Medication Overuse Headache

Questions from patients about pain conditions and analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. In reply to a question about medication overuse headache, its presentation, causes, treatment, and prevention will be discussed.     

Clinical Aspects of Medication Overuse Headaches

Medication overuse headache (MOH) is a subset of chronic daily headache, occurring from overuse of 1 or more classes of migraine abortive medication. Acetaminophen, combination analgesics (caffeine combinations), opioids, barbiturates (butalbital), non‐steroidal anti‐inflammatory drugs, and triptans are the main classes of drugs implicated in the genesis of MOH. Migraine seems to be the most common diagnosis leading to MOH. The development of MOH is associated with both frequency of use of medication and behavioral predispositions. MOH is not a unitary concept. The distinction between simple (type 1) vs complex (type 2) forms is based on both the class of overused medication and behavioral factors, including psychopathology and psychological drug dependence. MOH is a challenging disorder causing decline in the quality of life and causing physical symptoms, such as daily and incapacitating headaches, insomnia, and non‐restorative sleep, as well as psychological distress and reduced functioning. MOH is associated with biochemical, structural, and functional brain changes. Relapse after detoxification is a challenge, but can be addressed if the patient is followed over a prolonged period of time with a combination of prophylactic pharmacotherapy, use of abortive medication with minimal risk of MOH, withholding previously overused medication, and providing psychological (cognitive‐behavioral) therapy.     

Long‐Term Evolution of Chronic Daily Headache With Medication Overuse in the General Population

(Headache 2010;50:981‐988) 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.     

Screening And Behavioral Management: Medication Overuse Headache – The Complex Case

The new appendix criteria for a broader concept of chronic migraine from the International Headache Society no longer require headache resolution or return to the previous headache pattern to confirm the diagnosis of medication overuse headache (MOH). MOH can be subdivided into simple (Type I) and complex (Type II). Complex cases may involve long-term use of daily opioids or combination analgesics, multisourcing, multiple psychiatric comorbidities, and/or a history of relapse. Daily use of opioids for other medical conditions, psychiatric comorbidity including borderline personality disorder, prior history of other substance dependence or abuse, and family history of substance disorders are risk factors for MOH. Relapse for analgesic overusers can be as high as 71% at 4-year follow-up. A case illustration spans 20 years from initial presentation through multiple periods of recovery and relapse to illustrate issues in the screening and management of complex MOH patients.     

Hemicrania Continua and Symptomatic Medication Overuse

SYNOPSIS
Hemicrania continua (HC) is a rare, strictly unilateral, non-paroxysmal headache disorder characterized by its absolute responsiveness to indomethacin. The pain is usually moderate in intensity and frequently associated with a superimposed"jabs and jolts" headache.
We report two cases of HC which presented as chronic daily headache (CDH) with abortive medication overuse.
CDH can be due to transformed migraine (TM), new daily persistent headache (NDPH), chronic tension-type headache, and HC. All can be unilateral, and all can be associated with medication overuse. Our two cases meet the criteria for HC based on indomethacin responsiveness. One meets the criteria for TM, the other NDPH. Is HC a distinct disorder, or a subset of these other disorders? CDH with medication overuse includes in its differential diagnosis HC.     

Butalbital in the treatment of headache: history, pharmacology, and efficacy

Analgesics containing butalbital compounded with aspirin, acetaminophen, and/or caffeine are widely used for the treatment of migraine and tension-type headache. The butalbital-containing compounds are efficacious in placebo-controlled trials among patients with episodic tension-type headaches. Despite their frequent clinical use for migraine, they have not been studied in placebo-controlled trials among patients with migraine. Barbiturates can produce intoxication, hangover, tolerance, dependence, and toxicity. Butalbital can result in intoxication that is clinically indistinguishable from that produced by alcohol. Butalbital-containing analgesics can produce drug-induced headache in addition to tolerance and dependence. Higher doses can produce withdrawal syndromes after discontinuation. Butalbital-containing analgesics may be effective as backup medications or when other medications are ineffective or cannot be used. Because of concerns about overuse, medication-overuse headache, and withdrawal, their use should be limited and carefully monitored.     

Headache Prophylaxis With BoNTA: Patient Characteristics

( Headache 2010;50:63-70)
Objective.— To assess the characteristics of patients receiving botulinum toxin type A (BoNTA; BOTOX^®) in the treatment of headache (HA) disorders.
Methods.— The following observational epidemiologic data and baseline patient characteristics were prospectively collected from eligible patients treated with BoNTA at 10 US HA specialty centers: demographics; HA diagnoses and characteristics (frequency, severity, and disability); prior and current HA treatments and response; clinical response to BoNTA; Migraine Disability Assessment (MIDAS) questionnaire; and adverse events. Patients maintained a daily HA diary and were evaluated at each follow-up visit.
Results.— Of 703 patients enrolled (mean age 43.1 years, 78.5% females, 95.4% white), nearly 66% had a diagnosis of chronic migraine (CM), with or without medication overuse. Approximately 75% had severe disability (MIDAS grade IV), and the mean pain rating was 6.5 (where 0 = no pain, 10 = pain as bad as it can be). More than 90% of patients had ≥1 prophylactic HA treatment failure; median number of failures was 4. Significant association was observed between HA frequency and MIDAS grade ( P  < .001). Approximately 80% of patients with CM had severe (grade IV) disability. The median number of monthly medication days was higher in the group with MIDAS grade IV ( P  < .001). HA frequency and severity, failed prophylactic therapies, and greater number of coexisting medical conditions were all negatively associated with measures of health-related quality of life.
Conclusions.— Majority of patients treated with BoNTA in a specialty HA center presented with a CM diagnosis. HA disability was correlated with measures of frequency and treatment utilization.     

