Comparison of 3 treatment strategies for medication overuse headache

1. For patients with medication overuse headache, withdrawal and preventive medication was more effective at reducing headache than other strategy alone.

Evidence Rating: 1 (Excellent)

Medication overuse headache (MOH) affects more than 60 million people globally and is considerably disabling. Although current guidelines recommend withdrawal of medication and preventive medication usage, there is currently great debate regarding what the most effective strategy is for treating the condition. In this open-label, randomized clinical trial, researchers enrolled 120 patients with MOH to determine whether preventive medication alone, withdrawal alone, or a combination of the two would be the most effective treatment strategy. The withdrawal group would receive withdrawal advice and MOH education from trained headache nurses, followed by complete discontinuation of analgesics for 2 months, though rescue medications and antiemetics could be used during the treatment period. Preventive medication varied depending on the presenting complaint, and was adherent to guidelines outlined according to the Danish Headache Centre. Primary outcome was change in headache (days per month) from baseline at 6 months. Several secondary outcomes were also included, such as reduction of migraine days per month, reversion to episodic headaches, use of short-term medication, headache intensity, and number of patients with medication overuse at 6 months, for example. Headache days per month were most greatly reduced in the withdrawal plus preventive group (12.3; 95% CI, 9.3-15.3), by 9.9 (95% CI, 7.2-12.6) in the preventive group, and by 8.5 (95% CI, 5.6-11.5) in the withdrawal group (P = .20).  Although no differences were found in reduction of migraine days per month or headache intensity, 23 of 31 patients (74.2%) in the combination therapy group reverted to episodic headache, compared with 21 of 35 (60.0%) in the preventive group and 15 of 36 (41.7%) in the withdrawal group (P = .03). Likewise, 30 of 31 patients (96.8%) in the withdrawal plus preventive group were cured of MOH, compared with 26 of 35 (74.3%) in the preventive group and 32 of 36 (88.9%) in the withdrawal group (P = .03), corresponding to a 30% (relative risk, 1.3; 95% CI, 1.1-1.6) increased chance of MOH cure in the combinational therapy group compared with the preventive group (P = .03). While findings suggest that all three treatment strategies were effective in reducing MOH, combinational therapy with withdrawal and preventive medication appears to be the superior method. The study primarily consisted of patients with MOH secondary to simple analgesic overuse however, and as such, further large scale RCT’s should be performed to improve generalizability of findings and better inform clinical decision making for MOH treatment.

Click here to read the study in JAMA Neurology

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