Medication-Overuse Headache: Protocols and Outcomes in 149 Consecutive Patients in a Tertiary Brazilian Headache Center

Real-world clinical results of CGRP monoclonal antibody treatment for medication overuse headache of migraine without abrupt drug discontinuation and no hospitalization

Background

Abrupt discontinuation of overused medications is standard treatment for medication overuse headache (MOH), but discontinuation is difficult to maintain. The aim was to evaluate the real-world clinical results of anti-calcitonin gene-related peptide monoclonal antibody (CGRP-mAb) treatment for migraine with MOH without abrupt drug discontinuation and no hospitalization.

Methods

Data were collected before starting CGRP-mAb injections (baseline) and 1 month after each injection. The following items were compared between baseline and after the first, second, and third CGRP-mAb injections, monthly headache days (MHD), monthly migraine days (MMD), monthly acute medication use (AMU) days, monthly total amount of AMU tablets, headache impact test-6 (HIT-6), and the migraine-specific quality of life questionnaire (MSQ). Achieving reduction rates ≥50 % in the frequency of each headache and migraine was defined as a good response. Achieving reduction rates of both AMU days and tablets ≥50 % was defined as effective in reducing AMU.

Results

This study included 33 patients with migraine with MOH. After the third CGRP-mAb injection, MHD and MMD were significantly decreased from median 30.0 to 9.5 days, and 10.0 to 1.5 days, respectively. In addition, monthly AMU days and tablets were significantly decreased from median 28.0 to 8.0 days, and 30.0 to 9.5 tablets, respectively. After the third CGRP-mAb injection, the good MHD and MMD responder rates were 75.0 % and 85.7 %, respectively. The rate of reducing AMU was 78.6 %. HIT-6 and MSQ scores decreased significantly from baseline to after each CGRP-mAb injection.

Conclusions

When CGRP-mAb was administered to migraine with MOH, frequency of headache symptoms and AMU were reduced without abrupt drug discontinuation and no hospitalization.

One-Year and Five-Year Outcomes in Medication Overuse Headache: A Real-World Study

BACKGROUND

Medication overuse headache (MOH) is one of the global health-related problems that imposes significant morbidity. Effective management requires the abrupt cessation of the overused medications, transition therapy in the initial days, and initiation of preventive treatment. The objective of this study is to provide one-year and five-year follow-ups of study participants diagnosed with chronic migraine and MOH. The study will examine the efficacy of withdrawal therapy, the use of conventional preventive medication, and the use of anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies.

METHODOLOGY

We conducted a single-center, prospective, and descriptive study at a tertiary center in Brazil. The population was included by convenience sampling of consecutive subjects diagnosed with chronic migraine and MOH. Demographics and clinical data at baseline and one-year and five-year follow-ups were collected in the clinical records.

RESULTS

Among 142 subjects, 116 were females and 26 were males, with a mean age of 42.1±14.3. They were followed for five years. The diagnosis was performed at the mean age of 24.9±14.7 years after the headache onset, and the time with headache ≥15 days per month was 6.3±7.6 years. On baseline, the average number of headache days per month (HDM) was 25.2±5.9. There was a reduction in HDM. At one-year and five-year follow-ups, a ≥75% reduction in HDM was observed, respectively, in 51.4% and 70.4% of the sample.

CONCLUSIONS

The five-year follow-up of chronic migraine and MOH treated with the discontinuation of excessive medication, the use of preventative pharmacological agents, and the optional inclusion of anti-CGRP pathway monoclonal antibody led to a significant decrease in the initial occurrence of HDM.

[Medication overuse headache]

Medication overuse headache (MOH) is a globally prevalent and debilitating condition that results from excessive use of acute therapies and can significantly affect quality of life, despite the fact that simple information about the causes and consequences of the condition can help prevent or stop MOH. In recent years, many new insights have been gained into headaches caused by medication overuse. In addition, the diagnostic criteria and guideline recommendations have changed considerably. This article provides a comprehensive overview of the clinic, definition/classification, epidemiology, risk factors, pathophysiology, controversies, prevention, and treatment of MOH.

Effect of prednisolone for the treatment of medication-overuse headache: A 3-month result from a multicenter REgistry for Load and management of mEdicAtion overuSE headache (RELEASE) study

OBJECTIVE

To evaluate the efficacy of prednisolone in the treatment of medication-overuse headache (MOH) using data from a multicenter prospective registry (Registry for Load and Management of Medication Overuse Headache [RELEASE]).

BACKGROUND

The treatment of MOH is challenging, especially when withdrawal headache manifests during the cessation of overused medication. Although systemic corticosteroids have been empirically used to reduce withdrawal headaches, their efficacy on the long-term outcomes of MOH has not been documented.

