Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine, Phoenix, and St. Joseph’s Hospital Family Medicine Residency at Creighton University Arizona Health Education Alliance, Phoenix Allison.Crain@dignityhealth.org
The author reported no potential conflict of interest relevant to this article.
Medication withdrawal—with or without preventive medication—should reduce the frequency of MOH in 2 or 3 months. If headache does not become less frequent, however, the headache diagnosis might need to be reconsidered. Minimizing the use of abortive medication is generally recommended, but reduction or withdrawal of these medications does not guarantee that patients will revert to an episodic pattern of headache.
Inpatient care of withdrawal might be beneficial when a patient has a severe comorbidity; does not respond to, tolerate, or adhere to treatment; or relapses after withdrawal.
Treating withdrawal symptoms is a reasonable approach in some patients, but evidence does not support routinely providing bridging therapy.
Apply preventives carefully. Abortive medication withdrawal should generally be completed before initiating preventive medication; however, over the short term, starting preventive therapy while withdrawing the overused medication could assist in reducing headache frequency rapidly. This strategy can put patients at risk of medication adverse effects and using the medications longer than necessary, yet might be reasonable in certain patients, given their comorbidities, risk of relapse, and physician and patient preference. A preventive medication for an individual patient should generally be chosen in line with recommendations of the American Academy of Neurology45 and on the basis of the history and comorbidities.
Provide education, which is essential to lowering barriers to success. Patients with MOH must be counseled to understand that (1) a headache treatment that is supposed to be making them feel better is, in fact, making them feel worse and (2) they will get worse before they get better. Many patients are afraid to be without medication to use as needed. It is helpful to educate them on the different types of treatments (abortive, preventive); how MOH interferes with headache prophylaxis and medication efficacy; how MOH alters brain function (ie, aforementioned physiologic changes in pain processing and functional imaging changes23); and that such change is reversible when medication is withdrawn.
ACKNOWLEDGEMENT The author thanks Jeffrey Curtis, MD, MPH, for his support and editing assistance with the manuscript.
CORRESPONDENCE Allison Crain, MD, 2927 N 7th Avenue, Phoenix, AZ 85013; Allison.Crain@dignityhealth.org.
