Management Of Medication Overuse Headache Research Articles

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.

A Descriptive Review of Medication-Overuse Headache: From Pathophysiology to the Comorbidities.

Medication-overuse headache (MOH) is an important problem worldwide, with different areas of controversy regarding its entity. This article reviews the risk factors, comorbidities, pathophysiology, clinical presentation, effective management, and prognosis of MOH by summarizing and integrating the results and findings from previously performed more than 15,000 studies (from 2010 to 2023) available from the scientific database of the University Medical Library in the University Clinical Center of Niš, which aimed to investigate and define the complexity of this type of headache. It has been proposed that all acute migraine medications can lead to MOH, with differences in the propensity of different agents to cause the problem. Early data suggests that triptans and other painkillers used for the acute treatment of migraine may be an exception. Recent studies show that practitioners and the general public are still largely unaware of the problem of medication overuse and its damaging effects. Although it is likely that MOH does occur, restricting the number of acute medications is necessary to prevent it. It is also possible that increasing amounts of acute medications are simply a reflection of poorly controlled headaches rather than a cause. Further research needs to be developed to identify more precise mechanisms for effective MOH management and its evolution.

Activation of the microglial P2X7R/NLRP3 inflammasome mediates central sensitization in a mouse model of medication overuse headache.

Excessive use of headache treatments often leads to the development, progression and exacerbation of primary headache, which is defined as medication overuse headache (MOH). A significant pathophysiological mechanism of MOH is central sensitization. Recent evidence suggests that central sensitization in chronic headache is a result of inflammatory responses mediated by microglial activation in the trigeminal nucleus caudalis (TNC). However, it is unknown whether microglial activation has an impact on the central sensitization of MOH. Accordingly, the goal of this research was to determine how microglial activation and the P2X7R/NLRP3 inflammasome signaling pathway in the TNC contribute to the pathogenesis of MOH. Repeated intraperitoneal injection of sumatriptan (SUMA) was used to establish a mouse model of MOH. Basal mechanical hyperalgesia was evaluated using von Frey filaments. As central sensitization biomarkers, the c-Fos and CGRP expression levels were measured by immunofluorescence analysis. We estimated the expression of microglial biomarkers (Iba1 and iNOS) within the TNC by qRT-PCR, western blotting and immunofluorescence analysis. To elucidate the effect of microglial activation and the P2X7/NLRP3 signaling pathway on central sensitization in MOH, we evaluated whether the microglia-specific inhibitor minocycline, the P2X7R-specific antagonist BBG and the NLRP3-specific inhibitor MCC950 altered SUMA-caused mechanical hyperalgesia. Furthermore, we examined c-Fos and CGRP expression within the TNC following individual injections of these inhibitors. Repeated SUMA injection induced basal mechanical hyperalgesia, increased c-Fos and CGRP levels, and activated microglia within the TNC. Inhibiting microglial activation with minocycline prevented the emergence of mechanical hyperalgesia and cut down c-Fos and CGRP expression. Immunofluorescence colocalization analysis revealed that P2X7R was predominantly co-localized with microglia. The levels of P2X7R and the NLRP3 inflammasome were elevated by repeated SUMA injection, and blocking P2X7R and NLRP3 inhibited mechanical hyperalgesia and cut down c-Fos and CGRP expression within the TNC. Based on the current findings, inhibiting microglial activation could reduce central sensitization caused by chronic SUMA treatment via the P2X7R/NLRP3 signaling pathway. The clinical management of MOH may benefit from a novel strategy that inhibits microglial activation.

Medication Overuse Headache: an Updated Review and Clinical Recommendations on Management.

Medication overuse headache (MOH) is highly prevalent among individuals with primary headache disorders. (1) Provide an update on epidemiology, risk factors, and treatment strategies of MOH and (2) provide recommendations on the management of MOH. The prevalence of MOH ranges from 0.5 to 7.2%. Risk factors for MOH include female sex, lower socioeconomic status, some psychiatric conditions, and substance use disorders, among others. Recent large clinical trials support preventative therapy as an integral component of MOH management. Emerging clinical trial evidence supports anti-CGRP mAbs as effective preventative treatments among individuals with migraine and MOH. Among the large clinical trials, candesartan, topiramate, amitriptyline, and onabotulinumtoxinA were the most used preventative therapies, providing further support for these agents. MOH management requires a multifaceted and patient-centered approach that involves patient education, behavioral interventions, withdrawal of the overused medication, and initiation of preventative medication.

