Detoxification vs non-detoxification before starting an anti-CGRP monoclonal antibody in medication overuse headache

Abstract

Background Medication overuse headache significantly contributes to the chronification process and treatment refractoriness of migraine. Currently, abrupt discontinuation of the overused medication still represents the best management strategy for these patients, challenging public health system resources. Methods In this prospective study, chronic migraine and medication overuse headache sufferers with at least 28 days of analgesic consumption per month were included. Assessment of efficacy outcomes at three months were compared among patients who underwent in-hospital abrupt discontinuation of overused acute medication (YES-DETOX group) and patients who did not (NO-DETOX group) before starting an anti-CGRP monoclonal antibody. Results Of 401 patients who received either erenumab or galcanezumab, 28% (n = 111) satisfied inclusion criteria (YES-DETOX n = 28; NO-DETOX n = 83). After three months of treatment, 59% (n = 65; 47/83 YES-DETOX; 18/28 NO-DETOX) patients reverted from medication overuse headache and 51% (n = 57; 42/83 YES-DETOX; 15/28 NO-DEOTX) achieved ≥50% reduction in monthly headache days; yet no statistical differences were observed between the two groups (p = 0.4788 and p = 0.8393, respectively). Monthly consumption of pain medication was the only baseline prognostic factor in multivariate analysis in the overall cohort (p = 0.016). Conclusion Our results support the emerging evidence that anti-CGRP monoclonal antibodies may be effective in medication overuse headache patients irrespective of detoxification, yet further studies are needed to draw definitive conclusions.

Refractory Headaches

“…16 In a prospective cohort study of 111 patients with chronic migraine and MOH who used acute treatment at least 28 days per month, starting erenumab or galcanezumab was associated with significant improvement (decrease in monthly headache days, monthly pain medication intake, mean pain intensity, 6-item Head Impact Test [HIT-6], and Migraine Disability Assessment Score) after 3 months of treatment. 47 There was no significant difference in terms of improvement between the groups that underwent withdrawal of acute treatment in hospital and the group that did not. 47 In post-hoc analyses of the randomized trials for erenumab, fremanezumab, galcanezumab, and eptinezumab, CGRP monoclonal antibodies were more effective than placebo in terms of frequency and disability regardless of the presence of medication overuse.…”

“…47 There was no significant difference in terms of improvement between the groups that underwent withdrawal of acute treatment in hospital and the group that did not. 47 In post-hoc analyses of the randomized trials for erenumab, fremanezumab, galcanezumab, and eptinezumab, CGRP monoclonal antibodies were more effective than placebo in terms of frequency and disability regardless of the presence of medication overuse. [48][49][50][51] For example, erenumab had similar efficacy in terms of reduction in monthly migraine days and HIT-6 scores between the group with medication overuse and the group without.…”

“…CGRP monoclonal antibodies improve the frequency, intensity, and disability of chronic migraine with MOH and decrease the acute treatment use regardless of whether the frequently used acute treatment is acutely withdrawn, and seem to do so more effectively than topiramate or onabotulinumtoxinA. 35 47 48 49 There is currently not enough data on the potential effectiveness of prevention with β-blockers, valproic acid, or amitriptyline for the treatment of chronic migraine with MOH. 16 In a prospective cohort study of 111 patients with chronic migraine and MOH who used acute treatment at least 28 days per month, starting erenumab or galcanezumab was associated with significant improvement (decrease in monthly headache days, monthly pain medication intake, mean pain intensity, 6-item Head Impact Test [HIT-6], and Migraine Disability Assessment Score) after 3 months of treatment.…”

Monoclonal antibodies for chronic migraine and medication overuse headache: A real-world study

“…The efficacy of anti-CGRP mAbs for chronic migraine and medication-overuse headaches has been demonstrated in various subgroup analyses (15-17). Initially, specific subpopulations of patients with chronic migraine and MOH (15-17) were studied in the pivotal studies with the mAbs, but recently real-world studies aimed at these subsets of patients were also carried out and corroborated the potential usefulness of the mAbs, even in subjects who did not stop using the overused medications (14, 18,19).…”

“…Therefore, one might argue whether the use of anti-CGRP mAbs would add value to the improvement figures, with the supposed absence of differences in outcomes between the groups. Additionally, our study included only subjects with chronic migraine and MOH, different from other samples in which MOH was diagnosed in just some of the chronic migraineurs (14,18,19). This study is the first Brazilian study on MOH and the comparative use of mAbs and traditional pharmacological approaches.…”