Efficacy and safety of onabotulinumtoxinA in the treatment of medication overuse headache: a systematic review.

Purpose: Medication overuse headache (MOH) is a chronic headache caused by regular overuse of medications. OnabotulinumtoxinA (BoNTA) is used for preventive treatment of MOH. However, its efficacy and safety remain controversial. Methods: Seven online databases (Cochrane Library, Embase, Medline, PubMed, China National Knowledge Infrastructure, Wanfang data, and Chinese BioMedical Literature Database) were searched for relevant articles published between January 2002 and March 2024. We included randomized controlled trials (RCTs) and cohort studies on the treatment of MOH using BoNTA versus a placebo or other active treatments. Results: We retrieved 487 articles in the database search. Of these, four eligible RCTs were identified after detailed screening. A total of 1,259 patients with MOH (622 patients treated with BoNTA, 607 with placebo, and 30 with topiramate) were included in the four RCTs. We found that BoNTA significantly reduced headache frequency compared with placebo (mean difference, 1.89; 95% confidence interval (CI), 1.11-2.67; I 2 = 0%; p < 0.001). There was no significant difference between BoNTA and the placebo in terms of secondary outcomes, which included reductions in acute medication intake (MD, 1.30; 95% CI, -1.18-3.78; I 2 = 0%; p = 0.30), Migraine Disability Assessment questionnaire scores (MIDAS, MD, -4.04; 95% CI, -29.36-21.28; I 2 = 0%; p = 0.75), and Headache Impact Test scores (HIT-6, MD, 0.03; 95% CI, -1.77-1.83; I 2 = 0%; p = 0.97). BoNTA was more likely to cause adverse events (OR, 1.87; 95% CI, 1.45-2.42; I 2 = 0%; p < 0.001) than placebo. Conclusion: The results of this study show that BoNTA reduces headache frequency and is effective for the treatment of MOH. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022315845.

Comparative efficacy and safety of different pharmacological therapies to medication overuse headache: a network meta-analysis.

BACKGROUND: Controversy exists whether prophylactic drugs are necessary in the treatment of medication overuse headache (MOH). OBJECTIVES: To determine comparative benefits and safety of available drugs for the treatment of MOH including elimination of medication overuse (MO). METHODS: We systematically reviewed randomized controlled trials though an extensive literature search comparing different drug effects on MOH. A random-effect network meta-analysis was conducted to rank comparative effects of interventions. Outcome improvements from baseline include responder rate defined as ≥ 50% reduction of headache frequency, proportion of patients who revert to no acute medication overuse (nMO), and reduction in monthly headache and acute medication intake frequency. Certainty of evidence was classified using the Grading of Recommendations, Assessment, Development & Evaluation (GRADE). RESULTS: Of 8,248 screened publications, 28 were eligible for analysis. Topiramate was found to be beneficial based on its responder rate (odds ratios [OR] 4.93), headache frequency (weighted mean difference [WMD] -5.53) and acute medication intake frequency (WMD - 6.95), with fewer safety issues (i.e., tolerability, or more adverse events) than placebo (OR 0.20). Fremanezumab, galcanezumab and botulinum toxin type A (BTA) were beneficial for increased responder rates (OR 3.46 to 3.07, 2.95, and 2.57, respectively). For reversion to nMO, eptinezumab, fremanezumab and BTA were superior to placebo (OR 2.75 to 2.64, 1.87 to1.57, and 1.55, respectively). Eptinezumab, fremanezumab, erenumab 140 mg, and BTA were more efficacious than erenumab 70 mg (OR 3.84 to 3.70, 2.60 to 2.49, 2.44 and 2.16, respectively) without differences in safety and tolerability. CONCLUSION: Despite lower safety and greater intolerability issues, topiramate has large beneficial effects probably on increasing responder rates, reducing headache frequency, and might reduce monthly medication intake frequency. Fremanezumab, galcanezumab, and eptinezumab are promising for increasing responder rates. For reversion to nMO, eptinezumab has large beneficial effects, fremanezumab has a smaller effect. BTA might have a moderate effect on responder rates and probably has a small effect on reversion to nMO. TRIAL REGISTRATION: PROSPERO, CRD42021193370.

Prediction models for identifying medication overuse or medication overuse headache in migraine patients: a systematic review.