METHODS

This was a post hoc analysis of the RELEASE study. The RELEASE is an ongoing multicenter observational cohort study in which patients with MOH have been recruited from seven hospitals in Korea since April 2020. Clinical characteristics, disease profiles, treatments, and outcomes were assessed at baseline and specific time points. We analyzed the effect of prednisolone on MOH reversal at 3 months.

RESULTS

Among the 309 patients enrolled during the study period, prednisolone was prescribed to 59/309 (19.1%) patients at a dose ranging from 10 to 40 mg/day for 5-14 days; 228/309 patients (73.8%) completed the 3-month follow-up period. The MOH reversal rates at 3 months after baseline were 76% (31/41) in the prednisolone group and 57.8% (108/187) in the non-prednisolone group (p = 0.034). The effect of steroids remained significant (adjusted odds ratio 2.78, 95% confidence interval 1.27-6.1, p = 0.010) after adjusting for the number of monthly headache days at baseline, mode of discontinuation of overused medication, use of early preventive medications, and the number of preventive medications combined.

CONCLUSIONS

Although our observational study could not draw a definitive conclusion, prednisolone may be effective in the treatment of MOH.

Medication-overuse headache-a review of different treatment strategies

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.

Medication Overuse Headache, Chronic Migraine and Monoclonal Antibodies Anti-CGRP: A Real-World Study

OBJECTIVE

Medication overuse headache (MOH) in chronic migraineurs may be a cause or consequence of the overuse of symptomatic medications for headache attacks. It is highly prevalent in tertiary centers. We compared the efficacy of 3 anti-CGRP monoclonal antibodies with traditional pharmacological agents in patients with chronic migraine (CM) and MOH.

METHODS

A randomized, cross-sectional, prospective, and open trial with real-world comparison groups was carried out. The sample consisted of 100 consecutive patients having CM and MOH.

RESULTS

Eighty-eight patients (65 women and 23 men) were included in the study and divided into 4 groups: those having used erenumab (19.3%), galcanezumab (29.6%), fremanezumab (25%) and conventional medications, and the control group (26.1%). Ages ranged from 18 to 78 years (mean, 44.1 ± 13.6 years). In the 6 months of follow-up, there was a significant reduction in the number of headache days in the 3 groups when compared with the control ( P < 0.0001).

CONCLUSIONS

The small number of patients included in each group and the open design do not allow definitive conclusions, but the use of anti-CGRP monoclonal antibodies in patients with CM and MOH may result in lessening the number of headache days when compared with conventional treatment with drugs.

Monoclonal antibodies for chronic migraine and medication overuse headache: A real-world study

Background

Medication-overuse headache is highly prevalent in tertiary care centers. It may be a cause or consequence of the overuse of symptomatic medications for migraine attacks.

Objective

We aimed to compare the efficacy of anti-CGRP monoclonal antibodies (mAbs) added to conventional pharmacological treatments in patients with chronic migraine (CM) and medication overuse headache (MOH).

Methods

A cross-sectional, prospective, randomized, open study with real-world comparison groups of patients was carried out. The sample consisted of 200 patients with CM and MOH, who received the same approach to withdraw overused medications, started preventative treatment, and either did or did not receive mAbs.

Results

A total of 172 patients (126 women and 46 men) were included in the study and divided into two groups: group one consisting of 58 patients (control) and group two of 114 patients who used mAbs added to conventional pharmacological agents. The mean age was 44.1 ± 13.6 years, ranging from 18 to 78 years. In the 3 months follow-up after starting the treatment, both groups presented headache frequency reduction, but those with monoclonal antibodies had a significantly higher reduction in the number of headache days and symptomatic medication intake when compared to the control (p < 0.0001).

Conclusions

The addition of an anti-CGRP monoclonal antibody to the treatment for medication overuse headaches in chronic migraineurs may result in decreasing headache frequency and symptomatic medication use when compared to conventional treatments with drugs.

Is prednisone still a reasonable option in the treatment of withdrawal headache in patients with chronic migraine and medication overuse headache in the age of CGRP antibodies? A narrative review

OBJECTIVE

Along with the development of novel migraine therapies as the monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor, the question arises if the treatment of chronic migraine (CM) and medication overuse headache (MOH) must be reconsidered. Have previous therapeutic approaches, including glucocorticoids, lost their role in the management of this debilitating disorder? In this narrative review, we present an overview of the available treatment options in CM and MOH in light of CGRP antibodies as well as an evaluation of the role of glucocorticoids in withdrawal therapy.

