Three strategies are effective in managing patients with medication overuse headaches

Référence

Carlsen LN, Munksgaard SB, Nielsen M, et al. Comparison of 3 treatment strategies for medication overuse headache: a randomized clinical trial. JAMA Neurol 2020;77(9):1069-1078.

Sommaire

This study was fundamentally aimed at determining if detoxification is needed in patients with medication overuse headaches by comparing 3 outpatient strategies: detoxification plus pharmacologic prophylaxis, pharmacologic prophylaxis without withdrawal, and detoxification with pharmacologic preventive therapy delayed for 2 months. The authors report that the pharmacologic prophylactic therapy was at the discretion of the treating physician and that monoclonal antibody therapy was not available. They report the following prophylactic agents were ultimately used: metoprolol, Lisinopril, candesartan, topiramate, amitriptyline, mirtazapine, and onabotulinumtoxinA. All patients also had access to rescue antiemetic therapy during withdrawal. Forty patients with medication overuse headaches were randomized to receive each strategy (N =120); after 6 months, between 10% and 22.5% dropped out of each arm (overall drop-out rate was 15%). More than 20% dropouts is worrisome. Although the presentation of their data is confusing, the authors report that medication overuse headaches were cured in 97% of those completing the detox plus pharmacologic prophylaxis strategy compared with 74% of those completing the pharmacologic preventive strategy and 89% of those completing the detox strategy. They also observed no significant differences in the number of headache days, in the subsequent use of short-term analgesics, or in headache severity. Each strategy appeared to be highly effective, but the unmasked design, "loose" medication management, and spotty drop-out rates raise some concerns about the data. Finally, the authors plan additional follow-up at 12 months and at 4 years.