Combination Therapies Show Highest Efficacy Against Medication-Overuse Headache

Combination therapies appear effective as first-line treatment in medication-overuse headache (MOH) and may help reduce relapse risk, according to study results published in The Journal of Headache and Pain.

Researchers conducted a network meta-analysis to compare the efficacy of MOH treatment strategies. They analyzed data from randomized controlled trials (RCTs) of adult patients with MOH or primary headache disorder linked to medication overuse. Assessed treatment strategies included withdrawal methods, headache education and prevention, and bridging therapies involving neurostimulation. Control interventions included no intervention and oral or injectable placebo. The primary outcome was the reduction in monthly headache days or migraine frequency, which was evaluated in the 2 to 6 months after intervention initiation or 6 months after completion of education sessions.

A total of 16 RCTs published between 2006 and 2023 were included in the final analysis, representing 3000 unique patients; the duration of follow-up ranged from 8 to 24 weeks. Specific treatment strategies included abrupt withdrawal, oral preventive therapies, botulinum toxin injections, and anti-calcitonin gene-related peptide (CGRP) therapies. Combination strategies involved abrupt withdrawal paired with oral prevention, botulinum toxin, greater occipital nerve blocks (GONB), additional education, and restrictions on overused medications.

Combination therapies demonstrated the highest efficacy in the management of MOH when compared with control interventions. The greatest reduction in monthly headache days was observed with abrupt withdrawal combined with oral prevention plus GONB (mean difference [MD], -10.6 days; 95% CI, -15.03 to -6.16), followed by restriction of overused acute medications combined with oral prevention plus anti-CGRP therapies (MD, -8.47 days; 95% CI, -12.78 to -4.15).

The use of abrupt withdrawal alone showed no significant efficacy relative to control interventions (MD, -2.77 days; 95% CI, -5.74 to 0.20). However, the addition of either single oral preventive therapy or GONB was associated with significant improvement, reducing monthly headache frequency by 1.8 (95% CI, -3.3 to -0.2) and 2 days (95% CI, -3.7 to -0.2), respectively.

No significant differences were observed between the use of oral preventive medications, botulinum toxin, and anti-CGRP therapies for MOH management.

Study limitations include small sample sizes, differences in control conditions, the combined use of various oral headache-prevention strategies with anti-CGRP receptor therapies, and the lack of a sensitivity analysis for studies with the lowest risk of bias.

According to the researchers, “MOH management decisions should consider not only efficacy but also patient preferences, tolerability, comorbidities, contraindications, and costs.”

This article originally appeared on Clinical Pain Advisor