Many patients who experience a shift from periodic headaches to chronic daily headache syndrome have over-consumed acute pain-relief medications, which can result in medication-overuse headache (MOH). Drugs intended to provide symptom relief eventually cause a worsening of primary headaches and, ultimately, also make preventive medications ineffective. For this reason it is important to accurately identify and detoxify patients with MOH.
Symptoms accompanying progressive headache incidence and severity vary with each patient but can include neck pain, depression or anxiety, nonrestorative sleep, and vasomotor instability. The International Headache Society diagnostic criteria for MOH — previously called “rebound headache” — have been established as chronic headache that has occurred 15 or more days per month for 3 or more months and has worsened with acute medication use [IHS 2008]. The criteria further state that MOH can occur with the overuse of a single agent alone (eg, ergotamine, a triptan, or opioid agent) or by using a combination of these drugs on 10 or more days during a month. Evidence shows that simple analgesic use can cause MOH when used 15 or more days/month.
Overuse is usually the consequence of a patient’s desire to effectively treat acute headaches or due to fear of future headaches. MOH can be difficult to treat and most headache specialists recommend a medication withdrawal, or detoxification, program that requires a gradual weaning or medication-free period of several weeks. The goal of detoxification is to return the patient to the headache pattern that existed before medication overuse and initiate a preventive medication regimen from that point forward. Several strategies for this have been proposed.
In a recent detoxification study, headache and neurology experts in Italy evaluated the effectiveness of medication management advice as a first line of care in MOH management [Rossi et al. 2010]. Patients diagnosed with MOH and migraine, aged 16 to 65, at a headache clinic were divided into two groups: 1) patients with simple MOH (n=51) and 2) those with complicated MOH (n=49). MOH was considered complicated in patients who had coexisting medical illness, behavioral disorders, psychosocial or environmental problems, daily multidose use of analgesics, or detoxification relapse. Patients with severe medical or psychiatric illness and opioid overuse were excluded from the study.
During the first clinician visit, patients were evaluated and asked to keep an observational headache diary for 4 weeks. The second appointment included education on the cause and symptoms of MOH, detailed advice regarding the discontinuation of overused analgesics, and prescriptions for an antiemetic and a single analgesic agent like acetaminophen or naproxen if needed. Two follow-up visits were scheduled within 10 weeks of the start of detoxification.
At final follow-up, the researchers reported a high rate of successful detoxification. Their educational intervention alone was effective enough to provide detoxification in 92% of the patients in the simple MOH group and in about 65% of complicated MOH patients who completed the study. While the authors reported that further studies would be needed to propose well-defined classifications for simple and complicated MOH patients, they expressed satisfaction with the high rate of successful identification and treatment of migraine patients with simple MOH as defined in this study.
In contrast, an article published earlier this year in the Cleveland Clinic Journal of Medicine described two alternate approaches for MOH detoxification [Tepper et al. 2010]. Their ‘Slow Weaning’ protocol recommends beginning preventive medications in advance of tapering analgesic agents with a 5-week patient goal of achieving maintenance preventive therapy and discontinuing all overused analgesic drugs. Secondarily, their ‘Cold Turkey With Bridge’ approach discontinues the overused medication immediately and prescribes daily corticosteroids, NSAIDs, or triptans for 5 to 7 days until the patient has 24 headache-free hours. Additionally, a preventive medication is administered on an escalated dosing schedule so that the patient is on a maintenance medication and off the overused medications at the end of one week.
In all cases, patients are given strict dosing instructions for future analgesic consumption during acute attacks. While detoxification strategies vary and evidence shows that relapse rates can depend on several factors, including the analgesic medication overused, these reports provide 3 approaches to successful MOH detoxification from practitioners in headache clinic settings.
> Rossi P, Faroni JV, Nappi G. Short-term effectiveness of simple advice as a withdrawal strategy in simple and complicated medication overuse headache. Eur J Neurology. 2010(Jul 13); early online publication prior to print.
> Tepper SJ, Tepper DE. Breaking the cycle of medication overuse headache. Cleveland Clinic J Med. 2010(April);77(4):236-242 [details here].
> IHS (Headache Classification Committee of the International Headache Society). The International Classification of Headache Disorders, 2nd Ed (web-based edition); 2008 [details here].