Medication Overuse Headache Research Articles

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.

The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey

BackgroundGeneral practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management.MethodsWe invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey.Results367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients.ConclusionThe knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.

The burden of medication overuse headache and patterns of switching and discontinuation among triptan users: a systematic literature review

BackgroundA synthesis of real-world discontinuation and switching patterns among triptan users and rates of acute medication use among patients with medication overuse headache (MOH) is needed to better understand the burden among patients with migraine. The study objectives were to: (1) synthesize rates of switching and discontinuation from triptans; (2) characterize acute medication use among patients with MOH; and (3) describe the associated burden.MethodsA systematic literature review was conducted, under the Preferred Reporting Items for Systematic Review guidelines, using MEDLINE/EMBASE from database inception to July 2019. The search strategy targeted studies of adults with migraine, and included terms related to migraine and its treatment. Continuous variables were summarized using means, standard deviations, and ranges. Dichotomous and categorical variables were summarized using the number and proportion of individuals.ResultsTwenty studies were included; seven describing patterns of switching and discontinuation among triptan users, and 13 characterizing triptan overuse among patients with MOH. High rates of switching to non-specific acute medications and low two-year retention rates were reported; among US samples switching to opioids at the first refill (18.2%) or after 1-year (15.5%) was frequent. Compared to persistent use of triptans, switchers experienced greater headache related impact and either no improvement or increased headache-related disability. Rates of medication overuse by agent among patients with MOH varied greatly across the included studies, and only one study described factors associated with the risk of MOH (e.g. duration of medication overuse). Medication agent, increased headache frequency (p = .008), and increased disability (p = .045) were associated with unsuccessful withdrawal; patients overusing triptans were more successful at withdrawal than those overusing opioids or combination analgesics (P < .0001).ConclusionsThe evidence summarized here highlights that rates of WCS are low and many patients turn to other acute medication at their first refill. Patients may experience no improvement in disability when switching from one triptan agent to another, or experience increasing disability and/or increasing migraine frequency when turning to traditional acute treatment for migraine. Variability in health care settings, patient severity, and study design contributed to heterogeneity across the synthesis.

P.033 Eptinezumab reduced acute medication use in patients with chronic migraine and medication-overuse headache: subgroup analysis of Promise-2

Background: Eptinezumab is a preventive migraine treatment approved in the US. We evaluated the impact of eptinezumab on acute headache medication (AHM) use in patients diagnosed with chronic migraine (CM) and medication-overuse headache (MOH) in PROMISE-2. Methods: PROMISE-2 randomized patients with CM to eptinezumab 100mg, 300mg, or placebo for 2 intravenous doses administered every 12 weeks. Trained investigators diagnosed MOH at screening using 3-month medication history and ICHD-3b criteria. Endpoints included days/month of any AHM use (days of ≥1 medication class), total AHM use (summed days for each medication class), and triptan use over Weeks 1-12 and 13-24. AHM classes included triptan, ergot, opioid, simple analgesic, and combination analgesic. Results: Of 1072 PROMISE-2 patients, 431 (40.2%) were diagnosed with MOH (100mg, n=139; 300mg, n=147; placebo, n=145). During the 28-day baseline period, mean days of any AHM was ~16.4, total AHM was ~20.4, and triptan was ~8.9 across treatment arms. Over Weeks 1-12, mean days/month of any AHM was 8.8 (100mg), 9.9 (300mg), and 11.8 (placebo); total AHM was 10.8, 12.2, and 14.8; triptan was 4.3, 4.4, and 6.4. Similar or lower rates were observed over Weeks 13-24. Conclusions: In patients diagnosed with both CM and MOH, eptinezumab treatment reduced AHM use.