Unable to Work Due to Migraine for Which Tryptan is Taken 14 Times a Month or Less: Medication-Overuse Headache (MOH)

Management of refractory headache, particularly medication-overuse headache (MOH), is often difficult. In the management of MOH, it is important to determine the underlying primary headaches. Therefore, history taking and medical examinations are crucial for the diagnosis of headache type. Patient education and appropriate preventive therapy are beneficial in ameliorating MOH. As migraine is an underlying primary headache, the use of calcitonin gene-related peptide antibodies should be considered.

Interim analysis of the Registry for Load and Management of Medication Overuse Headache (RELEASE): A multicenter, comprehensive medication overuse headache registry.

Characteristics, disabilities, and optimal management of medication overuse headache remain uncertain. This study aimed to elucidate the clinical characteristics of patients with medication overuse headache enrolled in a medication overuse headache registry in Korea. The Registry for Load and Management of MEdicAtion OveruSE Headache (RELEASE), a cross-sectional prospective observational study including seven referral headache centers in Korea, started enrolling adult patients with medication overuse headache in April 2020. Data included information on headache characteristics, burden on daily function, depression, anxiety, history of acute and preventive medications, and treatment strategies. A total of 229 patients (85.6% females; mean age, 45.5 ± 13.5 years) were enrolled by June 2021. The average durations of chronic headaches and medication overuse were 6.5 and 4.3 years, respectively. In the past month before enrollment, patients had headaches for 25 days and severe headaches for 12 days, and used acute medications for 20 days. Patients were disabled in 66.8 days in the past 3 months and had moderate/severe depression and anxiety in 56% and 35%, respectively. The proportion of patients on preventive treatments increased from 38% to 93% during the study period. RELEASE study reflects the current management status and opportunities to improve the quality of care in patients with medication overuse headache.

Intravenous Chlorpromazine as Potentially Useful Treatment for Chronic Headache Disorders.

The aim of this study was to describe a group of patients with chronic headache disorders (CH) and medication overuse headache (MOH) treated with intravenous chlorpromazine (IVC). We hypothesized that IVC is an effective and safe addition to well-known treatment strategies for CH and MOH management. Up to 4% of the general population could experience CH. Most cases occur in women, in association with MOH. To date, evidence to support different treatment strategies is lacking. Although IVC is frequently used in the emergency room (ER), documentation on its use as supportive treatment for CH and for withdrawal management of MOH is poor. A retrospective cohort of patients hospitalized to receive treatment for CH in a specialized neurological center in Argentina was analyzed. A total of 35 CH patients were included. Of the 35 patients, 33 (94%) patients also presented MOH. Patients reported only minor side effects to IVC administration (mainly drowsiness and symptomatic hypotension). Three months after inpatient treatment, the number of ER visits made by these patients decreased from an average of 2.8 in the 3months prior to hospitalization to 0.7 after it (72%, P=.009). Headache frequency decreased in 20/34 (59%) patients during the same time period. Pain levels had dropped from a mean of 8 points at admission (in the scale of 1-10) to 2 points at discharge. In the first 3months of follow-up, the average number of days per month in which patients experienced headache decreased from 28.9 to 15.4days (53.3%, P<.0001). In this particular group of inpatients, there were no significant safety issues with IVC administration and the study might suggest that the efficacy of IVC as an add-on treatment for CH and MOH.

European Academy of Neurology guideline on the management of medication-overuse headache.

The frequent use of medication to treat migraine attacks can lead to an increase in migraine frequency and is called medication-overuse headache (MOH). Based on the available literature in this guideline, the first step in patient management is education and counselling. Patients with MOH should be managed by a multidisciplinary team of neurologists or pain specialists and behavioral psychologists. Patients in whom education is not effective should be withdrawn from overused drugs and should receive preventive treatment with drugs of proven efficacy. Patients with MOH in whom preventive treatment is not effective should undergo drug withdrawal. Drug intake can be abruptly terminated or restricted in patients overusing simple analgesics, ergots or triptan medication. In patients with long-lasting abuse of opioids, barbiturates or tranquilizers, slow tapering of these drugs is recommended. Withdrawal can be performed on an outpatient basis or in a daycare or inpatient setting.

