How to Prevent or Reverse Medication Overuse Headache

WASHINGTON, DC—Every neurologist who treats headache sees patients who are overusing medication. At the 57th Annual Meeting of the American Headache Society, Stewart J. Tepper, MD, discussed the recognition and diagnosis of medication overuse headache (MOH) and offered practical advice for preventing progression of medication overuse in patients with chronic headache conditions. He also described ways to reverse established medication overuse. Dr. Tepper is Professor of Medicine (Neurology) at the Cleveland Clinic Lerner College of Medicine.

Diagnosing Medication Overuse
The clinical picture of medication overuse is fluid; headache frequency and severity vary. The location and quality of pain are likewise variable, as are associated features. “And that’s in the same patient and across patients,” Dr. Tepper noted.

MOH also entails drug-dependent periodicity in which the early-morning onset may be a manifestation of withdrawal. Similarly, the autonomic symptoms of MOH may be a manifestation of withdrawal from opioids. “The variability of what they experience [from] day to day may be the variability of the drugs they are taking two days before, or one day before, as they withdraw at different rates,” Dr. Tepper said.

“Neck pain is an almost invariable feature of MOH and is attributed to cervicogenic headache all the time.” With proper treatment, the neck pain disappears. In patients with MOH nonrestorative sleep disturbance is the rule, and increased depression and anxiety occur frequently. “This all may go back to the idea that there is an emotional and supratentorial aspect to the control system,” Dr. Tepper said, “but, from a clinical standpoint, the more diagnoses made in a daily headache patient, the more treatments fail, the more procedures performed, the larger the chart, the more likely the diagnosis is rebound or MOH. And so, if you use rebound as your default diagnosis in daily headache, you’re usually going to be right. You just have to do the detective work.”

MOH correlates with headache frequency and is comorbid with or mistaken for other chronic headache conditions, including chronic daily headache, chronic migraine, chronic tension-type headache, and new daily persistent headache. The third iteration of the International Classification of Headache Disorders (ICHD-3) offers diagnostic criteria for chronic migraine and for MOH and suggests that patients meeting criteria for chronic migraine and MOH should be given both diagnoses. If the patient manifests episodic or chronic migraine after drug withdrawal, the diagnosis can be revised accordingly. In their approval of onabotulinumtoxinA for chronic headache, the FDA accepted a simplified definition of chronic migraine, which is headache with a duration of four or more hours per day on 15 days or more per month, that could be secondary to MOH.

Preventing Progression to MOH
Progression of low-frequency episodic migraine to high-frequency or chronic migraine with MOH is not a one-way street. “What we are interested in clinically is how to prevent increasing migraine frequency and how to encourage decreasing frequency,” Dr. Tepper said. The average annual incidence of new-onset chronic migraine in patients with episodic migraine is about 2.5% to 3% per year, but other studies have shown decreases in headache frequency. “That [observation] has important clinical implications, including not keeping patients on prophylaxis forever,” Dr. Tepper noted.

According to population-based studies, predictors of escalating frequency include white race, low education level, being previously married, obesity, diabetes, caffeine use, stressful life events in the previous year, head injury, snoring, high baseline headache frequency, medication overuse, history of smoking, other pain conditions, and inadequate acute treatment. Predictors of low likelihood of remission for patients with chronic migraine include less than a high school education, white race, those who were previously married, and a higher baseline frequency of medication overuse for chronic migraine. Remission also is hard to achieve in patients with MOH and baseline allodynia.

Regarding escalating headache frequency, the literature makes two points clear: Opiates and barbiturates should not be used for acute migraine treatment, and all prn treatment of episodic migraine should be limited to two days per week or fewer. “With those two simple rules, you can get very far in prevention of transformation into MOH.” Interventions that can help reduce escalation are losing weight, reducing caffeine use, bringing in behavioral help for stressful life events, addressing snoring, and documenting headache frequency and medication use in a diary.

Optimal acute treatment may prevent progression to chronic migraine or MOH. In the American Migraine Prevalence and Prevention (AMPP) study inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of a year.

“[The goal of] our clinical management for acute treatment for prevention of transformation into daily headache should be sustained pain-free response, one-and-done, and [to] decrease the number of treatments and headache days per month,” Dr. Tepper said. He suggested that this should be attempted with optimal doses of triptans or dihydroergotamine in optimal formulations with early intervention. Treatment should begin before allodynia and central sensitization. NSAIDs, either in monotherapy or in combination, may be used. Behavioral approaches should be used and, when necessary, daily prevention. “With those clinical approaches, you may be able to prevent MOH.”