Safety and Risk of Medication Overuse Headache in Lasmiditan and Second-Generation Gepants: A Rapid Review

The treatment of migraine is often complicated by insufficient headache relief, a miscellany of side effects and the risk of developing Medication Overuse Headache (MOH). Novel acute therapies have been recently developed and are now in the early post-marketing phase. Lasmiditan is a highly selective serotonin receptor agonist that binds to the 5-HT1F receptor, while ubrogepant and rimegepant antagonize the calcitonin gene-related peptide receptor. All three medications are now prescribed in a real-world setting, and an adequate level of knowledge is the starting point for rational use. In this rapid systematic review, we have established what is known about lasmiditan, ubrogepant and rimegepant, highlighting the most relevant safety aspects available from published studies and speculating about their risk of MOH.

CGRP Inhibitors and Oxidative Stress Biomarkers in Resistant Migraine: A Real-Life Study with Erenumab, Fremanezumab, and Galcanezumab

Patients with high-frequency resistant migraine and medication-overuse headache are still the main clinical challenge in tertiary headache centers. The approval of targeted antibodies against the calcitonin gene-related peptide (CGRP) and its receptor represents a powerful instrument. In this study, we observed how biological and clinical features of resistant migraineurs responded to erenumab, fremanezumab, or galcanezumab. We found a reduction in advanced oxidation protein products (AOPP) as a biomarker of improved redox state after six months of treatment. We also found that treatment efficacy was precocious and maintained with high individual responder rates. In particular, seven out of ten patients achieved a reduction of 50% from the baseline at three months, which was maintained at six months, while about one out of our patients experienced a 75% reduction in headache frequency from the first month of treatment. The migraine disability assessment (MIDAS) and the associated fatigue, anxiety, and sleep quality also significantly improved. The allodynia symptom dropped from moderate/severe to mild/absent as a sign of central sensitization reduction. Our study confirmed the safety and efficacy of CGRP inhibition in real-life, high-challenging patients. Additional evidence is needed to understand the role of oxidative stress as a migraine biomarker.

Chronic migraine with medication overuse headache: Is detoxification still necessary in the era of new prophylaxes?

Medication overuse headache (MOH) leads to high disability and poor quality of life; the debate on value and method of detoxification is still open, even more at the present time with new preventive treatments available. The aim of this study is to estimate the effectiveness of detoxification in multi-resistant chronic migraine (CM) with MOH patients who start prophylaxes Anti-CGRP monoclonal antibodies (mAb).

International Classification of Headache Disorders - ICHD-4. Will medication-overuse headache survive?

The article is a critical analysis of the diagnostic criteria for medication-overuse headache. This is an important discussion to improve the criteria in the next update, as well as providing a critical view for neurologists when applying the criteria to their clinical practice.

Preventive migraine treatment with eptinezumab reduced acute headache medication and headache frequency to below diagnostic thresholds in patients with chronic migraine and medication‐overuse headache