The Many Faces of Medication-Overuse Headache in Clinical Practice.

The management of medication-overuse headache (MOH) is multifaceted and headache experts have different views on the optimal strategy to tackle this type of secondary headache. The purpose of this review is to provide an overview of the literature on the management of MOH, and to highlight important considerations in the clinical evaluation of the MOH patient. Managing MOH in clinical practice starts by evaluating the headache patient with medication overuse, determining the overused drug(s), assessing the impact of headaches on the patient and assessing comorbid conditions and disorders. Withdrawal of the overused medication is the cornerstone of treatment. An inpatient or outpatient setting is chosen based on the clinical profile of the patient. There is evidence for abrupt withdrawal combined with headache preventive treatment. Bridging therapy to bring relief to withdrawal headaches and/or symptoms should be offered. Education and motivational work through multidisciplinary assessment show benefits in sustaining withdrawal and preventing relapse. Although the reversal of chronic headache after cessation of overused acute medication has been noticed worldwide, different aspects of the management of MOH, such as complete or gradual withdrawal, or preventive treatment with or without withdrawal are still debated.

Epidemiology and management of medication-overuse headache in the general population.

Medication-overuse headache is a worldwide challenge as it affects 1-2% of the general population. Some people are more prone to medication overuse, which can be ascertained by applying five simple questions about dependence. Detoxification of the overused medication is a cheap and effective treatment strategy. A short advice seems to be sufficient for people from the general population whom seek their general practitioner. Treatment is often more complicated in neurologist and hospital settings, most likely due to a combination of treatment failure in general practice and co-morbidity of other disorders including different types of headaches.

A Critical Evaluation on MOH Current Treatments.

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 155-195U 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.

Learnings and challenges to deploy an interprofessional and independent medical education programme to a new audience

ABSTRACTThe importance of interprofessional education (IPE) in continuing medical education and professional development has long been recognised by health organisations and academic societies, benefiting not only patient outcomes and interprofessional relationships but also overall health systems and workforce shortage. We report on the outcomes of an Australian IPE activity on medication-overuse headache (MOH) with general practitioners (GPs) and community pharmacists as learners. The design of the activity, which followed the predisposing–enabling–reinforcing instructional framework by Green and Kreuter, aimed to: (1) improve knowledge and foster a willingness in GPs and pharmacists to work collaboratively to enhance the prevention, diagnosis and management of MOH; and (2) address their educational gap by demonstrating the utility of a blended learning IPE strategy on MOH. Integrated into the activity was an assessment of its effectiveness and impact to instil change in the participants’ knowledge of MOH, attitude and willingness to treat, and clinical practice behaviours of GPs and pharmacists to work together. The learners gained knowledge and confidence in diagnosing and managing MOH and in their ability to educate patients. The IPE approach suited the activity and was valued by the participating GPs and pharmacists, who seldom experience such learning formats. However, for educational providers in Australia, developing and deploying an independent medical education (IME) programme can be challenging. Providers of IMEs need to be aware of the potential pitfalls when competing with pharmaceutical-company-sponsored and delivered programmes.

P067. Multimodal therapy in the management of MOH: a 3-year experience.

