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        Cluster Headache Help and Support >> Medications, Treatments, Therapies >> Medication Overuse Headache
        
(Message started by: Bob_Johnson on May 21st, 2008, 2:13pm)
Title: Medication Overuse Headache
Post by Bob_Johnson on May 21st, 2008, 2:13pm
Curr Pain Headache Rep. 2008 Apr;12(2):122-7.
Medication-overuse headache in patients with cluster headache.

Paemeleire K, Evers S, Goadsby PJ.

Headache Clinic, Department of Neurology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. koen.paemeleire@ugent.be

Cluster headache (CH) is associated with the most severe pain of the primary headache disorders. Barriers to optimal care include misdiagnosis, diagnostic delay, undertreatment, and mismanagement. Medication-overuse headache (MOH) may further complicate CH and may present as increased CH frequency or development of a background headache, which may be featureless or have some migrainous quality. A personal or familial history of migraine appears to be strongly associated with the development of MOH in CH, at least with the phenotype of background headache. Patients with CH, especially those with a personal and/or family history of migraine, must be carefully monitored for MOH, and medication withdrawal should be considered if a CH patient presents with features of MOH.

PMID: 18474192 [PubMed]
Title: Re: Medication Overuse Headache
Post by DennisM1045 on May 22nd, 2008, 10:18am
Great info Bob.

Does the report specify preventative or abortive medications as being more troublesome?  The abstract doesn't say.

-Dennis-
Title: Re: Medication Overuse Headache
Post by Bob_Johnson on May 22nd, 2008, 10:50am
MOH headaches are always in reference to pain meds.

Some time ago there was some concern about Imitrex also being involved but the literature is not fixed on that question. At least one report says that this med not a problem for CH but is for migraine.

Truth is never final! <bg>
Title: Re: Medication Overuse Headache
Post by DennisM1045 on May 22nd, 2008, 12:51pm
I'm feeling a bit dense today.  Sorry.

By pain meds do you mean narcotics?

-Dennis-
Title: Re: Medication Overuse Headache
Post by Bob_Johnson on May 22nd, 2008, 1:52pm
Medication overuse headache (MOH), or "rebound headache", is a common and disabling headache disorder that can develop and persist by the frequent and excessive use of symptomatic pain medications. Often these headaches begin early in the morning, and the location and severity of headache may change from day to day. People who have MOH may also have nausea, irritability, depression, or problems sleeping.

In susceptible individuals with a pre-existing episodic headache condition (most frequently migraine or tension-type headache), the frequent, near-daily use of simple analgesics (aspirin or paracetamol), combination analgesics (containing caffeine, codeine, or barbiturates), opioids, ergotamine, or triptans "transforms" the headache into one that occurs daily.

Characteristic features of MOH include the following:
1. the frequency of the headaches increases over time, without the patient being aware;
2. patient often wakes up in the early morning with a headache, even though this was not a feature of the original headache type;
3. some of the headache attacks may become nondescript – lacking features specific to migraine or tension-type headache;
4. the patient gets a headache more easily with stress or exertion;
5. greater doses of the medications are needed to alleviate the headache;
6. headaches occur within a predictable period after the last dose of medication, usually with reduced efficacy.

How much medication is too much?
The new 2004 International Headache Society (IHS) criteria guidelines2 state that MOH can be associated with the use of:


simple analgesics for 15 days or more, for more than 3 months

combination medications for 10 days or more, for more than 3 months

opioids for 10 days or more, for more than 3 months

ergotamine and triptans for more than 10 days per month, for more than 3 months

Frequent and regular use (ie. two or three times per week) is much more likely to cause MOH than taking medication in clusters of several treatment days separated by prolonged treatment-free intervals.

Caffeine is an ingredient in some headache medications. It may improve headaches initially, but daily intake of caffeine-containing medications, or caffeine-containing beverages, can result in greater headache frequency and severity. Stopping caffeine may actually make headaches worse, and some patients require professional help to overcome caffeine dependency.

As well, the new IHS criteria defines headache secondary to medication overuse as headache which has worsened in the face of 10 or more days of triptan use or 15 or more days of analgesic use. Headache must be present 15 or more days per month.

Treating MOH
Patients with CDH who overuse acute pain medications are advised to discontinue or taper the overused medication. There is the possibility of developing tolerance to the drug, and/or dependence. There is also the risk of developing liver, kidney and gastrointestinal disorders.

Most patients with MOH can be treated in the outpatient setting. Hospitalization is usually for patients overusing opioids, barbituates, or benzodiazepines, those with severe psychiatric comorbidities, or those who have failed previous withdrawal attempts as an outpatient.

Simple analgesics, ergotamines, triptans and most combination analgesics can be abruptly discontinued whereas opioids and barbituate-containing analgesics should be gradually tapered. Patients should be given a pain medication in a class they are not overusing, in limited doses, to help alleviate withdrawal symptoms, such as headache, nausea, vomiting, sleep disturbances, etc.). These symptoms typically last from 2 to 10 days.