BACKGROUND

Chronic migraine and medication overuse continues to be a difficult to treat condition. To date, potent treatment options are scarce and algorithms for advising patients with MOH are often still based on expert consensus rather than evidence-based medicine. For years and probably due to lack of effective alternatives, glucocorticoids have been used in MOH, especially to alleviate withdrawal symptoms caused by detoxification. Small case series report positive effects of steroids in this respective patient group; however, randomized controlled trials did not show a consistent benefit, although this may be due to methodological limitations. Because of these discrepancies, their role in MOH has been under debate ever since.

METHODS

We searched the electronic database PubMed for articles up to June 1, 2022 on the use of glucocorticoids in CM and MOH.

CONCLUSION

Despite popular use in clinical practice, there is currently still no scientific evidence for the efficacy of glucocorticoids in patients with CM and MOH. Treatment with monoclonal antibodies achieved high transition rates from medication overuse to non-overuse. However, further research is needed to evaluate the additional benefit of these new agents.

Medication overuse headache: an overview of clinical aspects, mechanisms, and treatments

INTRODUCTION

Medication-overuse headache (MOH) is a common debilitating neurological disorder, with a prevalence of 1% to 7% in general population. It affects more than 60 million people worldwide and provokes substantial burden. Despite that, most practitioners don't know MOH. This review aims at presenting MOH clinical features, pathophysiology insights, and recent knowledge and guidance regarding treatments.

AREAS COVERED

A literature search in the major medical databases including the terms 'medication overuse headache,' 'chronic daily headache,' 'chronic migraine,' 'symptomatic medication overuse' and others, published between 1990 and 2020, was carried out.

EXPERT COMMENTARY

Primary headache sufferers such as migraineurs and tension-type headache patients may increase the headache frequency and induce the transition from episodic to chronic forms, as well as develop MOH, in the presence of medication overuse. There is evidence of structural and functional changes in some areas of the brain, which may identify those likely to respond or not to treatments. Despite the geographical differences and lack of consensus regarding approaches, to educate the patients about reducing medication intake, to withdraw overused medications and to start prophylaxis in some sufferers are crucial steps. Emerging treatments as monoclonal antibodies to migraine may result in better adherence and tolerability profiles as well as outcomes.

Medication-overuse headache. Retrospective comparison of preventive treatments

ABSTRACT Objectives: Medication-overuse headache is commonly seen in tertiary centers. Limited evidence is available regarding treatment. We compared the use of one or two drugs, three drugs, or four pharmacological agents for the prevention of headache. Methods: This was a retrospective analysis of 149 consecutive patients. Sudden withdrawal and pharmacological prevention with one or more drugs were carried out. Adherence and the decrease of headache frequency of more than 50% were compared after four months between the one or two, three, and four drug groups. Results: There was no difference in adherence (p > 0.6). Headache frequency reduction was shown in 23 (54.8%, one or two drugs), 33 (70%, three drugs) and 11 (55%, four drugs); p = 0.13 and p = 0.98, not significant. There was a tendency towards significance between the one or two drug takers versus the three drug and four drug takers together (p = 0.09). Conclusions: The use of more drugs was not better at improving headache. However, there is the possibility that acting simultaneously on different sites may promote broader modulation and better outcome.

A Critical Evaluation on MOH Current Treatments

OPINION STATEMENT

Migraine is the most frequent neurological disorder observed in clinical practice characterized by moderate to severe pain attacks associated with neurological, gastrointestinal, and dysautonomic symptoms. Each year, 2.5% of patients with episodic migraine develop chronic migraine (CM). CM is characterized by high frequency of the attacks that may result into chronic intake of abortive medications. Nearly, the 70% of CM patients referring to tertiary head centers show acute pain medications overuse that may lead to the development of medication overuse headache (MOH). The management of MOH requires three steps: (1) education, (2) withdrawal of the overuse drug and detoxification, and (3) re-prophylaxis. In the last years, several real-life prospective studies provided further evidence in clinical setting of the onabotulinumtoxinA 155-195 U efficacy for the headache prophylaxis in CM with MOH patients. There is a general agreement on two factors: (1) withdrawal of the overuse drug is condicio sine qua non to reverse the pattern to medium-low-frequency migraine, and (2) the focus of management needs to shift from acute treatment of pain to prevention of headache. CM patients close to developing MOH, patients with high-frequency episodic migraine, and those already abusing of drugs require special attention and should refer to tertiary headache centers. For all of them, a solution could be an "early treatment." Early should be their referral to a tertiary headache center, early should be the withdrawal of the overuse drug and a proper detoxification, and perhaps early should be the start of a preventative therapy.