The relationship between migraine and psychopathology has been clinically discussed in various studies. Medication-overuse headache (MOH) has been often found comorbid with emotional disturbances and disordered personality traits [1, 2]. This might play a role in the evolution of migraine to MOH and might be associated with higher risks of chronicization and/or relapses in drug abuse. Psychological disturbances may also be risk factors for a later development of MOH [3]. Since 2012 the Psychology Service of Sant'Andrea Regional Referral Headache Centre has offered short cycles of psychological interviews mostly oriented towards the support of MOH patients during the post-rehabilitation infusional phase in order to prevent relapses. In these past 3 years 106 MOH patients afferent to the Headache Centre underwent the infusional therapy and were eligible for psychological support. Patients’ profiles highlighted avoidant and dependent personality traits together with a high level of anxiety and depressive mood. Patients showed a low perception of their personal skill, resources and a perception of their body mostly related to the head pain. The psychological intervention has been cognitive-behavioral and has improved patients’ perception of self relative to their body, their personal skills and resources. Psychological support together with prophylaxis therapy with OnabotulinumtoxinA produced in patients a reduction of relapses in drug abuse of 38% compared to a sample of 108 patients age and gender matched that was not eligible for psychological support but received the detoxification and prophylaxis therapy. This means that in some selected cases a multimodal therapy, consisting in a program of pharmacotherapy and psychological support, is necessary for the treatment of MOH patients in order to reduce the risks of relapses into drug abuse. Written informed consent to publish was obtained from the patient(s).

Medication-overuse headache: an update.

Medication-overuse headache (MOH) is a chronic daily headache evolving from an episodic primary headache (mainly migraine) due to overuse of one or more classes of migraine abortive medication. The development of MOH is associated with both overuse of one or more medication and behavioral predispositions. MOH causes a significant decline in the quality of life and reduces functioning in patients affected. In the same MOH patients, the presence of psychopathological disturbances may be a predictor of relapse and poor response to treatment. In a recent study of our group, we found that MOH patients had a more complex profile of psychiatric comorbidity compared to episodic migraine (EM) patients. Furthermore, clinically relevant obsessive-compulsive disturbances for abused drugs assessed by Yale-Brown Obsessive Compulsive Scale Y-BOCS, appeared to be more represented in the MOH group, while the prevalence of this trait in the EM group was comparable to that of healthy controls (unpublished results). Management of MOH represents a difficult challenge for clinicians and headache experts, particularly because of the high percentage of relapse after a successful withdrawal treatment. This can be addressed if the patient is followed over a prolonged period of time with a combination of prophylactic pharmacotherapy and use of abortive medication with minimal risk of MOH, avoiding previously overused medications. With the aim to verify the efficacy and safety of sodium valproate in the short-term treatment of MOH, we recently carried out a multicentre study (SAMOHA study) which demonstrated a superiority of the drug compared to placebo after detoxification[1]. In an ancillary study of SAMOHA, analysing responders and non responders to detoxification and advice to withdraw a benefit was excluded in patients with a long history of MOH[2]. In a further ancillary research we found a significant correlation between MOH relapse and the total MSQ score, the Role Preventive and the Emotional Function sub-scales, suggesting a poorer quality of life in non responders[3]. Recent evidence suggests an involvement of genetic factors in predisposition to medication overuse. In a recent study of our group involving a subsample of MOH patients enrolled in the SAMOHA study, we sequenced all exons, intron/exon junctions and 3'-5'UTR regions of HDAC3 gene which had been implicated in excessive medication consumption in MOH patients. Univariate analysis showed that the G allele of the exonic SNP rs2530223 was significantly associated with the number of acute medications/month used and with the number of days/month in which acute medication were used (unpublished results).

Risk Factors for and Management of Medication-Overuse Headache.

This review focuses on patients with migraine who frequently use acute medications. Chronic migraine and medication-overuse headache are common in the general population and often coexist. According to new diagnostic criteria, both diagnoses can be made for an individual patient. Evidence is slowly emerging on the most appropriate management approach for both disorders. Although the relationship of the primary headache disorder and the pattern of overuse varies, medication-overuse headache is a secondary disorder attributable to the overuse of acute medications. While distinguishing chronic migraine and medication-overuse headache may not always be possible, treatment approaches are similar for the two disorders.

Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey.