ObjectiveThis post hoc analysis in patients medically diagnosed with chronic migraine (CM) and medication‐overuse headache (MOH) evaluated reductions in the use of acute headache medication (AHM) and sustained changes in the diagnostic status of CM and MOH following eptinezumab treatment in the PROMISE‐2 study.BackgroundEptinezumab, a monoclonal antibody that inhibits calcitonin gene‐related peptide, is approved in the United States for the preventive treatment of migraine. A previous analysis showed that eptinezumab reduced monthly migraine days and was well tolerated in the subgroup of PROMISE‐2 patients diagnosed with both CM and MOH.MethodsThe phase 3, double‐blind, placebo‐controlled PROMISE‐2 study (NCT02974153) randomized adults with CM to eptinezumab 100 mg, 300 mg, or placebo (administered intravenously every 12 weeks for up to two doses). MOH was prospectively diagnosed at screening by trained physicians based on 3 months of medication history and International Classification of Headache Disorders‐3β criteria. This post hoc analysis evaluated changes in total and class‐specific days of AHM usage, the percentage of patients using AHM at or above MOH diagnostic thresholds, and the percentage of patients experiencing monthly headache and migraine day frequency below diagnostic thresholds for MOH and/or CM.ResultsIn PROMISE‐2, 431/1072 (40.2%) patients with CM were diagnosed with MOH (eptinezumab 100 mg, n = 139; 300 mg, n = 147; placebo, n = 145) and were included in this analysis. Total monthly AHM use decreased from 20.6 days/month at baseline to 10.6 days/month over 24 weeks of treatment (49% decrease) with eptinezumab 100 mg, from 20.7 to 10.5 days/month (49% decrease) with eptinezumab 300 mg, and from 19.8 to 14.0 days/month (29% decrease) with placebo. Numerically greater decreases from baseline with eptinezumab were also observed for individual drug classes. In each study month, the percentages of patients who were below MOH thresholds were numerically higher for both eptinezumab doses compared with placebo, as were the percentages of patients experiencing headache and migraine frequency below CM thresholds. Of patients with available data across the entire treatment period, 29.0% (58/200) of patients treated with eptinezumab stopped meeting and remained below diagnostic thresholds for both CM and MOH during Weeks 1–24, as well as 6.3% (6/96) of patients who received placebo.ConclusionsAcross 24 weeks of treatment, eptinezumab reduced AHM use in patients diagnosed with CM and MOH. More than one‐fourth (29%) of patients treated with eptinezumab did not meet the diagnostic thresholds for either CM or MOH for the entire treatment period.

Results of migraine treatment depending on its menstrual association

Introduction. Menstrual migraine attacks are considered more intense, prolonged, and resistant to treatment than non-menstrual ones. Currently, effect of preventive therapy on the course of menstrual-associated migraine has not been well studied; there are isolated studies on the beneficial effect of hormonal therapy on these attacks.The aim of the study was to compare the treatment results in the groups of menstrual-associated and non-menstrual migraine.Materials and methods. This comparative study included 91 patients aged 18 to 48 years (mean age 33,82 ± 8.4) with migraine and menstrual cycle. Depending on the menstrual association of migraine attacks, the patients were divided into 2 groups: group 1 – 54 patients (mean age 36.07 ± 7.37 years) with menstrual-associated migraine (MAM); group 2 – 37 patients (mean age 30.46 ± 8.81 years) with non-menstrual migraine (NMM).Results. Patients with MAM had more migraine days per month, more often received therapy associated with medication-overuse headache (MOH), more often had experience with triptans in comparison with NMM patients. After the treatment, the number of days with migraine per month in the MAM group remained more than in the NMM group: 8 or more days per month were noted in 36.4%, while among NMM patients – 10.8%. The transition to the new therapy with monoclonal antibodies to the CGRP receptor / ligand was positively assessed by 42.9% of MAM patients and 8.1% of NMM patients. Increased duration of hormonal therapy was characterized by a decrease in the number of days with migraines per month (cor = -0,28).Conclusion. In the MAM group, more severe diseases and frequent formation of MOH are observed, as well as a higher resistance to therapy than in NMM. In general, the use of standard therapy regimens for MAM is less effective than for NMM.

A prolactin-dependent sexually dimorphic mechanism of migraine chronification.

