COMMENTARY

Medication Overuse Headache: Inpatient vs Outpatient Treatment

Hans-Christoph Diener, MD, PhD

Disclosures

October 06, 2011

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Hello. My name is Christoph Diener. I'm a neurologist from Essen University in Germany. Today's topic is chronic headache and medication overuse.

You all know that people who have frequent headaches tend to take too much acute medication, and they might develop a disorder called medication overuse headache. The International Headache Society has defined this entity as a condition in people who have a primary headache disorder like migraine or tension-type headache and who use analgesics on more than 15 days per month or triptans on more than 10 days per month.

There is a longstanding and ongoing debate about the best way to treat people with medication overuse headaches. I think no one would argue that these people have to be withdrawn from the overuse medication, but the discussion is whether this should be done on an inpatient or outpatient basis.

Today I will discuss a study[1] that was published in the journal Cephalalgia in August of this year [2011]. This study originates from France. The investigators recruited 82 patients with primary headache and medication overuse and randomly assigned them to receive withdrawal treatment as inpatients or withdrawal therapy as outpatients. About half of these patients had migraines. The remainder of patients had either chronic tension-type headaches or combination headaches.

The most frequent overuse medications were analgesics followed by triptans. The investigators followed the patients for 2 months and again at 2 years. The primary endpoint was a reduction in headache days. After 2 months they found no difference between these treatment groups. Both showed a 50% reduction in headache days after withdrawal of acute medication. All these patients were put on preventive therapy after the withdrawal treatment. Most of them received amitriptyline. After 2 years, there was a similar result; again, no difference between inpatient and outpatient treatment.

What are the practical consequences of this study? I think the study clearly shows that in people who overuse simple analgesics and triptans, there is no reason to give the treatment on an inpatient basis.

I have to point out a very important difference between Europe and the United States. In Europe barbiturates in pain medication are banned and basically no one prescribes opioids for the treatment of headache. This is very different in the United States, where the leading drugs that are overused are barbiturates and opioids. In patients who overuse these 2 kinds of drugs, it is advisable to provide the withdrawal treatment on an inpatient basis because the relapse rate is very high if withdrawal treatment is done on an outpatient basis.

From this nicely conducted study in France, we learned the people with medication overuse headaches can be withdrawn on an outpatient basis.

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