BACKGROUND: Migraine is a debilitating neurological disorder that presents significant management challenges, resulting in underdiagnosis and inappropriate treatments, leaving patients at risk of medication overuse (MO). MO contributes to disease progression and the development of medication overuse headache (MOH). Predicting which migraine patients are at risk of MO/MOH is crucial for effective management. Thus, this systematic review aims to review and critique available prediction models for MO/MOH in migraine patients. METHODS: A systematic search was conducted using Embase, Scopus, Medline/PubMed, ACM Digital Library, and IEEE databases from inception to April 22, 2024. The risk of bias was assessed using the prediction model risk of bias assessment tool. RESULTS: Out of 1,579 articles, six studies with nine models met the inclusion criteria. Three studies developed new prediction models, while the remaining validated existing scores. Most studies utilized cross-sectional and prospective data collection in specific headache settings and migraine types. The models included up to 53 predictors, with sample sizes from 17 to 1,419 participants. Traditional statistical models (logistic regression and least absolute shrinkage and selection operator regression) were used in two studies, while one utilized a machine learning (ML) technique (support vector machines). Receiver operating characteristic analysis was employed to validate existing scores. The area under the receiver operating characteristic (AUROC) for the ML model (0.83) outperformed the traditional statistical model (0.62) in internal validation. The AUROCs ranged from 0.84 to 0.85 for the validation of existing scores. Common predictors included age and gender; genetic data and questionnaire evaluations were also included. All studies demonstrated a high risk of bias in model construction and high concerns regarding applicability to participants. CONCLUSION: This review identified promising results for MO/MOH prediction models in migraine patients, although the field remains limited. Future research should incorporate important risk factors, assess discrimination and calibration, and perform external validation. Further studies with robust designs, appropriate settings, high-quality and quantity data, and rigorous methodologies are necessary to advance this field.

The burden of headache disorders in the adult population of Mongolia: estimates, and a health-care needs assessment, from a cross-sectional population-based study.

BACKGROUND: Having previously shown headache disorders to be prevalent in Mongolia, here we elaborate on headache as a public-health concern in this country, reporting symptom burden and headache-attributed impaired participation at individual and societal levels, and conducting a health-care needs assessment. METHODS: The study followed the standardized methodology developed by the Global Campaign against Headache, generating a representative general-population sample through multi-level randomized cluster sampling. Participants aged 18-65 years were interviewed at unannounced household visits by interviewers administering the HARDSHIP questionnaire. Symptom burden was established through questions on frequency, duration and intensity of headache, with proportion of time in ictal state calculated from frequency and duration. Individual impaired participation was established through the HALT questionnaire, enquiring into lost time from paid and household work and from leisure activities. Symptom burden and impaired participation yesterday were also assessed in those reporting headache yesterday. Population-level estimates were derived by factoring in prevalence. RESULTS: The total sample included 2,043 participants. Those reporting any headache in the last year (n = 1,351) spent, on average, 9.7% of all their time with headache, losing 1.3 workdays and 2.4 household days/3 months. These losses were considerably higher among those with probable medication-overuse headache (37.5%, 3.5 workdays, 6.7 household days) or other headache on ≥ 15 days/month (H15+) (21.9%, 2.4 workdays, 5.1 household days). At population-level (including those with and without headache), 6.2-7.4% of all time was spent with headache, 3.1% with H15+; 0.8 workdays and 1.4 household days/person/3 months were lost to headache, 0.3 workdays and 0.6 household days to migraine (the biggest contributor of all headache types). Our needs assessment estimated that one third (33.2%) of the adult population of Mongolia have headache (mostly migraine or H15+) likely to benefit from health care. CONCLUSION: This first population-based study on headache burden in Mongolia shows high levels of individual and societal burden, with H15 + the cause of greater burden at population level than migraine and TTH combined. Migraine, however, has the biggest impact on the nation's productivity. From a purely economic perspective, Mongolia, with limited health resources, would probably be best served by focusing on mitigating migraine-attributed burden.

A population-based survey of Americans with frequent migraine and acute medication use: A plain language summary.

