Medication Overuse Headache Basics
Medication overuse headache (MOH) is a secondary headache disorder that is due to excessive use of acute medications. This usually happens when patient with pre-existing primary headache disease most commonly chronic migraine exceed the threshold for using acute medications for temporary symptomatic relief of their headache. MOH can also occur with withdrawal of acute medication triggering an attack or worsening of pre-existing primary headache disorder. This is also known as rebound headache. This typically leads to increase in headache days and escalating doses of acute medications. If headache worsens with amplified use of acute medications or improves once they are discontinued the diagnosis is supported.
MOH is dependent on quantities of medications and its class. Use of triptans, ergots, combination analgesics, or opioids on 10 or more days per month and simple analgesics like NSAIDs on 15 or more days per month constitutes overuse. Lastly, use of more than one medication for headache (eg: NSAIDS/Triptan) on a total of 10 or more days per month is considered medication overuse. Certain medications like opioids and barbiturates may alter pain processing pathways and make headache continuous without improvement after withdrawal of offending agent. Therefore starting a preventive medication very much needed for patients with MOH and chronic migraine. Topiramate and onabotulinumtoxinA are the two FDA approved medications for migraine prophylaxis and has shown good outcomes in terms of headache frequency. Non-pharmacologic management is also essential as medication overuse is due to behavioral reflex. Evidence has shown cognitive behavioral therapy, biofeedback and relaxation techniques to be helpful.
Read more here:
1. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 3rd edition (beta version). Cephalalgia 2013;33(9)
2. https://americanmigrainefoundation.org/ understanding-migraine/medication-overuse- headache-2/
3. Lipton, R. Risk Factors for and Management of Medication-Overuse Headache. Continuum. 2015 Aug;21(4): 1118-1131
4. Aurora SK, Dodick DW, Turkel CC, et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia 2010;30(7)
5. Silberstein SD, Lipton RB, Dodick DW, Topiramate Chronic Migraine Study Group. Efficacy and safety of topiramate for the treatment of chronic migraine: a randomized, double-blind, placebo-controlled trial. Headache 2007;47(2)
Altered functional connectivity architecture of the brain in medication overuse headache
The annual prevalence of medication-overuse headache (MOH) is 2%–3% in the general population, and at least 50% amongst people with chronic migraine headache. According to the diagnostic criteria of the International Classification of Headache Disorders 3 beta, the diagnosis of medication overuse headache is defined as headaches occur on at least 15 days per month in a person with a pre-existing headache disorder and for at least 3 months that person has regularly overused one or more drugs that can be taken for acute treatment of headache. The frequency of medication usage to meet criteria for “overuse” depends on the consumed medications:
(1) 10 or more days per month of ergots, triptans, opioids, combination analgesics, or multiple drug classes;
(2) 15 or more days per month of simple analgesics. The development of MOH is associated with both overuse of medication and behavioral predispositions.
MOH may result in a significant deterioration in quality of life and function. Management of MOH represents a difficult challenge for clinicians and headache experts, particularly because of the high percentage of relapse after a successful withdrawal treatment. The mechanisms of MOH is still incompletely understood. A recent study investigated the resting- state functional connectivity (RSFC) architecture changes of the brain in the patients with medication overuse headache (MOH) using functional connectivity density (FCD) and resting-state functional connectivity (RSFC) methods. This study presents an evidence that MOH and episodic migraine (EM) suffered from altered intrinsic functional connectivity architecture and opens a new perspective to better understand the neuromechanism of MOH and EM pathogenesis.
Read more here: https://www.ncbi.nlm.nih.gov/ pubmed/28220377
Medication Overuse Headache Treatment: Predictors of success
While the prevalence of medication overuse headache (MOH) is a common indication for referral to a secondary or tertiary headache clinic, there is no clear consensus regarding treatment of MOH. This study analyzed the data from a prospectively recruited cohort of 240 MOH patients from January 2000 to July 2005. These patients were treated by in- or out-patient withdrawal of overused drug, and the simultaneous administration of headache prophylaxis. These patients were subsequently followed until the end of 2013. These authors noted that by the end of follow up, 42.5% of patients were in remission. The most important predictors of remission were lower number of monthly headache days before the 1year follow up, as well as efficient initial drug withdrawal. Although interesting, this study is limited by a significant number of patients who were lost to follow up.
Read more here: http://journals.sagepub.com/doi/ full/10.1177/0333102416683918