The Effectiveness of Treatments for Patients With Medication Overuse Headache: A Systematic Review and Meta-Analysis

Worldwide, approximately 1 to 2% of the adult population suffers from chronic headache due to overuse of pain medication. Guidelines recommend acute withdrawal of medication, but the optimal treatment remains unknown. We aimed to evaluate the benefit of treatments for patients with medication overuse headache (MOH). We performed an extensive literature search until November 2015, selecting randomized controlled trials that evaluated interventions for adults with MOH. Two authors assessed the eligible trials and extracted data. We calculated effect estimates and used the random effects model for the pooled analysis. Our primary outcome measures were ‘headache days’ and ‘days with medication.’ Outcome data were categorized as short-term (up to 12 weeks) or long-term (≥12 weeks) outcomes. This review consists of 16 trials including 1,105 patients. Four trials evaluated the use of prednisone with placebo or celecoxib after medication withdrawal; 7 trials evaluated various methods of withdrawal versus other methods of withdrawal, and 5 trials evaluated prophylactic medication compared with placebo or ibuprofen. We found no significant differences in headache days between prednisone versus placebo or between outpatient versus inpatient treatment, but we found a significant difference in days with medication. Overall, we found no benefit of prophylactic medication versus placebo. We found low to very low quality of evidence of no benefit of prednisone, prophylaxis, and various withdrawal interventions. Because the burden of MOH for patients is enormous, larger and high-quality intervention trials are needed.

Medication Overuse Headache: Withdrawal and Prophylactic Therapeutic Regimen

(Headache 2010;50:989‐997) Background.— Medication overuse headache (MOH) is a secondary headache, whose diagnostic criteria were settled by the Second Edition of the International Classification of Headache Disorders and its subsequent revisions. Its diagnosis and treatment represent a growing problem worldwide and a challenge for headache specialists. Objective.— The aim of this study was to evaluate the efficacy of a therapeutic regimen for withdrawal of the overused drug and prophylaxis of headache in a population of patients suffering from MOH in 8 hospitals of Piemonte – Liguria – Valle d'Aosta. Patients and Methods.— Seventy patients, 58 females (82.9%) and 12 males (17.1%), mean age at observation 51.04 ± 12.59 years, affected by MOH following International Headache Society diagnostic revised criteria were treated as inpatients (n = 40) or in Day Hospital (n = 30). Headache Index (HI) and Daily Drug Intake (DDI) were used for evaluating the severity of headache and medication overuse. The patients were treated by abrupt discontinuation of the overused drug and by a therapeutic protocol including i.v. hydration, dexhamethasone, metoclopramide, and benzodiazepines for 7‐15 days. Prophylactic medication was started at the beginning of therapeutic protocol. Patients underwent follow‐up controls 1, 3, and 6 months after discharge. The initial diagnosis was MOH in all patients included in the study. The overused medications were simple analgesics in 18 cases (25.7%), combination analgesics in 26 cases (37.1%), triptans alone in 9 cases (12.9%), or in combination with analgesics in 13 cases (18.6%), and ergot derivatives (in combination) in 4 cases (5.7%). We collected data from 59 patients at first follow‐up (1 month), 56 after 3 months, and 42 after 6 months. Results.— Mean HI was 0.92 at admission, 0.19 at discharge, 0.35 after 30 days, 0.39 after 3 months, and 0.42 after 6 months. Mean DDI was 2.72 at admission, 0.22 at discharge, 0.31 after 1 month, 0.38 after 3 months, and 0.47 after 6 months. These results proved to be highly statistically significant. Conclusions.— The protocol was generally effective, safe, and well‐tolerated. The results tend to remain stable with time, and seem to be encouraging about long‐term use of this therapeutic protocol on a larger number of patients suffering from MOH.     

Medication Overuse Headache: Biobehavioral Issues and Solutions

This article reviews current research on medication-overuse headache (MOH), and provides clinical suggestions for effective treatment programs. Epidemiological research has identified reliance on analgesics as a predictive factor in headache chronicity. MOH can be distinguished as simple (Type I) or complex (Type II). Simple cases involve relatively short-term drug overuse, relatively modest amounts of overused medications, minimal psychiatric contribution, and no history of relapse after drug withdrawal. In contrast, complex cases often present with multiple psychiatric comorbidities and a history of relapse. Although limited, current research suggests that comorbid psychiatric disorders are more prevalent in MOH than in control headache conditions, and may precede the onset of MOH. There appears to be an elevated risk of family history of substance use disorders in MOH patients, and an increased risk of MOH in patients with diagnosed personality disorders. Current studies suggest a high rate of relapse at 3 to 4 years after drug withdrawal and pharmacological treatment, with most relapse occurring during the first year of treatment. Relapse is a greater problem with analgesics than ergots or triptans. The addition of behavioral treatment to prophylactic medication may significantly reduce the risk of relapse over a period of several years. Clinical recommendations include assessment and modification of psychological factors that may underlie MOH, provision of detailed educational information, and combining behavioral treatment with the current standard of drug withdrawal and use of prophylactic pharmacotherapy.