Medication Overuse Headache in Chronic Migraine Linked to High Burden

Todd J. Schwedt, MD

Recently published data from the Medication Overuse Treatment Strategy (MOTS) trial suggest that patients with chronic migraine who experience medication overuse headache (MOH) report a high level of burden in the US.

All told, the data from 607 adult patients with chronic migraine suggest that higher headache frequency is associated with a greater impact on individuals’ ability to function, interference with pain, and quality of life. On average, the cohort used acute headache medications 21.5 (standard deviation [SD], 7.5) out of 30 days, with a single medication class being overused by 70% of patients while 30% overused medications from 2 or more medication classes.

The most commonly overused medications reported as simple analgesics (378 of 607; 62%), combination analgesics (246 of 607; 41%), and triptans (128 of 607; 21%). Those were followed by multiple classes which were not individually overused (82 of 607; 14%), opioids (22 of 607; 4%), and ergotamines (6 of 607; 1%).

The study was conducted by Todd J. Schwedt, MD, chair, Neurology Research, Mayo Clinic, in an attempt to describe headache characteristics, medication use, disability, and quality of life in a large patient cohort. Disability was measured with the Headache Impact Test 6 (HIT‐6) and the Migraine Functional Impact Questionnaire (MFIQ), pain interference was measured with the PROMIS Pain Interference test, and quality of life with the EQ‐5D‐5L.

“Individuals who have [chronic migraine] with MOH who are patients from headache specialty, neurology, and primary care outpatient clinics in the United States have very frequent headaches, very high-frequency intake of acute medications, severe headache and migraine-related impact on function, substantial pain interference, high rates of anxiety and depression symptoms, and poor quality of life,” Schwedt et al. concluded.

The mean age of the patient population was 45 years (SD, 13), and 87.3% (n = 531) were women. Patients reported their first migraine a mean of 23 years prior, with a chronic migraine pattern ongoing for an average of 11 years. The mean number of headache days per month for the group was 24.3 (SD, 5.5), of which a mean of 13.6 (SD, 7.1) were headaches of moderate to severe intensity. Daily headaches were reported by 36.1% (n = 219) of patients, while 19.1% (n = 116) reported 15-19 headache days, 22.6% (n = 137) reported 20-24 days, and 22.2% (n = 135) reported 25-29 days.

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On an 11-point scale (0 being no pain, 10 being the most severe pain imaginable), the average headache intensity for the cohort was 6.3 (SD, 1.7). In total, 78% of patients reported headache intensity being exacerbated by physical activity, 85% of patients reported nausea, 48% reported vomiting, 91% reported photophobia, and 87% reported phonophobia.

Notably, only 44.9% (n = 272) of patients reported that they were taking a preventative migraine medication. “It is hoped that appropriate treatment for these highly burdened patients will lead to improved physical and psychological well-being,” Schwedt et al. noted.

The data suggest that the HIT-6, MFIQ, PROMIS Pain Interference, and EQ-5D-5L scores (n = 587) all demonstrated a substantial negative impact on patient functioning and quality of life. HIT-6 scores were a mean of 65.0 (SD, 5.3; Median, 65 [range, 44-78]) registering in the “severe impact” category. PROMIS Pain Interference raw scores averaged at 21.4 (SD, 4.9) with a T-score of 65.2 (SD, 5.4), 1.5 SD worse than the reference population. EQ-5D-5L crosswalk utility values averaged 0.73 (SD, 0.17).

MFIQ scores (n = 587) were a mean of 52 (SD, 21) for physical function, 42 (SD, 22) for usual activities, 48 (SD, 24) for the usual activities global item, 46 (SD, 24) for social function, and 49 (SD, 22) for emotional function. “Although there are not defined thresholds for interpreting MFIQ scores, the MOTS trial patients have substantially higher scores (indicating greater impact on patient functioning) than those previously reported for individuals with episodic migraine,” Schwedt et al. wrote.

They also observed that patients with more headache days had more days on which acute headache medications were used specifically to treat headache. Additionally, as headache frequency increased, the proportion of acute headache medication days to headache days decreased from 0.98 to 0.85—implying that the individuals with the highest headache frequency were using acute medicines proportionally less often.

“Three-quarters of the population have symptoms suggestive of at least mild depression, with 41% of the population having symptoms suggestive of moderate or severe depression. Just over two-thirds of the population have symptoms suggestive of at least mild anxiety, with 37% of the population having symptoms suggestive of moderate or severe anxiety. On average, there is severe headache and migraine-related impact on patient function, substantial pain interference, and poor quality of life,” Schwedt and colleagues wrote.

REFERENCE
Schwedt TJ, Hentz JG, Sahai-Srivastava S, et al. Headache characteristics and burden from chronic migraine with medication overuse headache: Cross‐sectional observations from the Medication Overuse Treatment Strategy trial. Headache. 2021;61(2):351-362. doi: 10.1111/head.14056