Reversing Established MOH
What about patients who already have MOH? “I think weaning is important for these patients for the benefits of detoxification,” Dr. Tepper said. “Addressing obesity and snoring is important, as are behavioral approaches, education, and some form of prophylaxis.” The only FDA-approved treatment for chronic migraine is onabotulinumtoxinA. For patients with MOH, this treatment would be first-line because of its lack of adverse events and its proven efficacy. Of the oral preventive options, none are FDA-approved for chronic migraine. The population studies of these options were generally heterogeneous, and their results modest. Furthermore, significant adverse events are associated with taking daily medicines. “Our plan would be to get the patients on some sort of prophylaxis, place limits on acute medicines, get behavioral intervention, and wean,” Dr. Tepper said.

Weaning
Weaning is based on two principles. First, overuse may interfere with preventive medicines. Second, overuse causes collateral damage. For example, if patients are using combination NSAIDs every day, they can get gastroenteropathy. Likewise, patients can develop analgesic nephropathy, habituation, and dependence. There could be exacerbation of depression, hyperalgesia, and addiction. “We need to take the responsibility for the wean right up front and not assume that our prophylactic regimen is going to do it for us,” Dr. Tepper advised.

Evidence suggests that rebound drugs interfere with prophylaxis. For example, the two randomized controlled trials of topiramate for chronic migraine allowed people with medication overuse to participate. In one trial, topiramate did not work in the group with medication overuse; in the other trial, topiramate worked about 50% less well in the medication-overuse group than in the chronic-migraine group without medication overuse. Studies indicate that administering onabotulinumtoxinA to patients with medication overuse is effective, but the magnitude of the response suggests that the treatment does not work as well in patients with MOH. “So, addressing the wean is important,” Dr. Tepper said.

He suggests slowly weaning the patient over a period of four to six weeks. “Start with onabotulinumtoxinA, slowly add the antimigraine drug of choice, put a quit date on the rebound medicines, and limit acute medicines.” An alternative method is to have the patient quit his or her medication cold turkey with an oral or IV bridge, either as an outpatient or an inpatient. Dr. Tepper advised using an inpatient or outpatient interdisciplinary program. “Having a team with psychology would be very helpful—always including education, always including behavioral help.”

Behavioral help is valuable because MOH is highly comorbid with psychiatric conditions. Patients with MOH are 4.5 times more likely to have a mood disorder, 3.5 times more likely to have anxiety, and 7.5 times more likely to have substance abuse disorder. “If you miss the behavioral treatment and you don’t evaluate these patients, you’re going to more likely have a poor outcome,” Dr. Tepper said. Combining behavioral treatment with medical management, which has been studied in prospective trials, improves outcomes and decreases relapses. Cognitive behavioral therapy, sleep, biofeedback, and other forms of relaxation therapy may help, “but you really must do this as part of your treatment for these patients.”

—Glenn S. Williams

WASHINGTON, DC—Every neurologist who treats headache sees patients who are overusing medication. At the 57th Annual Meeting of the American Headache Society, Stewart J. Tepper, MD, discussed the recognition and diagnosis of medication overuse headache (MOH) and offered practical advice for preventing progression of medication overuse in patients with chronic headache conditions. He also described ways to reverse established medication overuse. Dr. Tepper is Professor of Medicine (Neurology) at the Cleveland Clinic Lerner College of Medicine.

Diagnosing Medication Overuse
The clinical picture of medication overuse is fluid; headache frequency and severity vary. The location and quality of pain are likewise variable, as are associated features. “And that’s in the same patient and across patients,” Dr. Tepper noted.

MOH also entails drug-dependent periodicity in which the early-morning onset may be a manifestation of withdrawal. Similarly, the autonomic symptoms of MOH may be a manifestation of withdrawal from opioids. “The variability of what they experience [from] day to day may be the variability of the drugs they are taking two days before, or one day before, as they withdraw at different rates,” Dr. Tepper said.

“Neck pain is an almost invariable feature of MOH and is attributed to cervicogenic headache all the time.” With proper treatment, the neck pain disappears. In patients with MOH nonrestorative sleep disturbance is the rule, and increased depression and anxiety occur frequently. “This all may go back to the idea that there is an emotional and supratentorial aspect to the control system,” Dr. Tepper said, “but, from a clinical standpoint, the more diagnoses made in a daily headache patient, the more treatments fail, the more procedures performed, the larger the chart, the more likely the diagnosis is rebound or MOH. And so, if you use rebound as your default diagnosis in daily headache, you’re usually going to be right. You just have to do the detective work.”