Determination of possible sex differences in mechanisms promoting migraine progression and the contribution of prolactin and the prolactin long (PRLR-L) and short (PRLR-S) receptor isoforms. The majority of patients with chronic migraine and medication overuse headache are female. Prolactin is present at higher levels in women and increases migraine. Prolactin signaling at the PRLR-S selectively sensitizes nociceptors in female rodents, while expression of the PRLR-L is protective. Medication overuse headache was modeled by repeated sumatriptan administration in male and female mice. Periorbital and hindpaw cutaneous allodynia served as a surrogate of migraine-like pain. PRLR-L and PRLR-S isoforms were measured in the trigeminal ganglion with western blotting. Possible co-localization of PRLR with serotonin 5HT1B and 5HT1D receptors was determined with RNAscope. Cabergoline, a dopamine receptor agonist that inhibits circulating prolactin, was co-administered with sumatriptan. Nasal administration of CRISPR/Cas9 plasmid was used to edit expression of both PRLR isoforms. PRLR was co-localized with 5HT1B or 5HT1D receptors in the ophthalmic region of female trigeminal ganglion. A single injection of sumatriptan increased serum PRL levels in female mice. Repeated sumatriptan promoted cutaneous allodynia in both sexes but down-regulated trigeminal ganglion PRLR-L, without altering PRLR-S, only in females. Co-administration of sumatriptan with cabergoline prevented allodynia and down-regulation of PRLR-L only in females. CRISPR/Cas9 editing of both PRLR isoforms in the trigeminal ganglion prevented sumatriptan-induced periorbital allodynia in females. We identified a sexually dimorphic mechanism of migraine chronification that involves down-regulation of PRLR-L and increased signaling of circulating prolactin at PRLR-S. These studies reveal a previously unrecognized neuroendocrine mechanism linking the hypothalamus to nociceptor sensitization that increases the risk of migraine pain in females and suggest opportunities for novel sex-specific therapies including gene editing through nasal delivery of CRISPR/Cas9 constructs.

Enhanced functional connectivity between habenula and salience network in medication-overuse headache complicating chronic migraine positions it within the addiction disorders: an ICA-based resting-state fMRI study

BackgroundMedication-overuse headache (MOH) is a relatively frequently occurring secondary headache caused by overuse of analgesics and/or acute migraine medications. It is believed that MOH is associated with dependence behaviors and substance addiction, in which the salience network (SN) and the habenula may play an important role. This study aims to investigate the resting-state (RS) functional connectivity between the habenula and the SN in patients with MOH complicating chronic migraine (CM) compared with those with episodic migraine (EM) and healthy controls (HC).MethodsRS-fMRI and 3-dimensional T1-weighted images of 17 patients with MOH + CM, 18 patients with EM and 30 matched healthy HC were obtained. The RS-fMRI data were analyzed using the independent component analysis (ICA) method to investigate the group differences of functional connectivity between the habenula and the SN in three groups. Correlation analysis was performed thereafter with all clinical variables by Pearson correlation.ResultsIncreased functional connectivity between bilateral habenula and SN was detected in patients with MOH + CM compared with patients with EM and HC respectively. Correlation analysis showed significant correlation between medication overuse duration and habenula-SN connectivity in MOH + CM patients.ConclusionsThe current study supported MOH to be lying within a spectrum of dependence and addiction disorder. The enhanced functional connectivity of the habenula with SN may correlate to the development or chronification of MOH. Furthermore, the habenula may be an indicator or treatment target for MOH for its integrative role involved in multiple aspects of MOH.

Medication overuse headache: Updating of the French recommendations regarding the treatment strategies.

Regular and frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic migraine or medication-overuse headache (MOH). The one-year prevalence of this condition is between 1% and 2% in Europe, provoking substantial burden. MOH is more prevalent in people with comorbid depression, anxiety, and other chronic pain conditions. This paper aims at presenting an updating of French recommendations regarding treatments strategies. Prior French recommendations, published in 2014, were written in French. A literature search in the major medical databases including the terms "medication overuse headache", "symptomatic medication overuse", published between 2010 and 2020 was carried out. Three main strategies can be recommended and conducted in parallel: education and explanations about the negative consequences of overusing acute antimigraine drugs, discontinuation of the overused medication, and finally, preventive drug therapy and non-pharmacological prevention. Medication overuse headache remains a debated problem and evidence for the most effective treatment strategy is needed.

