Medication Overuse in Chronic Daily Headache
The frequent or regular intake of medication to treat acute headache episodes can lead to an increase in headache frequency and finally to a transition from episodic to chronic headache. Many patients with chronic headache take abortive medication on a daily basis. Medication overuse headache (MOH) is defined by the International Classification of Headache Disorders as a headache in patients with a pre-existing primary headache disorder (e.g., migraine or tension-type headache) occurring on ≥15 days per month for >3 months. Also, these primary headache disorders occur in association with overuse of medication for acute or symptomatic headache treatment. The prevalence of MOH in the general population is around 1%. MOH is more common in people with chronic migraine and chronic daily headache than in patients with episodic migraine. The phenotype of the headache in MOH depends on the initial primary headache and the type of overused acute medication. Treatment of MOH occurs in three stages. First, we educate patients about the relationship between frequent intake of acute headache medication and MOH to reduce intake of acute medication. In a second step migraine prevention should be initiated in chronic migraine (topiramate or onabotulinumtoxinA in migraine) or amitriptyline in chronic tension-type headache. In patients who fail to cease overuse of overused medication with preventive therapy, then detoxification occurs on an outpatient basis or in a day hospital or inpatient setting, depending on severity and comorbidities. The success rate of treatment is around 50–70%, with higher relapse rates in patients with opioid overuse. Patient education and continuity of care in the follow-up period reduce relapse rates.
KeywordsChronic daily headache Medication overuse Medication overuse headache Epidemiology Pathophysiology Management
H. C. Diener received honoraria for his participation in clinical trials, contribution to advisory boards, or oral presentations from Addex Pharma, Alder, Allergan, Almirall, Amgen, Autonomic Technology, AstraZeneca, Bayer Vital, Berlin Chemie, Böhringer Ingelheim, Bristol-Myers Squibb, Chordate, Coherex, CoLucid, Electrocore, GlaxoSmithKline, Grünenthal, Janssen-Cilag, Labrys Biologics, Lilly, La Roche, 3 M Medica, Medtronic, Menerini, Minster, MSD, Neuroscore, Novartis, Johnson & Johnson, Pierre Fabre, Pfizer, Schaper and Brümmer, Sanofi, St. Jude, Teva, and Weber & Weber. Financial support for research projects was provided by Allergan, Almirall, AstraZeneca, Bayer, Electrocore, GSK, Janssen-Cilag, MSD and Pfizer. Headache research at the Department of Neurology in Essen is supported by the German Research Council (DFG), the German Ministry of Education and Research (BMBF), and the European Union. H.C. Diener has no ownership interest and does not own stocks of any pharmaceutical company. HCD serves on the editorial boards of Cephalalgia and Lancet Neurology. HCD chairs the Clinical Guidelines Committee of the German Society of Neurology.
D. Holle-Lee has received financial support for research projects from Allergan, Grünenthal, and Lilly and research support from EFIC.
F. Freitag is an advisor to the Migraine Research Foundation and BioHealthonomics. He has received financial support for clinical research, consulting, and educational presentations from Alder, Allergan, Amgen, Avanir, Depomed, Mayo Clinic Phoenix, Dr. Reddy, Teva, and Weber & Weber.
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