Addressing medication overuse is one of  the most important decisions on your headache journey. Managing medication-overuse headache is not easy, but if there is a suspicion that overuse plays a role in the chronic headache problem, it must be done. 

Here are a few facts to help you to plan for a withdrawal.

Get information before you take the leap

It takes a lot of mental strength and determination to complete a withdrawal. Knowing what to expect is an essential part of the process. As you stop the medications, your brain will ask you for them, and you will need to stand firmly on WHY you are doing this. (See this post) 

What are the chances of improving after a withdrawal? 

Here are encouraging facts! 

After brief advice, and information in the office, 20 to 30% of people  can stop overusing and then improve significantly. 

After an organized withdrawal, 70% of patients can  return to an episodic status (<15 days of headache per month) and see their headaches improve by 50%. 

Roughly put, your chance of improving after a withdrawal is more than 50%!

Collaborate with your physician 

Your physician can help you by providing information and can prescribe a preventive treatment, bridge therapy, or other supportive medications that can help. Your physician can also sign a sick leave if needed. As the rebound headaches can be tough, sometimes it’s better to plan for some rest.

Get the support of your network

You should not be alone in this. Explain to your close ones what you are doing and why. Get your partner, friends, and close ones to support you. If they witness distress during the withdrawal, they should be able to encourage you, not tell you to give in and take medications. 

Be aware that there are situations easier than others 

A withdrawal is not always that difficult. 

Here are examples of easier situations:

  • No opioids 
  • No severe anxiety or insomnia
  • No addiction problem
  • No other chronic pain 
  • Shorter duration of the overuse
  • Underlying migraine (not tension-type or new daily headache) 
  • No history of previous failures at withdrawal

If the   above elements are present, the situation might require more support and careful planning. It does not mean that it cannot be a success! 

Starting a preventive in parallel with the withdrawal is an option

Most people who fall into the trap of medication overuse headache had frequent headaches to start with.  The withdrawal may help a lot, but you might still require preventive therapy in the long run. In the past, there was a dogma that preventive treatments were not effective, causing an overuse situation. 

We know now that preventives might still work and help to stop the overuse. Good results of prevention even in the presence of overuse have been observed with Botox, topiramate , and CGRP antibodies. 

In certain situations, overuse is driving the problem and might decrease the effectiveness of preventives. The use of opioids and barbiturates, in particular, may be an issue. You should discuss this with your physician.

Research suggests that stopping cold turkey is the best approach for simple situations

There is a lot of variability in the «how to detox» protocols  worldwide. Americans tend to use more bridge therapy and do not accept the cold turkey approach, stating that it’s too difficult. Interestingly, a recent Scandinavian study shows the reverse. 

People tried a withdrawal with limited amounts of acute meds or a cold turkey approach (no acute medications at all). In the end, the cold turkey group fared better, had even less anxiety (maybe because there was just no choice to take or not take medication), and had more success. We have to underline that participants in this study were not very complex cases, as these people are detoxed as inpatients in Denmark. 

Some people may need an inpatient withdrawal 

Indeed,  research suggests that a withdrawal at home is not always feasible. The anxiety may be too high to manage, there might be withdrawal symptoms, and if the person has to run the household, rest might be limited. Different protocols exist around the world. Most involve multidisciplinary care, nursing support, IV medications, and sometimes blocks and injections. The inpatient stay can be a few days to two weeks. 

In Canada, it is  difficult or often impossible to access inpatient withdrawal for medication overuse headache, as inpatient beds are usually reserved  for acute medical situations. 

How long should I stop the medications? 

A duration of one month is usually recommended. The first two weeks are usually the most difficult. The withdrawal of triptans might be quicker. Opioids may take longer. 

If I take opioids, is it dangerous to stop abruptly? Should I stop slowly? 

This is a question to be discussed with your physician. Most pain clinics advise a very slow taper if there is a problem with opioid tolerance or addiction . Some support therapies like Suboxone or Methadone can be used. If you are using high doses of opioids, it is possible that your headache neurologist will not be comfortable  managing your withdrawal. The help of a Pain Clinic might be needed. 

Many bridge therapies exist, but most are not clearly proven. 

A bridge therapy is usually a medication used during the withdrawal to ease the withdrawal symptoms and the rebound headaches. Examples include oral steroids, celecoxib, IV DHE, anti-emetics, anti-inflammatories, and even  long-acting triptans (if triptans are not overused). Clonidine can be used to manage opioid withdrawal. 

What if I have another chronic pain and need to take opioids for this reason? 

This is a complex situation that should be discussed with your physician. 

Even with the best conditions, withdrawal does not always work 

We have shared the success rates previously. Success after a withdrawal is not 100%. First, some people are just unable to stop the acute medications for different reasons. Dropping out of the withdrawal happens in 10 to 20% of people, especially in complex situations. This is not the end of the road, though. Another attempt could be successful, sometimes with a new preventive or more support. 

If you successfully stopped overuse, keep an eye for recurrency

YOU DID IT! You successfully stopped, and now you are doing much better. But your brain is still prone to headache and the vicious circle of overuse. During a more difficult headache phase, it is not uncommon to increase the use of acute medications again. 25 to 35% of people will relapse. Be watchful, use a diary, and if you see things slipping out of control, discuss with your physician to find other ways to decrease your headache frequency. 

Act like a Migraine Warrior! 

Bring this article to your physician. This freely accessible medical article provides excellent information on MOH and withdrawal for health care providers.

Read More:

https://www.mdedge.com/ccjm/article/89107/drug-therapy/breaking-cycle-medication-overuse-headache

https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/media_f959a1b_236.pdf

REFERENCES

Fischer MA, Jan A. Medication-overuse Headache (MOH).  StatPearls. Treasure Island (FL): StatPearls Publishing

StatPearls Publishing LLC.; 2019.

Kristoffersen ES, Straand J, Vetvik KG, Benth JS, Russell MB, Lundqvist C. Brief intervention by general practitioners for medication-overuse headache, follow-up after 6 months: a pragmatic cluster-randomised controlled trial. J Neurol. 2016;263(2):344-53.

Chiang CC, Schwedt TJ, Wang SJ, Dodick DW. Treatment of medication-overuse headache: A systematic review. Cephalalgia. 2016;36(4):371-86.

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