Medication Overuse Migraine

Medication overuse headache is a condition in which disabling headaches occur as a result of overusing acute headache medication. There are several strategies for treatment, some of which were discussed by Rigmor Jensen in her presentation at MTIS 2020.

Medication overuse headache (MOH) is a condition that results from frequent and prolonged use of medication for the treatment of a headache disorder, leading to worsening headaches.1 MOH is not as prevalent as tension-type headache and migraine, but it is still highly disabling.1 During her presentation at MTIS 2020, the Migraine Trust Virtual Symposium held 3–9 October 2020, Professor Rigmor Jensen (University of Copenhagen, Denmark) discussed the treatment of MOH and attempted to provide some clarity on the best course of action to mitigate the debilitating effects of the condition.

 

MOH treatment: The problem

 

First and foremost, Prof. Jensen wanted her audience to understand the severity and problems posed by MOH. She stated that the disease is classified as headache occurring on at least 15 days per month in a patient with regular overuse of one or more drugs for treatment of headache for more than three months. Prof. Jensen noted that the prevalence of the condition is 1–2% of the global population, and 30–50% in specialized headache centers. According to the Global Burden of Disease report, MOH ranked 18th globally among 301 acute and chronic diseases in years lived with disability.1

 

The good news, according to Prof. Jensen, is that MOH is both treatable and preventable; the problem is deciding how exactly to achieve these goals. She then posed one of the key questions of her presentation: to stop or not to stop? Prof. Jensen remarked that there are two main strategies for withdrawal from MOH: completely stop the patient’s use of medication, or limit them to a restricted intake in which the number of days per month that the patient uses the medication is reduced.

 

MOH treatment: The evidence

 

Prof. Jensen went on to present the evidence of several studies—some of them from her research group at the University of Copenhagen—that have investigated treatment strategies for MOH. The first study Prof. Jensen discussed was a randomized, controlled, open-label trial that compared two medication withdrawal programs: complete detoxification (program A) and restricted medication (program B).2 Prof. Jensen stated that 74% of patients with chronic headache in program A and 46% in program B reverted to episodic headache after 12 months. While both programs reduced disability and increased quality of life, complete detoxification was the more effective strategy.2

 

Another study from Prof. Jensen’s research group was done in several countries in Europe and Latin America to collect information about acute medication and healthcare utilization in MOH.3 Prof. Jensen remarked that her group made the recommendation to have patients withdraw their acute medication and supplement this withdrawal with preventive medication to treat their MOH. She opined that this strategy had a highly significant effect on use of medication, pain intensity and duration, costs of healthcare, quality of life, and reducing anxiety and depression.

 

Prof. Jensen also discussed the results of a study that compared three treatment strategies: a combination of medication withdrawal and preventive treatment (W+P), withdrawal from acute medication alone, and preventive treatment alone. She noted that W+P had a greater reduction in headache days than either withdrawal or preventive treatment alone. Additionally, Prof. Jensen stated that there was a 80% higher chance to revert to episodic headache and a 30% higher chance to be cured of MOH in W+P than in withdrawal or preventive treatment alone.

 

"One of our key elements in treatment of medication overuse is education—education before the patient goes into the withdrawal period, so they know what they will go through and are ready for withdrawal."

 

Rigmor Jensen

 

MOH treatment: The decision

 

Prof. Jensen concluded her presentation by remarking that withdrawal from acute medication is both effective in treating MOH as well as cost-effective. She believes that complete detoxification is the best withdrawal strategy, and that supplementing this with preventive medication makes it even more effective. She reiterated that withdrawal combined with preventive medication leads to a fast reduction in monthly migraine days and a greater chance of being cured of MOH. Prof. Jensen’s last remarks were directed to healthcare professionals who may be treating patients with headache disorders: “Prevention of overuse is crucial for all headache patients. Always inform them about the risks of medication overuse headache.”

 

References

 

  1. Westergaard ML, Munksgaard SB, Bendtsen L, Jensen RH. Medication-overuse headache: a perspective review. Ther Adv Drug Saf 2016;7:147–58.

  2. Nielsen M, Carlsen LN, Munksgaard SB, Engelstoft IMS, Jensen RH, Bendtsen L. Complete withdrawal is the most effective approach to reduce disability in patients with medication-overuse headache: A randomized controlled open-label trial. Cephalalgia 2019;39:863–72.

  3. Find NL, Terlizzi R, Munksgaard SB, et al. Medication overuse headache in Europe and Latin America: general demographic and clinical characteristics, referral pathways and national distribution of painkillers in a descriptive, multinational, multicenter study. J Headache Pain 2016;17:20.

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