Predicting Outcomes of Detoxification for Medication-Overuse Headache

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Greater depressive symptomatology and longer chronic headache duration may predict negative outcomes of detoxification treatment for medication-overuse headache.

Greater depressive symptomatology and longer chronic headache duration may predict negative outcomes of detoxification treatment for medication-overuse headache (MOH), according to a study published in Cephalalgia.

Because MOH is a frequent complication in individuals treated for recurrent headaches, investigators sought to determine the impact of a set of psychological, clinical, and therapeutic variables on patients who have undergone detoxification. Evaluating the positive or negative effects during withdrawal of migraine disability, quality of life, and psychiatric comorbidities before detoxification is critical for identifying at-risk individuals.

A total of 492 patients from 6 centers who completed 6 months’ follow-up were considered in this post-hoc analysis. All participants underwent detoxification and withdrawal and were assessed at baseline, 2, and 6 months. Study participants completed the Hospital Anxiety and Depression Scale (HADS), Migraine Disability Assessment (MIDAS), and World Health Organization QoL (WHOQoL) index questionnaires.

Six months posttreatment, patients were categorized as overusers (n=85; mean age, 41.7 years; 85% women) or non-overusers (n=407; mean age, 40.2 years; 78% women). In the “overuser” category, patients were further divided into those who never ceased overuse (n=62) and patients who initially ceased overuse but relapsed by 6 months (n=23). Non-overusers were divided into responders (n=287) for whom headaches had shifted from chronic to episodic (<15 days/month), and partial responders (n=120), for whom headaches remained chronic. Non-overusers were further divided into those who achieved ≥50% headache-free days per month (n=290) and ≥75% headache-free days per month (n=132; optimal responders).

After multivariate analysis, lower HADS scores were found to be associated with overuse cessation (OR 0.891; P =.001). Response to treatment was found to be predicted by the type of headaches study participants were experiencing (tension-type headache: OR 0.224; P =.001; migraine plus tension-type headache: OR 0.467; P =.002), as well as by treatment with flunarizine (OR 0.891; P =.001). Relapse was found to be predicted by longer chronic headache duration (OR 1.053; P =.032). Neither WHOQoL scores nor disability assessed with the MIDAS questionnaire were found to be strongly related to any of the endpoints.

Study strengths included a large and well-characterized sample, a homogeneous population, lack of severe psychiatric diagnoses, and study participants who were naive to withdrawal procedures.

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Study limitations included the use of the HADS questionnaire to assess depression and anxiety, the possibility that the sample was not representative of the entire MOH population, and the exclusion of severe psychiatric conditions and patients who had previously undergone detoxification for MOH.

“All together, these findings suggest the importance of treating these patients as early as possible in order to overcome medication overuse more easily,” noted the authors. They recommended that future studies attempt to replicate their findings and include the full range of psychiatric illnesses. Clinicians should fully profile their patients accordingly in order to facilitate optimal management of patients with MOH.


The authors disclosed receipt of the following financial sup- port for the research, authorship, and/or publication of this article: This work was supported by the COMOESTAS Project – EC contract number 215366 (COMOESTAS) FP7 – Thematic priority ICT and by a grant from the Italian Ministry of Health to the National Neurological Institute C. Mondino, 2013-2015.

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Bottiroli S, Allena M, Sances G, et al. Psychological, clinical, and therapeutic predictors of the outcome of detoxification in a large clinical population of medication-overuse headache: a six-month follow-up of the COMOESTAS ProjectCephalalgia. 2018:1-13.