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Pain Criteria and Pathophysiology from Excessive Drug Use in Migraine


Medication overuse headache (MOH) is defined in the latest ICHD-3 criteria as a secondary headache caused by the worsening of a pre-existing headache (usually primary headache) due to overuse of one or more episode-stopping or pain-relieving drugs. MOH can be debilitating and can result from biochemical and functional brain changes caused by certain medications taken too often. Various risk factors have been assumed in MOH, some modifiable, other unchangeable (Multiple Gene Polymorphisms).
It is noticeably found that psychiatric comorbidities (anxiety and depression) seen in MOH are incidentally much more accompanying diseases. This must be effectively managed in conjunction with treatment strategies for MOH for an effective response to withdrawal therapy. Extensive literature and clinical evidence demonstrated in prospective research, the best treatment for MOH is abstinence therapy. The mainstay of MOH therapy is not only to detoxify patients and stop chronic headaches, but possibly also to improve responsiveness to acute or prophylactic medications. There are studies mainly advocating prophylactic therapy that respond well to topiramate and OnabotulinumtoxinA, but less prominent for prednisolone, but it is not recommended for every patient.
Management can be complex and should be done through the MDT approach, including adequate treatment of acute withdrawal symptoms, educational and behavioral programs, with the involvement of specialists when necessary, to ensure that the patient understands the situation and compliance. There are controversies on both sides of inpatient and outpatient cessation for MOH patients, which are highly dependent on individual circumstances. patient motivation, duration of overuse, type of overused medications, history of possible previous detoxification failures and comorbidities. These patients still need to try treatment to determine the best evidence-based approach for clinicians to help break the headache cycle.

Pain Criteria and Pathophysiology from Excessive Drug Use in MigraineHeadache Disorders Criteria in Excessive Drug Use

Medication overuse headache (SB) is a headache that occurs 15 days a month in an affected person with a pre-existing headache disorder. Regular overuse of one or more drugs for> three months, which can be taken for acute or symptomatic treatment of headache. It is not better represented by any other ICHD-3 diagnosis. Medications that cause these headaches are as follows;
Ergotamine overuse headache
Triptan overuse headache
Non-opioid analgesic overuse headache
Paracetamol (acetaminophen overuse headache
Nonsteroidal anti-inflammatory drug (NSAID) overuse headache
Acetylsalicylic acid overuse headache
Other non-opioid analgesic overuse headache
Opioid overuse headache
Combination analgesic overuse headache
Medication overuse headache attributed to combination drug classes that are not individually overused
Drug overuse headache attributed to unspecified or unconfirmed overuse of various drug classes
• Overuse of medication headaches attributed to different drugs

Headache Caused by Excessive Drug Use Pathophysiology

MOH was first described in 1951 in relation to ergotamine overuse. In 1984, the relationship between analgesic consumption and exacerbation of headaches was recognized with improvement in headache relief. In the first classification of headache disorders (ICHD-1), it is called ‘drug-induced headache’. ICHD-2 described this as ‘drug overuse headache’ in 2004. It has been said that the situation is likely, as the definitive diagnosis is only given after the headache subsides 2 months after the cessation of the overused drug. The 2006 amendment expanded the definition and eliminated the necessary improvement after cessation of treatment, and this continued in both ICHD-3 beta and ICHD-3 criteria.

Clinical Features

Pain Criteria and Pathophysiology from Excessive Drug Use in MigraineThe headache of medication overuse is the headache of the primary headache disorder. Migraine patients who use triptan excessively are more frequent in the frequency of pre-existing headaches, with intermittent aggravation, and when more triptan doses are skipped. An almost daily increase is observed and the patient enters a vicious circle with headaches that increase in proportion to the triptans consumed. Likewise, patients with tension headaches report that their featureless headaches are getting worse. Few people can distinguish between primary headaches and persistent dull and widespread headaches that they describe as MOH. SB developed more rapidly with triptan and resolved faster with withdrawal compared to combination and simple analgesics. This perception has been confirmed by a French study.
Diagnostic criteria for MOH do not fully demonstrate the complexity of diagnosing MOH. It is important to realize that drug overuse and MOH are two different entities that can have different consequences and consequences. Medication overuse refers only to the number of days a person consumes the pain reliever and is not necessarily a cause of ongoing headache. In some chronic pain conditions such as low back pain; arthritis etc. There is drug overuse but there is no accompanying headache
Another observation is that not every individual will develop a headache with acute medication overuse. It is not entirely clear why overuse worsens headaches for some and not others. Considered a secondary headache disorder, MOH should be defined according to the type of drug overused. Primary headache disorder should also be defined.

Common and Common Risk Factors

Pain Criteria and Pathophysiology from Excessive Drug Use in MigraineMost of the studies reported the overall prevalence of MOH in the normal population to be 0.5-2.6%. Higher rates were observed in Russia (7.6%) and Iran (4.6%), where excessive drug use was much more common than in other countries. However, no speculative reason or hypothesis has been presented for this. The prevalence for SB is 0.5-2.6%, but the availability of over-the-counter pain relievers (OTC) has been reported much higher in Russia (7.6%) and Iran (4.6%). The availability of OTC varies with codeine-based analgesics available in the UK, while in the US it varies with barbiturates containing painkillers.
Figures from third world countries such as India and Pakistan are difficult to obtain, given that all pain relievers that do not have a precise prescription system in the country are sold without a prescription. In Norway and Taiwan, the prevalence observed in two epidemiological studies is less common in adolescents (0.3-0.5%) than in adults. In general, women are more affected than men (5: 4), and those with chronic migraine have a much higher incidence of drug overuse (11-70%) than observed in the general population.

References:
https://www.ncbi.nlm.nih.gov/books/NBK538150/
https://americanmigrainefoundation.org/resource-library/medication-overuse/

Author: Ozlem Guvenc Agaoglu


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