Tuesday, December 1, 2009

Migraine Relief: Looking Beyond Medications

A troublesome impediment to effective and continuing control of chronic migraines is medication overuse headache (MOH). In a recent article, the authors describe MOH as a biobehavioral disorder that can be addressed by nonpharmacological approaches for achieving greater long-term pain relief.

Medication overuse headache (sometimes called “rebound headache”) occurs when usually effective pain-relieving agents are used inappropriately and excessively, leading to decreased headache relief. Once this rebound phenomenon occurs, preventive, abortive, or analgesic agents may paradoxically increase the frequency and severity of head pain. Writing in the journal Neurological Sciences, clinicians from the U.S. and Italy note that MOH is now recognized as a condition wherein emotion and pain become intermingled, rather than its being a painful condition associated solely with neurobiological physiology.

Considering the behavioral or psychological aspects of MOH, there are some basic issues that can be key contributors to the disorder:
> A belief that medication is the only or the best treatment option.
> Panic due to anticipatory fear of headache pain (‘‘cephalagiaphobia’’).
> Intolerance to or difficulty dealing with pain.
> Seeking sedation (“soporophilia”).
> The need to be functional despite pressures that may provoke headache.
> The presence of psychiatric comorbidities, primarily depression and anxiety.

In a typical scenario, the authors describe how patients become conditioned to taking antimigraine medications at the first sign of a headache attack in anticipation of debilitating pain. Eventually, the medications, which often have sedating and/or anxiolytic effects, are taken in a preemptive or prophylactic manner during times of anticipated stress or events that might trigger a migraine. Eventually, medication overuse headache “rears its ugly head,” they write. However, these and other behavioral risk factors can be modified to avert MOH.

The general consensus seems to be that patients need to be withdrawn from all medications involved in overuse. Then, a first step involves educating patients about MOH and the pathways to headache chronicity. The second step concerns working with patients to identify risk factors and current behaviors that are contributing to the problem. The final step involves behavioral interventions, such as cognitive behavioral therapies to cope with stress, biofeedback, and/or various relaxation techniques. While these and other behavioral treatments rarely provide the rapid relief that can occur with medications, patients learn to restructure their perspectives on pain, essentially learning how to tolerate discomfort, reduce pain-related emotional distress, stop their pharmacological preemptive treatment of anticipated headache, and reduce debilitating aspects of the headache experience. If the nonpharmacologic approaches are reinforced and maintained over time, the learned behaviors help reduce the likelihood of overusing pain medication and MOH relapse in the future. The authors note that, in their own clinical experience, migraineurs receiving both behavioral and appropriate medication therapies had long-term (3-year) success rates in headache control without relapse to MOH.

Clinical Comment: Patients with frequent headaches frequently progress to overuse of their medications. The diagnosis of chronic migraine with MOH is clinically important because patients rarely respond to preventive medications while overusing acute medications. Treatment of MOH can be difficult because there is no clear consensus about the best strategies, so further research is needed to confirm the most effective approaches. The application of behavioral modification therapies in conjunction with the judicious reintroduction of antimigraine medications makes sense; however, the entire process would require much time and effort by both practitioners and patients. This may be the purview of headache specialists and their clinics; whether it also can be addressed adequately in other clinical settings is of some concern since there are many locales where headache specialists are few and far between.

Reference: Andrasik F, Grazzi L, Usai S, Buse DC, Bussone G. Non-pharmacological approaches to treating chronic migraine with medication overuse. Neurol Sci (2009) 30 (Suppl 1):S89–S93 [abstract here].
Also see:
> Weeks RE. Practical strategies for treating chronic migraine with medication overuse: case examples and role play demonstrations. Neurol Sci. 2009;30(Suppl 1):S95–S99 [
abstract here].
> Grazzi L, Andrasik F, Usai S, Bussone G. Treatment of chronic migraine with medication overuse: is drug withdrawal crucial? Neurol Sci. 2009;30(Suppl 1):S85–S88 [
abstract here].

Addendum: The journal publisher, Springer, originally made these important articles available in full at no charge; then, changed their mind. While we strongly support an open access policy, others believe differently. —SBL