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MOH

Caffeine and opioid (narcotic) drugs, if taken regularly, are proven to worsen headaches. This will not come as a surprise to anyone drinking large amounts of coffee – skipping your morning cup will leave you with a headache. Taking too much Excedrin, Fioricet, or Percocet will also make you want to take these drugs more and more often and with diminishing relief. However, most neurologists and headache specialists believe that triptans (sumatriptan, rizatriptan, et al.) and NSAIDs (naproxen, ibuprofen, et al.) can also cause “medication overuse headaches”. This remains a belief, rather than a scientific fact and it leads to thousands of headache sufferers being unfairly accused of causing or worsening their own headaches. They are being denied a safe and effective treatment that could relieve their suffering and reduce disability. My most popular blog post that so far has elicited 247 comments, is one on the daily use of triptans.

Drs. Ann Scher of Uniformed Services University, Paul Rizzoli and Elizabeth Loder of Brigham and Women’s Hospital have just published an article in a leading neurology journal, Neurology, entitled, Medication overuse headache. An entrenched idea in need of scrutiny. Last year I described a debate on this topic between Dr. Scher and Dr. Richard Lipton of the Montefiore Headache Clinic at the meeting of the American Headache Society. The abstract of this new article can be easily understood by the lay public, so I am including its full text.

“It is a widely accepted idea that medications taken to relieve acute headache pain can paradoxically worsen headache if used too often. This type of secondary headache is referred to as medication overuse headache (MOH); previously used terms include rebound headache and drug-induced headache. In the absence of consensus about the duration of use, amount, and type of medication needed to cause MOH, the default position is conservative. A common recommendation is to limit treatment to no more than 10 or 15 days per month (depending on medication type) to prevent headache frequency progression. Medication withdrawal is often recommended as a first step in treatment of patients with very frequent headaches. Existing evidence, however, does not provide a strong basis for such causal claims about the relationship between medication use and frequent headache. Observational studies linking treatment patterns with headache frequency are by their nature confounded by indication. Medication withdrawal studies have mostly been uncontrolled and often have high dropout rates. Evaluation of this evidence suggests that only a minority of patients required to limit the use of symptomatic medication may benefit from treatment limitation. Similarly, only a minority of patients deemed to be overusing medications may benefit from withdrawal. These findings raise serious questions about the value of withholding or withdrawing symptom-relieving medications from people with frequent headaches solely to prevent or treat MOH. The benefits of doing so are smaller, and the harms larger, than currently recognized. The concept of MOH should be viewed with more skepticism. Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication. Frequent use of symptom-relieving headache medications should be viewed more neutrally, as an indicator of poorly controlled headaches, and not invariably a cause.”

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Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other).

Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts.

Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS:

“It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month”.

And then she posed a question: How many are being harmed vs helped by this advice?

While Dr. Lipton quoted scientific articles supporting the existence of MOH, Dr. Scher’s conclusions reflected my clinical experience that MOH is not a proven entity as it relates to triptans and NSAIDs. I see it only in those who overuse caffeine or caffeine-containing drugs (Excedrin, Fioricet, etc) or narcotic pain killers (Percocet or oxycodone, Vicodin or hydrocodone, and other).

Dr. Scher concluded that, “Since the existence of MOH has not been proven (and may be non-provable for practical purposes), one is obligated to remain agnostic about this entity. And the corollary is that there is no evidence that undertreating will prevent headache frequency progression and may harm more people than help”.

In fact, the same headache experts who limit abortive therapies to twice a week, recommend aggressive abortive therapy for migraines because undertreatment of episodic migraine can lead to its transformation into chronic migraine.

She also indicated that “Quality of evidence for medication withdrawal alone as treatment for MOH is poor” and “Medication withdrawal alone is not clearly better than doing nothing and may be worse”. Meaning that in addition to withdrawal of the acute medication, patients should be given prophylactic treatment.

Studies indicate that after one year, 60% and after two years, 70% of those with chronic migraines (15 or more headache days in a month) revert to episodic ones (less than 15 headache days a month) regardless of treatment. In 15% headaches decrease to less than one a week. This is because fortunately, migraines often improve with time on their own.

