Table 2 Clinical management of MOH: questions and answers

Should medication withdrawal be abrupt or gradual?

No formal evidence-based recommendation can be made.

The majority of headache specialists consider drug withdrawal more effective if done immediately. In general, triptans, ergots, paracetamol, aspirin and NSAIDs should be stopped abruptly.

Should patients receive replacement therapy?

Evidence from available controlled trials suggest that non-complicated MOH patients may achieve successful drug withdrawal through the simple imparting of advice to withdraw symptomatic medications and the use of rescue medications with limits on intake.

What are the most effective therapeutic programmes for controlling withdrawal symptoms?

Patients overusing drugs containing opioids, barbiturates or tranquillisers usually require a replacement therapy (clinical experience-based recommendation).

Should replacement therapy be administered routinely or as rescue therapy?

Although this is not yet supported by scientific evidence, patients overusing analgesics, ergots, combination drugs or combinations of acute medications (especially those using multiple daily doses), who experience intolerable withdrawal symptoms or present medical and psychiatric illnesses that could complicate their withdrawal programme, should be considered for regular replacement therapy, whether symptoms are present or not (clinical experience-based recommendation).

No evidence-based recommendation can be made on the most effective replacement therapy in these patients.

Should preventive treatment be started before, during or after withdrawal?

No evidence-based recommendation can be made on the use of preventive treatment (who, when and what) for the clinical management of MOH.

In non-complicated MOH patients, the decision on whether or not to start a preventive treatment may be postponed until a follow-up visit performed 2–3 months after the start of the withdrawal treatment. Complicated MOH patients, especially those who already had a high headache frequency before development of medication overuse and who had tried more than one preventive treatment in the past, probably need early prophylaxis (clinical experience-based recommendation).

What are the most effective preventive treatments?

There are no evidence-based indications supporting the use of specific preventive drugs in MOH (valproic acid as well as topiramate have been shown to have beneficial effects in the prophylactic treatment of chronic migraine, complicated by excessive analgesic intake in open-label and double-blind trials).

Should patients be managed through inpatient or outpatient withdrawal programmes?

No evidence-based recommendation can be made. In non-complicated MOH patients, effective drug withdrawal may be obtained in an outpatient setting. MOH patients overusing opioids, barbiturates or benzodiazepines, or presenting psychological problems or medical illnesses liable to complicate withdrawal programmes undertaken on an outpatient basis, are candidates for hospitalisation, as are those who have previously failed as outpatients or who lack the motivation needed to undertake an outpatient withdrawal programme (clinical experience-based recommendation).

What is the best approach to adopt to prevent the relapse?

The fact that a large proportion of MOH patients are at risk of relapse after withdrawal provides an indication of the lack of effective strategies for preventing this outcome.

The most practical strategy in MOH is to prevent medication overuse through education and early and appropriate headache prophylaxis in patients who present a high headache frequency (author’s personal view).