WHAT IS THIS SUMMARY ABOUT?: The Harris Poll Migraine Report Card was a survey about people's experiences and challenges with headaches and migraine. The survey was conducted from December 9, 2021, to January 10, 2022, in the United States. The people who took the survey had frequent headaches/migraine attacks (on 8 or more days per month) and used acute headache/migraine medication to relieve head pain and other symptoms (on 10 or more days per month). This summary focuses on the responses of adults with frequent headaches and frequent acute medication use at the time of the survey or within the few months (not specified) before the survey (and not those who previously had frequent headaches and frequent acute medication use at some point in their life prior to the survey). The group of people who took the survey will be called 'respondents'. The term 'headaches' can mean any type of headache including as part of a migraine attack, a tension type headache, or another unknown headache type. All respondents screened positive for having migraine, so many of the headaches they reported on may have been a migraine headache or part of a migraine attack. WHAT WERE THE RESULTS?: Over 50% of respondents said their headaches affected their overall quality of life. Many respondents wished their healthcare provider who was managing their headaches understood more about how headaches affect their mental well-being, how much pain their headaches cause, and why they get headaches. 80% of respondents had concerns about their overall health. Over 60% of respondents said they have experienced anxiety and/or depression. In this survey, although all respondents were eligible to receive a preventive headache/migraine medication because of their headache frequency, only 15% were taking one. WHAT DO THE RESULTS OF THE SURVEY MEAN?: The findings from this survey showed many ways that headaches/migraine care can improve, including talking about mental and emotional well-being, making sure the treatment plan works and does not have side effects that cannot be tolerated, and trying to prevent headaches/migraine from occurring.

Emotion regulation among adults with asthma: Links with short-acting inhaler medication overuse and utilization of acute medical care.

OBJECTIVE: Existing research suggests that emotion plays an important role in airway inflammation and asthma symptom control. The objective of this study was to determine whether difficulties regulating emotion were associated with overuse of short-acting inhaled medications and acute medical care usage in adults with asthma. METHODS: The sample included 401 adults with asthma recruited from an online panel of adults with chronic respiratory disease. Sequential binary logistic regression models were used to examine the associations of emotion regulation with short-acting inhaled medication use and acute medical care use, controlling for patient characteristics and comorbid mental health conditions. RESULTS: Greater difficulties with emotion regulation were significantly associated with greater odds of short-acting inhaler medication overuse (p < 0.001), emergency department visits (p < 0.001), and hospitalizations (p = 0.001). CONCLUSIONS: Emotion dysregulation may play an important role in asthma management. Evidence-based interventions to reduce difficulties in emotion regulation may help improve problematic patterns of short-acting medication overuse and acute service use. The current findings should be interpreted in the context of several limitations, including the use of self-report measures. Future research should use electronic medical records or metered dose inhalers to objectively assess short-acting inhaler overuse and acute medical care use.

Acute medications' intake for migraine: a one-year report in patients undergoing first evaluation at a third level Italian headache center.

Background: Headache disorders, particularly primary headaches like migraine and tension-type headache, still remain underdiagnosed and undertreated despite their high prevalence and significant impact on quality of life. In recent years, several specific medications targeting key pathways in the pathophysiology of migraine have been developed. Despite this advancement, numerous studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics remain the most commonly used drugs. This study focused on the use of NSAIDs and simple analgesics as acute treatments for migraine among patients at a tertiary headache center. Methods: A retrospective observational study was conducted at the Fondazione Policlinico Universitario Campus Bio-Medico throughout 2022. Data were collected on the type and frequency of headaches, the usage and dosage of NSAIDs and other medications, and changes in their use at follow-up visits. Statistical analyses were performed to evaluate the efficacy and determinants of NSAID consumption and headache frequency changes. Results: Two hundred and eightythree patients diagnosed with migraine undergoing their first examination at our center were enrolled. Initially, 58.7% of patients used NSAIDs or simple analgesics, which decreased to 46.6% 3 months after, while triptan use increased from 65.1 to 72.8%. Changes in prophylactic therapies were significantly associated with a decrease in NSAID intake (W = 834.000, p = 0.004) and in headache frequency (W = 5960.5, p = 0.003). Specifically, the addition of topiramate or amitriptyline was associated with a reduction in NSAID use and headache frequency. Even pain freedom after the intake of NSAIDs improved from 55.2 to 79.4% of cases at follow-up. Conclusion: The study highlights the importance of appropriate diagnosis and tailored treatment strategies in the management of primary headaches. It underscores the need for specialized care to enhance treatment efficacy and patient outcomes, demonstrating that adjustments in prophylactic therapy can significantly reduce NSAID intake and improve headache care. This reinforces the role of tertiary headache centers in providing specialized care that can adapt treatments to individual patient needs and improve overall headache management.

Medication-Overuse Headache: Update on Management.

