem. Medication-overuse headache (MOH) can be identified by using the Severity of Dependence Scale (SDS). A “brief intervention” scheme (BI) has previously been used for detoxification from drug and alcohol overuse in other settings. Short, unstructured, individualised simple information may also be enough to detoxify a large portion of those with MOH. We have adapted the structured (BI) scheme to be used for MOH in primary care.

Methods/Design

A double-blinded cluster randomised parallel controlled trial (RCT) of BI vs. business as usual. Intervention will be performed in primary care by GPs trained in BI. Patients with MOH will be identified through a simple screening questionnaire sent to patients on the GPs lists. The BI method involves an approach for identifying patients with high likelihood of MOH using simple questions about headache frequency and the SDS score. Feedback is given to the individual patient on his/her score and consequences this might have regarding the individual risk of medication overuse contributing to their headache. Finally, advice is given regarding measures to be taken, how the patient should proceed and the possible gains for the patient. The participating patients complete a headache diary and receive a clinical interview and neurological examination by a GP experienced in headache diagnostics three months after the intervention. Primary outcomes are number of headache days and number of medication days per month at 3 months. Secondary outcomes include proportions with 25 and 50% improvement at 3 months and maintenance of improvement and quality of life after 12 months.

Discussion

There is a need for evidence-based and cost-effective strategies for treatment of MOH but so far no consensus has been reached regarding an optimal medication withdrawal method. To our knowledge this is the first RCT of structured non-pharmacological MOH treatment in primary care. Results may hold the potential of offering an instrument for treating MOH patients in the general population by GPs.

Trial registration

ClinicalTrials.gov identifier: NCT01314768

Treatment of medication overuse headache--guideline of the EFNS headache panel

BACKGROUND

  Medication overuse headache is a common condition with a population-based prevalence of more than 1-2%. Treatment is based on education, withdrawal treatment (detoxification), and prophylactic treatment. It also includes management of withdrawal headache.

AIMS

  This guideline aims to give treatment recommendations for this headache.

MATERIALS AND METHODS

  Evaluation of the scientific literature.

RESULTS

  Abrupt withdrawal or tapering down of overused medication is recommended, the type of withdrawal therapy is probably not relevant for the outcome of the patient. However, inpatient withdrawal therapy is recommended for patients overusing opioids, benzodiazepine, or barbiturates. It is further recommended to start individualized prophylactic drug treatment at the first day of withdrawal therapy or even before. The only drug with moderate evidence for the prophylactic treatment in patients with chronic migraine and medication overuse is topiramate up to 200mg. Corticosteroids (at least 60mg prednisone or prednisolone) and amitriptyline (up to 50mg) are possibly effective in the treatment of withdrawal symptoms. Patients after withdrawal therapy should be followed up regularly to prevent relapse of medication overuse.

DISCUSSION AND CONCLUSION

  Medication overuse headache can be treated according to evidence-based recommendations.

Chronic migraine plus medication overuse headache: two entities or not?

Chronic migraine (CM) represents migraine natural evolution from its episodic form. It is realized through a chronicization phase that may require months or years and varies from patient to patient. The transition to more frequent attacks pattern is influenced by lifestyle, life events, comorbid conditions and personal genetic terrain, and it often leads to acute drugs overuse. Medication overuse headache (MOH) may complicate every type of headache and all the drugs employed for headache treatment can cause MOH. The first step in the management of CM complicated by medication overuse must be the withdrawal of the overused drugs and a detoxification treatment. The goal is not only to detoxify the patient and stop the chronic headache but also to improve responsiveness to acute or prophylactic drugs. Different methods have been suggested: gradual or abrupt withdrawal; home treatment, hospitalization, or a day-hospital setting; re-prophylaxes performed immediately or at the end of the wash-out period. Up to now, only topiramate and local injection of onabotulinumtoxinA have shown efficacy as therapeutic agents for re-prophylaxis after detoxification in patients with CM with and without medication overuse. Although the two treatments showed similar efficacy, onabotulinumtoxinA is associated with a better adverse events profile. Recently, the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program proved that patients with CM, even those with MOH, are the ones most likely to benefit from onabotulinumtoxinA treatment. Furthermore, it provided an injection paradigm that can be used as a guide for a correct administration of onabotulinumtoxinA.