The first step to treating MOH is to educate the patient about the role of medication overuse in the patient’s chronic daily headache. If there is comorbid depression and/or anxiety, it needs to be addressed at the same time. Biofeedback can be used to help the patient learn relaxation techniques, and lifestyle habits have to be modified. This can include decreasing caffeine consumption, increasing exercise, using stress management strategies, and improving sleep habits.

The goal of withdrawal is to get rid of daily or near-daily medication use and its associated symptoms, to restore an episodic pattern of headache, and to establish an effective treatment strategy including both preventive and acute medications. In patients with a long history of near-daily or daily headaches it may be more realistic to aim to reduce the intensity of daily pain, restore the patient’s ability to function, and to provide an effective strategy for acute management of severe headaches.

References:
1. Dowson AJ, Dodick DW, Limmroth V. Medication overuse headache in patients with primary headache disorders: epidemiology, management and pathogenesis. CNS Drugs 2003 (in press).
2. Headache Classification Subcommittee of the International Headache Society. The International classification of headache disorders, 2nd ed. Cephalalgia 2004;24(suppl 1):1-160.

Sources:
Gladstone J, Eross E, Dodick DW. Chronic daily headache: a rational approach to a challenging problem. Semin Neurol 2003;265-276.
American Family Physican - Rebound Headache.
Title: Re: Medication Overuse Headache
Post by icedragon on May 22nd, 2008, 9:47pm
There may be some truth to this statement, but I did not see any study info to back it up.  If we are already having trouble with most of the medical world giving proper/correct treatment for CH as it is what are we to do with this?  I see this as being something to create more problems for us clusterheads...  Wait until the insurance companys that already try to limit our meds, find out about this.  Scary!!!
Title: Re: Medication Overuse Headache
Post by DennisM1045 on May 22nd, 2008, 10:26pm
Thanks again Bob.

-Dennis-
Title: Re: Medication Overuse Headache
Post by cluster on May 23rd, 2008, 3:07am

on 05/21/08 at 14:13:24, Bob_Johnson wrote:



Quote:
Curr Pain Headache Rep. 2008 Apr;12(2):122-7.
...
Patients with CH, especially those with a personal and/or family history of migraine, must be carefully monitored for MOH, and medication withdrawal should be considered if a CH patient presents with features of MOH.

PMID: 18474192 [PubMed]


Bob,

According to what I've read about this so far I  think this migraine bit is the issue. MOH headache does scarcely seem to happen in clusterheads who do not have migraines, or migraine in the family.

In this study about 1/3 of the cluster headache patients had migraines or migraine in the family:
Bahra A, May A, Goadsby PJ.: Cluster headache: a prospective clinical study in 230 patients with diagnostic implications. Neurology. 2002; 58(3): 354–361. PMID 11839832. Abstract: http://www.neurology.org/cgi/content/abstract/58/3/354

The original study from Pameleire et al. about Medication-overuse headache in patients with cluster headache was published 2006:


Quote:
Neurology. 2006 Jul 11;67(1):109-13.

Medication-overuse headache in patients with cluster headache.

Paemeleire K, Bahra A, Evers S, Matharu MS, Goadsby PJ.

Headache Group, Institute of Neurology, Queen Square, London, UK.

OBJECTIVE: Medication-overuse headache (MOH) in cluster headache (CH) patients is incompletely described, perhaps because of the relatively low prevalence of CH. METHODS: The authors describe a retrospective series of 17 patients (13 men, 4 women) with CH who developed MOH in association with overuse of a wide range of monotherapies or varying combinations of simple analgesics (n = 9), caffeine (n = 1), opioids (n = 10), ergotamine (n = 3), and triptans (n = 14). The series includes both episodic (n = 7) and chronic (n = 10) CH patients.

RESULTS: A specific triptan-overuse headache diagnosis was made in 3 patients, an opioid-overuse headache diagnosis was made in 1 patient, and an ergotamine-overuse headache diagnosis was made in 1 patient. In approximately half of the patients (n = 8), the MOH phenotype was a bilateral, dull, and featureless daily headache. In the other 9 patients, the MOH was characterized by at least one associated feature, most commonly nausea (n = 6), exacerbation with head movement (n = 5), or throbbing character of the pain (n = 5). The common denominator in 15 patients was a personal or family history, or both, of migraine. The 2 other patients gave a family history of unspecified headaches. Medication withdrawal was attempted and successful in 13 patients.

CONCLUSIONS: Medication-overuse headache is a previously underrecognized and treatable problem associated with cluster headache (CH). CH patients should be carefully monitored, especially those with a personal or family history of migraine.

PMID: 16832088 [PubMed - indexed for MEDLINE]
Source: http://www.ncbi.nlm.nih.gov/pubmed/16832088?dopt=Abstract

Neurology(r) Data supplement (free): http://www.neurology.org/cgi/content/full/67/1/109/DC1



pf wishes,
Friedrich


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