We have evidence that Botox injections and some preventive medications can make discontinuation of acute medications easier. We always try to stop Fioricet (butalbital, acetaminophen, and caffeine), Fiorinal (butalbital, aspirin, and caffeine), Excedrin (caffeine, acetaminophen, aspirin) with the help of regular aerobic exercise, biofeedback or meditation, magnesium and other supplements, Botox injections, and sometimes preventive medications.

However, we do have several dozen patients whose headaches are controlled by the daily intake of triptans. These patients have tried given prophylactic medications, Botox injections and other treatments, but find that only triptans provide good relief and eliminate migraine-related disability. The most commented on post on this blog (with 175 comments to date) is one on the daily use of triptans.

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“Daily triptan use for intractable migraine” is the title of a report by Dr. Egilius Spierings published in the latest issue of the journal Headache. This is a controversial topic, which I addressed in a previous post. Dr. Spierings, who is affiliated with both Tufts Medical Center and Harvard Medical School presents a case of a 50-year-old woman who failed trials of multiple preventive medications. This woman responded well to sumatriptan, 100 mg, which she took daily and occasionally twice a day with excellent relief and no side effects. Dr. Spierings discusses the evidence for Medication Overuse Headaches (MOH), which is common with caffeine-containing drugs, butalbital (a barbiturate), and opioid drugs (narcotics). It is less clear whether triptans cause MOH and he mentions that most patients who end up taking a daily triptan do so only after they failed many preventive (prophylactic) drugs and after they discover that they can have a normal life if they take a triptan daily. This applies not only to sumatriptan, but any other similar drug, such as Amerge (naratriptan), Zomig (zolmitriptan), Maxalt (rizatriptan), Relpax (eletriptan), and other. After 20 years of being on the market, we have no evidence that these drugs have any long-term side effects. In Europe several of these drugs are sold without a prescription. The major obstacle to their daily use has been the cost. However, several of these medications are now available in a generic form and a 100 mg sumatriptan tablet costs as little as $1.50.

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A small number of my patients take triptan medications daily. Many doctors, including neurologists and headache specialists think that taking these drugs daily makes headaches worse, resulting in rebound, or medication overuse headaches (MOH). However, there is no evidence to support this view. Sumatriptan (Imitrex, Treximet), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova) have revolutionized the treatment of migraines. I started my career in 1986, five years before the introduction of sumatriptan when treatment options were limited to ergots with and without caffeine (Cafergot), barbiturates with caffeine and acetaminophen (Fioricet), and narcotic or opioid drugs (codeine, Vicodin, Percocet). These drugs were not only ineffective for many migraine sufferers, but they also made headaches worse. Dr. Richard Lipton and his colleagues followed over 8,000 patients with migraine headaches for one year. Results of their study showed that taking barbiturates (Fioricet, Fiorinal) and narcotic pain killers increased the risk of migraines become more frequent and even daily and resulting in chronic migraines. We know from many other studies that withdrawal from caffeine and narcotics can result in headaches. However, taking triptans and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin (Migralex), naproxen (Aleve), ibuprofen (Advil, Motrin) does not lead to worsening of headaches. Only those patients who were taking NSAIDs very frequently to begin with were more likely to develop even more frequent headaches at the end of the year. Aspirin, in fact, was found to have preventive properties – if you were taking aspirin for your migraines at the beginning of the year you were less likely to have worsening of your headaches by the end of the year.
There are also studies showing that NSAIDs taken daily can be effective for the prophylactic (preventive) treatment of migraine headaches. Unfortunately, no studies have been done to show that taking triptans daily can also prevent headaches.
Over the years, I have treated dozens patients with daily triptans. Prescribing sumatriptan or another triptan for daily use was never my original intent. However, most of these patients failed multiple preventive medications, Botox injections, various supplements, biofeedback and acupuncture. Because of the widespread belief that triptans cause rebound headaches most of them tried to stop taking these drugs. After a week or even several weeks, their headaches did not improve, as should be the case with rebound or MOH. In fact, most of them became unable to function and I would resume prescribing 30 and up to 60 tablets of a triptan each month. Sometimes I would prescribe 6 of one, 9 of another, and 18 tablets of the third triptan, depending on what the insurance company would allow. For some patients all triptans work equally well, for some several do, and for others only one out of seven would provide good relief without causing side effects.
The cost of these drugs, even after sumatriptan going generic, has been very high and is now the main obstacle for most patients. The original main concern we had early after the introduction of triptans was the potential serious side effects. But now, 20 years of experience strongly suggests that taking triptans daily does not cause any serious long-term side effects. I do not suggest that they cannot or do not cause serious side effects – they can and do and are contraindicated in patients with coronary artery disease and strokes, but in healthy people they are very safe. For the past several years, triptans have been available in Europe without a prescription.
In conclusion, daily triptans can be a highly effective and safe treatment for a small group of patients with chronic migraine headaches. They should not be prescribed for the prevention of migraines or for daily abortive use, unless other options (excluding barbiturate, caffeine, or narcotics) have been tried.

