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Medication-Overuse Headache: a Review

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Year: 2019
COI code: HEADACHC06_009
Paper Language: English

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Authors Medication-Overuse Headache: a Review

  Fariborz Khorvash - Associate Professor Of Neurology, Isfahan University Of Medical Sciences, Isfahan, Iran


The prevalence of MOH in the general population in the western world is 1%–2%. However, a recent review concludes that this varies in different parts of the world depending on the definitions used. The review reported a wide range of prevalence 0.5%–7.2%. The incidence of MOH was 0.72 per 1,000 person-years in a large prospective cohort study from Norway.The male to female ratio is 1:3–4, and the condition is most prevalent in the forties. The prevalence seems to decrease with increasing age, and among people over 65 years, the prevalence based on different definitions has been reported to be 1.0%–1.5%. The prevalence of MOH in children and adolescents has been suggested to be 0.3%–0.5%. In studies of specialist care in children, approximately 20% of patients with chronic headache had medication-overuse, suggesting MOH to be a problem also in school-aged children. It is suggested that MOH generally starts earlier in life than other types of chronic headache.The drugs implicated in MOH change over time and differ between regions. As an example, butalbital-containing medicine is still a problem in the USA, but is banned in the European Union. Ergotamine is no longer the large problem it once was in western Europe, but still is in other parts of the world. However, triptans are now one of the most com- mon causes of MOH in the Western world, but are probably too expensive to be a big problem in developing countries, where simple analgesics and ergotamine are much cheaper options.The clinical features of MOH caused by different headache medications are quite similar. The fact that many patients overuse more than one type of acute headache drug makes it somewhat difficult to conclude if different types of drugs give different types of headache characteristics. However, one study showed that people overusing triptans developed a more migraine-like headache, in contrast with those overusing ergotamines and analgesics, who developed a more tension-type-like headache.In another study, MOHcaused by a combination of analgesics and triptans resulted in a higher frequency and intensity of headache, but this needsto be further explored.The proportion ofpatients with migraine or tension-type headache as their primary headache disorder differ depending on the classification used and at which health care level the investigation was conducted; 50%–70% have co-occurrence of migraine in population- based studies compared with 80%–100% for co-occurrence of migraine in studies from some headache centers.Many psychosocial and socioeconomic factors are associated with MOH. However, whether these are directly or indirectly associated is hard to ascertain because the findings are mainly based on cross-sectional studies. In addition, many of these factors may merely be markers of a complex health situation since many aspects may be affected by having chronic headache, as with other chronic conditions As for other frequent headaches, MOH patients tend to be of low socioeconomic status with low income and education, but it is uncertain whether this may be a cause of or aneffect of headache.Whether or not to detoxify MOH patients initially andwhether prophylactic medication should be initiated immediately at withdrawal or after withdrawal therapy has been completed are probably the most disputed areas in the treatment of MOH. Although recently debated, withdrawal of the overused medication(s) is regarded by most headache experts as the treatment of choice, since withdrawal of the overused medication(s) in most cases leads to an improvement of the headache.Most patients experience withdrawal symptoms lasting 2–10 days after detoxification. The most common symptom is an initial worsening of the headache (rebound-headache), accompanied by various degrees of nausea, vomiting, hypotension, tachycardia, sleep disturbances, restlessness, anxiety, and nervousness. The duration of withdrawal head- aches has been found to vary with different drugs, being shorter in patients overusing triptans than in those overusingergotamine or analgesics.Detoxification procedures vary widely and include both inpatient (2 days to 2 weeks) and outpatient withdrawal.7Headache centers often report treatment success rates of around 70%. These results are commonly based on inpatient treatment, rescue medication, and continued support. How- ever, the definition of success rate is based on very variable outcome measures and therefore difficult to compare.Studies have reported a 20%–40% relapse rate within the first year after withdrawal. Only few relapse after 12 months.Considering that possibly anyone with primary episodic headache may be at risk of developing MOH, the number of people at risk is high. Adding the fact that, in many cases, just simple advice leads to successful medication withdrawal, the potential benefit of giving information on MOH is high. New information campaigns and strategies to target people at risk have to be developed.Given that most patients with MOH have been in contact with a general practitioner, and almost half have had such contact in the previous year, primary care is probably the ideal setting for prevention and treatment of headache and medication-overuse. The general practitioner has a key role in providing patient education and prophylactic headache medication before headaches become chronic. Further, general practitioners have the continued and clear responsibility for the patients over time. This long-term alliance with their own patients may further enhance the treatment effects andavoidance of relapse.


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Type: Medical University
Paper No.: 3184
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