By Louise M. Klebanoff, MD
Assistant Professor of Clinical Neurology, Weill Cornell Medical College
Dr. Klebanoff reports no financial relationships relevant to this field of study.
SYNOPSIS: A brief intervention that focuses on patient education can be effective in reducing headache frequency and medication dependency in patients with medication overuse headache.
SOURCE: Kristoffersen ES, et al. Disability, anxiety and depression in patients with medication-overuse headache in primary care — the BIMOH study. Eur J Neurol 2015;23(Suppl 1):28-35.
Medication overuse headache (MOH) affects approximately 50% of patients with chronic headaches (headaches occurring at least 15 days per month), causing significant personal burden and economic costs. The recommended treatment of MOH is withdrawal of the overused medication; however, interventions to accomplish this have varied. Education and simple advice about the relationship of medication overuse and chronic headaches may in and of itself be an effective intervention. This study examined the efficacy of this brief intervention strategy in the primary care setting.
The authors conducted a double-blind, pragmatic, cluster-randomized, controlled trial in a primary care setting in Norway from 2011-2012. They enrolled patients aged 18-50 years with self-reported chronic headaches occurring > 15 days/month and with head-ache medication use > 10 days/month. All patients met International Classifications of Headache Disorders criteria for MOH. Patients were cluster-randomized according to their general practitioners (GPs); the GPs either received training in the brief intervention prior to the study (n = 23, brief intervention [BI] group) or following completion of the study (n = 27, business as usual [BAU] group).
Patients with MOH randomized to the BI group were initially evaluated by their GP using the Severity of Dependence Scale (SDS), an easily administered five-question scale to evaluate drug dependence. Based on their SDS result, patients were given information about their SDS score and personal risk for MOH, the need to cut down on medication use, the expected gains and difficulties to be overcome, and how the withdrawal could be achieved with the GP’s support. The patients discussed the need for rescue medication and/or short-term medical leave with their GP. The GPs did not prescribe medication for headache prophylaxis but left that as an option if the headaches persisted at the 3-month follow-up.
The main outcomes at 3 months were number of headache days/month, number of medication days/month, and change from baseline. Secondary outcomes were disability and psychological problems, as measured by the Migraine Disability Assessment (MIDAS), the Headache Impact Test (HIT-6), and the Hospital Anxiety and Depression Scale (HADS). The BI group had a clear reduction in both headache days and medication days when compared to the BAU group. At the 3-month follow-up, the BI group reported an average of 17.4 (13.2-21.5) headache days/month vs 24.6 (22.6-26.6) in the BAU group. The BI group reported an average of 13.4 (8.8-18.0) medication days/month vs 21.7 (19.2-24.2) in the BAU group. There was no significant difference in the MIDAS or HIT-6 scores between the two groups, although the BI group tended to have lower scores. The mean MIDAS score for all MOH patients was 70.7 (49.1-92.2) consistent with severe disability and significantly higher than patients with chronic headache (average 26.9, range 8.2-45.7) or population controls (average 7.1, range -1.1 to 15.4). There were no significant differences in the anxiety and depression scores between the BI and BAU groups; however, higher anxiety scores were noted in all MOH patients when compared to controls.
The authors concluded that for patients with MOH in a primary care setting, detoxification achieved through a behavioral, non-pharmacological intervention significantly improved headache disability without the use of prophylactic medication.
COMMENTARY
This small study shows that brief intervention, primarily education and physician support, can reduce headache disability in MOH patients in the primary care setting. The intervention is simple and easily administered in the office setting. Patients with MOH are among the most disabled headache patients with significant psychological comorbidity. Although headache and medication days were reduced with the intervention, after 3 months, patients continued to experience frequent headaches and psychological distress. The study supports the importance of detoxification for patients with MOH. However, additional investigation is needed to assess how to further reduce headache days and disability once the patient has completed detoxification. In addition, more aggressive interventions, such as rescue medications, corticosteroids, or early introduction of prophylactic medication need to be evaluated in future studies.
A brief intervention that focuses on patient education can be effective in reducing headache frequency and medication dependency in patients with medication overuse headache.
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