Migraine Treatment: Medication Overuse Headache

The use of analgesics and opioids to treat acute migraine was associated with a higher risk for developing medication overuse headache (MOH) compared with other migraine treatments, according to the results of a literature review.

 “These findings should be of interest to patients, clinicians, and policy-makers as many patients may self-medicate, and the magnitude of analgesic use is potentially higher than what has generally been observed in population-based studies,” researcher Kristian Thorlund, of the department of clinical epidemiology & biostatistics, McMaster University, Hamilton, Ontario, and colleagues, wrote in TheJournal of Headache and Pain. “While our findings are in line with current clinical guidelines and prejudice in favor of targeted migraine-specific pharmacotherapy, they should still only be interpreted as exploratory due to their observational nature.”

MOH is a headache that occurs on 15 or more days per month caused by overuse of medications for migraine or other pain disorders. There are a variety of medications used for the treatment of acute migraines including analgesics, ergots, opioids, and triptans. With this study, Thorlund and colleagues wanted to determine whether any of these classes of medications were more likely to elicit MOH.

They performed a comprehensive literature review of studies that reported MOH according to the International Classification of Headache Disorders. They identified 29 studies for inclusion in their review.

Fourteen studies discussed MOH for both triptans and ergots: four yielded a relative risk in favor of triptans, two yielded no difference, and eight studies yielded an adjusted relative risk in favor of ergots.

Both triptans and ergots appeared favorable for MOH when compared to opioids, the researchers found.

Seven studies discussed MOH for ergots and opioids. Four studies had a relative risk in favor of ergots, one showed no difference, and two studies yielded a relative risk in favor of opioids. The fixed-effect weighted average relative risk was 0.76, suggesting an average 24% relative risk reduction in MOH with ergots compared with opioids.

Eleven studies covered MOH for both triptans and opioids. Five studies favored triptans, one study showed no difference, and five studies yielded a relative risk in favor of opioids. There was a fixed-effect weighted average adjusted relative risk of 0.35, suggesting an average of 65% relative risk reduction in MOH with triptans compared with opioids.

Twelve of the studies included in the review discussed MOH for ergots and analgesics. Eleven of the 12 studies had a relative risk in favor of ergots. The fixed effect weighted average adjusted relative risk, suggesting an average of 59% relative risk reduction in MOH with ergots compared with analgesics.

Finally, the researchers also found that analgesics and opioids appeared to yield a similar risk of MOH. Nine studies discussed MOH for analgesics and opioids. Three studies showed an adjusted relative risk estimate in favor of analgesics, and six studies in favor of opioids. The fixed-effect weighted average adjusted relative risk was 1.09, suggesting an average 9% increased risk of MOH with analgesics compared with opioids.

The researchers suggested that there are several possible reasons for increased MOH associated with analgesic and opioid use, including the fact that analgesics are an over-the-counter medication that patients can self-administer compared with triptans, which are a prescription medication.

Thorlund K, et al. Risk of medication overuse headache across classes of treatments for acute migraine. J Headache Pain. 2016;17:107.