MOH correlates with headache frequency and is comorbid with or mistaken for other chronic headache conditions, including chronic daily headache, chronic migraine, chronic tension-type headache, and new daily persistent headache. The third iteration of the International Classification of Headache Disorders (ICHD-3) offers diagnostic criteria for chronic migraine and for MOH and suggests that patients meeting criteria for chronic migraine and MOH should be given both diagnoses. If the patient manifests episodic or chronic migraine after drug withdrawal, the diagnosis can be revised accordingly. In their approval of onabotulinumtoxinA for chronic headache, the FDA accepted a simplified definition of chronic migraine, which is headache with a duration of four or more hours per day on 15 days or more per month, that could be secondary to MOH.

Preventing Progression to MOH
Progression of low-frequency episodic migraine to high-frequency or chronic migraine with MOH is not a one-way street. “What we are interested in clinically is how to prevent increasing migraine frequency and how to encourage decreasing frequency,” Dr. Tepper said. The average annual incidence of new-onset chronic migraine in patients with episodic migraine is about 2.5% to 3% per year, but other studies have shown decreases in headache frequency. “That [observation] has important clinical implications, including not keeping patients on prophylaxis forever,” Dr. Tepper noted.

According to population-based studies, predictors of escalating frequency include white race, low education level, being previously married, obesity, diabetes, caffeine use, stressful life events in the previous year, head injury, snoring, high baseline headache frequency, medication overuse, history of smoking, other pain conditions, and inadequate acute treatment. Predictors of low likelihood of remission for patients with chronic migraine include less than a high school education, white race, those who were previously married, and a higher baseline frequency of medication overuse for chronic migraine. Remission also is hard to achieve in patients with MOH and baseline allodynia.

Regarding escalating headache frequency, the literature makes two points clear: Opiates and barbiturates should not be used for acute migraine treatment, and all prn treatment of episodic migraine should be limited to two days per week or fewer. “With those two simple rules, you can get very far in prevention of transformation into MOH.” Interventions that can help reduce escalation are losing weight, reducing caffeine use, bringing in behavioral help for stressful life events, addressing snoring, and documenting headache frequency and medication use in a diary.

Optimal acute treatment may prevent progression to chronic migraine or MOH. In the American Migraine Prevalence and Prevention (AMPP) study inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of a year.

“[The goal of] our clinical management for acute treatment for prevention of transformation into daily headache should be sustained pain-free response, one-and-done, and [to] decrease the number of treatments and headache days per month,” Dr. Tepper said. He suggested that this should be attempted with optimal doses of triptans or dihydroergotamine in optimal formulations with early intervention. Treatment should begin before allodynia and central sensitization. NSAIDs, either in monotherapy or in combination, may be used. Behavioral approaches should be used and, when necessary, daily prevention. “With those clinical approaches, you may be able to prevent MOH.”

Reversing Established MOH
What about patients who already have MOH? “I think weaning is important for these patients for the benefits of detoxification,” Dr. Tepper said. “Addressing obesity and snoring is important, as are behavioral approaches, education, and some form of prophylaxis.” The only FDA-approved treatment for chronic migraine is onabotulinumtoxinA. For patients with MOH, this treatment would be first-line because of its lack of adverse events and its proven efficacy. Of the oral preventive options, none are FDA-approved for chronic migraine. The population studies of these options were generally heterogeneous, and their results modest. Furthermore, significant adverse events are associated with taking daily medicines. “Our plan would be to get the patients on some sort of prophylaxis, place limits on acute medicines, get behavioral intervention, and wean,” Dr. Tepper said.

Weaning
Weaning is based on two principles. First, overuse may interfere with preventive medicines. Second, overuse causes collateral damage. For example, if patients are using combination NSAIDs every day, they can get gastroenteropathy. Likewise, patients can develop analgesic nephropathy, habituation, and dependence. There could be exacerbation of depression, hyperalgesia, and addiction. “We need to take the responsibility for the wean right up front and not assume that our prophylactic regimen is going to do it for us,” Dr. Tepper advised.

