An emerging problem in clinical practice: how to treat chronic headache patients

Abstract

In this issue, an interesting article by Farinelli and coworkers [1] debates an important emerging and not yet resolved problem: how to treat the chronic headaches complicated by medication overuse. Headache is the most common neurological disease in clinical practice. In Europe, this affects about 51% of the population, of which 31% are tension-type headache and 14% are migraine sufferers; 2% of these patients become chronic sufferers, more than 15/day/month, and chronic daily headache (CDH). 4-5% of general population suffers from a chronic form (CDH), with prevalence between 1.7 and 2.1% in men and between 2.8 and 6.8% in women [2]; within this group of patients in the US general population ranges around 1.3-2% of chronic migraine (CM).A number of possible pathophysiological mechanisms for the transformation from episodic to chronic headache have been proposed including a progressive damage of the central nociceptive system. One physiopathological hypothesis is the activation of N-methyl-D-aspartate (NMDA) and non-NMDA receptors glutamate, released by central nociceptive terminations, induces calcium entry in dorsal horn neurons, as well as in the trigeminal nucleus caudalis. Calcium entry leads to the activation of nitric oxide (NO) synthetase causing NO synthesis. These neurotransmitters produce the release of sensory neuropeptides, such as CGRP and substance P, which support the development of hyperalgesia and maintain central sensitization [3][4][5].Medication near-daily use and subsequent medication overuse headache (MOH) have been described by the revised International Classification of Headache Disorders (ICHDs)-IIR criteria as the use of each drug for at least 3 months, for a certain number of days per month, and is one of the most critical parameters in the process of becoming chronic.In the past few years, a lot of studies have shed light on potential risk factors for CM such as medication-overuse headache, temporomandibular disorders, obstructive sleep apnea and obesity. Recent clinical trials have started to focus on CM or CDH. Topiramate, onabotulinum toxin type A, gabapentin, pentasites and tizanidine are among the agents that appear to be effective in the treatment of CM. In the treatment of CM, preventive treatment and a better understanding of its risk factors will allow clinicians to better identify individuals at the greatest risk and prevent the development of CM [6].The main problem remains how to treat these patients to avoid a relapse in the daily drug use because recurrence of headaches and the management of CM patients in re-prophylaxis after detoxification of abuses still appears complicated.Regarding abusers, the first step always consists in drug interruption. Only after detoxification can a new prophylaxis therapy be commenced, which will otherwise be useless from the start.Within the possible treatment strategies in the review of Farinelli are examined the use of topiramate and the onabotulinum toxin A, a substance obtained from the grampositive anaerobic bacterium Clostridium bo...

Increased efficacy of regularly repeated cycles with OnabotulinumtoxinA in MOH patients beyond the first year of treatment

“…Our data can confirm this point based on our previous experiences according on the beneficial effect due to an early medication discontinuation even on the psychological structure and compliance of patients in the scheduled program [ 26 , 27 ].…”