Pain processing in medication overuse headache: a functional magnetic resonance imaging (fMRI) study

OBJECTIVE

The primary aim was to investigate functional differences between medication overuse headache (MOH) patients and controls with the purpose of evaluating the presence of a global alteration in the processing of noxious stimuli throughout the pain matrix. The secondary aim was to investigate whether activations in MOH patients normalize after medication withdrawal, which would suggest a possible role of the pain matrix in headache chronification.

DESIGN

Functional magnetic resonance imaging was performed during painful mechanical stimulation in nine female patients with MOH immediately and at 6 months after beginning medication withdrawal, and in nine control participants.

RESULTS

Compared with controls, immediately after beginning withdrawal, the MOH patients showed reduced pain-related activity across the primary somatosensory cortex, inferior parietal lobule, and supramarginal gyrus, as well as in regions of the lateral pathway of the pain matrix. At 6 months, these differences were no longer detectable.

CONCLUSION

Our findings suggest that significant functional changes occur in the lateral pain pathway in MOH patients. These could result from different processes: 1) cortical down-regulation aimed at reducing painful input to the cortex; 2) activity-dependent plasticity induced by excessive painful input during migraine attacks; and 3) direct effect of medication overuse. At 6 months after withdrawal, activity in these regions normalized, suggesting that no irreversible changes occur due to medication overuse.

Short-term effectiveness of simple advice as a withdrawal strategy in simple and complicated medication overuse headache

BACKGROUND AND PURPOSE

The aim of this study was to compare the effectiveness of intensive advice (to withdraw the overused medication/s) as a withdrawal strategy in patients with simple and complicated medication overuse headache (MOH).

METHODS

One hundred consecutive MOH patients were included in the study. Exclusion criteria were co-existent severe medical or psychiatric illnesses, treatment with migraine prophylactic drugs within the past 3 months, and overuse of opioids and/or barbiturate-containing agents. MOH was defined as complicated in patients fulfilling at least one of the following criteria: (i) a diagnosis of co-existent, significant, and complicating medical illnesses; (ii) a current diagnosis of mood disorder, anxiety disorder, eating disorder, or substance addiction disorder; (iii) a relapse after previous detoxification treatment; (iv) psycho-social and environmental problems; and (v) daily use of multiple doses of symptomatic medication/s. Withdrawal therapy was considered successful if, after 2 months, the patient had had reverted to an intake of NSAIDs lower than 15 days/month or to an intake of other symptomatic medication/s lower than 10 days/month.

RESULTS

Fifty-one patients had simple MOH and 49 patients had complicated MOH. Eleven patients failed to attend follow-up visits (simple MOH=3, complicated MOH=8, P>0.05). Of all the patients included in the study, we were able to detoxify 79% (92.1% of the patients with simple MOH and 65.3% of those with complicated MOH, P<0.01).

CONCLUSIONS

Simple advice is highly effective in simple MOH and effective in most complicated MOH patients and should be regarded as the first step in a step-care approach to MOH management.

Rehabilitating chronic migraine complicated by medication overuse headaches: how can we prevent migraine relapse?

Headache is among the most common neurological symptoms in clinical practice. In some cases of episodic migraine, the headache intensifies into a chronic form, defined as chronic migraine (CM) and such a condition encompasses a headache frequency of 15 days/month, with features similar to those of migraine attacks. The assessment of CM in the US general population ranges around 1.3-2%. Migraine progression from an episodic into a chronic form is realized through a period of time involving several months or years, during which an increase attack frequency occurs. Both Topiramate and Onabotulinum toxin A can be considered to be safe as well as effective medications, therefore, representing a treatment choice. Regarding drug abusers, the initial relief step always consists of drug interruption. Only after detoxification can a new prophylaxis therapy be commenced, which otherwise would be useless from the start. The feasible diagnostic setting for the tailored treatment of CM based on the application of pharmacogenomics will allow us in predetermining the efficacy of a single old and new drugs by avoiding abuse due to non-responsivity of the abused drug.