Evidence suggests that rebound drugs interfere with prophylaxis. For example, the two randomized controlled trials of topiramate for chronic migraine allowed people with medication overuse to participate. In one trial, topiramate did not work in the group with medication overuse; in the other trial, topiramate worked about 50% less well in the medication-overuse group than in the chronic-migraine group without medication overuse. Studies indicate that administering onabotulinumtoxinA to patients with medication overuse is effective, but the magnitude of the response suggests that the treatment does not work as well in patients with MOH. “So, addressing the wean is important,” Dr. Tepper said.

He suggests slowly weaning the patient over a period of four to six weeks. “Start with onabotulinumtoxinA, slowly add the antimigraine drug of choice, put a quit date on the rebound medicines, and limit acute medicines.” An alternative method is to have the patient quit his or her medication cold turkey with an oral or IV bridge, either as an outpatient or an inpatient. Dr. Tepper advised using an inpatient or outpatient interdisciplinary program. “Having a team with psychology would be very helpful—always including education, always including behavioral help.”

Behavioral help is valuable because MOH is highly comorbid with psychiatric conditions. Patients with MOH are 4.5 times more likely to have a mood disorder, 3.5 times more likely to have anxiety, and 7.5 times more likely to have substance abuse disorder. “If you miss the behavioral treatment and you don’t evaluate these patients, you’re going to more likely have a poor outcome,” Dr. Tepper said. Combining behavioral treatment with medical management, which has been studied in prospective trials, improves outcomes and decreases relapses. Cognitive behavioral therapy, sleep, biofeedback, and other forms of relaxation therapy may help, “but you really must do this as part of your treatment for these patients.”

—Glenn S. Williams

WASHINGTON, DC—Every neurologist who treats headache sees patients who are overusing medication. At the 57th Annual Meeting of the American Headache Society, Stewart J. Tepper, MD, discussed the recognition and diagnosis of medication overuse headache (MOH) and offered practical advice for preventing progression of medication overuse in patients with chronic headache conditions. He also described ways to reverse established medication overuse. Dr. Tepper is Professor of Medicine (Neurology) at the Cleveland Clinic Lerner College of Medicine.

Diagnosing Medication Overuse
The clinical picture of medication overuse is fluid; headache frequency and severity vary. The location and quality of pain are likewise variable, as are associated features. “And that’s in the same patient and across patients,” Dr. Tepper noted.

MOH also entails drug-dependent periodicity in which the early-morning onset may be a manifestation of withdrawal. Similarly, the autonomic symptoms of MOH may be a manifestation of withdrawal from opioids. “The variability of what they experience [from] day to day may be the variability of the drugs they are taking two days before, or one day before, as they withdraw at different rates,” Dr. Tepper said.

“Neck pain is an almost invariable feature of MOH and is attributed to cervicogenic headache all the time.” With proper treatment, the neck pain disappears. In patients with MOH nonrestorative sleep disturbance is the rule, and increased depression and anxiety occur frequently. “This all may go back to the idea that there is an emotional and supratentorial aspect to the control system,” Dr. Tepper said, “but, from a clinical standpoint, the more diagnoses made in a daily headache patient, the more treatments fail, the more procedures performed, the larger the chart, the more likely the diagnosis is rebound or MOH. And so, if you use rebound as your default diagnosis in daily headache, you’re usually going to be right. You just have to do the detective work.”

MOH correlates with headache frequency and is comorbid with or mistaken for other chronic headache conditions, including chronic daily headache, chronic migraine, chronic tension-type headache, and new daily persistent headache. The third iteration of the International Classification of Headache Disorders (ICHD-3) offers diagnostic criteria for chronic migraine and for MOH and suggests that patients meeting criteria for chronic migraine and MOH should be given both diagnoses. If the patient manifests episodic or chronic migraine after drug withdrawal, the diagnosis can be revised accordingly. In their approval of onabotulinumtoxinA for chronic headache, the FDA accepted a simplified definition of chronic migraine, which is headache with a duration of four or more hours per day on 15 days or more per month, that could be secondary to MOH.

Preventing Progression to MOH
Progression of low-frequency episodic migraine to high-frequency or chronic migraine with MOH is not a one-way street. “What we are interested in clinically is how to prevent increasing migraine frequency and how to encourage decreasing frequency,” Dr. Tepper said. The average annual incidence of new-onset chronic migraine in patients with episodic migraine is about 2.5% to 3% per year, but other studies have shown decreases in headache frequency. “That [observation] has important clinical implications, including not keeping patients on prophylaxis forever,” Dr. Tepper noted.

