Monday, July 16, 2012

Factors for Migraine Chronification: Medication Overuse Headache

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I recently introduced a series about factors that may cause episodic migraines to become chronic. Today I'm breaking down one of those factors, Medication Overuse Headache, in more detail.

Medication Overuse Headache (MOH) may be one factor that contributes to the progression of episodic migraine to chronic migraine. 

According to the International Headache Society Classification ICHD-II, MOH is characterized by regular "overuse" of acute treatment medications for more than 3 months when the patient's headaches have worsened during that time period and improve or return to their previous pattern after the overused medication is discontinued. To constitute overuse the patient must be using the medication frequently and regularly (i.e. a few times a week). When a patient takes acute medication a few days in a row, then doesn't consume any for a lengthy period, he/she is much less likely to experience MOH. 

Headaches in patients experiencing MOH often shift from migraine-like qualities to tension-type qualities. MOH can occur in headache-prone patients who are taking these medications for other purposes, such as arthritis or back pain and is not observed in patients who are not headache prone.

Studies seem to differentiate between the effect of overuse of barbiturates and opioids versus triptans. Overuse of triptans has not been observed as a risk factor for chronification, while overuse of barbiturates and opioids has. However, long-acting opioids seem to be less likely to result in medication overuse headache and may be a better option for some patients than short-acting opioids.

A lingering question related to the chronification issue is whether MOH is a cause or consequence of chronic migraine. We do know that overuse of acute medications can make a patient's migraine disease worse, but it is also true that a patient experiencing more than 15 migraine attacks per month is likely to be using more doses of treatment medication than a patient with fewer attacks. Studies on the subject have clearly demonstrated that some patients do not improve after stopping the overused medication. It may be that it varies by individual, which would require treatment providers to assess individuals on a case-by-case basis and proceed accordingly with an individualized treatment plan.

Though only marginally related to this discussion of chronicification, it is important to be aware that patients are unlikely to respond to preventive therapies if they are experiencing MOH. So even though we are currently not clear on the relationship between MOH and chronification, it is important to avoid over treating migraine attacks with acute medications in order to give a trial of a preventive medication a fair shot.

Finally, Dr. Larry Robbins notes in an article about chronic migraine that use of opioids, triptans and Botox improved the quality of life for a majority of chronic migraine patients included in that study. This is an important consideration because while we want to try to prevent chronification of migraine, once patients are dealing with chronic migraine they need a full arsenal of tools at their disposal to aid in coping and improve their daily functioning as much as possible. Medication is only one part of this set of tools, however. Behavioral pain management provides additional resources for patients living with chronic migraine.

Related Posts: 

1. Bigal, Marcelo E. and Lipton, Richard B. "Modifiable Risk Factors for Migraine Progression." Headache 2006; 46: 1334–1343. 2. Katsarava, Zaza; Buse, Dawn C.; Manack, Aubrey N.; and Lipton, Richard B. "Defining the Differences Between Episodic Migraine and Chronic Migraine." Current Pain and Headache Reports 2012; 16(1): 86–92. 3. Lipton, Richard B., "Tracing transformation: chronic migraine classification, progression, and epidemiology." Neurology 2009; 72: S3-7. 4. Robbins, Lawrence. "Refractory chronic migraine: long-term follow-up using a refractory rating scale." Journal of Headache Pain 2012; 13:225–229.

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DISCLAIMER: Nothing on this site constitutes medical or legal advice. I am a patient who is engaged and educated and enjoys sharing my experiences and news about migraines, pain and depression. Please consult your own health care providers for advice on your unique situation.