PracticeUpdate Neurology Best of 2018

EDITOR’S PICKS 13

Complete Detoxification Is the Most Effective Treatment of Medication-Overuse Headache Cephalalgia: An International Journal of Headache Take-home message • Medication-overuse headache is a common problem encountered in practice. With the dilemma of chronic opioid use becoming a focus of national attention, effective methods of treating medication-overuse headache are important to discuss. The authors of this study argue that there is lack of evidence on how to detoxify patients with medication-overuse headaches, and thus they conducted a prospective, outpatient randomized, controlled trial with two detoxification programs. In program A, patients had no analgesics or acute migraine medications, and, in program B, those drugs were restricted to 2 days a week. If preventive medication was needed, it was prescribed. The percentage reduction of headache days per month after 6 months was the primary outcome. In all, 59 patients of the 72 patients enrolled with a primary headache disorder eventually completed the detoxification. Interestingly, results show that the reduction in headache days/month was superior in the patients in group A at 46% (95% CI, 34–58) compared with 22% (95% CI, 11–34) in the patients in program-B (P =. 005). In addition, as expected, the reduction in daily headaches had an impact on migraine days/month, which were reduced by 7.2 in patients in program A (P < .001) and 3.6 in patients in program B (P < .002) after 6 months. • While these results should be used with caution and practitioners should establish safety of withdrawal from different types of analgesics used by patients, they are very encouraging, showing that detoxification for medication-overuse headaches works and that complete detoxification is more effective. This provides some management guidance when approaching care of these patients. Omar Khan MD Abstract BACKGROUND There is lack of evidence on how to detoxify medication-overuse headache. AIM To compare the effect of complete stop of acute medication with restricted intake. headache days/month after 6 months was the primary outcome. 3.6 in program B (p=0.002) after 6 months. CONCLUSION Both detoxification programs were very effective. Detoxification without analge- sics or acute migraine-medication was the most effective program.

RESULTS We included 72 medication-overuse headache patients with a primary migraine and/ or tension-type headache diagnosis. Fifty-nine completed detoxification, 58 (81%) were followed up at month 6 and 53 (74%) at month 12. At month 6, program A reduced headache days/month by 46% (95% CI 34-58) compared with 22% (95% CI 11-34) in program-B (p=0.005), and 70% in program A versus 42% in program B were reverted to epi- sodic headache (p=0.04). Migraine-days/month were reduced by 7.2 in program A (p<0.001) and

METHODS Medication-overuse headache patients were included in a prospective, out- patient study and randomized to two months’ detoxification with either a) no analgesics or acute migraine-medication (program A), or b) acute medication restricted to two days/week (program B). Detoxification was followed by pre- ventives if indicated. Patients were followed up at 2, 6 and 12 months. Percentage reduction in

Complete Detoxification Is the Most Effec- tive Treatment of Medication-Overuse Headache: A Randomized Controlled Open-Label Trial. Cephalalgia 2018 Feb 01;38(2)225-236, LN Carlsen, SB Munksgaard, RH Jensen, L Bendtsen. www.practiceupdate.com/c/65605 " Whiletheseresults should be used with caution and practitioners should establish safety of withdrawal from different types of analgesics used by patients, they are very encouraging… "

VOL. 3 • NO. 4 • 2018