A narrative review on the management of medication overuse headache: the steep road from experience to evidence

The management of medication overuse headache (MOH) is based essentially on the withdrawal of the overused drug(s). Drug withdrawal is performed according to widely differing protocols, both within and across countries; therefore, therapeutic recommendations for the acute phase of detoxification vary considerably among studies. Basically, the aims of MOH management are: (a) to withdraw the overused drug(s); (b) to alleviate withdrawal symptoms by means of a bridge therapy, which includes pharmacological and non-pharmacological support, designed to help the patient to tolerate the withdrawal process; (c) to prevent relapse. Today, there is extensive debate over the best strategies for achieving these goals and the different aspects of this debate are discussed in this review. The authors searched for the best available evidence relating to the following questions: should medication withdrawal be abrupt or gradual? Should patients receive replacement therapy? What are the most effective therapeutic programmes for controlling withdrawal symptoms? Should replacement therapy be administered routinely or as rescue therapy? Should preventive treatment be started before, during or after withdrawal? What are the most effective preventive treatments? Should patients be managed through inpatient or outpatient withdrawal programmes? What is the best approach to adopt in preventing relapses? Treatment of MOH is a difficult challenge, but may be very rewarding. Although there is still a lack of high-quality studies providing evidence-based answers to the many specific questions it raises, neurologists need to know that the combination of education with a rational use of selected therapeutic strategies may be beneficial to people with chronic headache and help to relieve their suffering.

The Link Between Pain Patient and Analgesic Medication is Greater in Migraine than in Rheumatic Disease Patients

Our aim was to measure and compare the link between pain patients and the different kinds of analgesic medications they use by the Leeds Dependence Questionnaire (LDQ). This is a self-completion 10-item instrument to measure the severity of dependence upon a variety of substances. LDQ was administered to 200 episodic migraine patients (EM group), 77 chronic migraine patients (CM group) overusing acute medications, and 114 patients suffering from rheumatic disease (RD group), consecutively attending the Headache Centre or the Rheumatology Clinic of the University Hospital of Modena in the course of the first semester of 2007. The link with analgesics was greater in migraine patients than in patients with rheumatic disease, since the LDQ total score was significantly higher in the EM (6.65 ± 0.32, P < 0.005) and CM groups (9.61 ± 0.59, P < 0.0001) than in the RD group (5.17 ± 0.37) (Kruskal–Wallis and Mann–Whitney U-tests). Migraine patients were significantly more linked to triptans and to combined medications than to non-steroidal anti-inflammatory drugs. The strength of the link between migraine patients and the analgesic medications they take could represent a factor of vulnerability: overusing these medications could develop medication overuse headache.

Current migraine management - patient acceptability and future approaches

Despite its high prevalence and individual as well as societal burden, migraine remains underdiagnosed and undertreated. In recent years, the options for the management of migraine patients have greatly expanded. A number of drugs belonging to various pharmacological classes and deliverable by several routes are now available both for the acute and the preventive treatments of migraine. Nevertheless, disability and satisfaction remain low in many subjects because treatments are not accessible, not optimized, not effective, or simply not tolerated. There is thus still considerable room for better education, for more efficient therapies and for greater support from national health systems. In spite of useful internationally accepted guidelines, anti-migraine treatment has to be individually tailored to each patient taking into account the migraine subtype, the ensuing disability, the patient's previous history and present expectations, and the co-morbid disorders. In this article we will summarize the phenotypic presentations of migraine and review recommendations for acute and preventive treatment, highlighting recent advances which are relevant for clinical practice in terms of both diagnosis and management.