European Academy of Neurology guideline on the management of medication‐overuse headache

Abstract

Background: The frequent use of medication to treat migraine attacks can lead to an increase in migraine frequency and is called medicationoveruse headache (MOH). Methods: Based on the available literature in this guideline, the first step in patient management is education and counselling.Results: Patients with MOH should be managed by a multidisciplinary team of neurologists or pain specialists and behavioral psychologists. Patients in whom education is not effective should be withdrawn from overused drugs and should receive preventive treatment with drugs of proven efficacy. Patients with MOH in whom preventive treatment is not effective should undergo drug withdrawal. Drug intake can be abruptly terminated or restricted in patients overusing simple analgesics, ergots or triptan medication. In patients with long-lasting abuse of opioids, barbiturates or tranquilizers, slow tapering of these drugs is recommended. Withdrawal can be performed on an outpatient basis or in a daycare or inpatient setting.

Efficacy, tolerability, and safety of eptinezumab in patients with a dual diagnosis of chronic migraine and medication‐overuse headache: Subgroup analysis of PROMISE‐2

“…At present, weaning or rapid withdrawal with eventual termination or reduction of the intake of drugs to manage migraine attacks is recommended 31 . The present findings may indicate that patients with MOH could benefit from eptinezumab 8 ; approximately 50% of eptinezumab‐treated patients had meaningful reductions in acute headache medication use and headache/migraine days (i.e., were below diagnostic thresholds) consistently across 6 months of treatment, suggesting resolution of both diagnoses. A rapid (day 1) and sustained magnitude of change in acute headache medication use over 6 months by the same population of patients, in combination with reductions in MMDs, suggests a clinical resolution of MOH in many patients; however, this cannot be positively affirmed as the IHS classification does not provide a definition for a change in status of MOH.…”

“…The objective of this subgroup analysis was to investigate the efficacy, tolerability, and safety of eptinezumab for the prevention of migraine in patients with a dual diagnosis of CM and MOH. [1][2][3][4][5][6][7][8][9][10][11][12]. Therapeutic benefits with eptinezumab were observed from day 1 after dosing, and improvements were sustained with an additional dose.…”

“…This vicious cycle of symptoms often improves after reducing the intake of acute or symptomatic medication or discontinuing the medication followed by preventive therapy of the primary headache disorder. 8 The worldwide prevalence of MOH is estimated to be 1%-2% of the general population or more, depending on the country and study. 2,9 MOH affects three to four times more women than men, 10 which could be partly attributable to the higher prevalence of migraine and tension-type headaches in women compared with men.…”

Medication overuse in a subgroup analysis of phase 3 placebo-controlled studies of galcanezumab in the prevention of episodic and chronic migraine

“…While there is experimental evidence indicating prolonged exposure to acute drugs can drive cephalic nociception, overuse of acute medications for headache may be the consequence rather than the cause in some patients (20). Current evidence indicates recidivism rates are high and only a modest proportion of patients with medication overuse derive long-term benefit from treatment limitation or discontinuation alone (20,21). There is a clinical belief that patients have to wean off or discontinue acute medications for preventive drugs to be effective (8).…”

Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 3rd edition, 2020

“…MOH is treated by withdrawal therapy (stop of the overuse of short-term medication) [53], either by a complete stop of all short-term medication for a 2 months period, or by a reduced intake of short-term medication to maximum 2 days a week in average. A complete stop has proven most effective in treating MOH [47].…”