Breaking the cycle of medication overuse headache
Care of this disorder can be complex—from ruling out another secondary cause of headache to supervising detox from abortives, providing preventives, and educating often-fearful patients.
PRACTICE RECOMMENDATIONS
› Avoid prescribing barbiturates or opioids for a headache disorder. A
› Limit use of a headache-abortive medication to twice a week when starting a patient on the drug. C
› Consider providing bridging therapy during detoxification of the overused medication. C
› Do not provide a preventive medication without withdrawing the overused agent. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Cognitive behavioral therapy, exercise, a headache diary, and biofeedback should be considered in every patient’s treatment strategy because a multidisciplinary approach increases adherence and leads to improvement in headache frequency and a decrease in disability and medication use.43
Predictors of Tx success
A prospective cohort study determined that the rate of MOH relapse is 31% at 6 months, 41% at 1 year, and 45% at 4 years, with the highest risk of relapse during the first year.44 Looking at the correlation between type of medication overused and relapse rate, the research indicates that
- triptans have the lowest risk of relapse,44
- simple analgesics have a higher risk of relapse than triptans,22,44 and
- opioids have the highest risk of relapse.22
Where the data don’t agree. Data on combination analgesics and on ergots are conflicting.22 In addition, data on whether the primary type of headache predicts relapse rate conflict; however, migraine might predict a better outcome than tension-type headache.22
To recap and expand: Management pearls
The major goals of headache management generally are to rule out secondary headache, reach a correct diagnosis, reduce overall headache frequency, and provide effective abortive medication. A large component of reducing headache frequency is addressing and treating medication overuse.
Seek to understand the nature of the patient’s headache disorder. Components of the history are key in identifying the underlying headache diagnosis and ruling out other, more concerning secondary headache diagnoses. The ICHD-3 is an excellent resource for treating headache disorders because the classification lists specific diagnostic criteria for all recognized headache diagnoses.
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