Long-term frequent use of acute pain medication for the treatment of headaches has paradoxically been shown to increase the frequency of headaches. So-called medication-overuse headache (MOH) is particularly problematic in patients with migraine who overuse triptans and opioids. Prevention through education remains the most important management strategy. Once established, MOH can be difficult to treat. Although complete or near-complete withdrawal of acute pain medication for 8-12 weeks has been shown to benefit most patients, this can be hard to achieve. The use of OnabotulinumtoxinA and drugs that target the calcitonin gene-related peptide system for the prevention of migraines have been shown to benefit patients with MOH. Furthermore, the use of novel acute pain medication for migraines, including Gepants and Ditans, which do not cause MOH, are likely to improve patient outcomes. In this review article we examine the following: the burden of MOH; who develops MOH; the pathophysiological mechanisms; and the treatment strategies.

Prevalence and Awareness of Medication Overuse Headache among Undergraduate Students at the University of Belgrade.

BACKGROUND: Medication overuse headache (MOH) is a prevalent and potentially preventable secondary headache disorder linked to the excessive use of medications intended for primary headache management, particularly migraine. AIM: The aim of our study was to assess the prevalence of MOH among undergraduate students and explore their awareness. METHODOLOGY: This observational cross-sectional study included 401 active undergraduate students from the University of Belgrade. Data were collected through an anonymous online questionnaire which was distributed among student groups and via social media. The questionnaire specially designed for this study was developed in accordance with established guidelines for headache epidemiological research. RESULTS: Among the surveyed students, 10 of them (2.5%) met the criteria for the diagnosis of MOH. Awareness of MOH was noted in 149 (37.2%) students, with higher awareness among medical students and those aged 22-25 years. Despite this awareness, there was no significant difference in MOH occurrence between those aware and unaware of the condition (aware 2.7% vs. unaware 2.4%, p = 1.000). Additionally, significant gaps in education and communication about MOH were evident. LIMITATIONS: Participants were recruited through convenience sampling from a single university at one time point. The questionnaire was not specifically validated in the student population, and the data relied on self-reporting. CONCLUSIONS: Our study highlighted a notable prevalence of MOH among undergraduate students, with a substantial portion exhibiting awareness of its risks. Despite this awareness, our findings suggest ongoing gaps in education and communication regarding MOH, emphasizing the need for targeted interventions.

Hypoperfusion of hypothalamic subunits in medication-overuse headache using a 3D PCASL MRI.

Hypothalamus is a crucial deep brain area that is responsible for the integration and coordination of various brain functions. The altered perfusion of hypothalamus during headache caused by medication-overuse headache (MOH) was previously unknown. In the current study, the altered perfusion of hypothalamic subregions in MOH patients was investigated using state-of-the-art 3D pseudo-continuous arterial spin labeling (PCASL) MR imaging. In this study, 29 normal controls subjects (NCs) and 29 MOH patients underwent 3D PCASL and brain structural MR imaging. The hypothalamus was automatically segmented into 10 subunits and the volume of each subunit was automatically determined using Freesurfer software (v7.4.1). All segmented hypothalamic subunits were converted to individual hypothalamic subunit masks. The cerebral blood flow (CBF) images were coregistered with the raw brain structural images and resliced. The CBF value of each hypothalamic subunit was extracted from the warped CBF images. The volume and CBF value of each hypothalamic subunit were analyzed using the independent sample T test and Mann-Whitney U test, receiver operating characteristic (ROC) curve analysis, and Pearson and Spearman correlation analysis. Hypothalamic subunits with significantly decreased perfusion were located in the left posterior, left tubular superior, right anterior-inferior, right tubular inferior, right tubular superior, right posterior subunit and the entire right hypothalamus [CBF value for MOH vs NC (mL/100 g·min): 48.41 ± 6.75 vs 54.08 ± 11.47, 44.44 ± 4.79 vs 48.11 ± 7.73, 41.49 (32.90, 61.46) vs 49.38 ± 10.47, 46.62 ± 7.04 vs 53.90 ± 11.75, 42.12 ± 5.74 vs 47.02 ± 9.99, 42.79 ± 5.15 vs 47.93 ± 10.48 and 43.58 ± 5.06 vs 48.65 ± 9.33, respectively] in MOH compared to NC (P < 0.05). ROC analysis for these positive subunits revealed that area under the curve was 0.658-0.693, and ROC curve for left posterior subunit had the highest specificity of 93.10% while the entire right hypothalamus had the highest sensitivity of 72.41%. Further correlation analysis showed that the CBF value of the left posterior, right anterior-inferior, right tubular superior, whole right hypothalamus presented significantly negative correlation with Hamilton Depression Scale (HAMD) score (P < 0.05). Hypoperfusion of hypothalamic subunits may contribute to the understanding of MOH pathogenesis, and the 3D PCASL could be considered as a potential diagnostic and assessment tool for MOH.

The prevalence of headache disorders in children and adolescents in Benin: a schools-based study.

