Withdrawal and preventive therapy best management for medication overuse headache

Medication overuse headache (MOH) is best treated with a combination of analgesic withdrawal and pharmaceutical prophylaxis, the authors of a study in JAMA Neurology have said (26 May 2020)^[1]
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The open-label trial involved 120 patients who were randomly assigned to one of three treatments: analgesic withdrawal plus immediate preventive medication; preventive medication without withdrawal; or withdrawal with optional preventive medication two months later.

At six months, the researchers found no significant difference between the groups in the reduction in headache days per month. However, 96.8% of those in the withdrawal plus prevention group were cured of MOH compared with 74.3% in the prevention-only group and 88.9% in the withdrawal and delayed prevention group.

These findings corresponded to a 30% increased chance of MOH cure in the withdrawal plus preventive group compared with the preventive group (relative risk: 1.3; 95% confidence interval 1.1-1.6).

MOH is a type of chronic headache usually caused by a worsening of episodic headache from overuse of analgesia. It is treated through withdrawal of the overused medication and, sometimes, prophylactic treatment, such as topiramate. However, the optimal treatment strategy is debated.

While all three strategies were effective, the researchers concluded that “withdrawal therapy combined with preventive medication therapy from the start of withdrawal was the most effective treatment according to several secondary end points and is recommended as the preferred management of MOH.”