What is the relationship between acute medication use and medication-overuse headache?

The term medication-overuse headache implies headache caused by overuse of medication, but overuse of acute medications is an indicator of poorly controlled headache and not invariably the cause, said expert Professor David Dodick, Phoenix, AZ, at IHC2021. In addition, optimal management requires not only withdrawal of the overused medication but also starting preventive treatment at the same time to treat the underlying primary headache. 

Medication overuse headache is an indicator of poorly controlled headache

Headache for many individuals in the general population with medication overuse headache does not improve after detoxification

The International Classification of Headache Disorders, 3rd edition describes medication-overuse headache (MOH) as headache occurring on 15 or more days/ month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped.1

The implication of this description is that MOH results from the overuse of medication, said Professor David Dodick, Phoenix, AZ. However, overuse of acute medications is an indicator of poorly controlled headache and not invariably the cause.2,3

Withdrawing acute medications does not treat the underlying migraine

Furthermore:

  • It has been estimated that only 60% of individuals in the general population who meet the criteria for MOH have true MOH based on reversion to episodic headache after detoxification3
  • Withdrawal of acute medication can then lead to non-MOH2

 

Which is the best management strategy: withdrawal, prevention or both?

Although MOH may resolve on withdrawing acute medications,1 this strategy does not treat the underlying primary headache, said Professor Dodick.

Starting preventive treatment at the same time as acute medication withdrawal, however, treats the biologic basis of chronic migraine and MOH,4 he added. And starting preventive treatment without withdrawing acute medication reduces total headache suffering more effectively than abrupt withdrawal.5

Starting preventive treatment at the same time as acute medication withdrawal treats the biologic basis of chronic migraine

Professor Dodick highlighted:

  • A systematic review of treatment for MOH that demonstrated adding preventive medication to early discontinuation led to a better outcome than early discontinuation alone6
  • A randomized clinical trial comparing three treatment strategies for MOH —withdrawal and preventive medication, preventive medication, and withdrawal alone — which demonstrated that all three strategies were effective, but based on the results, the authors recommended withdrawal therapy combined with preventive medication from the start of withdrawal as treatment for MOH7

Withdrawal therapy combined with preventive medication from the start of withdrawal is recommended for MOH

Professor Dodick concluded that:

  • Education and a patient-centered approach are essential for treating chronic migraine with MOH
  • The optimal approach is withdrawal of overused medication, switching to limited intake (< 2 days/week) of an alternative acute medication, starting preventive treatment and comprehensive biobehavioral and disease management to address risk factors

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38(1):1–211.
  2. Scher AI, et al. Medication overuse headache: An entrenched idea in need of scrutiny. Neurology 2017;89(12):1296–1304.
  3. Loder EW, Scher AI. Medication overuse headache: The trouble with prevalence estimates. Cephalalgia 2020;40(1):3–5.
  4. Diener HC, et al. European Academy of Neurology guideline on the management of medication-overuse headache. Eur J Neurol 2020;27(7):1102–1116.
  5. Hagen K, et al. Management of medication overuse headache: 1-year randomized multicentre open-label trial. Cephalalgia 2009;29(2):221–232.
  6. Chiang C-C, et al. Treatment of medication-overuse headache: A systematic review. Cephalalgia 2016;36(4):371–386.
  7. Carlsen LN, et al. Comparison of 3 treatment strategies for medication overuse headache. A randomized clinical trial. JAMA Neurol 2020;77(9):1069–1078.
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