Study Examines Treatment Strategies for Medication Overuse Headache

Investigators at the Danish Headache Center (DHC) in Glostrup, Denmark, compared 3 debated treatment avenues for medication overuse headache (MOH).

MOH is a highly debilitating disorder that is prevalent all over the globe, affecting an estimated 60 million individuals worldwide. Those with MOH often suffer from primary headache disorders, including migraine, cluster, or tension-type headaches and take less effective or nonspecific medications. This often leads to overuse of the medication, as well as headaches in a headache-prone patient, the researchers explained.

Medication overuse by patients with episodic headaches may be a critical factor in progressing to chronic headache, according to investigators. In order to determine the most effective MOH treatment methods, investigators compared 3 treatment strategies:

1. Withdrawal with preventative treatment from start (withdrawal plus preventative strategy)
2. Preventative treatment without withdrawal (preventative strategy)
3. Withdrawal with postponed optional preventative treatment (withdrawal strategy)

The open-label, randomized clinical trial (RCT) collected data from October 25, 2016 to June 28, 2019 and included 120 patients aged 18 years and older with migraine and/or tension-type headache. The mean (SD) age was 43.9 years; 79.4% (81) were women, and more than 75% of participants had a single type of medication overuse, triptans, or combination analgesics. Patients were randomized 1:1:1 to 1 of 3 outpatient groups: the withdrawal plus preventative treatment group, preventative treatment group, or withdrawal group. The study had a follow-up period of 2 and 6 months and by phone at 1 and 4 months after they began treatment.

Both the withdrawal group and the withdrawal plus preventative group received individualized recommendations on withdrawal and MOH from trained nurses, as well as complete discontinuation of the medication for 2 months. Patients in the preventative group were offered information about their particular preventative treatment as per DHC guidelines.

Investigators measured the change in headache days per month from baseline to 6 months within the 3 treatment groups. Patient groups were additionally compared on the basis of change in headache days per month, change in migraine days per month, change in days per month with short-term medication use, and change in total monthly headache intensity.

Fifty-eight percent of patients in the withdrawal plus preventative group achieved complete discontinuation of short-term analgesics. Fifty-five percent in the withdrawal group achieved the same. In addition, the majority of patients in the withdrawal plus preventative group and the preventative group began candesartan preventative treatment. Headache days per month were reduced by 12.3 in the withdrawal plus preventative group, by 9.9 in the preventative group, and by 8.5 in the withdrawal group.

The study authors concluded that all 3 treatment strategies were effective for MOH. The results showed no significant variations between groups on the basis of reductions in monthly headache days.

“Our study is, to our knowledge, the first attempt to directly compare the 3 debated treatment strategies, addressing the clinically relevant question about how we should treat patients with MOH,” study authors wrote.

Reference:

1. Carlsen LN, Munksgaard SB, Nielsen M, et al. Comparison of 3 treatment strategies for medication overuse headache a randomized clinical trial. JAMA. September 26, 2020. doi: 10.1001/jamaneurol.2020.1179.