BACKGROUND: A global schools-based programme within the Global Campaign against Headache is estimating the burden of headache in children (6-11 years) and adolescents (12-17 years), cluster-sampling the world by conducting national studies in all world regions. Its purpose is to complement population-based studies in adults, adding to knowledge of the burden of headache and informing educational and health policies. This study in Benin was the third in the programme from sub-Saharan Africa (SSA). METHODS: We followed the generic protocol for the global study. In a cross-sectional survey, the child and adolescent versions of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) structured questionnaire were administered to pupils within their classes in 16 schools selected from across the country to be representative of its diversities. Headache diagnostic questions were based on ICHD-3 criteria but for the inclusion of undifferentiated headache (UdH). RESULTS: Very large proportions of pupils were absent on the survey days. The sampled population defined by class registers totalled 11,802 pupils, of whom only 2,488 were present. A further 193 pupils (or their parents) declined the survey. The surveyed sampled (N = 2,295; males 1,156 [50.4%], females 1,139 [49.6%]) included 1,081 children (47.1%) and 1,214 adolescents (52.9%), with a non-participating proportion (193/2,488) of 7.8%. Headache ever was reported by 97.3% of the sample. Age- and gender-adjusted 1-year prevalences, according to responses given, were 53.4% for migraine (almost three quarters of this being probable migraine), 21.3% for tension-type headache, 8.2% for UdH, 1.0% for probable medication-overuse headache (pMOH) and 2.6% for other headache on ≥ 15 days/month (H15+). Both pMOH and other H15 + were substantially more prevalent among adolescents. CONCLUSION: The finding for migraine is anomalous, but, within this series of studies, the same was found in Zambia and similar in Ethiopia, both in SSA. While many cases identified as probable migraine, especially among children, might better have been diagnosed as UdH, the true prevalence of migraine almost certainly exceeds 21%. Regardless of diagnosis, headache is very common among children and adolescents in Benin. The study sounds an alarm with regard to pMOH as a developing problem pre-adulthood.

Situational prevention in migraine: are we doing the right thing?

This commentary addresses the use of rimegepant for situational prevention in migraine management. While the approach of using prophylactic treatments during high-risk periods is not new, its application with rimegepant described by Lipton et al. raises ethical and clinical concerns. These include the challenge of defining high-risk periods, the potential for overmedication, and the risk of medication overuse headache (MOH). The current evidence on MOH with gepants is inconclusive, and recommendations on dosing may be insufficient. Additionally, the long-term safety of calcitonin gene-related peptide (CGRP) antagonists remains uncertain, especially regarding cardiovascular and other systemic effects. The commentary emphasizes the need for caution and thorough investigation into the long-term risks and benefits of situational prevention with rimegepant before widespread adoption.

The burdens attributable to headache disorders in Cameroon: national estimates from a population-based door-to-door survey, including a headache-care needs assessment.

BACKGROUND: We have previously shown headache to be highly prevalent in Cameroon. Here we present the attributed burden. We also perform a headache-care needs assessment. METHODS: This was a cross-sectional survey among adults (18-65 years) in the general population. Multistage cluster-sampling in four regions (Centre, Littoral, West and Adamawa), home to almost half the country's population, generated a representative sample. We used the standardised methodology of the Global Campaign against Headache, including the HARDSHIP questionnaire, with diagnostic questions based on ICHD-3 and enquiries into symptom burden, impaired participation (lost productivity and disengagement from social activity), quality of life (QoL) using WHOQoL-8, and willingness to pay (WTP) for effective care. We defined headache care "need" in terms of likelihood of benefit, counting all those with probable medication-overuse headache (pMOH) or other headache on ≥ 15 days/month (H15 +), with migraine on ≥ 3 days/month, or with migraine or tension-type headache (TTH) and meeting either of two criteria: a) proportion of time in ictal state (pTIS) > 3.3% and intensity ≥ 2 (moderate-to-severe); or b) ≥ 3 lost days from paid and/or household work in the preceding 3 months. RESULTS: Among 3,100 participants, mean frequency of any headache was 6.7 days/month, mean duration 13.0 h and mean intensity 2.3 (moderate). Mean pTIS was 9.8%, which (with prevalence factored in) diluted to 6.1-7.4% of all time in the population. Most time was spent with H15 + (5.3% of all time), followed by TTH (1.0%) and migraine (0.8%). For all headache, mean lost days/3 months were 3.4 from paid work, 3.0 from household work and 0.6 from social/leisure activities, diluting to 2.5, 2.2 and 0.6 days/3 months in the population. QoL (no headache: 27.9/40) was adversely impacted by pMOH (25.0) and other H15 + (26.0) but not by migraine (28.0) or TTH (28.0). WTP (maximally XAF 4,462.40 [USD 7.65] per month) was not significantly different between headache types. An estimated 37.0% of adult Cameroonians need headache care. CONCLUSION: Headache disorders in Cameroon are not only prevalent but also associated with high attributed burden, with heavily impaired participation. Headache-care needs are very high, but so are the economic costs of not providing care.

Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia.

BACKGROUND: Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization. METHODS: We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint. RESULTS: Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications). CONCLUSIONS: Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.

Complicated Form of Medication Overuse Headache Is Severe Version of Chronic Migraine.

Background: MOH (medication overuse headache) is regarded as a complication of chronic migraines (CMs), with a general acknowledgment of reciprocal triggering between these two conditions. The present study aims to investigate the clinical parameters of relevance for the development of MOH among patients with CM, as well as for the subtype classification of MOHs. Method: We compared two groups of CM patients, with and without MOH, separated based on their demographic data and migraine characteristics. A subgroup of MOH accompanied by psychiatric co-morbidities (depression, anxiety, sleep disorder) was delineated, and the clinical features of relevance for the progression of MOH into the complicated state were evaluated. Results: The study revealed a higher prevalence of a family history of migraine in both the MOH and potentially complicated MOH subgroups (p < 0.001, p = 0.036), along with a higher prevalence of bilateral pain localization (p = 0.033, 0.021). Symptoms commonly associated with migraines, such as nausea, vomiting, photophobia, phonophobia, and osmophobia, were more common in both the MOH and potentially complicated MOH subgroups (p < 0.05). Furthermore, a positive correlation was found for the frequency (p < 0.001) and severity (p = 0.010) of migraine attacks and the duration of headaches (p = 0.007), atopy (p = 0.017), sleep disturbances (p = 0.011), and emotional stress (p = 0.022) in the MOH group. Conclusion: We found a positive correlation between the prevalence of MOH among patients with CM and a family history of migraines, higher frequency and intensity of headaches, bilateral manifestation, sleep disturbances, and emotional stress. Moreover, symptoms accompanying migraines were found to be more prevalent in individuals with MOH and potentially complicated MOH.

Three-month treatment outcome of medication-overuse headache according to classes of overused medications, use of acute medications, and preventive treatments.

Medication overuse headache (MOH) is a chronic headache disorder that results from excessive use of acutely symptomatic headache medications, leading to more frequent and severe headaches. This study aims to assess the 3-month treatment outcomes in MOH patients, focusing on the types and usage of overused medications, as well as preventive treatments. This prospective cross-sectional study analyzed the treatment outcomes of 309 MOH patients from April 2020 to March 2022. Patients were advised to discontinue overused medications immediately and offered preventive treatments based on clinical judgment. Data on headache characteristics, medication use, and impact on daily life were collected at baseline and 3 months. Results showed overall significant improvements in headache-related variables in patients completing the 3-month treatment follow-up. The median number of headache days per month decreased from 15 days at baseline to 8 days after 3 months (p < 0.001). Patients who overused multiple drug classes demonstrated increased disability levels (mean Headache Impact Test-6 score: 62 at baseline vs. 56 at 3 months, p < 0.01). Those who continued overusing medications reported more days of severe headache (mean 18 days at baseline vs. 14 days at 3 months, p < 0.05) and greater impact (mean Migraine Disability Assessment score: 35 at baseline vs. 28 after 3 months, p < 0.05) compared to the baseline. Differences in headache outcomes were evident across different preventive treatment groups, with generalized estimating equation analyses highlighting significant associations between clinical characteristics, overused medication classes, and preventive treatments. Most MOH clinical features significantly improved after 3 months of treatment. However, notable interactions were observed with certain clinical presentations, suggesting possible influences of overused medication classes, usage patterns, and preventive treatment types on MOH treatment outcomes. This study underscores the importance of individualized treatment strategies and the potential benefits of discontinuing overused medications.

Headache/migraine-related stigma, quality of life, disability, and most bothersome symptom in adults with current versus previous high-frequency headache/migraine and medication overuse: results of the Migraine Report Card survey.

