Analysis Outlines Factors Associated With Acute Medication Overuse in Migraineurs

Among both chronic and episodic migraineurs, those with acute medication overuse (AMO) experience more headache-related disability, anxiety, depression, and emergency department (ED)/ urgent care (UC) use for headache than those without AMO, according to an analysis of the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Findings were published in Neurology Clinical Practice.

“The goal of acute treatment [for migraine] is to relieve symptoms and restore function,” authors explained. However, “current acute treatments are often inadequately effective, contributing to the need for more frequent dosing and overuse, thereby substantially increasing migraine burden as well as the risk of disease progression.”

CaMEO is a cross-sectional and longitudinal internet study that collected data relating to migraine from a systematic sampling of the US population between September 2012 and November 2013.

In comparison to medication overuse headache (MOH) (headache occurring ≥15 days per month in individuals with a preexisting headache disorder and regular overuse of acute medications for more than 3 months) AMO is defined as taking specific medications for 10 or more days per month for most medications, or 15 or more days per month for simple analgesics.

As such, those with AMO may not meet the headache-day criteria for MOH, while some may use medication on headache-free days in anticipation of a migraine attack, researchers noted.

In an effort to estimate the relative frequency of AMO, characterize the types of acute medications overused, and identify other factors affecting those with AMO, investigators analyzed data from 16,789 CaMEO respondents with migraine.

Of these participants, 14,936 (89%) reported using any acute medication to treat attacks while use of over-the-counter (OTC) drugs was reported by 14,279 (85%) of respondents. In addition, 4902 (29.2%) of respondents reported using any prescription drug and 4245 (25.2%) used both OTC and prescription medications.

A total of 2975 individuals (17.7%) met criteria for AMO. These patients were more likely to be obese, were less likely to have a 4-year college degree, had a higher median number of monthly headache days (MHDs) and were more likely to have at least 15 or more MHDs.

Additional analyses revealed:

• Approximately 67.9% (2,021 of 2,975) of AMO respondents reported <15 MHDs
• Simple analgesics, combination analgesics, and opioids were the medication classes most commonly overused
• Factors associated with AMO in the final multivariable logistic regression model included ≥15 MHDs, moderate to severe disability, severe migraine interictal burden, use of preventive medication, and an ED/UC visit for headache within 6 months
• Overusing opioids for the acute treatment of headache was associated with a lower likelihood of employment (odds ratio [OR] 0.61, 95% CI, 0.47–0.79)
• Overusing triptans for the acute treatment of headache was associated with a greater likelihood of diagnosis of migraine by a physician (OR 4.11, 95% CI, 2.5–6.75)

“The differences in the relative frequency of self-reported medical diagnosed comorbidities between AMO and non-AMO respondents were greatest in the <15 MHDs subgroups, with many pain-related comorbidities exhibiting the largest differences in the AMO subgroup compared with the non-AMO subgroup,” authors said.

As migraine is associated with numerous comorbidities, these conditions may contribute to increased medication use, while the pain comorbidities of migraine could lead to increased analgesic use.

AMO is also associated with the risk of disease progression from episodic to chronic migraine. “Although the relationship between medication use and disease progression is not straightforward across all acute medication classes, the suboptimal treatment of migraine attacks is a risk factor for progression,” researchers explained.

Results support the notion that providers should review the frequency of acute medication use among all migraineurs, regardless of monthly headache frequency.

Due to the nature of the study, causality cannot be determined while participation bias may have been present, marking a limitation.

“Use of comprehensive migraine treatment plans that include improved acute treatment options as well as considering guideline-based preventive treatments, including both pharmacologic and nonpharmacologic modalities, combined with appropriate education may help to reduce the relative frequency of AMO and the associated burden from possible MOH,” authors concluded.

Reference

Schwedt TJ, Buse DC, Argoff CE, et al. Medication overuse and headache burden: results from the CaMEO study. Neurol Clin Pract. 2021;11(3):216-226. doi:10.1212/CPJ.0000000000001037