Medication overuse headache: withdrawal plus preventive treatment works best

  • Carlsen LN & al.
  • JAMA Neurol
  • 26.05.2020

  • von Susan London
  • Clinical Essentials
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Takeaway

  • Three treatment strategies similarly reduced headache days in patients with medication overuse headache, but combined withdrawal and preventive treatment netted the highest cure rate.

Why this matters

  • Medication overuse headache is prevalent, costly, and disabling.

Key results

  • At 6 months, reduction in headache days per month (95% CIs) did not differ by treatment strategy (P=.20):
    • 12.3 (9.3-15.3) with withdrawal plus prevention.
    • 9.9 (7.2-12.6) with prevention.
    • 8.5 (5.6-11.5) with withdrawal plus optional prevention.
  • Rate of reversion to episodic headache (P=.03):
    • 74.2% with withdrawal plus prevention.
    • 60.0% with prevention.
    • 41.7% with withdrawal plus optional prevention.
  • Rate of cure (P=.03):
    • 96.8% with withdrawal plus prevention.
    • 74.3% with prevention alone.
    • 88.9% with withdrawal plus optional prevention.
  • Likelihood of cure was 30% higher with withdrawal plus prevention vs prevention (relative risk, 1.3; 95% CI, 1.1-1.6).

Study design

  • Danish population-based randomized controlled trial (DEFINE3 trial).
  • 120 patients with medication overuse headache (migraine and/or tension-type headache).
  • Randomization:
    • Withdrawal plus preventive treatment from start.
    • Preventive treatment only.
    • Withdrawal plus optional delayed preventive treatment.
  • Main outcome: change in headache days per month.
  • Funding: TrygFonden.

Limitations

  • Majority of patients overused only simple analgesics.
  • Inability to achieve blinding.
  • Patients with complexity were excluded.