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Medication overuse headache

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Brief review of diagnosis and management of medication-overuse headache, based on a continuum paper.

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Medication overuse headache

  1. 1. Medication-overuse headache Daniel Vela-Duarte, MD PGY-3. Department of Neurology Loyola University Medical Center August 2013
  2. 2. Definition  MOH (Medication-Overuse headache)  Secondary chronic daily headache Headache induced by the overuse of analgesics, triptans or other acute headache compounds, ocurring 15 days/month, 4hrs/day, per 3 months or more.   Repeated medication reaches a threshold causing transformation (chronification)
  3. 3. Introduction / Epidemiology  Higher preponderance in woman  In a study on episodic migraineurs (n=532), the 1-year incidence of chronic headache was 14%, with a higher risk for patients who had a higher headache frequency at baseline and for patients taking greater amounts of analgesics.  Ergotamine, analgesics, barbiturates and caffeine  Poorer quality of life (Measured by scales: higher score on MIDAS: Migraine disability assessment scale)
  4. 4. Clinical manifestations     Criteria established by the International Headache Society (IHS) in 2005 The primary headache disorder leading to MOH is migraine in most cases. MOH mainly occurs in patients with a primary headache disorder Comorbidities    Subclinical obsessive-compulsive disorder Anxiety - Mood disorders Type of medications overused.
  5. 5. Symptoms  Circadian periodicity  Patients may be awakened from sleep or have onset upon arising  Neck pain / Cervicogenic pain.  Rhinorrhea, nasal stuffiness, postnasal drip, and ocular or gastrointestinal symptoms, likely caused by withdrawal and most evident in opioid rebound. Nonrestorative sleep disturbance 
  6. 6. Diagnostic criteria Lancet Neurol 2010 Apr; 9(4): 391-401.
  7. 7. Diagnostic criteria  There is no certainty whether combined drugs are more likely to cause MOH or not, compared to single substances.  The headache features of MOH caused by ergotamine derivatives are more severe than those caused by triptans.   Overuse of ergotamine + analgesics: daily tension-type-like headache, Overuse of triptans: (daily) migraine-like headache or an increase in migraine frequency
  8. 8. Withdrawal treatment  Detoxification process  Improve responsiveness to acute and prophylactic drugs  Abrupt discontinuation vs. tapered withdrawal  Main symptoms of withdrawal  worsening of the headache  nausea, vomiting  arterial hypotension, tachycardia  sleep disturbances  restlessness, anxiety, nervousness
  9. 9. Withdrawal treatment  Inpatient vs. Outpatient  Overuse of opioids, barbiturates, or benzodiazepines  psychological problems  severe medical comorbidities  severe withdrawal  symptoms (eg, vomiting and status migrainous)  previous medication withdrawal failure
  10. 10. Tepper SJ, Continuum (Minneap Minn). 2012 Aug;18(4):807-22.

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