Research urged for medication overuse headaches

The problem of medication overuse headaches is global and in need of prevention strategies. Such pain, which is associated with the excessive use of drugs to control it, should be the focus of research to determine the best treatment course, states a collection of papers examining the incidence of the condition in eight nations. It was published in a supplement to the November Cephalalgia.

"MOH is associated with severe disability, unmet treatment need and little clinical data to support current management strategies," said David W. Dodick, MD, editor of the collection and author of the main paper. He is also a professor of neurology at Mayo Clinic Arizona in Scottsdale and president-elect of the American Headache Society.

Current strategies usually involve convincing affected patients to discontinue headache medications and helping them through the detoxification period. This process can involve other pharmaceuticals, lifestyle changes, mental health services or alternative therapies.

"It's really important that they understand that they're not likely to get better if they don't get off their daily symptomatic medicine," said Morris Maizels, MD, a family physician and director of Kaiser Permanente's Woodland Hills Headache Clinic in California. "And they need to know that the first week or two they may actually be worse."

This circumstance can be particularly hard for the many patients who have multiple pain-related conditions. For example, the paper on MOH incidence in Germany reported epidemiological data indicating those with chronic headache also often have low back pain.

Depression and anxiety are common in this patient population worldwide, and more than one medication frequently plays a role. Relapse is not uncommon.

"These people ... need a lot of intervention, and they're difficult to manage," said R. Allan Purdy, MD, co-author on the Canadian-focused paper. He is a professor of medicine at Dalhousie University Faculty of Medicine in Halifax, Nova Scotia. "It's worth investing the time, although even if you do everything right, some [patients] may not get better."

An emerging approach increasingly chosen by some headache experts is prescribing drugs that prevent migraine to ease patients through the difficult transition period. Others favor using steroids and analgesics, although strategies vary widely with little evidence supporting one over another. Because of this, most see an urgent need for more research to get a better handle on the difficulty.

"We don't know what the mechanism of MOH is. We don't know why some people get it, and others don't. And we need controlled trials to know the best way to help people get better," said Stephen Silberstein, MD, professor of neurology at Jefferson Medical College of Thomas Jefferson University and director of the Jefferson Headache Center in Philadelphia. He also co-wrote the main paper with Dr. Dodick.

The authors of these papers called for increased emphasis on identifying those at risk for developing this type of headache and educating them on the issue to make it less likely medication overuse will occur. Patient diaries should record symptoms as well as drugs taken. Restrictions should be placed on the use of acute meds.

"Physicians need to be vigilant about what medications they prescribe for migraine and other kinds of headaches and what over-the-counter medications patients are taking," Dr. Dodick said.

According to the other papers in the supplement, causes, prevalence and treatment of medication overuse headache are determined largely by a country's culture and accessibility to acute treatments. For example, the syndrome was less common in India, where patients tend to choose topical pain balms. Codeine and caffeine are not used in combination painkillers in Japan, meaning these products do not play a role in MOH there as they do in North America and Europe.