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Medication overuse (rebound) headache (MOH) has been the subject of many studies and reports.  Another review of this subject appeared in the latest issue of journal Pain by Italian neurologists. This review addressed possible causes, predisposing factors, and possible treatments. The list of possible drugs which can lead to overuse headaches included in this article includes every possible headache medicine. However, the authors do not mention that for some drugs there is more scientific evidence than for other. For example, only caffeine and opioid (narcotic) analgesics have been proven to cause MOH, while drugs such as aspirin may actually prevent the development of MOH. There is only anecdotal (case reports) evidence for triptans (sumatriptan, or Imitrex, rizatriptan, or Maxalt, and other). The authors suggest that both environmental and genetic factors may contribute to patient’s vulnerability to substance overuse, dependence, and withdrawal in MOH. They also think that psychological comorbidities such as depression, anxiety and poor pain coping abilities may contribute to chronification of headaches.
The authors report on different detox strategies, including the need for hospital admission for patients taking large doses of narcotics or barbiturates (such as butalbital, found in Fioricet, Fiorinal, Esgic). However, almost all patients seen at the New York Headache Center are successfully withdrawn on an out-patient basis. Many patients fear worsening of pain from medication withdrawal, but several treatments can make the process less painful. Botox injections, intravenous infusions of magnesium, topiramate (Topamax), gabapentin (Neurontin) and a short course of steroids are some of the most commonly used strategies. Elimination of dietary caffeine, regular aerobic exercise, biofeedback, and acupuncture are also very useful adjunctive therapies.

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Medication overuse headache (MOH) does not respond to steroids according to a new study published in the July 3 issue of journal Neurology. Patients who take Fioricet, Fiorinal, Esgic, Excedrin and other, mostly caffeine-containing drugs often have a headache that is perpetuated by the constant intake of these drugs. This is less likely to happen from triptans, such as Imitrex, Maxalt and Relpax or ibuprofen and acetaminophen. When we try to stop these medications headache usually worsens for several days or weeks before it gets better. We do use corticosteroids (prednisone, dexamethasone, methylprednisolone) to treat not only headaches that result from medication withdrawal but also severe migraines that do not respond to the usual migraine drugs. Corticosteroids are safe when taken occasionally, but can cause many different and often dangerous side effects if taken for long periods of time (weeks and months). We limit the use of corticosteroids to a few days a month.
The editorial which accompanies this report comments on the fact that a previous, larger but less rigorous study found that steroids are beneficial for MOH. The possible reasons for this discrepancy are: 1. the dose of prednsione used in the study was not high enough; 2. corticosteroids are only effective for MOH in patients who suffer from migraines and not tension-type headaches (both were included in this study); and 3. the older and larger study was not blinded and placebo might have played a bigger role.
The bottom line is that because of our positive experience and in the absence of a definitive negative study, we at the NYHC will continue using corticosteroids both for MOH and for other refractory migraine attacks when other treatments (triptans, intravenous magnesium, Botox, etc) fail.

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