Latest / VJNeurology Podcast / Breaking the Cycle: Debating Management Approaches in Medication Overuse Headache

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Breaking the Cycle: Debating Management Approaches in Medication Overuse Headache · VJNeurology Podcast

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Hello, and welcome to today's VJ Sounds podcast from the Video Journal of Neurology,
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your source for the latest news and breakthroughs in neurology across all major disciplines.
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We are an open access video journal offering exclusive insights from renowned
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experts on hot topics in the field.
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In this episode, we will delve into medication overuse headaches,
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exploring current treatment strategies and discussing ongoing clinical trials.
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Medication overuse headaches typically arise in individuals with existing primary
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headache disorders such as migraine or tension type headaches who overuse the
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medication to relieve their symptoms.
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This cycle of medication overuse leads to more frequent headaches with the very
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medications meant to treat the primary headache now contributing to the problem.
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Management strategies involve of education educating
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the patient implementing effective preventive measures
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discontinuing the overused analgesic and
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providing follow-up care to prevent recurrence throughout the
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episode we will talk to esteemed professors sate ashina morris levin alan rapaport
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and lichia grazi to find out more about the latest breakthroughs in the field
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by reviewing medication overuse
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headaches headaches from all angles and speaking to a range of experts,
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we hope to provide you with a detailed and engaging overview of the disorder.
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Professor Seyit Ashina from Harvard Medical School will start off the conversation,
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explaining further what medication overuse headache is.
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I started my lecture with explaining what the prevalence, one year prevalence
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of medication overuse or chronic daily headache was in the population.
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And I showed that on average worldwide,
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I mean, there is approximately 2.2% of the population who suffers from medication
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overuse and chronic migraine or medication overuse headache.
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So medication overuse headache is a distinct headache condition.
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It's a secondary headache disorder, while the chronic migraine is a primary headache disorder.
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So medication and overuse headache usually develops after the overuse of headache
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abortive medications, which could be triptans, simple analgesics,
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or unfortunately in some cases opioids.
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And the medication overuse just indicates that the patient overuses medications,
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on 10 or more days per month and takes any of those medications.
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While medication overuse a headache is a condition. It's a diagnosis of headache
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occurring on 15 or more days per month and for at least three months with a
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sign of worsening of the headache while the patient has been overusing the medication.
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So, if you look at the headache centers, which are more specific centers for
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management of headaches, there we see a lot of patients coming with medication
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overuse or medication overuse headaches.
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For example, there are studies showing that approximately 50% of patients coming to the U.S.
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Headache centers or tertiary headache centers report medication overuse or have
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medication overuse headache.
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In Argentina, for example, it's up to 70% of patients in specialized headache
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clinics report medication overuse or medication overuse headache.
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Now, if you look at the types of medications overused in a population,
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so we have a study from 2006 by Marcelo Begal and colleagues.
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These are the data from, I think it's from AMPP showing that the most commonly
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used overused drug in a general population is actually acetaminophen or paracetamol,
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followed by non-steroidal anti-inflammatory drugs, called NSAIDs,
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and then combination of analgesics.
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Unfortunately, 11% in the study, which was published in Cephalology in 2008,
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showed to take the opioids were in management of the acute headaches.
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The overuse of triptans was in approximately 18.7% of the population.
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Now if you look at the clinics, so the more specialized centers,
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there we see patients who overuse unfortunately combination of analgesics and
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the most common one in the United States is the betabitol or the brand name
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theuracet and that's a big problem because in that study, particular study from 2004,
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which was also performed by Dr.
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Pagal, it showed that 45% patients in the 90s were overusing betabitol.
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And after 95, they were 48.1%, so not so much big change.
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It's still a big problem.
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There's still a lot of patients overusing this combination The next group was
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acetaminophen followed by opioids, which is very problematic in the United States.
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I recently showed in one of my studies, which I've been involved with,
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it's part of the Overcome study, where up to 20% of patients were reporting
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using opioids for acute treatment,
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in the past year, which is quite alarming given that there are more micro-specific
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and and effective treatments for myocardial infarction.
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Now, we will hear again from Sait Ashina, who will describe the predictors of
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relapse and medication overuse headache.
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So the major issue is when you do the abrupt withdrawals, you can get relapse of the headaches.
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And what are the predictors? So the studies have shown that the relapse rate
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after one year is around 30%, which is quite high.
