Expert insights into medication overuse headache

Medication overuse headache (MOH) in population studies generally refers to headache at least 15 days/month associated with overuse of acute medication, explained Professor David Dodick, Phoenix, AZ.² It has a 1-year prevalence of 1–2% in the general population and is more common in women than in men.³

Acute medications vary in their risk of inducing MOH¹

Medication overuse among people with migraine

The prevalence of medication overuse among people with migraine is unknown, said Professor Dodick. A cross-sectional survey of 13,649 US adults with migraine (the MAST study) has, however, revealed that 15% of people with migraine met the criteria for acute medication overuse; and frequent headache was a powerful risk factor.¹

Frequent headache is a powerful risk factor

The MAST study also revealed that compared to people not overusing medications, people with acute medication overuse were significantly more likely to be taking each class of acute migraine drug but significantly less likely to be taking nonsteroidal anti-inflammatory drugs.¹

How might sustained acute medication induce headache?

Understanding the biology of MOH will lead to more effective preventive and treatment options, said Professor Dodick. Views on MOH pathophysiology vary,⁴ but preclinical models of MOH have demonstrated pathophysiology linked to sustained acute medication as follows:

Preclinical models of MOH have demonstrate pathophysiology linked to sustained acute medication

• Increased susceptibility to cortical spreading depression⁵
• Long-lasting alterations in descending pain modulation after prolonged exposure to migraine treatments followed by acute nociceptive stimulation⁶
• Changes leading to latent peripheral and central sensitization⁷

Treatment of MOH must be individualised

Professor Michael Marmura, Philadelphia, PA, highlighted that patients with migraine have different migraine and medication histories and that the treatment of MOH must be individualised.

Patients with migraine have different migraine and medication histories

He also outlined the European Academy of Neurology guidelines for the management of MOH, which recommend a multifaceted approach that may involve a multidisciplinary team of neurologist or pain specialist and behavioural psychologists and the following strategies:

1. Patient education and counselling
2. If education is not effective, withdrawal of overused medications and preventive treatment with medications of proven efficacy
3. If no response to preventive therapy, medication withdrawal⁸

Psychoeducation and withdrawal from acute medication

Treatment of MOH with psychoeducation and withdrawal from acute medication was discussed by Professor Christofer Lundqvist, Oslo, Norway.

Regular contact with patients can help with medication withdrawal and prevent relapse

He highlighted:

• A brief intervention providing information about the possible role of medication overuse significantly reduced the mean number of medication days and improved headache⁹
• Withdrawal of medication is followed by a short period of worsening headache, but this is then followed by fewer headaches, fewer medication side-effects, lower costs, easier to choose prophylactic medication and better effect of prophylactic medications
• The Severity of Dependence Scale (SDS)¹⁰ can be used to differentiate patients for treatment with a brief intervention (SDS score ≥5) from those who need only preventive information
• The importance of reassuring patients that they will be supported throughout and followed up to avoid relapse

This satellite symposium was sponsored by H. Lundbeck A/S.