Published on January 9, 2014
Medication-overuse headache Daniel Vela-Duarte, MD PGY-3. Department of Neurology Loyola University Medical Center August 2013
Definition MOH (Medication-Overuse headache) Secondary chronic daily headache Headache induced by the overuse of analgesics, triptans or other acute headache compounds, ocurring 15 days/month, 4hrs/day, per 3 months or more. Repeated medication reaches a threshold causing transformation (chronification)
Introduction / Epidemiology Higher preponderance in woman In a study on episodic migraineurs (n=532), the 1-year incidence of chronic headache was 14%, with a higher risk for patients who had a higher headache frequency at baseline and for patients taking greater amounts of analgesics. Ergotamine, analgesics, barbiturates and caffeine Poorer quality of life (Measured by scales: higher score on MIDAS: Migraine disability assessment scale)
Clinical manifestations Criteria established by the International Headache Society (IHS) in 2005 The primary headache disorder leading to MOH is migraine in most cases. MOH mainly occurs in patients with a primary headache disorder Comorbidities Subclinical obsessive-compulsive disorder Anxiety - Mood disorders Type of medications overused.
Symptoms Circadian periodicity Patients may be awakened from sleep or have onset upon arising Neck pain / Cervicogenic pain. Rhinorrhea, nasal stuffiness, postnasal drip, and ocular or gastrointestinal symptoms, likely caused by withdrawal and most evident in opioid rebound. Nonrestorative sleep disturbance
Diagnostic criteria Lancet Neurol 2010 Apr; 9(4): 391-401.
Diagnostic criteria There is no certainty whether combined drugs are more likely to cause MOH or not, compared to single substances. The headache features of MOH caused by ergotamine derivatives are more severe than those caused by triptans. Overuse of ergotamine + analgesics: daily tension-type-like headache, Overuse of triptans: (daily) migraine-like headache or an increase in migraine frequency
Withdrawal treatment Detoxification process Improve responsiveness to acute and prophylactic drugs Abrupt discontinuation vs. tapered withdrawal Main symptoms of withdrawal worsening of the headache nausea, vomiting arterial hypotension, tachycardia sleep disturbances restlessness, anxiety, nervousness
Withdrawal treatment Inpatient vs. Outpatient Overuse of opioids, barbiturates, or benzodiazepines psychological problems severe medical comorbidities severe withdrawal symptoms (eg, vomiting and status migrainous) previous medication withdrawal failure
Tepper SJ, Continuum (Minneap Minn). 2012 Aug;18(4):807-22.
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