Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine, Phoenix, and St. Joseph’s Hospital Family Medicine Residency at Creighton University Arizona Health Education Alliance, Phoenix Allison.Crain@dignityhealth.org
The author reported no potential conflict of interest relevant to this article.
Care of this disorder can be complex—from ruling out another secondary cause of headache to supervising detox from abortives, providing preventives, and educating often-fearful patients.
› Avoid prescribing barbiturates or opioids for a headache disorder. A
› Limit use of a headache-abortive medication to twice a week when starting a patient on the drug. C
› Consider providing bridging therapy during detoxification of the overused medication. C
› Do not provide a preventive medication without withdrawing the overused agent. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
References
Medication overuse headache (MOH), a secondary headache diagnosis, is a prevalent phenomenon that complicates headache diagnosis and treatment, increases the cost of care, and reduces quality of life. Effective abortive medication is essential for the headache sufferer; when an abortive is used too frequently, however, headache frequency increases—potentially beginning a cycle in which the patient then takes more medication to abort the headache. Over time, the patient suffers from an ever-increasing number of headaches, takes even more abortive medication, and so on. In the presence of MOH, there is a reduction in pain response to preventive and abortive treatments; when medication overuse is eliminated, pain response improves.1
Although MOH is well recognized among headache specialists, the condition is often overlooked in primary care. Since headache is a top complaint in primary care, however, and prevention is a major goal in family medicine, the opportunity for you to recognize, treat, and prevent MOH is significant. In fact, a randomized controlled trial showed that brief patient education about headache care and MOH provided by a primary care physician can lead to a significant reduction in headache frequency among patients with MOH.2
Although medication overuse headache is well recognized among headache specialists, the condition is often overlooked in primary care.
This article reviews the recognition and diagnosis of MOH, based on historical features and current criteria; addresses risk factors for abortive medication overuse and how to withdraw an offending agent; and explores the value of bridging and preventive therapies to reduce the overall frequency of headache.
Typically, MOH is a chronification of a primary headache disorder. However, in patients with a history of migraine who are undergoing treatment for another chronic pain condition with an opioid or other analgesic, MOH can be induced.3 An increase in the frequency of headache raises the specter of a concomitant increase in the level of disability4; psychiatric comorbidity5; and more headache days, with time lost from school and work.
The Migraine Disability Assessment (MIDAS) questionnaire, a validated instrument that helps the provider (1) measure the impact that headache has on a patient’s life and (2) follow treatment progress, also provides information to employers and insurance companies on treatment coverage and the need for work modification. The MIDAS score is 3 times higher in patients with MOH than in patients with episodic migraine.6,7
The annual associated cost per person of MOH has been estimated at $4000, resulting in billions of dollars in associated costs8; most of these costs are related to absenteeism and disability. After detoxification for MOH, annual outpatient medication costs are reduced by approximately 24%.9
Efforts to solve a common problem create another
Headache affects nearly 50% of the general population worldwide,10 accounting for about 4% of primary care visits11 and approximately 20% of outpatient neurology consultations.12 Although inpatient stays for headache are approximately half the duration of the overall average hospital stay, headache accounts for 3% of admissions.13 According to the Global Burden of Disease study, tension-type headache, migraine, and MOH are the 3 most common headache disorders.10 Headache is the second leading cause of disability among people 15 to 49 years of age.10
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