СОЦІАЛЬНО-ДЕМОГРАФІЧНІ ТА КЛІНІЧНІ ХАРАКТЕРИСТИКИ ПАЦІЄНТІВ З АБУЗУСНИМ ГОЛОВНИМ БОЛЕМ В ПОЄДНАНІ З ХРОНІЧНИМ ГОЛОВНИМ БОЛЕМ НАПРУГИ

Introduction. A study of medication overuse headache (MOH) can define the risk group for MOH in patients with primary headaches. The aim of the research is to study the socio-demographic, clinical and pharmacotherapeutic characteristics of patients with MOH and chronic tension-type headache (CTTH). Material and methods. We examined 28 patients with MOH in combination with CTTH and 34 patients with CTTH. MOH and CTTH were diagnosed according to the International Classification of Headache Disorders 3rd revision. Anxiety and depressive signs were assessed by the Hospital Anxiety and Depression Scale; abdominal obesity was determined using waist circumference. Quantitative values were presented as the median and the interquartile range. Quantitative samples were analyzed according to Mann-Whitney U-test, qualitative samples - according to Fisher's exact test. Differences at p &lt;0.05 were considered significant. Results. Patients with MOH and CTTH had the following characteristics: female gender - 79%, age - 41.0 (33.0-49.5) years, familyless state - 54%, higher education - 25%, employment - 46%, smoking - 43%, anxiety signs - 71%, depressive signs - 75%, cervicalgia - 36%, lower back pain - 61%, arterial hypertension - 21%, diabetes mellitus - 7%, abdominal obesity - 46%, mild traumatic brain injury - 43%, headache intensity - 5.0 (4.0-6.3) points on a visual analog scale, duration of headache attacks - 7.0 (5.0-8.3) hours, age of CTTH onset - 31,5 (23,0-41,0) years, duration of CTTH - 9.0 (6,8-10,3) years, duration of MOH – 15.5 (8.3-20.8) months. Patients with MOH and CTTH compared to patients with CTTH were significantly younger, had a history of traumatic brain injury, had significantly more headache days per month. Patients with MOH and CTTH overused combined analgesics (47%), nonsteroidal anti-inflammatory drugs (32%), triptans with analgesics (21%). Abortive medications had been used on 23.0 (18.0-28.5) days a month, in form of 32.0 (27.3 -41.8) doses a month.

Candidate Genes and Proteomic Biomarkers of Serum and Urine in Medication-Overuse Headache

Chronic headache is a topical problem of neurology, psychiatry and general practice. The medication-overuse headache (MOH) is one of the leading pathologies in the structure of chronic headache. However, early diagnosis of the MOH is challenging. We analyzed potential proteomic biomarkers of serum and urine in patients with MOH. Methods: We searched PubMed, Springer, Scopus, Web of Science, ClinicalKey, and Google Scholar databases for English publications over the past 10 years using keywords and their combinations. Results: We found and analyzed seven studies that met the search criteria for the purpose of the review, including 24 serum proteomic biomarkers and 25 urine proteomic biomarkers of MOH. Moreover, the candidate genes and locus of the studied serum (vitamin D-binding protein, lipocalin-type prostaglandin D2 synthase, apolipoprotein E, etc.) and urine proteomic biomarkers (uromodulin, alpha-1-microglobulin, zinc-alpha-2-glycoprotein, etc.) of MOH are presented in this review. Conclusions: The serum and urine proteomic biomarkers of MOH can potentially help with the identification of patients with MOH development. Due to the relevance of the problem, the authors believe that further investigation of the MOH proteomic biomarkers in different ethnic and racial groups of patients with primary headache is necessary. In addition, it is important to investigate whether medications of different drug classes influence the levels of serum and urine proteomic biomarkers.

Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost-effectiveness of implementation in Europe: findings and conclusions

BackgroundThere have been several calls for estimations of costs and consequences of headache interventions to inform European public-health policies. In a previous paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache. Here we apply this methodology and present the findings.MethodsData sources were published evidence and expert opinions, including those from an earlier economic evaluation framework using the WHO-CHOICE model. We used three headache-type-specific analytical models, for migraine, tension-type-headache (TTH) and medication-overuse-headache (MOH). We considered three European Region case studies, from Luxembourg, Russia and Spain to include a range of health-care systems, comparing current (suboptimal) care versus target care (structured services implemented, with provider-training and consumer-education). We made annual and 5-year cost estimates from health-care provider and societal perspectives (2020 figures, euros). We expressed effectiveness as healthy life years (HLYs) gained, and cost-effectiveness as incremental cost-effectiveness-ratios (ICERs; cost to be invested/HLY gained). We applied WHO thresholds for cost-effectiveness.ResultsThe models demonstrated increased effectiveness, and cost-effectiveness (migraine) or cost saving (TTH, MOH) from the provider perspective over one and 5 years and consistently across the health-care systems and settings. From the societal perspective, we found structured headache services would be economically successful, not only delivering increased effectiveness but also cost saving across headache types and over time. The predicted magnitude of cost saving correlated positively with country wage levels. Lost productivity had a major impact on these estimates, but sensitivity analyses showed the intervention remained cost-effective across all models when we assumed that remedying disability would recover only 20% of lost productivity.ConclusionsThis is the first study to propose a health-care solution for headache, in the form of structured headache services, and evaluate it economically in multiple settings. Despite numerous challenges, we demonstrated that economic evaluation of headache services, in terms of outcomes and costs, is feasible as well as necessary. Furthermore, it is strongly supportive of the proposed intervention, while its framework is general enough to be easily adapted and implemented across Europe.

Medication overuse headache in patients with chronic migraine using cannabis: A case-referent study.

To examine whether cannabis use predicts medication overuse headache (MOH) in patients with chronic migraine (CM). Electronic chart review was conducted by combining the terms "CM," "medication overuse," "cannabis," "cannabidiol," and "tetrahydrocannabinol" for patients seen at our headache clinics from 2015 to 2019. Of 729 charts consecutively screened, 368met our inclusion criteria, that is, adult patients with CM with ≥1-year CM duration. The following variables were extracted from the included patient charts: MOH diagnosis, age, sex, migraine frequency, current CM duration, current cannabis use duration, overused acute migraine medications, current MOH duration, and types of cannabis products used. Logistic regression was used to identify variables predicting MOH while controlling for remaining predictors. Agglomerative hierarchical clustering (AHC) was conducted to explore natural clusters using all predictor variables. There were 212 patients with CM and MOH (cases; median age 43years, interquartile range [IQR] 33-54; 177 [83%] females) and 156 patients with CM without MOH (referents; median age 40years, IQR 31-49; 130 [83%] females). MOH was present in 81% (122/150) of current cannabis users compared with 41% (90/218) in those without cannabis use-adjusted odds ratio 6.3 (95% CI: 3.56 to 11.1, p< 0.0001). Current cannabis use was significantly associated with opioid use (Spearman's rho 0.26, p<0.0001). Both current cannabis use (rho 0.40, p<0.0001) and opioid use (rho 0.36, p<0.0001) were significantly associated with MOH. Similarly, AHC revealed two major natural clusters. Cluster I patients featured 9.3 times higher current cannabis use, 9.2 times higher current opioid use, and 1.8 times higher MOH burden than those in Cluster II (p<0.0001). Cannabis use was significantly associated with increased prevalence of MOH in CM. Bidirectional cannabis-opioid association was observed-use of one was associated with use of the other. Advising patients with CM and MOH to reduce cannabis use may help treat MOH effectively.

