Preliminary results of a withdrawal and detoxification therapeutic regimen in patients with probable chronic migraine and probable medication overuse headache

Abstract

Chronic migraine (CM) is an invalidating condition affecting a significant population of headache sufferers, frequently associated with medication overuse headache (MOH). Controlled trials and guidelines for the treatment of MOH are currently not available. We studied the efficacy of a therapeutic regimen for the withdrawal of the overused drug and detoxification in a sample of patients suffering from probable CM and probable MOH during admission in eight hospitals of Piemonte–Liguria–Valle d’Aosta. Fifty patients, 42 females (84%) and 8 males (16%), mean age at observation 50.66±13.08 years, affected by probable CM and daily medication overuse following IHS diagnostic criteria were treated as inpatients or in a day hospital. Headache index (HI) and daily drug intake (DDI) were used for evaluating the severity of headache and medication overuse. The patients were treated by abrupt discontinuation of the overused drug and by a therapeutic protocol including i.v. hydration, dexamethasone, metoclopramide and benzodiazepines for 7–10 days. Prophylactic medication was started immediately after admission. Analgesics or triptans were used under medical control only in cases of severe rebound headache. Diagnostic protocol included routine blood tests (at admission and at discharge), dosage of B12 and folic acid. Patients underwent follow-up controls one, three and six months after discharge. The initial diagnosis was probable CM in almost all patients included in the study (41 patients); in nine patients the diagnosis was not specified (coded only as CDH). The overused medications were simple analgesics in 17 cases (34%), combination analgesics in 19 cases (38%), triptans alone or with analgesics in 13 cases (26%) and ergotamine in 2 cases (4%). We collected data from 39 patients at first follow–up (1 month), 32 after 3 months and 14 after 6 months. Mean HI was 0.91 at admission, 0.22 at discharge, 0.38 after 30 days, 0.46 after 3 months and 0.48 after 6 months. Mean DDI was 2.80 at admission, 0.39 at discharge, 0.41 after 1 month, 0.52 after 3 months and 0.59 after 6 months. These results are on average positive and tend to remain stable with time. Although preliminary and obtained on a limited number of patients at 6–month follow–up, our results seem to be encouraging about the use of the proposed therapeutic protocol.

Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta‐analysis and Systematic Review of the Literature

“…These studies indicate that approximately 90% of admitted hospital patients receiving dexamethasone in addition to standard antimigraine medications achieve headache resolution. 13,19 Comparable results were seen with the addition of dexamethasone to standard headache therapies Potentially enrolled nonmigraine headache patients DB = double-blind; DHE = dihydroergotamine; IV = intravenous; PC = placebo controlled; PO = by mouth; PRCT = prospective, randomized, controlled trial; RR = risk ratio.…”

“…9,10 Uncontrolled clinical trials have shown that, in both the inpatient setting and the outpatient clinic setting, dexamethasone is highly effective in reducing the severity of migraine headache and the rate of headache recurrence. [11][12][13][14][15][16][17][18][19] Although initial controlled clinical trials demonstrated the same high-level of efficacy, [20][21][22][23][24][25][26] the results of several recent ED-based trials have questioned the utility of dexamethasone for this purpose. [27][28][29][30][31][32][33][34][35][36][37][38][39][40] The goals of this systematic review were to critically appraise the existing literature and to provide recommendations for patient care regarding the use of dexamethasone for the prevention of headache relapse in patients with acute migraine headache in the ED.…”

Evidence‐Based Understanding of Medication‐Overuse Headache: Clinical Implications

“…Clinical observations support the concept of medication‐overuse headache. Among patients with chronic daily headache, a subset will experience significant improvement of their headache intensity and frequency once they discontinue their use of certain simple analgesics and symptomatic medications 27,36 . Clinicians have also observed that the continuous use of some antimigraine medications renders some patients less responsive to other acute and preventive migraine therapies.…”

Cefaleia Por Uso Excessivo De Medicamentos

“…Alguns autores sugerem que o tratamento profilático só deve ter início se o processo de desintoxicação não for resolvido (46,47), uma vez que profilaxia sem desintoxicação implica maior recorrência da CEM (16). No entanto, Diener (2011) não apoia um "agressivo" programa de desintoxicação como primeiro passo para todos os pacientes com evidência de CEM, antes da medicação preventiva, pois este pode ser inviável e desconfortável para muitos, além de causar ansiedade injustificada (39).…”