European Academy of Neurology guideline on the management of medication-overuse headache.

BACKGROUND: The frequent use of medication to treat migraine attacks can lead to an increase in migraine frequency and is called medication-overuse 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 Patients in whom education is not effective should be withdrawn from overused drugs and should receive preventive treatment with drugs of proven efficacy.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.

More precise phenotyping of cluster headache using prospective attack reports.

BACKGROUND AND PURPOSE: The clinical characteristics of cluster headache (CH) are based mainly on retrospective attack descriptions of 'usual' attacks, but whether these reports are reliable is uncertain. The aim was to compare retrospective and prospective attack descriptions and describe the within- and between-patient variability of attacks. METHOD: Fifty-seven CH patients underwent a semi-structured interview obtaining a retrospective account of usual CH attacks. Patients thereafter prospectively recorded the clinical characteristics of up to 10 attacks per patient in a headache diary. Four different attack characteristics were investigated: (i) severity, (ii) duration, (iii) number of autonomic symptoms and (iv) number of migrainous symptoms. Retrospective and prospective data were compared. Within- and between-patient variability of attacks was assessed. RESULTS: Retrospective attack descriptions (n = 57) were significantly longer (P = 0.046) and more severe (P < 0.0001) for untreated attacks compared with prospective reports (n = 500). The number of autonomic symptoms was significantly higher in the retrospective reports compared to the prospective reports (P < 0.0001). Within-patient variability for attack duration, pain severity and number of autonomic and migrainous symptoms was low. Compared to men, more women reported longer (P = 0.026) and more severe (P = 0.028) attacks with more migrainous symptoms (P = 0.033). CONCLUSIONS: Important differences were found between prospectively and retrospectively reported attacks with duration and severity of untreated attacks overestimated in retrospective attack descriptions. CH attacks display low within-patient variability, but the presentation of CH attacks varies between patients. The high prevalence of symptoms typically associated with migraine should raise more diagnostic awareness for CH, especially in women who are more often misdiagnosed as having migraine.

Medication-overuse headache detoxification reduces headache disability - the Akershus study of chronic headache.

BACKGROUND AND PURPOSE: Medication-overuse headache (MOH) is a chronic headache (≥15 days/month) associated with overuse of acute headache medication. The objective was to investigate headache-related disability before and after self-detoxification from MOH in the general population, as well as possible predictors for successful outcome. METHODS: This was a prospective cohort study. Participants were identified in a cross-sectional epidemiological sample of 30 000 persons aged 30-44 from the general Norwegian population. People with MOH received short information about the possible role of medication overuse in headache chronification. A total of 108 of the 128 participants (84%) were eligible for follow-up 1.5 years later. RESULTS: Using the Migraine Disability Assessment (MIDAS), people with MOH in the general population were heavily disabled (mean MIDAS score 42.1, 95% confidence interval 31.7-52.6) with a majority in the severe disability class. The MIDAS score was significantly reduced at follow-up (P < 0.001) for those with successful self-detoxification. In multivariate analyses, co-occurrence of migraine (P = 0.044) and lower headache frequency at baseline (P = 0.001) increased the odds for successful self-detoxification and reversion to episodic headache. CONCLUSION: Medication-overuse headache causes substantial disability in the general population. Self-detoxification leads to reduced headache frequency and disability, although 24% of the participants did not complete self-detoxification. Detoxification should be offered to MOH patients as early as possible with a focus on headache frequency, disability and psychological distress.

Lasting improvement of medication-overuse headache after brief intervention - a long-term follow-up in primary care.

BACKGROUND AND PURPOSE: Withdrawal therapy improves the headache situation for many patients with medication-overuse headache (MOH), but relapses are common. The objective was to assess the long-term effectiveness of a general practitioner conducted brief intervention (BI) for MOH. METHODS: Sixty MOH patients initially participating in a blinded cluster-randomized controlled trial evaluating BI versus business as usual (BAU) were followed up for 16 months. Follow-up was open after 6 months. Headache and medication days per month were evaluated in three groups: BI early (BI throughout the study, n = 24), BI late (initial BAU, then cross-over to BI, n = 22) and BAU throughout the study (n = 14). RESULTS: Fifty-five of 60 initially included patients completed the follow-up. The mean change over 16 months' observation in the BI early group was a reduction of 8.4 (5.4-11.4) headache and 13.5 (9.6-17.3) medication days per month. The relapse rate into medication overuse was 8.3%. Patients in the BI late group also improved significantly after a BI. BAU showed no significant improvement. CONCLUSIONS: Treatment for MOH in primary care through a BI is a simple intervention with lasting effects and low relapse rate. This approach may be a logical first step in MOH treatment, and referral should generally be reserved for primary care non-responders.

Predictors of successful primary care detoxification treatment for medication-overuse headache.

OBJECTIVES: To investigate predictors for successful treatment outcome after a brief intervention (BI) for medication-overuse headache (MOH). MATERIALS AND METHODS: This study evaluated predictors of successful withdrawal among patients initially participating in a pragmatic cluster-randomized controlled trial with single crossover in Norwegian general practice (the BIMOH study). BI (early or after crossover) was compared to business as usual (BAU) for the treatment of MOH. Patients were followed up 3 months after the BI. RESULTS: In total, 46 patients had the chance to receive the BI (24 early and 22 after crossover) and were included in the predictor analyses. The mean reduction in headache and medication days/month from baseline for the BI was 6.9 (95% CI: 4.8-9.1) and 10.9 (8.1-13.6). The mean percentage reduction in headache and medication days was 30.5% (21.4-39.7) and 50.4% (39.5-61.3). Only five patients started prophylactic medication. Neither age, gender, co-occurrence of migraine, main type of overused drug at baseline nor Severity of Dependence Scale score at baseline predicted successful withdrawal in the prespecified analyses. Headache days/month and medication use at baseline were significant predictors in exploratory analyses with more headache and medication days predicting worse outcome. CONCLUSIONS: Brief intervention for MOH is a simple and effective intervention in primary care. As the only identified predictors were frequency of headache and medication use, we conclude that treatment for all MOH patients should be attempted in primary care before referral. A raised awareness of MOH is important, as the condition is highly preventable and treatable. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01314768.

Disability, anxiety and depression in patients with medication-overuse headache in primary care - the BIMOH study.

BACKGROUND AND PURPOSE: Medication-overuse headache (MOH) is common in the general population. Detoxification is the general treatment principle for MOH. The present paper is based on a study of a brief intervention (BI) for MOH in primary care. New data on headache disability and the Hospital Anxiety and Depression Scale (HADS) for MOH patients compared to population controls with and without chronic headache are presented and compared to previously published main outcome data. METHODS: This was a double-blind pragmatic cluster randomized controlled trial carried out amongst 50 general practitioners in Norway. The BI was compared to business as usual (BAU) and population controls, and patients were followed up after 3 months. Primary outcomes were headache and medication days per month after 3 months. Headache disability and HADS were also measured as secondary outcomes. RESULTS: Sixty MOH patients and 40 population controls were included. BI was significantly better than BAU after 3 months regarding primary outcomes. Non-intervention population controls did not change. The MOH patients had significantly higher headache disability and anxiety scores than the population controls. CONCLUSIONS: Patients with MOH are a highly disabled group where anxiety and depression are important comorbidities. Detoxification of MOH by a BI in primary care is effective and has potential for saving resources for more treatment-resistant cases in neurologist care.