COMMENTARY—Variations on a Theme: Detoxifying Patients With Medication Overuse Headache

The results of the carefully designed COMOESTAS study on medication overuse headache (MOH), presented by Dr. Cristina Tassorelli of Pavia, Italy, at the European Headache and Migraine Trust International Congress in London in September, are promising for patients with MOH. Patients overusing acute care medications in many countries throughout Europe and Latin America were treated with similar protocols of rapid detoxification from the overused medication, starting up of preventive medication, cautious use of acute care medication, and alerting of abuse by an electronic diary. The results, in terms of decreased headache days per month, less use of acute care medication, and improved disability and quality of life, with lessening of depression, were considerable. Certain rescue medications were permitted for the first seven days. Some patients were treated in the hospital, and some as outpatients.

I have been using a similar but nonstructured protocol for these difficult-to-treat MOH patients, as was the late Dr. Fred Sheftell, since 1979. We were taught about MOH (which was called rebound headache in those days) by Dr. Lee Kudrow of Los Angeles. We do things slightly differently from this new protocol. I think the initial day of education is vital, but I start preventive medication several weeks prior to detoxification so the patient has a therapeutic blood level of preventive medication when we start a slower withdrawal of medication. I often use clonidine to prevent withdrawal symptoms and a tricyclic antidepressant at night for sleep problems, depression, and to help the headache. Possibly the most critical part of the program is an evaluation by, and frequent treatment from, a PhD behavioral specialist. We also use bridge therapy with either steroids or dihydroergotamine. This shows that there are many variations on the theme, and they can all lead to patient improvement.

The key to successful treatment of MOH is education and convincing the patient to do what may not seem intuitive to them. Then you must get them over the one to two weeks of worsening of their headaches that may occur before improvement.

The multicountry COMOESTAS study has demonstrated once more that these difficult-to-treat patients can be successfully weaned from their overused medication and improve considerably. What I like about this study is that it encourages doctors all over the world to follow a simple protocol to help patients with a complex problem.