VALENCIA, SPAIN—Medication overuse headache (MOH) is strongly associated with high stress levels and several unhealthy but modifiable behaviors, according to a large Danish population-based study.
“High stress plus smoking, low physical activity, or obesity has synergistic effects in MOH. So, stress reduction is highly relevant in MOH management,” said Rigmor H. Jensen, MD, Professor of Neurology and Director of the Danish Headache Center at the University of Copenhagen, at the International Headache Congress.
Stopping the overused medications remains central to the successful treatment of MOH. The findings of the Danish study suggest that stress reduction and lifestyle modification, in addition to their many recognized mental and physical health benefits, might also have effects specific to MOH, according to Dr. Jensen.
A Survey of Headache Symptoms
Dr. Jensen presented the results of a questionnaire survey sent to a representative sample comprising 129,150 Danish adults. The survey focused on headache symptoms, lifestyle, and stress, as measured by the validated 10-question Perceived Stress Scale. The survey response rate was 53%.
A total of 3.4% of the 68,518 respondents were classified as having chronic headache based upon self-report of headache on at least 15 days per month for three months. Using the International Classification of Headache Disorders, the researchers further categorized this group as having MOH—as did 1.8% of the total study population—or chronic headache without medication overuse.
Of adults with MOH, 58% scored in the top fifth of the total study population in terms of stress level. Those with chronic headache without medication overuse were not as well represented at the high end of the stress spectrum. Approximately 46% of these individuals were in the top stress quintile, as were 18% of people without chronic headache, said Dr. Jensen.
Unhealthy Behaviors Increased Risk of MOH
She and her coinvestigators examined the relationship between MOH, stress level, and five unhealthy lifestyle behaviors (ie, daily smoking, excessive alcohol intake, physical inactivity, obesity, and illicit drug use). In multivariate logistic regression analysis, smoking, physical inactivity, and obesity were strongly associated with MOH, while excessive drinking and illicit drug use were not.
Women in the top quintile for stress were 3.8 times more likely to have MOH if they smoked, compared with smokers in any of the four lower-stress quintiles. Women in the top quintile for stress also were 3.5 times more likely to have MOH if they were sedentary, compared with sedentary women in lower-stress quintiles. In addition, women in the top quintile for stress were 2.9 times more likely to have MOH if they were obese, compared with obese women with lower stress levels. For men in the top quintile for stress, the respective odds ratios for MOH ranged between 5 and 5.6 for the three lifestyle factors.
After controlling for stress level, the odds of having MOH were greatest among individuals with all five unhealthy behaviors, compared with those with none. The researchers found a 5.1-fold increase among men and 2.8-fold increase in women in the odds of MOH for people with all five behaviors.
The Danish data do not indicate that patients need to attain below-average stress levels to manage MOH successfully in the long term. The independent association between stress and MOH was statistically significant only for individuals in the top two stress quintiles. Men in the fifth or top quintile for stress were 10.3 times more likely to have MOH than those in the first quintile, while those in the fourth quintile were 4.3 times more likely to have MOH than those in the first. In women, the associations were less dramatic, including a 3.9-fold increased risk of MOH if they were in the fifth stress quintile and a twofold increase if they were in the fourth.
—Bruce Jancin