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And the predictors could be a long duration of migraines before the medication
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overuse headache, a tension type headache as a primary headache,
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high number of previous preventative treatments, intake of combination of analgesics after withdrawal.
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And analgesic withdrawal itself was actually a predictor, just kind of speaks
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again, is use of the strategy.
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And taking the cause of the medication again. So if you use,
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for example, Triptan and if you start to get it back or same Triptan,
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there is a higher risk of relapse.
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Increased frequency of headaches after withdrawal, just in general,
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then there is a high risk of relapse as well.
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Use of codeine-containing drugs, which is opioid-related drugs. Use of ergotamine.
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Interestingly, male, sex, or gender and sleep quality has been associated with MRHF-Labs.
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Next, Morris Levin, MD, University of California, San Francisco,
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provides valuable insights into the management of medication overuse headaches,
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including current strategies and unmet needs?
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Medication overuse headache has been a concept that's been around since around
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the 1980s, probably even earlier.
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It became very popular in the 1980s as a target.
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And the concept, for those of you who don't know about it, is that when patients
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with particularly migraine overuse, overdo acute meds, their headaches get worse.
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They get more headaches, they get worse, they're or unresponsive to preventive
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medications, for example.
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And therefore, the obvious treatment is let's take away the acute medications.
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The problem is as soon as we do that, headaches get worse. People aren't happy.
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They're not comfortable.
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And so all sorts of strategies have come up about what to do about the difficulty
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in getting people to stop these offending acute medications.
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And unfortunately, the data really don't help us that much. There are some data
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for sure. And there's some good studies that have been done and attempted.
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But the simple answer is we don't exactly know the best way to detoxify or treat
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medication over use headache.
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And I have a theory about one of the main reasons why that is.
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And my theory is that there's not just one kind of medication overuse headache.
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There are many, depending on the medication that's causing the medication overuse headache.
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And the person. There are people who probably can take plenty of acute medications
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and not fall into this vicious cycle.
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Other people, they take a minor analgesic more than a couple of days a week,
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and they're locked into this medication overuse headache.
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So, I think we'll probably learn more about it when we learn,
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or we'll learn more about the best treatment for MOH when we learn about the
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causes of MOH, which we really don't fully understand yet.
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I think we have enough evidence and also experience, just clinical experience,
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to say that when people seem to be in medication overuse headache,
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they do need not just detoxification,
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they need a good preventive medication.
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And we're kind of lucky here because the new groups of preventive medications.
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Which are the CGRP monoclonal antibodies and the small molecule CGRP antagonists,
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they seem to be useful even when the acute medications are not discontinued
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or when acute medications can be switched to different acute medications.
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That may not be true. That seems not to be true with other preventive meds.
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So we're kind of lucky. This is a good time to be treating patients with medication
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overuse headache and you know, we have more and more options I think as the
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years go by and I'm talking about maybe the five year period,
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we're going to have even better options.
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Alan Rappaport, M.D., University of California, Los Angeles,
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will continue the discussion, delving into the debate about whether detoxification
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is necessary, drawing on his extensive experiences and the evolving literature.
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For many years, about 40 that I'm aware of, we've been treating this very difficult
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problem, medication overuse headache, with three different directives.
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First, we have to explain lean to the patient exactly what's going on because
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most patients think when they have a headache, they should take something for
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the pain or for the headache or for the other symptoms.
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And if they have more problems, they take more.
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They don't realize that if they take it too frequently, that is five days a
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week instead of one or two days a week, they'll actually get worse and it's
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harder to get them better.
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But when you say that to a patient, they get very nervous because they're dependent
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on this medication, even though they're still not feeling well.
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So the way we've always done it, we educate them, we detoxify them by telling
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them to stop the medication that they're overusing, either abruptly,
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which is what most people do, or gradually, which is what I used to do,
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and then just put them on a very good preventive medicine,
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something they take on a regular basis to decrease their headache.
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Up until a few years ago, we didn't have great preventive medicine,
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so it didn't always work that well.
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So it was the most difficult thing that I've done in my neurologic career was
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to try to treat these people because I didn't have great medicines and I was
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taking them off their crutch.
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Now we have medications that are preventives that are a little bit better.
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We have two groups of them.
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One is an injectable called a monoclonal antibody against calcitonin gene-related peptide, or CGRP.
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And more recently, just since about 19, I'm sorry, 2020,
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we start to have two GPANS,
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which which also work against CGRP, but they're much shorter acting and they're
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usually used for acute care of migraine, but there are two forms of them that
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can be used preventively also.
