A Qualitative Study on Patients With Chronic Migraine With Medication Overuse Headache

Comparing Frequent and Non-Frequent Relapsers

Chiara Scaratti, PsyD; Venusia Covelli, PhD; Erika Guastafierro, MSc; Matilde Leonardi, MD; Licia Grazzi, MD; Paul B. Rizzoli, MD; Domenico D'Amico, MD; Alberto Raggi, PsyD, PhD


Headache. 2018;58(9):1373-1388. 

In This Article

Abstract and Introduction


Background: It is common clinical experience that, after structured withdrawal, some patients with chronic migraine and medication overuse headache (CM with MOH) are more prone than others to relapse and to be in need of further structured treatments. Our aim was to explore similarities and differences between frequent relapsers (FRs) and non–frequent relapsers (NFRs) by considering their point of view, perceptions, and perspective of their subjective experience with relapse into CM with MOH.

Methods: Patients were consecutively recruited on occasion of a structured withdrawal treatment and were interviewed individually about their headache experience and their perspectives on relapse into CM with MOH. We considered FR those patients requiring 2 or more structured withdrawals for MOH within 3 years. A narrative approach with no preconceived coding schemes was employed. To facilitate coding, categorization and organization of data the software QRS NVivo 11.0 was used: themes were defined as common to FR and NFR, or peculiar (by frequency or content) to one of the 2 groups.

Results: Sixteen patients (13 women; mean age of 53) were interviewed: 7 were classified as FRs. A total of 22 themes emerged from 552 single quotations (the 10 most relevant covered 82% of the entire body of quotations). Four themes were commonly reported by both FR and NFR patients, and 6 were peculiar to one group only. Common aspects included issues connected to the dilemma between disclosing, concealing and the feelings of isolation around MOH, the idea of being addicted to medication, presence of anxiety, and the attempt to use non–pharmacological therapies as an alternative to medication. Peculiar aspects included causal attribution (FRs attributed headache to uncontrollable factors); future expectations at the time point of withdrawal (FRs were generally resigned); high–performance functioning (FRs believed they are "forced" to reach high levels of performance as a consequence of others' inability); coping strategies (FRs tended to "passively accept" problems and showed avoidance–related behaviors). Moreover, FRs were less frequently aware of their problems and described more frequently depressive symptoms.

Conclusions: Our results highlight that some differences between FR and NFR patients with CM and MOH exist. Frequent relapsers among patients with CM and MOH reported some important peculiarities of the lived experience of having chronic migraine; clinicians should recognize these psychosocial aspects such as social relationships, future expectations, the experience of illness, medication management, and how the withdrawal experience is regarded, as they may be associated with frequent relapse into MOH.


Chronic migraine (CM) is a negative evolution of the migraine course characterized by 15 or more headache days per month for more than 3 months, and is frequently associated with the overuse of medication for acute treatment.[1] The International Classification of Headache Disorders, version 3–beta (ICHD–3 beta),[1] as well as the recently released ICHD–3,[2] suggests that the term medication overuse headache (MOH) be used to address those situations in which the increase in headache frequency is a consequence of regular overuse of acute or symptomatic headache medication.[1] However, in addition to the overuse of medications, there are several other factors that are deemed to play a role in migraine chronification, such as endocrine and metabolic dysfunctions, presence of comorbidities, genetic predisposition, and lifestyle issues.[3–6] The European guidelines on treatment of MOH suggest withdrawal treatment of overused drugs, prescription of individualized prophylaxis, and the combining of medical treatments with advice and education to prevent relapse into MOH.[7]

Withdrawal is considered effective when a reduction of 50% in headache frequency is confirmed at 12 months,[8] and research findings show an effectiveness of withdrawal up to 5 years after discharge.[9] However, it is common clinical experience that some patients are more prone to relapse into MOH and to need further treatment after a shorter period than others, with 1–year relapse rates found to be between 20.5 and 41%.[10–14] The predictors of short–term relapse include: high frequency of migraine attacks, recent history of withdrawal treatment, emergency room admission after withdrawal, high–depression scores, residual symptomatology after withdrawal treatment and a greater number of previously tried preventive treatments, type of primary headache and type of overused medication, and a genetic predisposition for success of detoxification therapy and 12–month relapse was also shown.[10–17] Lastly, being on medical therapy only, compared to adjuvant behavioral technique, may be another factor. In 2 previous studies, we defined as "frequent relapsers" those patients requiring 2 or more structured withdrawals within 3 years:[17,18] these patients had an almost 4–fold risk of 12–month relapse into MOH,[17] and had a worse clinical and psychosocial situation, ie, lower education, higher disability and lower quality of life, higher frequency and intensity of headaches, and higher depression scores.[18]