According to population-based studies, predictors of escalating frequency include white race, low education level, being previously married, obesity, diabetes, caffeine use, stressful life events in the previous year, head injury, snoring, high baseline headache frequency, medication overuse, history of smoking, other pain conditions, and inadequate acute treatment. Predictors of low likelihood of remission for patients with chronic migraine include less than a high school education, white race, those who were previously married, and a higher baseline frequency of medication overuse for chronic migraine. Remission also is hard to achieve in patients with MOH and baseline allodynia.

Regarding escalating headache frequency, the literature makes two points clear: Opiates and barbiturates should not be used for acute migraine treatment, and all prn treatment of episodic migraine should be limited to two days per week or fewer. “With those two simple rules, you can get very far in prevention of transformation into MOH.” Interventions that can help reduce escalation are losing weight, reducing caffeine use, bringing in behavioral help for stressful life events, addressing snoring, and documenting headache frequency and medication use in a diary.

Optimal acute treatment may prevent progression to chronic migraine or MOH. In the American Migraine Prevalence and Prevention (AMPP) study inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of a year.

“[The goal of] our clinical management for acute treatment for prevention of transformation into daily headache should be sustained pain-free response, one-and-done, and [to] decrease the number of treatments and headache days per month,” Dr. Tepper said. He suggested that this should be attempted with optimal doses of triptans or dihydroergotamine in optimal formulations with early intervention. Treatment should begin before allodynia and central sensitization. NSAIDs, either in monotherapy or in combination, may be used. Behavioral approaches should be used and, when necessary, daily prevention. “With those clinical approaches, you may be able to prevent MOH.”

Reversing Established MOH
What about patients who already have MOH? “I think weaning is important for these patients for the benefits of detoxification,” Dr. Tepper said. “Addressing obesity and snoring is important, as are behavioral approaches, education, and some form of prophylaxis.” The only FDA-approved treatment for chronic migraine is onabotulinumtoxinA. For patients with MOH, this treatment would be first-line because of its lack of adverse events and its proven efficacy. Of the oral preventive options, none are FDA-approved for chronic migraine. The population studies of these options were generally heterogeneous, and their results modest. Furthermore, significant adverse events are associated with taking daily medicines. “Our plan would be to get the patients on some sort of prophylaxis, place limits on acute medicines, get behavioral intervention, and wean,” Dr. Tepper said.

Weaning
Weaning is based on two principles. First, overuse may interfere with preventive medicines. Second, overuse causes collateral damage. For example, if patients are using combination NSAIDs every day, they can get gastroenteropathy. Likewise, patients can develop analgesic nephropathy, habituation, and dependence. There could be exacerbation of depression, hyperalgesia, and addiction. “We need to take the responsibility for the wean right up front and not assume that our prophylactic regimen is going to do it for us,” Dr. Tepper advised.

Evidence suggests that rebound drugs interfere with prophylaxis. For example, the two randomized controlled trials of topiramate for chronic migraine allowed people with medication overuse to participate. In one trial, topiramate did not work in the group with medication overuse; in the other trial, topiramate worked about 50% less well in the medication-overuse group than in the chronic-migraine group without medication overuse. Studies indicate that administering onabotulinumtoxinA to patients with medication overuse is effective, but the magnitude of the response suggests that the treatment does not work as well in patients with MOH. “So, addressing the wean is important,” Dr. Tepper said.

He suggests slowly weaning the patient over a period of four to six weeks. “Start with onabotulinumtoxinA, slowly add the antimigraine drug of choice, put a quit date on the rebound medicines, and limit acute medicines.” An alternative method is to have the patient quit his or her medication cold turkey with an oral or IV bridge, either as an outpatient or an inpatient. Dr. Tepper advised using an inpatient or outpatient interdisciplinary program. “Having a team with psychology would be very helpful—always including education, always including behavioral help.”

Behavioral help is valuable because MOH is highly comorbid with psychiatric conditions. Patients with MOH are 4.5 times more likely to have a mood disorder, 3.5 times more likely to have anxiety, and 7.5 times more likely to have substance abuse disorder. “If you miss the behavioral treatment and you don’t evaluate these patients, you’re going to more likely have a poor outcome,” Dr. Tepper said. Combining behavioral treatment with medical management, which has been studied in prospective trials, improves outcomes and decreases relapses. Cognitive behavioral therapy, sleep, biofeedback, and other forms of relaxation therapy may help, “but you really must do this as part of your treatment for these patients.”

—Glenn S. Williams