All About Medication overuse headache

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All About Medication overuse headache
Key Take-Away: 

Medication-overuse headache (MOH) is a debilitating condition in which frequent and prolonged use of medication for the acute treatment of pain results in the worsening of the headache. Management of MOH consists of withdrawing pain medication, focusing on prophylactic and non-medical treatments, and limiting acute symptomatic medication.

Medication-overuse headache (MOH) is a debilitating condition in which frequent and prolonged use of medication for the acute treatment of pain results in the worsening of the headache. According to the International Classification of Headache Disorders, 3rd Edition, Beta (ICHD-3,''MOH is defined as the headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more, or 15 or more days per month, depending on the medication) for more than 3 months''. Prevalence is often reported as 1–2% but can be as high as 7% overall, with higher proportions among women and in those with a low socioeconomic position. It is not as prevalent as tension type headache or migraine but it is very disabling. The pathophysiology is complex and not completely known. It involves genetic and behavioral factors.

MOH is prevalent in people tend to have a low socioeconomic status with low income and education. Previous primary headache such as migraine, tension-type headache, regular use of tranquilizers, combination of chronic musculoskeletal and gastrointestinal complaints as well as smoking and physical inactivity increased the risk for MOH. It can be argued that increasing medication use is not always the cause of MOH but ‘indispensable medication’ could be the reason for the pain.

Management consists of withdrawing pain medication, focusing on prophylactic and non-medical treatments, and limiting acute symptomatic medication. Drug withdrawal still remains the key element in the treatment of Medication Overuse Headache (MOH), as withdrawal of the overused medication(s) in most cases leads to an improvement of the headache. Most patients experience withdrawal symptoms lasting 2–10 days after detoxification. The most common symptom is an initial worsening of the headache, accompanied by various degrees of nausea, vomiting, hypotension, tachycardia, sleep disturbances, restlessness, anxiety and nervousness. The different strategies include: just simple advice; multidisciplinary approaches; use of anti emetics, tranquilizers, neuroleptics, rescue medication (another analgesic than the overused); intravenous hydration; and/or administration of oral, nasal or intravenous ergot amines. Stress reduction and lifestyle interventions may support the change towards rational pain medication use. Support, follow up, and education are needed to help patients through the detoxification period. Different studies has been conducted for evaluating the efficacy of withdrawal of pain medication along with use of preventive medicines and identifying and limiting the use of acute symptomatic medications.

Study conducted for identification and limiting the use of acute medications leading to MOH:

A comprehensive literature review was made with 29 studies aimed to determine whether certain classes of acute migraine drugs are more likely to elicit MOH than others. Risks associated with certain classes of drugs like single analgesics, ergots, opioid's, and triptans was assessed and it was found that analgesics and opioid's are associated with a higher risk of developing MOH compared with other treatments. These findings provide incentive for better monitoring of use of analgesics and opioid's for treating acute migraine, and suggest possible clinical preference for use of so-called “migraine-specific” treatments, that is, triptans and ergots.

Study conducted for withdrawal of drug and prophylactic medications:

Education on medication overuse and drug withdrawal still remain the key elements in the treatment of medication overuse headache. The study included MOH patients, unresponsive to a 3 months prophylaxis, underwent withdrawal therapy on an inpatient basis. Overused medications were abruptly stopped and methylprednisolone 500 mg i.v. (A) or paracetamol 4 g i.v. (B) or placebo i.v. (C) were given daily for 5 days. Results indicated that Methylprednisolone and Paracetamol may be useful in reducing the intensity of rebound headache during the second day of withdrawal, but they are not superior to placebo at the end of the detoxification program.             

References

  • Westergaard M.L et al., Medication-overuse headache: a perspective review, Therapeutic advances in drug therapy, 2016 Aug; 7(4): 147–158.
  • Espen Saxhaug Kristoffersen and Christofer Lundqvist, Medication-overuse headache: epidemiology, diagnosis and treatment, Ther Adv Drug Saf. 2014 Apr; 5(2): 87–99.
  • Cheung V., Medication overuse headache, Curr Neurol Neurosci Rep. 2015 Jan;15(1):509.
  • Thorlund K., Risk of medication overuse headache across classes of treatments for acute migraine, J Headache Pain. 2016; 17(1): 107
  • Cevoli., Treatment of withdrawal headache in patients with medication overuse headache: a pilot study, J Headache Pain. 2017; 18(1): 56.

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