How to Prevent or Reverse Medication Overuse Headache

“[The goal of] our clinical management for acute treatment for prevention of transformation into daily headache should be sustained pain-free response, one-and-done, and [to] decrease the number of treatments and headache days per month,” Dr. Tepper said. He suggested that this should be attempted with optimal doses of triptans or dihydroergotamine in optimal formulations with early intervention. Treatment should begin before allodynia and central sensitization. NSAIDs, either in monotherapy or in combination, may be used. Behavioral approaches should be used and, when necessary, daily prevention. “With those clinical approaches, you may be able to prevent MOH.”

Reversing Established MOH
What about patients who already have MOH? “I think weaning is important for these patients for the benefits of detoxification,” Dr. Tepper said. “Addressing obesity and snoring is important, as are behavioral approaches, education, and some form of prophylaxis.” The only FDA-approved treatment for chronic migraine is onabotulinumtoxinA. For patients with MOH, this treatment would be first-line because of its lack of adverse events and its proven efficacy. Of the oral preventive options, none are FDA-approved for chronic migraine. The population studies of these options were generally heterogeneous, and their results modest. Furthermore, significant adverse events are associated with taking daily medicines. “Our plan would be to get the patients on some sort of prophylaxis, place limits on acute medicines, get behavioral intervention, and wean,” Dr. Tepper said.

Weaning
Weaning is based on two principles. First, overuse may interfere with preventive medicines. Second, overuse causes collateral damage. For example, if patients are using combination NSAIDs every day, they can get gastroenteropathy. Likewise, patients can develop analgesic nephropathy, habituation, and dependence. There could be exacerbation of depression, hyperalgesia, and addiction. “We need to take the responsibility for the wean right up front and not assume that our prophylactic regimen is going to do it for us,” Dr. Tepper advised.

Evidence suggests that rebound drugs interfere with prophylaxis. For example, the two randomized controlled trials of topiramate for chronic migraine allowed people with medication overuse to participate. In one trial, topiramate did not work in the group with medication overuse; in the other trial, topiramate worked about 50% less well in the medication-overuse group than in the chronic-migraine group without medication overuse. Studies indicate that administering onabotulinumtoxinA to patients with medication overuse is effective, but the magnitude of the response suggests that the treatment does not work as well in patients with MOH. “So, addressing the wean is important,” Dr. Tepper said.

He suggests slowly weaning the patient over a period of four to six weeks. “Start with onabotulinumtoxinA, slowly add the antimigraine drug of choice, put a quit date on the rebound medicines, and limit acute medicines.” An alternative method is to have the patient quit his or her medication cold turkey with an oral or IV bridge, either as an outpatient or an inpatient. Dr. Tepper advised using an inpatient or outpatient interdisciplinary program. “Having a team with psychology would be very helpful—always including education, always including behavioral help.”

Behavioral help is valuable because MOH is highly comorbid with psychiatric conditions. Patients with MOH are 4.5 times more likely to have a mood disorder, 3.5 times more likely to have anxiety, and 7.5 times more likely to have substance abuse disorder. “If you miss the behavioral treatment and you don’t evaluate these patients, you’re going to more likely have a poor outcome,” Dr. Tepper said. Combining behavioral treatment with medical management, which has been studied in prospective trials, improves outcomes and decreases relapses. Cognitive behavioral therapy, sleep, biofeedback, and other forms of relaxation therapy may help, “but you really must do this as part of your treatment for these patients.”

—Glenn S. Williams