The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) has published its first guideline for general practitioners to describe how to diagnose and treat the most common types of headache, including medication overuse headache. The evidence-based guideline explains when clinicians should consider a diagnosis of medication overuse headache and provides advice about how to treat the condition.
Although OTC treatments reduce headache pain effectively, medication overuse headache is estimated to occur in 1% to 2% of the population (ie, around one in 50 people), according to European studies. Women are estimated to be five times more likely to have medication overuse headache than men.
Recognizing and Treating Medication Overuse Headache
Medication overuse headache may arise in patients who take triptans, opioids, ergots, or combination analgesic medications for at least 10 days per month for three months or more, according to the guideline. Taking paracetamol, aspirin, or a nonsteroidal anti-inflammatory drug for at least 15 days per month for three months or more also could lead to medication overuse headache.
The guideline advises clinicians to recommend that patients with medication overuse headache immediately discontinue overused headache medications for at least one month. Noting that headache symptoms may worsen and that patients may have withdrawal symptoms, the guideline suggests that clinicians follow up with patients closely and provide necessary support.
Physicians are advised to consider referring a patient to a specialist or providing him or her with inpatient withdrawal if he or she is using strong opioids, has comorbidities, or has unsuccessfully tried to withdraw from an overused medication in the past. The diagnosis should be reviewed at four to eight weeks after the start of withdrawal, according to the guideline.
In addition, the guideline recommends that health care professionals not refer their patients for neuroimaging purely for patients’ reassurance, because improved diagnostic assessments will make such referrals unnecessary.
Guideline May Help Physicians and Patients
“Patients with frequent tension-type headaches or migraines can get themselves into a vicious cycle where their headaches are getting increasingly worse, so they take more medication, which makes their pain even worse,” said Martin Underwood, MD, Head of the Division of Health Sciences at Warwick Medical School in Coventry, UK, and coauthor of the guideline, in a NICE press release. “I hope this guideline will improve awareness of medication overuse headache, both in primary care and among the general public, because prevention is simple and treatment is difficult. Explaining to patients that they should abruptly stop their medication, knowing that their headache will get much worse for several weeks before it will improve, is not an easy consultation.”
“The key features of medication overuse and the symptoms that distinguish the types of primary headache can be overlooked, and concerns from patients about possible underlying causes can lead to unnecessary hospital investigations,” said Gillian Leng, MD, Deputy Chief Executive of NICE, in a press release. “Our guideline outlines the assessments and treatments that people should expect to receive for primary headaches and medication overuse. We hope that this will help [general practitioners] and other health care professionals to correctly diagnose the type of headache disorder and better recognize patients whose headaches could be caused by their overreliance on medications,” she added.
“By clearly outlining the common features associated with primary headaches, the guideline will improve recognition and empower health care professionals to manage headaches more effectively, with better targeting of treatments,” said Manjit Matharu, MD, an honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery in London, in a press release. “Also, it will enable health care professionals to undertake investigations confidently while avoiding the need for unnecessary brain scans. Clearly, neuroimaging is still an important diagnostic tool, but most peoples’ headaches will not be caused by brain tumors or other serious health problems, and so these should not be offered to patients solely for reassurance,” he concluded.
—Erik Greb
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