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So my feeling is when I give somebody one of these long acting monoclonal antibodies.
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Even though they're still on the medication that they should be coming off,
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they start getting better right away.
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So I no longer have to really intentionally detoxify them.
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So I simply say to them, I'm going to give you this medication.
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It's probably going to start decreasing your headaches a bit.
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And I don't want you to take as much of the medication that you you're overusing,
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but you use it as you need to.
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But remember, if it's a milder headache than you're used to,
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don't take it because ultimately I want you to either get off these medicines
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completely or just get them down to one or two days a week.
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The other side of the debate is you still have to detoxify them because you
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want them to come off the medication.
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And it's clearly the wrong way because it's much easier not to fight with the
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patient and fight with yourself to detoxify them.
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And that's what I'm finding I'm able to do.
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So it's an important debate because I'm going to show the literature of what
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the most important people in the world have said about this and they say you
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must detoxify them and you have to do it abruptly.
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I never do it abruptly and I certainly don't have to do it now.
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So it's a very interesting debate and I think people will learn that my way
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may be a better way and that will spread around the world. That's what I'm hoping.
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Up until recently, the literature definitely was against what I just said,
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because it didn't really include these brand new medications that we have.
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The latest literature, which I'm going to be showing, is a little incomplete.
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It's not exactly what we need, but it shows that even without detoxification,
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the patients get better.
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And it It shows that when you treat somebody with medication overuse,
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they do at least as well as people that don't have medication overuse and actually somewhat better.
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So when I put all that literature together with my own personal experience,
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I know that it's not necessary to formally detoxify these patients.
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Alan Rappaport also emphasises the importance of the follow-up care required
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to have successful migraine treatment and advocates for patients to meticulously
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track their medication use.
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If you do everything right for the patient,
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but say goodbye, it was nice knowing you, and they go off on their own and maybe
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get their own doctor to prescribe the medication that's working on them,
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but they don't really see a headache specialist after that,
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they're likely to kind of drift back into trouble again because things might
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not go that well and they'll pick up the same medicine that they overused before
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and ultimately overuse that.
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Or they might go to another medicine, but possibly overuse that.
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So if it's a patient that I'm taking care of, I say to them,
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I want you to keep a very accurate record of how much of which medicines you're taking,
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how often you have a headache, what type of headache is it.
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Today, we use an app, an electronic calendar as opposed to a paper calendar,
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but a paper would be okay.
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It's just that the patient has to record all of this.
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So when they come back to see me in a month or two months, I can look at with them what has happened.
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Because if they go away and come back to me in a month and I say,
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how are you doing? They say, well, I think I'm better.
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So how many headaches have you had? And they try to remember, and they can't.
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And how many of those pills that I told you it would be better not to take so
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much of, how many are you taking?
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And they don't really know. It's kind of garbage in and garbage out,
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and I can't really figure out what's going on.
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So follow-up with good information from the patient that has been recorded is
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really essential in these patients.
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Next, Licia Grazzi, MD, offers fascinating insights into the use of mindfulness
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in headache disorders, sharing preliminary findings from a phase three trial
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on mindfulness added to regular treatments.
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The mindfulness practice has been used in the last decades to help patients
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to manage chronic pain conditions and migraine too.
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There are several reports in the recent literature that demonstrate that mindfulness
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practice can be very helpful for patients to be more conscious about their clinical condition,
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to use at the best the medication that we give them.
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So, we started this kind of project with 170 patients with chronic migraine
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and medication overuse, and we randomized these patients after a withdrawal.
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On one side, we treated patients just with traditional pharmacological compounds,
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because at that time, in 2018, we didn't have MAPS.
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On the other side, we treated patients with pharmacological treatment added by mindfulness.
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And what we found after one year of follow-up
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is that patients who have been treated with pharmacological treatment and mindfulness
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are going much better because they can manage their pain more adequately by using the practice.
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So in our opinion, this is an important because we can give patients some tools to manage the pain.
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And in this way, even if we have fantastic molecules that are new for the treatment
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of of a migrant, we can improve much more the efficacy of these molecules.
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And at the same time, to give patients instruments for being more responsible,
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and more cautious about their clinical condition,
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and this can be important because there are some implications for social costs,
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sanitary costs, health system costs, so in direct costs and indirect costs that
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are connected to the chronic migraine condition.
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So we will see the last results of this project and we hope to have good data to publish in.
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That's all from us today. Thank you so much for listening.
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