Medication Overuse Headache — Approaches Studied then Followed-Up 4 Years Later

Continuous use of all medications commonly used to treat headaches (ergotamine, analgesics, opioids and triptans), alone or in combination, in patients with primary headache disorders such as migraine, can lead to the development of an additional headache syndrome called medication overuse headache (MOH). The treatment of MOH generally includes abruptly stopping the overused medication. However, this can lead to "withdrawal headache," in addition to other symptoms such as nausea, vomiting, anxiety, rapid heart rate, sleep disturbances and low blood pressure as well as other symptoms.While different approaches for dealing with MOH have been attempted, there is not currently a consensus on how best to treat this complex problem. In a recently published study, investigators in Norway report on 50 people who had previously been included in a study on medication overuse headache and were followed for an additional 4 years after the completion of the original investigation. The purpose of the follow-up was to further evaluate the outcome of the study participants as well as the influence on outcomes of their particular unique patient characteristics.

The Original Study

In the first study, people were randomly assigned to one of three possible treatment regimens including; migraine prevention medication from the start without first undergoing a total medication withdrawal (detoxification), undergoing a standard out-patient detoxification program without migraine prevention treatment from the start, or receiving no specific treatment. The primary outcome measure, change in headache days per month, was not significantly different among the groups. However, the “prevention” group had the greatest decrease in headache days compared with baseline, and also a significantly greater reduction in other headache measures including intensity and duration of headache symptoms. At the conclusion of the 1 year study, about half of the patients in the prevention group had a greater than 50% reduction in monthly headache days compared with about a quarter of the withdrawal group. The authors concluded that early introduction of preventive treatment without a previous detoxification program reduced total headache suffering more effectively when compared with abrupt withdrawal.

Four Year Study Follow-Up

In the 4 year follow-up study of 50 patients, about a third of the MOH patients still had a greater than 50% reduction in the frequency of headaches as compared to the beginning of the study and two-thirds were not experiencing medication-overuse headache. The authors also looked at individual characteristics of the study participants including education level, sex, age, employment status, and depression and anxiety measures and could not find any patient characteristics that pointed to any specific reason for their response. Investigators also point to possible limitations of both the original study as well as the follow-up such as incomplete headache diaries and other inconsistent self reported information. With regard to the type of initial intervention that was offered, no significant difference in the number of headache days per month was seen possibly due to the fact that the patients continued to have access to optimal migraine care during the follow-up period.

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