Treatment of medication overuse headache: Effect and predictors after 1 year-A randomized controlled trial.

BACKGROUND: Combined withdrawal and early preventive medication was the most effective treatment for medication overuse headache (MOH) within the first 6 months in a previous study, but results from a longer follow-up period are lacking. OBJECTIVE: (1) To measure the efficacy at 1 year of three different treatment approaches to MOH; (2) to compare withdrawal and early preventives (W+P), preventives with potential withdrawal therapy after 6 months (P+pW), and withdrawal with delayed potential preventives (W+pP); and (3) to identify predictors of chronic headache after 1 year. METHODS: Patients with MOH and migraine and/or tension-type headache were randomly assigned to one of the three outpatient treatments. Headache calendar and questionnaires were filled out. Primary outcome was a reduction in headache days/month after 1 year. RESULTS: Of 120 patients, 96 completed 1-year follow-up, and all were included in our analyses. Overall headache days/month were reduced from 24.6 (23.4-25.8) to 15.0 (13.0-17.0) (p < 0.0001), and only 11/96 patients (11%) relapsed. Reduction in monthly headache days was 10.3 days (95% CI: 6.7-13.9) in the W+P group, 10.8 days (95% CI: 7.6-14) in the P+pW group, and 7.9 days (95% CI: 5.1-10.7) in the W+pP group. No significant differences in treatment effect were seen between the three groups (p = 0.377). After 1 year, 39/96 (41%) had chronic headache. Predictors of chronic headache after 1 year were higher headache frequency (aOR 1.19; 1.09-1.31), more days with acute medication (aOR 1.11; 1.03-1.19), higher pain intensity (aOR 1.04; 1.01-1.08), and depression (aOR 4.7; 1.38-18.95), whereas higher self-rated health (aOR 0.61; 0.36-0.97) and high caffeine consumption (aOR 0.40; 0.16-0.96) were predictors of a lower risk of chronic headache. No adverse events were reported. CONCLUSIONS: All treatment strategies proved effective in treating MOH with a low relapse rate. The W+P strategy leads to the fastest effect, confirming earlier treatment recommendations. Identification of predictors for chronic headache may help identify more complex patients.

Dependence-like behaviour in patients treated for medication overuse headache: A prospective open-label randomized controlled trial.

BACKGROUND: Dependence-like behaviour may complicate withdrawal and increase risk of relapse of medication overuse headache (MOH). The most effective treatment for reducing dependence-like behaviour is unknown. OBJECTIVES: To compare patient-reported outcomes among three treatment strategies for MOH. The primary outcome was change in Severity of Dependence Scale (SDS) score from baseline to 6 months. METHODS: Patients with MOH were randomized to (1) withdrawal combined with preventive medication from start (W+P), (2) preventive medication without withdrawal (P), or (3) withdrawal with optional preventive medication 2 months after withdrawal (W). At baseline, 2, and 6 months, patients filled out SDS (used for measurements of dependence-like behaviour and treatment feasibility), Headache Under-Response of Treatment (HURT) and WHO Quality of Life BREF questionnaires. RESULTS: Out of 120 patients with MOH, 100 completed the 6-month follow-up and filled out questionnaires. The W+P arm was the most effective in treating MOH. After 6 months, the SDS score was reduced by 3.69 (95% CI 3.23-4.49) in the W+P arm, by 3.19 (95% CI 2.43-3.96) in the W arm, and by 1.65 (95% CI 0.96-2.33) in the P arm (p = 0.04). At baseline and after 2 months, the P arm was considered the most feasible treatment, but at 6-month follow-up, there was no difference in feasibility score, change in HURT score, or quality of life. CONCLUSIONS: Dependence-like behaviour was reduced most in the two withdrawal arms. Withdrawal combined with preventive medication is recommended for the treatment of MOH. SIGNIFICANCE: Withdrawal combined with preventive medication from start is the treatment strategy that reduces dependence-like behaviour the most in MOH patients. Patients initially considered preventive treatment without withdrawal as the most feasible treatment. However, no difference in feasibility between the three arms was found at 6-month follow-up. Withdrawal combined with preventive medication is recommended for treatment of MOH.

Mercury Pollution from Small-Scale Gold Mining Can Be Stopped by Implementing the Gravity-Borax Method--A Two-Year Follow-Up Study from Two Mining Communities in the Philippines.

Mercury is used globally to extract gold in artisanal and small-scale gold mining. The mercury-free gravity-borax method for gold extraction was introduced in two mining communities using mercury in the provinces Kalinga and Camarines Norte. This article describes project activities and quantitative changes in mercury consumption and analyzes the implementation with diffusion of innovations theory. Activities included miner-to-miner training; seminars for health-care workers, school teachers, and children; and involvement of community leaders. Baseline (2011) and follow-up (2013) data were gathered on mining practices and knowledge about mercury toxicology. Most miners in Kalinga converted to the gravity-borax method, whereas only a few did so in Camarines Norte. Differences in the nature of the social systems impacted the success of the implementation, and involvement of the tribal organization facilitated the shift in Kalinga. In conclusion, the gravity-borax method is a doable alternative to mercury use in artisanal and small-scale gold mining, but support from the civil society is needed.

Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review.

BACKGROUND: Case definitions of medication-overuse headache (MOH) in population-based research have changed over time. This study aims to review MOH prevalence reports with respect to these changes, and to propose a practical case definition for future studies based on the ICHD-3 beta. METHODS: A systematic literature search was conducted to identify MOH prevalence studies. Findings were summarized according to diagnostic criteria. RESULTS: Twenty-seven studies were included. The commonly used case definition for MOH was headache ≥15 days/month with concurrent medication overuse ≥3 months. There were varying definitions for what was considered as overuse. Studies that all used ICHD-2 criteria showed a wide range of prevalence among adults: 0.5%-7.2%. CONCLUSIONS: There are limits to comparing prevalence of MOH across studies and over time. The wide range of reported prevalence might not only be due to changing criteria, but also the diversity of countries now publishing data. The criterion "headache occurring on ≥15 days per month" with concurrent medication overuse can be applied in population-based studies. However, the new requirement that a respondent must have "a preexisting headache disorder" has not been previously validated. Exclusion of other headache diagnoses by expert evaluation and ancillary examinations is not feasible in large population-based studies.

The Headache Under-Response to Treatment (HURT) Questionnaire: assessment of utility in headache specialist care.

The HURT Questionnaire consists of eight questions which the patient answers as a measure of effectiveness of intervention against headache. This first assessment of clinical utility was conducted in headache specialist centres in three countries in order to demonstrate that HURT was responsive to change induced by effective management. We administered HURT on three occasions to 159 consecutive patients seeking non-urgent care from centres in Denmark and the United Kingdom: the first before the initial visit to the centres; the second at the initial visit; and the third when the specialist judged that the best possible outcome had been achieved in each patient. Questionnaires were also answered by 42 patients at initial and final visits to a centre in Italy. Internal consistency reliability was very good (α = 0.85) while test-retest reliability was fair to low (κ = 0.38-0.62 and r (s) = 0.49-0.76), possibly because headache was unstable prior to start of management. There were significant changes in responses post-intervention compared with baseline (p < 0.01), indicating a favourable outcome overall in up to 77% of patients, and responsiveness to change, but there was no improvement in patients' concerns about side effects of medication (p = 0.18). We conclude that the questionnaire has utility across headache disorders. It can help patients describe headache frequency and headache-attributed disability, medication use/efficacy/tolerability, self-efficacy and knowledge about headache. It may guide physicians in assessment of disability of individual patients, how to proceed with management towards the best possible outcome, and in evaluating the quality of management.