This cross-sectional study investigated associations between chronic headache (CH) with and without medication overuse, healthy lifestyle behaviour, and stress. Questionnaires were sent to 129,150 adults. Those with headache ≥15 days per month for three months were classified as having CH then further described as having medication-overuse headache (MOH) or CH without medication overuse. Associations between headache and daily smoking, physical inactivity, obesity, excessive drinking, illicit drug use, and high stress were analysed by logistic regression. CH with and without medication overuse (prevalence 1.8% and 1.6%, respectively) had strong, graded associations with stress. Associations with daily smoking, physical inactivity, and obesity were significant only for MOH. Odds for MOH were highest among people who had all three factors compared to those who had none (OR 2.8 in women and 5.1 in men). High stress plus any of these three factors had synergistic effects in MOH but not clearly in those who had CH without overuse. Associations between CH subtypes and excessive drinking or illicit drug use were not statistically significant. Results suggest strong links between healthy lifestyle behaviour and stress in MOH. Stress reduction and promoting healthy behaviour are highly relevant in MOH management.

EHMTI-0043. Clinically-oriented stratified approach and patient-preference approach in the management of MOH – a comparison between two strategies

Background and aim The management of medication overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. The aim of this study is to compare the cost-effectiveness of two different stratified approaches of drug withdrawal in 100 MOH subjects. Materials and methods In the first approach, called clinically-oriented stratified strategy (COSS), patients were stratified based on the presence/absence of complicated MOH. Patients with complicated MOH received a standard inpatient withdrawal programme whereas patients with simple MOH received an advice to withdraw the offending drug. In the second approach, called patient-preference stratified strategy (PPSS), the patients received information about the effectiveness of the different withdrawal regimens (1) simple advice, 2) outpatient detoxification and 3) inpatient detoxification) and they were treated according to their preferences. The primary outcome measures used for comparing COSS and PPSS were: 1) number of responders ; 2) number of dropouts 3) cost per detoxified patient, 4) number of relapsers at 6 months follow-up. Results The Number of responders (80% vs 70%) , dropouts (16% vs 18%) and relapsers (12.5 vs 14.5%) did not differ between COSS and PPSS. The cost per detoxified patient was 1211 € for COSS and 430 € for PPSS.

EHMTI-0245. Some clinical characteristics and prophylactic treatment in patients with moh in an out-patient clinical sample

Medication Overuse Headache (MOH) is a well-known condition and diagnostic entity, recognized as a relevant medical and socio-economic problem everywhere. Whether initial primary headache type, its frequency, co-morbid conditions or else, it is not truly clear. The therapeutic management of MOH is often difficult and still not properly and step-by-step guided.

Medication-overuse headache: a review.

Medication-overuse headache (MOH) is a worldwide health problem with a prevalence of 1%–2%. It is a severe form of headache where the patients often have a long history of headache and of unsuccessful treatments. MOH is characterized by chronic headache and overuse of different headache medications. Through the years, withdrawal of the overused medication has been recognized as the treatment of choice. However, currently, there is no clear consensus regarding the optimal strategy for management of MOH. Treatment approaches are based on expert opinion rather than scientific evidence. This review focuses on aspects of epidemiology, diagnosis, pathogenesis, prevention, and treatment of MOH. We suggest that information and education about the risk of MOH is important since the condition is preventable. Most patients experience reduction of headache days and intensity after successful treatment. The first step in the treatment of MOH should be carried out in primary care and focus primarily on withdrawal, leaving prophylactic medication to those who do not manage primary detoxification. For most patients, a general practitioner can perform the follow-up after detoxification. More complicated cases should be referred to neurologists and headache clinics. Patients suffering with MOH have much to gain by an earlier treatment-focused approach, since the condition is both preventable and treatable.

A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study

The management of medication-overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. In this study we defined and tested a consensus protocol for the management of MOH on a large population of patients distributed in different countries. The protocol was based on evidence from the literature and on consolidated expertise of the members of the consensus group. The study was conducted according to a multicentric interventional design with the enrolment of 376 MOH subjects in four centres from Europe and two centres in Latin America. The majority of patients were treated according to an outpatient detoxification programme. The post-detoxification follow-up lasted six months. At the final evaluation, two-thirds of the subjects were no longer overusers and in 46.5% of subjects headache had reverted back to an episodic pattern of headache. When comparing the subjects who underwent out-patient detoxification vs those treated with in-patient detoxification, both regimens proved effective, although the drop-out rate was higher in the out-patient approach. The present findings support the effectiveness and usability of the proposed consensus protocol in different countries with different health care modalities.