title: Medication-Overuse Headache: Protocols and Outcomes in 149 Consecutive Patients in a Tertiary Brazilian Headache Center.
abstract: OBJECTIVE
  Medication-overuse headache (MOH) is a challenging clinical disorder often resulting in frustration for patients and physicians. Adherence issues are common and limited treatment evidence is an obstacle to effective care. Individual bias usually directs the treatment. The aim of this study was to evaluate outcome and treatment strategies in consecutive MOH patients from a tertiary center.
  
  
  METHODS
  Every consecutive patient seen between January and December 2014 with the diagnosis of MOH was included. Psychiatric comorbidities, inability to report baseline headache frequency, current or previous 2-month use of preventive medications, and refusal to sign informed consent were exclusion criteria. The patients were evaluated by the same specialist (AVK) in thorough initial consultations. The diagnosis and treatment strategies were clearly explained, and a detailed headache diary was given to all patients. Endpoints were headache frequency and adherence after 2, 4, and 8 months.
  
  
  RESULTS
  One hundred sixty-eight patients (31 M, 137 F) met the inclusion criteria. Nineteen patients (11.3%) were excluded. All patients had migraine or chronic migraine as primary headache. Mean baseline frequency was 24.8 headache days/month, average headache history was 20.6 years (1-37), and mean time with > 15 headache days/month was 4.8 years (.5-32). All patients were overusing acute symptomatic medications (SM), and 59 (39.5%) were using more than one pharmacological class. Outpatient withdrawal from overused medications was carried out with all patients, who received different preventive treatment choices and triptan plus NSAID for the acute attacks (maximum of 2 days/week). One hundred and one patients (67.8%) received prednisone during the first 5-7 days. After 2 months, 30 (20.1%) were lost to follow-up, and in those who followed up, the mean headache frequency decreased to 10.7 headache days/month (ITT 13.1). After 4 and 8 months, 109 and 105 patients, respectively, were under treatment, with a mean headache frequency of 7.9 and 8.2 headache days/month. Patients who received prednisone did not perform better than those who did not (P = .3032, 5 d vs no prednisone; P = .639, 7 d vs no prednisone).
  
  
  CONCLUSIONS
  Withdrawing overused medications, starting prevention, and motivating patients may have helped the high adherence rates and decreasing headache frequency. Additionally, real-world patient studies are scarce and may be useful to guide clinicians struggling to help their daily headache patients. Open studies do not allow definitive conclusions and controlled studies with this subset of patients are necessary.
authors.affiliation: Headache Center of Rio, Rio de Janeiro, Brazil.
authors.forename: Abouch V
authors.initials: AV
authors.lastname: Krymchantowski
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
authors.forename: Stewart J
authors.initials: SJ
authors.lastname: Tepper
authors.affiliation: Headache Center of Rio, Rio de Janeiro, Brazil.
authors.forename: Carla
authors.initials: C
authors.lastname: Jevoux
authors.affiliation: Universidade Federal de Pernambuco, Recife, Brazil.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Valença
mesh_terms: D000293:Adolescent; D000328:Adult; D001938:Brazil; D002985:Clinical Protocols; D005260:Female; D005500:Follow-Up Studies; D051271:Headache Disorders, Secondary / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult; D016903:Drug Monitoring
keywords: chronic migraine; medication overuse headache; migraine; treatment; withdrawal