Risk and burden of medication-overuse headache among patients with migraine

What is the risk of medication-overuse headache among patients with migraine, including patients who are pregnant, and how does it affect them? These questions were addressed by studies presented in three posters at AAN 2021.

Approximately 15% of patients with migraine report acute medication overuse1 and this is associated with medication-overuse headache (MOH). The International Classification of Headache Disorders, 3rd edition (ICDH-3) diagnostic criteria for MOH are:

Headache frequency in patients with MOH ranged from 17 to 27 days per month

  • Headache on at least 15 days a month in a patient with a pre-existing headache disorder
  • Regular overuse for over 3 months of one or more drugs for acute and/or symptomatic treatment of headache
  • Not better accounted for by another ICHD-3 diagnosis2

 

A systematic literature review to evaluate the burden of MOH among adults?

Between 8% and 100% of patients with MOH had a history of migraine

The results of a systematic literature review to evaluate the burden of MOH among adults with migraine were presented by Deighton et al.3

Thirteen population-based studies reporting on outcomes for patients with MOH in North America, Europe, Asia, and South America were identified and their data was mainly derived from inpatient programs.

These studies reported that for patients with MOH:

  • 8% to 100% had a history of migraine
  • Headache frequency ranged from 17 to 27 days per month
  • Mean age ranged from 38 to 70 years
  • 30% to 91% were female
  • 0% to 46% overused triptans, 17%-71% overused combination analgesics, 0% to 48% overused opioids, and 2% to 43% overused ergots3

Unsuccessful withdrawal of medication ranged from 3% to 19% at 1 year and was associated with mood disorders and anxiety, duration of MOH, medication type, greater migraine-related disability, and higher frequency of headache.3

 

What is the relationship between triptan exposure and MOH in real-world practice?

A dose-response effect is observed between triptan exposure and MOH

To assess the relationship between triptan exposure and the risk and timing of MOH in patients with migraine and prior acute treatment with triptans over 5 years, data from a US-based longitudinal claims dataset of adults between Jan 1, 2014 to Dec 31, 2018 were analyzed by Mohajer et al.

Less than 1% of patients (18,057) progressed to a diagnosis of MOH. An increased hazard of MOH and a shorter probable time to diagnosis was observed in triptan-treated migraine patients with an exposure-related trend for both hazard and timing.

Triptan use correlates with how rapidly MOH is likely to manifest

When compared with “triptan-untreated” patients, the magnitude of hazard for “triptan-treated” patients was:

  • Four times higher for those with the lowest number of days of medication supply (used as a proxy indicator of treatment duration)
  • Six times higher for those with the highest number of days of medication supply

This hazard was significantly higher than that associated with a range of other potentially relevant covariates.

 

MOH during pregnancy

59% of pregnant women attending a tertiary headache centre were diagnosed with MOH

The records of 37 patients in the University of Washington Headache Clinic database who were pregnant on their first visit were analyzed by Cuneo et al.

  • 27 (78%) were diagnosed with chronic migraine
  • 22 (59%) were diagnosed with MOH, with 62% of these patients overusing acetaminophen, while 38% were overusing other medications, including triptan sand NSAIDs

The authors concluded that the burden of chronic migraine in pregnancy can be decreased by addressing MOH.

The posters presented by Deighton A, et al. and Mohajer A, et al. were funded by Biohaven Pharmaceuticals, Inc.

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