SCOTTSDALE, ARIZ. – Early treatment of migraine can contribute to development of medication-overuse headaches in pain-adverse patients, Dr. James R. Couch warned at a symposium sponsored by the American Headache Society.
These patients will take their pills every time they think they might be about to get a migraine, said Dr. Couch, a professor of neurology at the University of Oklahoma Health Sciences Center in Oklahoma City.
“The more they think they are getting a headache and take the medication early, the more likely that this may lead to developing an MOH [medication-overuse headache]-induced chronic daily headache,” he said.
The conundrum for prescribing physicians, as presented by Dr. Couch, is that current and previous studies show patients really do have a better response if they take their medications at the first sign of a migraine. He recommended early treatment for the patient who has an occasional menstrual-induced migraine, but suggested a cautious approach for those with more frequent headaches.
“If a patient is having 10 or more headaches a month, do not get them into the early treatment or be careful about the early treatment,” he said. Instead, make sure these patients know when they are starting a headache as opposed to thinking they might be getting one.
“I think this is one of the main problems,” Dr. Couch said.
He added that patients who “get a buzz” from their medication also could be at greater risk of developing MOH. Some patients will use their headache medication like a dose of alcohol, he warned.
He recommended asking whether the patient feels a lot better immediately after taking a headache remedy. In his experience, some will say that it gives them energy in the afternoon, helping them to finish their work.
The pathophysiology of MOH is not clear, according to Dr. Couch, but genetic predisposition and psychological factors appear to be involved. Depression and bipolar disorder are common in MOH patients, he said. Typically, the MOH patient has an underlying headache, but sometimes social factors drive the medication overuse. “Is there something else going on there?” he urged physicians to explore in these patients.
Chronic daily headaches and MOH are a worldwide problem, according to Dr. Couch. He pointed to studies in the United States, Spain, China, and Ethiopia that show 4%-5% of the population have headaches 15 days or more each month.
In developed countries, he said about 1% of the population develops MOH. These patients account for 20% of the chronic daily headache population and may be increasing in number. In the 25− to 50-year-old age group where MOH is most prevalent, Dr. Couch said it is as common as epilepsy and more common than multiple sclerosis or stroke.
The best treatment is prevention, he said. Know what medications your patients are taking, keep track of refills, and discuss the possibility of MOH as soon as you recognize the patient is at risk, he urged.