Can medication overuse headache be treated by abrupt withdrawal of the overused agent?

Medication-overuse headache

Medication-overuse headache is defined as headache occurring on more than 15days in a month in people with pre-existing primary headache, and developing as a consequence of regular overuse of acute headache treatments. Medication-overuse headache is common in general neurology clinics and can be difficult to manage. Most patients have a background of migraine, which has slowly transformed over months and years from the episodic to chronic form; with this comes an increased use of acute migraine treatment. This paper identifies who is at risk of developing medication-overuse headache, and reviews preventive measures and current treatment strategies.

Update on chronic daily headache

OPINION STATEMENT

Chronic daily headache (CDH), defined as a primary headache occurring at least 15 days per month, is a problem of worldwide scope, which is seen in 3% to 5% of the population. Though it has been recognized since ancient times, only recently have there been attempts to define and classify it. CDH usually consists of a mixture of migraine and tension-type headaches (TTH), with the more severe headaches having migraine features and the less severe headaches fitting the definition of TTH. Some patients have pure chronic TTH and no migrainous features, and others have only migraine, but most have a mixed migraine-TTH pattern. New daily persistent headache, a CDH pattern that comes on over a few days, constitutes 9% to 10% of this group and is otherwise indistinguishable from CDH. Hemicrania continua (1% of CDH) appears to be unique in being absolutely responsive to indomethacin. Accurate diagnosis of CDH is critical to management, as all organic etiologies of chronic headache must be ruled out. Problems often associated with CDH and complicating the diagnosis are head injury or medication overuse (rebound-withdrawal headache). These accompanying issues must be recognized and treated appropriately in the management plan. Finally, psychiatric problems (unipolar depression, bipolar disease, generalized anxiety disorder, and obsessive/compulsive disorder) often accompany CDH, as they are comorbid with migraine. These conditions must be recognized and treated along with the headache itself for treatment to succeed fully. Treatment of CDH is multimodal. The cornerstone of therapy is the use of prophylactic antimigraine medications to prevent or modulate the next headache. Amitriptyline, topiramate, valproic acid, and gabapentin have all had class I studies showing effectiveness in reducing headache occurrence. Recent studies with botulinum toxin have also shown effectiveness in reducing the headache burden. Recognition and treatment of medication overuse headache (MOH) must be carried out as part of the initial approach. Use of acute symptomatic treatments such as triptans or NSAIDs must be undertaken with care, as frequent use of these agents can lead to MOH. Educating the patient about the condition and reasonable expectations for therapy is essential to success. Recognition and appropriate treatment of psychiatric disorders is likewise essential. Adjunctive nondrug therapies and lifestyle changes round out the requirements for a management plan. The chances for long-term remission or significant improvement are up to 65%. The patient and physician must understand that CDH is a long-term process with relapses and remissions. A strong and trusting relationship between patient and physician is a major asset in managing this condition.

Medication overuse headache: awareness, detection and treatment

Episodic migraine is a disabling painful disease that can affect the normal function of daily routine activities such as performance at work and school, and home and social relationships. In addition to the physical disability during migraine, between attacks many patients experience a condition referred to as interictal burden, which can present as pre-event worry about future attacks and can result in the anticipatory use and/or overuse of acute care medications. The overuse of medication can often lead to medication overuse headaches (MOHs) and chronic migraine. Unfortunately, patients, and even some physicians, are often unaware of this phenomenon. Therefore, it is important for knowledgeable physicians to raise awareness and to address the risks of medication overuse with their patients through effective communication. Future management of medication overuse should include detoxification and a comprehensive programme that includes the use of preventive medications such as sodium valproate (divalproex sodium) and topiramate in order to reduce dependency on acute care medication. Also, MOHs may be most effectively managed with the initiation of preventive treatment prior to detoxification, in addition to the decreased use of acute care medication. A long-term treatment plan, including behavioural therapy, migraine preventive medication and appropriate acute care therapy, may be optimal in treating patients with MOHs.