Medication overuse headache is the term used to define the condition of increasing migraine severity caused by medication prescribed to relieve migraines. The exact mechanism behind MOH is not completely clear. Dr Hans-Christopher Diener summed it up best, when he stated: ‘it’s a chicken and egg dilemma. Does [the] migraine get worse and patients take more medication? Or do patients take more medication and [the] migraine gets worse?’
Finding out which of these hypothesis’ are correct is significant in helping Clinicians alter treatment plans and eliminate MOH completely. Let’s look at both sides of the MOH debate, so you can get a better sense of the puzzling nature of Medication overuse headaches.
THE ORTHODOX VIEW
The general consensus in regards to medication overuse headaches is that they are poorly understood. What is clear in regards to MOH is the fact that a significant percentage of chronic migraine sufferers will, at some point, experience it. Dr. Diener (Professor of Neurosciences at the University of Essen) states that between 25-50 percent of migraineurs suffer with MOH. An added complication to MOH is the fact that they are linked with the use of opioid drugs, which have a predilection for being habit-forming, and hard to wean off.
The best current protocol for alleviating MOH is the strategic withdrawal of opioid medication. Dr Diener has observed that ‘the majority of patients with medication overuse headache revert to episodic migraine after successful treatment’. Unfortunately ‘there is a subgroup of patients where you withdraw the medication and the headache doesn’t change’. This paradox muddies a simple cause and effect relationship. It is one of the core challenges of MOH and the reason for why MOH warrants further study and observation.
AN ALTERNATE VIEW
Dr Diener’s views on MOH are the orthodox view on the topic. There is no unanimous agreement on the nature of MOH, however. Dr Elizabeth Loder (Harvard Medical School) believes this orthodox view of the condition is more a ‘gospel of medication overuse headache’ rather than an accurate assessment of the evidence. Though she acknowledges that MOH is indeed a real condition, the evidence in support of its essential concepts ‘is quite weak’.
For Dr Loder, the fact that not all MOH are alleviated with the removal of opioids implies that the pathway with which these drugs dull pain may not be the causative factor for MOH. She asserts most studies in regards to the topic of MOH are ‘observational’ and rely on vague, unclear definitions of MOH. She further posits that if MOH does indeed exist, it is not a monolithic, uniform, disease; rather, there ‘must be a spectrum of susceptibility’
Dr Loder wishes further investigation into MOH; more clinical studies with control groups to observe MOH. She is against telling patients to simply quit opioid medications, as this may cause ‘unnecessary suffering’, especially if it is found these drugs are not the causative trigger of MOH. In Dr Loder’s view, it is time ‘to take a more neutral view of medication overuse’, as ‘we cannot tell with certainty how much medication is too much’
‘The general consensus in regards to medication overuse headaches is that they are poorly understood.’
FINAL THOUGHTS
Whether it is Dr Diener or Dr Loder who eventually prove their theories correct about MOH, debate and dialogue is healthy within the scientific community. If a scientific hypothesis cannot stand the critiquing of opposing views, perhaps something is missing in its view of MOH. Perhaps it takes a tearing down of old dogma, to finally unravel the complex nature of Medication overuse headaches. On the other hand, if the current orthodox view stands strong after all the doubt and investigation, this only helps future researchers feel secure that they are building upon strong foundations. Either way, this is good news for any chronic migraine sufferers: the best minds are working on making MOH a thing of the past.
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