The identification of risk factors predicting relapse into MOH is of importance to improving the clinical management of these patients. A previous study underlined that not only the characteristics of headache (eg, family recurrence) and overuse (eg, amount and type of overused drugs), but also the patient's general circumstances (eg, being unemployed or living alone) and psychological status (presence of risk factors for psychiatric and personality disorders) act as negative prognostic factors,[19] but results are conflicting. Comorbid anxiety and mood disorders have been associated with a negative long–term prognosis in migraine and might play a role in perpetuating MOH,[20,21] and dependency–like behaviors could impair the clinical course of migraine and increase the risk of relapse into MOH.[22–24] However, these studies are heterogeneous with respect to a series of variables: the number of included subjects (which varied from 17 to 694), the type of study (eg, clinical studies, population surveys) and, as a consequence, the way in which diagnosis was appointed (ie, by a physician or based on self–reports of information), as well as, when appropriate, the procedure for withdrawal process (ie, inpatient or outpatient). Corbelli and colleagues failed to identify specific psychopathological factors associated with the response to the withdrawal program, but found that patients who did not respond to treatment showed a drug dependence pattern similar to that previously described in addicts. On the contrary, among patients who positively responded to the procedure, drug–abuse behavior seemed to be a consequence of chronic headache, reflecting the need for daily analgesic use to cope with everyday life.[25]

Previous studies[26–29] have found that psychologically mediated factors such as locus of control, self–efficacy, social support, and emotional states influence the course of headache by affecting perceived pain, migraine management, and the overall impact of headache on related disability and quality of life. Moreover, Sances and colleagues[19] suggested that psychosocial variables should be included as outcome measures in future studies on risk of relapse in MOH. In the light of these findings, it could be useful to consider not only the characteristics of personality or eventual psychiatric conditions, but to include other factors that could impact on the relapse into MO, such as the social relationships, the expectation toward the future, the experience of illness, the management of medications and how the withdrawal is faced.

Patients' perspectives and experience on being a chronic migraineur and overuser of symptomatic drugs have been poorly addressed by previous research. In fact, almost all the studies addressing factors associated with relapse into MOH employed quantitative approaches, which do not enable to get the complexity of the psychosocial facets associated to patients' experience. Such a gap could be filled through a qualitative approach as showed, for instance, by Lonardi's study.[30] The collection of life stories from patients affected by chronic headache allowed to explore interesting psychosocial aspects related to the disease and its complex social representation. In fact, chronic headache sufferers face a dilemma in social relationships, about concealing or make evident their disease: if patients conceal their condition they risk carrying the burden of the disease alone, with no social support; on the other hand, making chronic headache visible could result in stigma.[30] Morgan and colleagues underlined that the qualitative method was particularly appropriate to investigate the feelings of the patients with migraine and their expectations toward the therapy, highlighting the importance of a patient–centered approach to create tailored programs.[31] The meaning of living with migraine was also investigated in a qualitative study by Rutberg and Öhrling. Their results suggested that healthcare professionals should increase their awareness of the meaning of living with migraine, to be able to meet patients' needs.[32] Finally, a recent meta–synthesis of qualitative studies on migraine treatment, based on 10 studies and a total of 161 patients, showed that five themes were commonly relevant across these studies.[33] Themes included: difficulties with health care utilization; the perceived relationships with healthcare providers – which also included trust in the provider and the providers' knowledge in managing headaches; thoughts about the various migraine treatments, which included patients' opinion on different medications, non–pharmacological and in particular behavioral treatments; understanding diagnosis/triggers; societal implications, ie, the feelings of not being seriously taken into consideration by others, and issues related to quality of life.

The aim of this study was to explore the psychological and social features underlying the relapse phenomenon and to observe eventual differences between frequent relapsers (FRs) and non–frequent relapsers (NFRs) by considering their point of view, perceptions, and perspective of their subjective experience with relapse into CM with MOH. Our exploratory hypothesis is that frequent relapsers may show a specific pattern of characteristics that make them more at risk to relapse into MOH.