Thus, there was a hierarchy of risk, with butalbital being the worst, opioids in the middle, and NSAIDs and triptans the least risky. None of the agents had to be taken daily to trigger medication overuse headache.
PREVENTION IS THE BEST TREATMENT
The best approach to medication overuse headache is to prevent it while the patient still has episodic migraine.
Outcomes are better with triptans or ergots
Undertreatment of migraine leads quickly to overuse of symptomatic medications, and from there to medication overuse headache.
Outcomes of episodic migraine are better when triptans or ergots (which are migrainespecific) are used first-line in patients with disabling migraine and no vascular contraindications. Patients who start with nonspecific treatment and step up to a more specific treatment when lower-level medications fail have less favorable outcomes in terms of migraine relief and disability time than those treated with triptans from the beginning. 25
To put this in perspective, if a patient takes an acute medication, gets only partial relief (not a pain-free response) at 2 hours and then takes another pill, or gets a recurrence and takes another pill, the likelihood of prolonging an attack and using more medications goes up. If a patient takes a triptan and gets a sustained pain-free response, the attack is truncated and the medication usage reduced. Therefore, migraine-specific acute treatments are more likely to not be overused.
Daily preventive medication, if necessary
As noted above, if the number of headache days exceeds 10 per month, the likelihood of developing daily headache escalates steeply. Thus, patients with 10 or more days of headache per month should be prescribed preventive medications to be taken daily to reduce the frequency, severity, and duration of attacks. Preventive treatment may also increase the efficacy of the acute treatments.
The drugs used for preventive treatment are different than those used for acute treatment and are not likely to cause medication rebound headache. However, they are not very effective. Those that have the best evidence of efficacy are beta-blockers, tricyclic antidepressants, and anticonvulsants; calcium channel blockers and NSAIDs are also popular. This topic has been reviewed in detail elsewhere. 26,27
REVERSING MEDICATION OVERUSE HEADACHE
If a patient already has medication overuse headache, the clinician is faced with the problem of weaning her or him from the overused medication while establishing a reasonable regimen of prophylaxis and acute medications with limits.
For the most part, these tasks can be accomplished in a series of clinic visits. However, some patients have such severe comorbid medical and psychiatric illnesses that outpatient treatment is impossible. For them, a day hospital or inpatient program with infusion capabilities is often useful.
Outpatient treatment of medication overuse headache
Outpatient treatment of medication overuse headache involves:
Educating patients about the genesis of the problem and reassuring them that you are not accusing them of being an addict. Most patients who develop medication overuse headache are habituated inadvertently, and this needs to be made clear, along with the overall plan and the likely prognosis.