In patients with chronic migraine and medication overuse (CM-MO), individuals who frequently relapse into overuse following withdrawal have a worse clinical and psychological profile than patients who relapse less frequently, according to a study published in Neurological Sciences.1
Patients with migraine who experience at least 15 headache days per month for more than 3 months and overuse their headache medications are considered CM-MO.2 For the estimated 14% of patients with migraine who meet these criteria, treatment “requires withdrawal of overused drugs, prescription of prophylaxis, and education to prevent relapses, and is successful when at one year headaches frequency is reduced by 50% or more,” according to the investigators in the new study.3
Previous findings suggest that a subgroup of patients may be more at risk of relapsing into CM-MO after successful withdrawal, with relapse rates of up to 41% in the first year.4 The current study aimed to examine features specific to these patients that differentiate them from other CM-MO patients. Of the total sample of 188 patients (82% female), 30.8% were frequent relapsers requiring 2 or more structured withdrawals within a 3-year period.
Compared with non-frequent relapsers, these patients were more likely to receive inpatient treatment (+18%; P =.021), to live alone (+12%; P =.023), have a lower education level (+17%; P =.027), have greater headache frequency in the past 3 months (+16%; P =.01), have higher headache-related pain intensity on a 0 to10 scale (+8%; P =.006), have lower scores on the Migraine-Specific Quality of Life Questionnaire (–24% overall; for role restriction, P =.002; for role prevention, P <.001; for emotional functioning, P =.005); and higher scores on both the World Health Organization (WHO)-Disability Assessment Schedule (WHODAS 2.0; +20%; P =.005), and the Beck Depression Inventory (BDI-II; +27%; P =.005). No differences were observed between groups based on the type of overused medication (triptans vs non-triptans, alone or in combination).
Earlier studies have linked medication overuse with reversible modifications of the pain network (ie, in the right supramarginal gyrus and the right inferior and superior parietal cortex), while others indicate a potential role of altered tyrosine metabolism – affecting dopamine and norepinephrine levels – in the development of CM-MO.5-7 “It would be of interest to evaluate whether there are differences in pain networks, through neuroimaging and tyrosine metabolism studies, between [frequent relapsers] and those patients in which MO is ‘occasional,’” which may ultimately result in new treatment options, noted the researchers.
These findings suggest the need for more rigorous follow-up monitoring in CM-MO patients who are frequent relapsers. “Clinicians should be aware of the utility of assessing whether CM-MO patients submitted to withdrawal recently underwent similar procedures: their specific psychosocial and clinical features should be assessed in planning post-withdrawal clinical follow-up,” the researchers concluded.
Summary and Clinical Applicability
In patients with chronic migraine with medication overuse, frequent relapsers were characterized by a worse clinical and psychosocial profile compared with non-frequent relapsers, and these features should be considered during treatment planning for post-withdrawal care.
Because all patients in the sample had medication overuse and high headache frequency and mood impairment, the results may not be generalizable to lower-complexity cases.
- Raggi A, Grazzi L, Ayadi R, et al. Clinical and psychosocial features of frequent relapsers (FR) among patients with chronic migraine and medication overuse. Neurol Sci. 2017;38(Suppl 1):169-171. doi:10.1007/s10072-017-2894-9
- Bigal ME, Lipton RB. Migraine chronification. Curr Neurol Neurosci Rep. 2011;11(2):139-148. doi:10.1007/s11910-010-0175-6
- Evers S, Jensen R. Treatment of medication overuse headache–guideline of the EFNS headache panel. Eur J Neurol. 2011;18(9):1115-1121. doi:10.1111/j.1468-1331.2011.03497.x
- Katsarava Z, Muessig M, Dzagnidze A, et al. Medication overuse headache: rates and predictors for relapse in a 4-year prospective study. Cephalalgia. 2005;25(1):12-15. doi:10.1111/j.1468-2982.2004.00789.x
- Grazzi L, Chiapparini L, Ferraro S, et al. Chronic migraine with medication overuse pre-post withdrawal of symptomatic medication: clinical results and FMRI correlations. Headache. 2010;50(6):998-1004. doi:10.1111/j.1526-4610.2010.01695.x
- Ferraro S, Grazzi L, Mandelli ML, et al. Pain processing in medication overuse headache: a functional magnetic resonance imaging (fMRI) study. Pain Med. 2012;13(2):255-162. doi:10.1111/j.1526-4637.2011.01183.x
- D’Andrea G, Cevoli S, Colavito D, et al. Biochemistry of primary headaches: role of tyrosine and tryptophan metabolism. Neurol Sci. 2015;36(Suppl 1):17-22. doi:10.1007/s10072-015-2131-3