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.
Clarify with your health care provider if a withdrawal is necessary
People who use frequent acute medications often suffer from chronic migraine [1] to start with. Sometimes, the best way is to optimize prevention. Treatments like topiramate [2], Botox, CGRP antibodies and gepants have been shown to be effective even when someone is «overusing». Indeed, if a preventive works, then the person uses less acute meds and there is no problem of overuse anymore!
In certain situations, the overuse is really driving the headache problem and might decrease the effectiveness of preventive. The use of opioids and barbiturates, in particular, may be an issue. You should discuss this with your health care provider.
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 [3])
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 health care provider
Your HCP can help you by providing information and can prescribe a preventive treatment [4], bridge therapy, or other supportive medications that can help. Your physician can also sign a sick leave if needed. As the rebound headaches during withdrawal 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 opioid use
- No severe anxiety or insomnia [5]
- No addiction problem
- No other chronic pain
- Shorter duration of the overuse
- Underlying migraine [6] (not tension-type or new daily headache)
- No history of previous failures at withdrawal
If the elements above are present, the situation might require more support and careful planning. It does not mean that it cannot be a success!
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 headaches, 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 [7] 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 [7] (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 out for recurrency
YOU DID IT! You successfully stopped, and now you are doing much better. But your brain is still prone to headaches 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 [8]
REFERENCES
Vandenbussche N, Paemeleire K, Katsarava Z. The Many Faces of Medication-Overuse Headache in Clinical Practice. Headache. 2020;60(5):1021-36.
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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