HENDERSON, NEV. – Treating medication overuse headache involves a three-pronged approach of patient education, teaching pain coping skills, and addressing psychological issues that put patients at risk for relapse, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.
Most patients don't understand that excessive use of opioids can actually make them hypersensitive to pain, said Dr. Lake of the Michigan Head Pain and Neurological Institute, Ann Arbor. “They believe the pain is stronger than the medication, not that the medication is actually making them worse.” This thought process can be the root of ever-increasing medication use, as the patient experiences “pain anxiety” and attempts to forestall pain by premedicating.
The first step is to teach patients how medication overuse exacerbates headache pain, he said. Only when they have a clear understanding of this relationship will they be open to adhering to medication limits.
Sustained opioid use downregulates opioid receptors and upregulates excitatory receptors. This results in increased synthesis of excitatory neuropeptides. “Opioid tolerance is a red flag for induced abnormal pain sensitivity,” Dr. Lake said.
Overusing analgesics also interferes with effective prophylaxis, he said, citing a “seminal” 1990 study in which all patients received the same training in coping skills. Those who discontinued their daily analgesic and got a new prophylactic drug experienced the biggest improvement with their headaches.
Those who discontinued their analgesic but stayed on the same preventative improved as well, although not as much, while those who continued their daily analgesic experienced almost no improvement (Headache 1990;30:634–8).
“This study, which I use as a teaching tool, also shows patients that improvement doesn't happen immediately. They need to stay the course. It takes time for the receptors to remodulate, and how much time depends on how long they've been taking the medication and how much they've been on,” Dr. Lake said.
Simply taking away the analgesic isn't the answer, he stressed. Patients need to understand that drugs are not the only way to alleviate headaches, and that they will probably have to tolerate some level of pain. “The evidence, clinically and empirically, shows that it's very difficult for these patients to move to pain-free days. They have to find ways of dealing with headache that doesn't involve drugs.”
Biofeedback, stress management, and antidepressants all may be effective tools in relearning responses to headache pain. A 2001 study concluded that a combination of stress management and antidepressants was more effective than was either treatment alone in reducing chronic tension-type headache (JAMA 2001;285:2208–15).
And a 2002 study of medication overuse relapse showed that 3 years after medication withdrawal, patients on a combination of biofeedback and prophylactic medication experienced significantly fewer headaches per month and used less analgesic medication per month than did those on prophylaxis only (Headache 2002;42:483–90).
Treating any comorbid psychiatric disorder is critical, Dr. Lake said. His own unpublished study of 267 consecutive patients shows how common psychiatric disorders are in headache patients: All of the patients had at least one Axis I disorder, including depression (70%) and anxiety (40%). Another 26% had an Axis II personality disorder. Of those with an Axis II disorder, 63% had medication overuse headache, compared with 42% of those without such a disorder. The presence of an Axis II disorder was significantly associated with a poor long-term outcome.
Hospitalization may be the best way to assess the presence of these additional problems. “This gives you an opportunity to observe not only the patient's behavior, but family interactions and marital problems that you might not see otherwise. When they come into your office they may be able to pull it all together for a half an hour, but when you see them day in and day out, you have the opportunity to get to know the patient and family. It's all right there in front of you,” Dr. Lake said.