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Views & Reviews
August 18, 2017
Letter to the Editor

Medication overuse headache
An entrenched idea in need of scrutiny

September 19, 2017 issue
89 (12) 1296-1304

Abstract

It is a widely accepted idea that medications taken to relieve acute headache pain can paradoxically worsen headache if used too often. This type of secondary headache is referred to as medication overuse headache (MOH); previously used terms include rebound headache and drug-induced headache. In the absence of consensus about the duration of use, amount, and type of medication needed to cause MOH, the default position is conservative. A common recommendation is to limit treatment to no more than 10 or 15 days per month (depending on medication type) to prevent headache frequency progression. Medication withdrawal is often recommended as a first step in treatment of patients with very frequent headaches. Existing evidence, however, does not provide a strong basis for such causal claims about the relationship between medication use and frequent headache. Observational studies linking treatment patterns with headache frequency are by their nature confounded by indication. Medication withdrawal studies have mostly been uncontrolled and often have high dropout rates. Evaluation of this evidence suggests that only a minority of patients required to limit the use of symptomatic medication may benefit from treatment limitation. Similarly, only a minority of patients deemed to be overusing medications may benefit from withdrawal. These findings raise serious questions about the value of withholding or withdrawing symptom-relieving medications from people with frequent headaches solely to prevent or treat MOH. The benefits of doing so are smaller, and the harms larger, than currently recognized. The concept of MOH should be viewed with more skepticism. Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication. Frequent use of symptom-relieving headache medications should be viewed more neutrally, as an indicator of poorly controlled headaches, and not invariably a cause.

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Letters to the Editor
6 September 2017
Medication overuse headache: The brink of ignorance and untenable practices
Vinod K. Gupta, Physician / Director

I read with interest the Views & Reviews article by Scher et al. which questions the concept and treatment of medication overuse headache (MOH). [1] In 2006, I made a passionate appeal to revise concepts of MOH as well as its hopelessly inapprorpiate management strategy. [2] Now, the genie is fully out of the bottle, but it still may be many decades before we reach the right template for managing patients with MOH symptoms. Little headway will be made until we learn more about migraine itself.

To begin grasping the fundamentals of migraine, without the influence from neuronal and vascular theories of the past 100 years, I suggest reading my book, "Adaptive Mechanisms in Migraine: A Comprehensive Synthesis in Evolution - Breaking the Migraine Code." [3] You don't have to believe me. Just put your nose to the book.

1. Scher AI, Rizzoli PB, Loder EW. Medication overuse headache: An entrenched idea in need of scrutiny. Neurology Epub 2017 Aug 18.

2. Gupta VK. Orbitofrontal cortex hypometabolism, medication overuse headache, substance abuse and migraine: key pathophysiological issues. Brain 2006;129:E52.

3. Gupta VK. Adaptive Mechanisms in Migraine: A Comprehensive Synthesis in Evolution - Breaking the Migraine Code. New York: Nova Science Publishers, Inc; 2009.

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 89Number 12September 19, 2017
Pages: 1296-1304
PubMed: 28821684

Publication History

Received: January 24, 2017
Accepted: May 10, 2017
Published online: August 18, 2017
Published in print: September 19, 2017

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Disclosure

A. Scher: consultant/advisory board member for Allergan. P. Rizzoli and E. Loder report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Ann I. Scher, PhD
From the Department of Preventive Medicine and Biostatistics (A.I.S.), Uniformed Services University, Bethesda, MD; and Department of Neurology (P.B.R., E.W.L.), Brigham and Women's Hospital, Boston, MA.
Disclosure
Scientific Advisory Boards:
1.
(1) Commercial entity: Allergan, Inc
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
(1) Associate editor Cephalalgia (2) Associate editor Pain Medicine
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
(1) Commercial entity: Allergan, Inc
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) Defense Medical Research and Development Program, PI, 2011-14 (2) Center for Neuroscience and Regenerative Medicine, PI, 2012-14 (3) Center for Neuroscience and Regenerative Medicine, PI, 2011-13 (4) Military Clinical Neuroscience Center of Excellence, PI, 2015-17 (5) USAMRMC, Co-PI, 2016-18
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Paul B. Rizzoli, MD
From the Department of Preventive Medicine and Biostatistics (A.I.S.), Uniformed Services University, Bethesda, MD; and Department of Neurology (P.B.R., E.W.L.), Brigham and Women's Hospital, Boston, MA.
Disclosure
Scientific Advisory Boards:
1.
2017 Pernix Inc
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
2015 travel and honorarium. Italian Neurologic Assn for Headache Research 2017 travel and honorarium. Italian Neurologic Assn for Headache Research
Editorial Boards:
1.
Headache. Associate Editor 2013-present
Patents:
1.
NONE
Publishing Royalties:
1.
Royalties. Cambridge University Press
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Consulting. Sharecare, Inc
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Axon Optics- Study PI
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
Patient Centered Research Outcomes Institute- Site PI
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Elizabeth W. Loder, MD, MPH
From the Department of Preventive Medicine and Biostatistics (A.I.S.), Uniformed Services University, Bethesda, MD; and Department of Neurology (P.B.R., E.W.L.), Brigham and Women's Hospital, Boston, MA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
American Headache Society and American Migraine Foundation -- non-profit: funding for travel to conduct business, educational and outreach activities for the society. The British Medical Journal, non-profit: funding for travel to conduct business, educational and outreach activities for the journal
Editorial Boards:
1.
The British Medical Journal. Acting head of research September 2014-present; US associate editor 2006- September 2014 Cephalalgia, associate editor, 2003-present Headache, associate editor, 2000-present
Patents:
1.
NONE
Publishing Royalties:
1.
Common Pitfalls in the Evaluation and Management of Headache, Cambridge University Press, 2014-present
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
Harvard Medical School, Milton Fund $40,000 for research not pertaining to this manuscript
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Scher: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Ann Scher: study concept and design, analysis and interpretation, approval of final version. Elizabeth Loder: study concept and design, critical revision of the manuscript for important intellectual content, approval of final version. Paul Rizzoli: critical revision of the manuscript for important intellectual content, approval of final version.

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