Patient-centric management of medication-overuse headache

Medication overuse is common among patients who are impacted by migraine and up to 70% of patients with chronic migraine will develop medication-overuse headache. Optimal management of patients with chronic migraine and medication-overuse headache should include a patient-centric approach to ensure reduction of acute medication use and prevention of further disease progression, explained experts at EAN 2022.

Migraine chronification and medication-overuse headache (MOH) develop through a vicious cycle of increased migraine frequency, increased acute medication use, and less relief by acute medications, driving further attack frequency and disability,1–3 said Professor Gisela Terwindt, Leiden, The Netherlands.

Up to 70% of patients with chronic migraine develop medication-overuse headache4

Health care professionals should be aware of the risk factors associated with migraine chronification and MOH. These include allodynia (the perception of pain upon a non-painful stimulus to the skin) and hypersensitivity to pain,5 co-morbid depression and anxiety6 and medication overuse,2 added Professor Terwindt.

 

A patient-centric approach is key for managing medication-overuse headache

Several risk factors are associated with the development of migraine and medication-overuse headache

Not only does MOH affect patient functioning and quality of life,7 said Professor Christofer Lundqvist, Oslo, Norway, but the “overuse” terminology can add to the patient’s burden by suggesting dependence and addiction.8

A patient-centric non-stigmatizing approach can benefit patients and a brief intervention approach can help patients reduce medication use and headache frequency in patients with MOH,9 explained Professor Lundqvist.

A patient-centric non-stigmatizing, brief intervention approach can reduce medication overuse and headache frequency

Medication-overuse headache is stigmatizing and affects patient function and quality of life

Steps in the strategy include:

  • Identifying and individualizing the risk
  • Providing information about the need to decrease use of acute medications
  • Information about the potential gains and challenges (including worsening of the headache over 1–2 weeks before improvement)
  • An agreed treatment plan based on joint decision-making between the patient and the clinician, with support as necessary7

 

The role of preventive medication in the management of medication-overuse headache

Withdrawal therapy combined with preventive medication from the start of withdrawal is effective in patients with chronic migraine and medication-overuse headache

Evidence for the most appropriate treatment strategy for each individual patient is lacking, said Dr Patricia Pozo-Rosich, Barcelona, Spain. However, a comparison of three strategies — withdrawal with preventive, preventive and potential withdrawal, and withdrawal with potential preventive — has shown that withdrawal therapy combined with preventive medication from the start of withdrawal is most effective.10

The current European Academy of Neurology guidelines acknowledge the role of preventive therapy in migraine with medication-overuse headache, added Dr Pozo-Rosich. They recommend that patients with MOH for whom education is not effective should be withdrawn from overused drugs and receive preventive treatment with drugs of proven efficacy.4

New clinical studies designed to evaluate the role of preventive medication in migraine with medication overuse are warranted

Dr Pozo-Rosich also reviewed evidence for the efficacy of monoclonal antibodies against calcitonin gene related polypeptide in the prevention of migraine and medication overuse. However, studies specifically designed to assess the role of preventive medications in migraine with medication overuse are needed, concluded Dr Pozo-Rosich.

 

This satellite symposium was sponsored by Lundbeck.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. May A, Schulte LH. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol. 2016;12(8):455–64.
  2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
  3. Silberstein SD, Blumenfeld AM, Cady RK, et al. OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline. J Neurol Sci. 2013;331(1–2):48–56.
  4. Diener HC, Antonaci F, Braschinsky M, et al. European Academy of Neurology guideline on the management of medication-overuse headache. Eur J Neurol. 2020;27(7):1102–16.
  5. Louter MA, Bosker JE, van Oosterhout WP, et al. Cutaneous allodynia as a predictor of migraine chronification. Brain. 2013;136(Pt 11):3489–96.
  6. Buse DC, Silberstein SD, Manack AN, et al. Psychiatric comorbidities of episodic and chronic migraine. J Neurol. 2013;260(8):1960–9.
  7. Schwedt TJ, Hentz JG, Sahai-Srivastava S, et al; MOTS Investigators. Headache characteristics and burden from chronic migraine with medication overuse headache: Cross-sectional observations from the Medication Overuse Treatment Strategy trial. Headache. 2021;61(2):351–62.
  8. Lundqvist C, Gossop M, Russell MB, Straand J, Kristoffersen ES. Severity of analgesic dependence and medication-overuse headache. J Addict Med. 2019;13(5):346–53.
  9. Kristoffersen ES, Straand J, Vetvik KG, et al. Brief intervention for medication-overuse headache in primary care. The BIMOH study: a double-blind pragmatic cluster randomised parallel controlled trial. J Neurol Neurosurg Psych. 2015;86:505–12.
  10. Carlsen LN, Munksgaard SB, Nielsen M, et al. Comparison of 3 treatment strategies for medication overuse headache: A randomized clinical trial. JAMA Neurol. 2020;77(9):1069–78.

 

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