The impact of an online adult headache guideline on headache referrals to the neurology clinic

Headache is a common problem in primary care and one of the main reasons general practitioners (GP) consult the neurology service. We developed an online adult headache guideline (Supporting Information Appendix S1) for the greater Wellington Region as a resource for GP to guide identification of concerning headaches, initiation of prophylactic medications for migraine and management of analgesic overuse headache. To examine the effectiveness of this adult headache guideline in reducing demand on the neurology outpatient service for headache patients that could readily be managed in primary care. We reviewed electronic referrals to Wellington Hospital's neurology department before and after the implementation of the online headache guideline. The primary outcome was the proportion of referrals for headache. Secondary outcomes included proportion of referrals requiring clinic review, rate of pre-referral trial of headache prophylactic medication and medication overuse headache diagnosed at neurological consultation. Nine hundred neurology referrals before and 801 referrals after the publication of the online headache guideline were included. There was a statistically significant reduction in proportion of referrals for headache (15.4% vs 11.7%; P = 0.026). There was neither an increased rate of pre-referral adequate prophylactic medication trial (33.8% vs 27.7%; P = 0.320) nor fewer medication overuse headaches diagnosed during the neurology assessment (21.9% vs 25.0%; P = 0.674). The launch of an online headache guideline was associated with a reduction in demand on neurology service. Further education could improve the utilisation of this guideline, to avoid delays in prophylactic treatment and reduce the harm of medication overuse.

Medication Overuse Headache Successfully Treated by Three Types of Japanese Herbal Kampo Medicine

Medication overuse headache (MOH) usually resolves after the overuse is stopped and starting prophylactic medications. However, it can be challenging to prescribe common prophylactic medications when patients have a history of side effects. As an alternative therapy, traditional Japanese herbal kampo medicine can be used. We herein report a case of a MOH woman with a history of side effects by such common prophylactic medications. A 50-year-old woman presented with a severe migraine attack. She had suffered from migraines for 10 years. She had taken loxoprofen and sumatriptan every day for over eight years. As prophylactic medications, lomerizine, valproic acid, and amitriptyline had been prescribed in the past, but they were discontinued due to side effects. Therefore, she could continue only propranolol as prophylactic medication. She had severe pulsatile headaches and nausea every day. We diagnosed triptan- and non-steroidal anti-inflammatory drug-overuse headache (the International Classification of Headache Disorders 3rd edition code 8.2.2 and 8.2.3.2) and chronic migraine (code 1.3). She was admitted and stopped loxoprofen and sumatriptan. We prescribed three types of Japanese herbal kampo medicines - kakkonto (TJ-1), goreisan (TJ-17), and goshuyuto (TJ-31). Her headache was relieved on day 5, and she was discharged on day 7. In the 40 days after discharge, she had only three times mild headaches with a numeric rating scale (NRS) of 2/10. She did not need any triptans nor anti-inflammatory drugs. We herein presented the MOH woman who was successfully treated using three types of kampo medicine. We should pay attention to their side effects, but kampo medicine may be useful for MOH treatment as acute and prophylactic medications for primary headaches.

FRAMES protocol versus simple advice for medication-overuse headache: a prospective, randomized, controlled clinical trial.

It is central to the management of patients with Medication-overuse headache that they reverse their behavior regarding the frequent use of pain medication. The objective of this study wasto compare two counseling techniques for treating patients with Medication-overuse headache (MOH). This was a randomized, blind, controlled clinical trial that compared a structured (FRAMES) and unstructured counseling, for the treatment of MOH. Patients were assessed before the counseling and then again four and eight weeks after it. Semi-structured interview, headache diary, the Headache Impact Test (HIT-6) and the Hospital Anxiety and Depression Scale were used. Primary endpoints were the following: number of patients who stopped medication overuse; days with acute medication use; HIT-6; the number of patients who returned for consultations. Secondary endpoints were as follows: days per month of headache; 50% reduction in monthly days with acute medication use; the number of patients with less than 15days of headache. Thirty-seven patients were allocated to the "FRAMES Group" and 33 to the "Control Group". There was no difference regarding primary or secondary outcomes between the two groups. There was a significant reduction in the frequency of headache and the number of days using pain medication in the first and second months of follow-up compared to baseline in both groups. There was a significant reduction in the HIT-6 in the first and second months of follow-up compared to baseline in the FRAMES Group, but not in the control group. Patients in both counseling groups significantly decreased the use of pain medications and the frequency of their headaches.