BACKGROUND: High-frequency headache/migraine (HFM) and overuse of acute medication (medication overuse [MO]) are associated with increased disability and impact. Experiencing both HFM and MO can potentially compound impacts, including stigma; however, evidence of this is limited. The objective of this report was to evaluate self-reported stigma, health-related quality of life (HRQoL), disability, and migraine symptomology in US adults with HFM + MO from the Harris Poll Migraine Report Card survey. METHODS: US adults (≥ 18 yrs., no upper age limit) who screened positive for migraine per the ID Migraine™ screener completed an online survey. Participants were classified into "current HFM + MO" (≥ 8 days/month with headache/migraine and ≥ 10 days/month of acute medication use over last few months) or "previous HFM + MO" (previously experienced HFM + MO, headaches now occur ≤ 7 days/month with ≤ 9 days/month of acute medication use). Stigma, HRQoL, disability, and most bothersome symptom (MBS) were captured. The validated 8-item Stigma Scale for Chronic Illnesses (SSCI-8) assessed internal and external stigma (scores ≥ 60 are clinically significant). Raw data were weighted to the US adult population. Statistically significant differences were determined by a standard t-test of column proportions and means at the 90% (p < 0.1) and 95% (p < 0.05) confidence levels. RESULTS: Participants (N = 550) were categorized as having current (n = 440; mean age 41.1 years; 54% female; 57% White, not Hispanic; 24% Hispanic; 11% Black, not Hispanic) or previous (n = 110; mean age 47.2 years; 49% female; 75% White, not Hispanic; 13% Hispanic; 4% Black, not Hispanic) HFM + MO. Compared to those with previous HFM + MO (21%), adults with current HFM + MO were more likely to experience clinically significant levels of stigma (47%). Men with current HFM + MO (52% compared to men with previous HFM + MO [25%] and women with current [41%] or previous [18%] HFM + MO), non-Hispanic Black (51% compared to White, not Hispanic [45%] and Hispanic [48%] current HFM + MO groups and White, not Hispanic previous HFM + MO [12%]), current HFM + MO aged 18-49 years (50% compared to those with current HFM + MO aged ≥ 50 years [33%] and those with previous HFM + MO aged 18-49 [34%] and ≥ 50 years [4%]), and employed respondents (53% current and 29% previous compared to those not employed [32% current and 12% previous]) reported higher rates of clinically significant stigma. Those with current HFM + MO were more likely to have worse HRQoL and disability due to headache/migraine. Respondents aged ≥ 50 years with current HFM + MO were more likely than respondents aged 18-49 years with current HFM + MO to indicate that their overall quality of life (66% vs. 52%) and their ability to participate in hobbies/activities they enjoy were negatively impacted by headache/migraine (61% vs. 49%). Pain-related symptoms were identified as the MBS. CONCLUSIONS: Together these data suggest that current and previous HFM + MO can be associated with undesirable outcomes, including stigma and reduced HRQoL, which were greatest among people with current HFM + MO, but still considerable for people with previous HFM + MO.

[Sleep disorders in patients with medication-overuse headache]. / Narusheniya sna u bol'nykh s lekarstvenno-indutsirovannoi golovnoi bol'yu.

OBJECTIVE: To analyze complaints about sleep disorders and assess the incidence of various sleep disorders, using relevant scales, in patients with medication-overuse headache (MOH) in comparison with patients without MOH. MATERIAL AND METHODS: The prospective case-control study included 171 patients, aged 18 years and older, with MOH (main group), and173 patients with primary headaches without MOH (control group). A neurologist conducted an initial examination and professional interview before the start of treatment. To diagnose sleep disorders, the International Classification of Sleep Disorders (3rd edition, 2014) was used. Additionally, an assessment was made using the Insomnia Severity Index Scale, the Epworth Sleepiness Scale (ESS) and the Lausanne Obstructive Sleep Apnea Syndrome Scale (NoSAS). RESULTS: Statistically significant differences were revealed in the prevalence of the following complaints about sleep disorders in patients with MOH: lack of sleep (51.5%), frequent awakenings during sleep (43.3%), discomfort in legs before falling asleep or at rest in the evening (37.4%). Difficulties falling asleep occurred equally often in both patients with MOH (43.9%) and without MOH (37.0%), as well as daytime sleepiness (40.4% vs 36.4%) and the presence of snoring (13% of patients in each group). Patients with MOH were significantly more likely to suffer from chronic insomnia (60.2% and 47.4%, respectively, p=0.02; OR 1.7; 95% CI 1.1-2.6) and restless legs syndrome (37.4% and 22.0%, respectively, p=0.002; OR 2.1; 95% CI 1.3-3.4). The incidence of hypersomnia and obstructive sleep apnea syndrome did not have statistically significant differences. CONCLUSION: Patients with MOH compared to patients without MOH have a significantly higher incidence of main complaints of sleep disorders, chronic insomnia and restless legs syndrome, which indicates the importance of sleep disorders in the pathogenesis of medication-overuse headaches and requires timely diagnosis and treatment to prevent the progression of both headaches and sleep disorders.

