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Breaking the cycle of medication overuse headache

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can be done gradually, tapering the drugs over 4 to 6 weeks, during which preventive medications are introduced. Alternatively, the discontinuation of rebound medications can be done abruptly, with transitional medications (eg, corticosteroids, NSAIDs, dihydroergotamine, or triptans) used as a bridge to blunt withdrawal, during which the prophylaxis is established ( Table 1 ).

Establishing daily preventive medications. The prophylactic regimen can be established either before or during the weaning.

Providing acute medications, with limits. At a certain point in the weaning, advise the patient not to treat low-level headaches, and provide a triptan or dihydroergotamine to use for severe attacks, no more than twice weekly and less than 10 days per month. If the patient is in triptan rebound, dihydroergotamine would be the choice.

Instructing the patient to keep a headache diary to follow adherence and outcomes.

Psychology consultation can be very helpful to teach patients behavioral techniques to deal with anticipatory anxiety during the weaning.

Multidisciplinary programs with infusion capability

Some patients need a more intensive approach to restore an episodic migraine pattern. Examples: those on very high doses of narcotics or barbiturates, those with comorbid medical illnesses that limit both acute and preventive treatments, and those with severe and complicating comorbid psychiatric illnesses.

Multidisciplinary programs are available, with specialists in neurology, primary care, psychology, and physical and occupational therapy providing treatment. Patients check into the hospital or a “day hospital,” where they can also receive intravenous infusions to get through the weaning. The goal is to shift the locus of control back to patients as they revert from daily headache to episodic migraine. Patient education is crucial.

OUTCOMES ARE GOOD

There is much good news about medication overuse headache.

It can be prevented with careful monitoring of acute medication outcomes and number of headache days. Prophylaxis should be used when treating high-frequency or very disabling migraine.

Most patients improve when weaned and treated with preventive medications. “Recovery” means at least 3 months off the overused medications. In studies, more than half of patients who underwent treatment for medication overuse headache remained better and had an episodic pattern of headache 5 years later. 26

Unfortunately, the initial improvement often seen with patients after weaning and being given preventive medication (72%–85% of patients improve) in the first year is often followed by preventable relapse, so it is very important to follow up with patients regularly. 28–32

Helping restore a patient’s quality of life is an outcome rewarding to primary care provider and specialist alike.

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