CONy 2024 | Medication overuse headache: is detoxification necessary?
Alan Rapoport, MD, University of California, Los Angeles, CA, discusses the ongoing debate regarding whether detoxification is necessary when treating medication overuse headache (MOH). Several different approaches are used to treat MOH, with a lack of clear evidence as to which method is optimal. Management approaches include: discontinuation of the overused medication before starting preventive therapy after the 2 month withdrawal period; preventive therapy initiation at the time of overused medication withdrawal; or initiation of preventive therapy while continuing overused medication. Prof. Rapoport argues that the introduction of new and effective preventive treatment options, such as CGRP monoclonal antibodies and gepants, has eliminated the need for detoxification. This differs from the traditional approach, which uses abrupt detoxification before being put on any preventive medicine. Prof. Rapoport believes his approach may optimal for patients and the evolving literature supports that formal detoxification may not always be necessary for successful treatment. This interview took place at the 18th Annual Congress on Controversies in Neurology (CONy 2024) in London, UK.
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Transcript
For many years, about 40 that I’m aware of, we’ve been treating this very difficult problem, medication-overuse headache, with three different directives. First, we have to explain to the patient exactly what’s going on, because most patients think when they have a headache, they should take something for the pain, or for the headache, or for the other symptoms. And if they have more problems, they take more...
For many years, about 40 that I’m aware of, we’ve been treating this very difficult problem, medication-overuse headache, with three different directives. First, we have to explain to the patient exactly what’s going on, because most patients think when they have a headache, they should take something for the pain, or for the headache, or for the other symptoms. And if they have more problems, they take more. They don’t realize that if they take it too frequently, that is five days a week instead of 1 or 2 days a week, they’ll actually get worse, and it’s harder to get them better. But when you say that to a patient, they get very nervous because they’re dependent on this medication, even though they’re still not feeling well. So, the way we’ve always done it, we educate them. We detoxify them by telling them to stop the medication that they’re overusing, either abruptly, which is what most people do, or gradually, which is what I used to do. And then just put them on a very good preventive medicine, something they take on a regular basis to decrease their headache.
Up until a few years ago, we didn’t have great preventive medicine, so it didn’t always work that well. So it was the most difficult thing that I’ve done in my neurologic career was to try to treat these people, because I didn’t have great medicines and I was taking them off their crutch. Now we have medications that are preventives that are a little bit better, we have two groups of them. One is an injectable called a monoclonal antibody against calcitonin gene related peptide, or CGRP. And more recently just since about 2020, we’ve started to have two gepants, which also work against CGRP, but they’re much shorter acting and they’re usually used for acute care of migraine but there are two forms of them that can be used preventively also. So, my feeling is when I give somebody one of these long-acting monoclonal antibodies, even though they’re still on the medication that they should be coming off, they start getting better right away. So I no longer have to really intentionally detoxify them. So I simply say to them, I’m going to give you this medication, it’s probably going to start decreasing your headaches a bit, and I don’t want you to take as much of the medication that you are overusing, but you use it as you need to. But remember, if it’s a milder headache than you’re used to, don’t take it, because ultimately I want you to either get off these medicines completely or just get them down to 1 or 2 days a week.
The other side of the debate is, you still have to detoxify them because you want them to come off the medication, and it’s clearly the wrong way, because it’s much easier not to fight with the patient and fight with yourself to detoxify them. And that’s what I’m finding I’m able to do. So it’s an important debate, because I’m going to show the literature of what the most important people in the world have said about this. And they say you must detoxify them and you have to do it abruptly. I never do it abruptly, and I certainly don’t have to do it now. So it’s a very interesting debate, and I think people will learn that my way may be a better way, and that will spread around the world. That’s what I’m hoping.
Up until recently, the literature definitely was against what I just said, because it didn’t really include these brand new medications that we have. The latest literature, which I’m going to be showing, is a little incomplete. It’s not exactly what we need, but it shows that even without detoxification, the patients get better. And it shows that when you treat somebody with medication-overuse, they do at least as well as people that don’t have medication-overuse, and actually somewhat better. So when I put all that literature together with my own personal experience, I know that it’s not necessary to formally detoxify these patients.
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