The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study.

BACKGROUND: Our recent studies have shown headache disorders to be very common in the central and western sub-Saharan countries of Benin and Cameroon. Here we report headache in nearby Mali, a strife-torn country that differs topographically, culturally, politically and economically. The purposes were to estimate headache-attributed burden and need for headache care. METHODS: We used cluster-random sampling in seven of Mali's eleven regions to obtain a nationally representative sample. During unannounced household visits by trained interviewers, one randomly selected adult member (18-65 years) from each household was interviewed using the structured HARDSHIP questionnaire, with enquiries into headache in the last year and, additionally, headache yesterday (HY). Headache on ≥ 15 days/month (H15+) was diagnosed as probable medication-overuse headache (pMOH) when associated with acute medication use on ≥ 15 days/month, and as "other H15+" when not. Episodic headache (on < 15 days/month) was recorded as such and not further diagnosed. Burden was assessed as impaired participation (days lost from paid and household work, and from leisure activity). Need for headache care was defined by criteria for expectation of benefit. RESULTS: Data collection coincided with the SARS-CoV-2 pandemic. The participating proportion was nonetheless extremely high (99.4%). The observed 1-year prevalence of any headache was 90.9%. Age- and gender-adjusted estimates were 86.3% for episodic headache, 1.4% for pMOH and 3.1% for other H15+. HY was reported by 16.8% with a mean duration of 8.7 h. Overall mean headache frequency was 3.5 days/month. Participants with pMOH lost more days from paid (8.8 days/3 months) and household work (10.3 days/3 months) than those with other H15+ (3.1 and 2.8 days/3 months) or episodic headache (1.2 and 0.9 days/3 months). At population level, 3.6-5.8% of all time was spent with headache, which led to a 3.6% decrease in all activity (impaired participation). Almost a quarter (23.4%) of Mali's adult population need headache care. CONCLUSION: Headache is very common in Mali, as in its near neighbours, Benin and Cameroon, and associated with substantial losses of health and productivity. Need for headache care is high - a challenge for a low-income country - but lost productivity probably translates into lost gross domestic product.

Long-term effectiveness of eptinezumab in the treatment of patients with chronic migraine and medication-overuse headache.

OBJECTIVE: This post hoc analysis of the PREVAIL study explored the effectiveness of eptinezumab for up to 2 years of open-label treatment in the subgroup of patients with chronic migraine who had a confirmed diagnosis of medication-overuse headache (MOH) at screening. BACKGROUND: MOH is a disabling and costly secondary headache disorder characterized by increased headache frequency and/or severity with increased acute headache medication use. Eptinezumab, an anti-calcitonin gene-related peptide monoclonal antibody, reduces headache frequency, severity, and associated disability and improves functioning and health-related quality of life as a preventive migraine therapy; short-term benefits in patients with concurrent MOH have also been reported. METHODS: Participants received up to eight quarterly intravenous infusions of eptinezumab 300 mg in the phase 3, single-arm, open-label PREVAIL study. Safety and patient-reported outcome measures (Migraine Disability Assessment [MIDAS], 6-item Headache Impact Test [HIT-6], patient-identified most bothersome symptom [PI-MBS], Patient Global Impression of Change [PGIC], and 36-item Short-Form Health Survey [SF-36]) were conducted at predefined intervals. Patients were observed up to 20 weeks after their last infusion (Week 104). RESULTS: A total of 49/128 (38.3%) patients enrolled in PREVAIL had an MOH diagnosis at screening. In the MOH subgroup, long-term eptinezumab treatment was associated with reductions in headache frequency (43/49 [87.8%] patients reported ≥50% reduction in MIDAS-derived headache days at ≥1 visit), severity (2.2-point reduction [on a 10-point scale]), disability (mean MIDAS total score reduction of 51.9 points), and impact (mean HIT-6 total score reduction of 9.7 points) at Week 104. Most patients described a "much improved" or "very much improved" status by Week 48 (PI-MBS, 31/46 [67.4%]) and Week 104 (PGIC, 31/36 [86.1%]). Health-related quality of life improvements in the SF-36 were also observed. CONCLUSION: Eptinezumab preventive therapy in patients with chronic migraine showed benefits that extended to the subset of patients with concomitant MOH.