In patients with chronic migraine and medication overuse, the effectiveness of preventive therapy does not appear to be reliant on stopping the overused medication first.

The overuse of acute pain medication is common in patients with chronic migraine and is associated with devel­oping more frequent headaches. To deter­mine the optimum treatment strategy for addressing chronic migraine with medica­tion overuse, researchers conducted an open­ label clinical trial. They randomised 720 adult participants 1:1 to migraine preventive medication and (a) switching from the overused medication to an alternative used no more than two days per week, or (b) continuation of the over­ used medication with no maximum limit. The primary outcome was moderate to severe headache day frequency at weeks nine to 12 and during weeks one and two after randomisation.

Migraine preventive medication with­ out switching of the overused medication was not inferior to preventive medication with switching in terms of moderate­ to­ severe headache day frequency during weeks nine to 12 (switching = 9.3 headache days [SD, 7.2] vs no switching = 9.1 head­ache days [SD, 6.8]; p = 0.75). Prevalence of medication overuse during weeks nine to 12 was significantly lower with switch­ing (53% vs 73% in the no­ switching group), and mean frequency of days using symp­tomatic medication was also lower in the switching group. Serious adverse events did not differ substantially between the groups. 

Comment: Prior studies have provided evidence for the efficacy of optimising preventive therapy with and without dis­continuation of the overused medication (Cephalalgia 2016; 36: 371­-386 and Cepha­lalgia 2018; 38: 225­-236). However, head­ to­ head comparisons to determine which strategy is superior have been limited, with only one prior study to date (JAMA Neurol­ogy 2020; 77: 1069­-1078). This study pro­vides useful clinical information that the effectiveness of preventive therapy is not contingent on stopping the overused medi­ cation first. Although there was no differ­ence for the primary outcome parameter, some secondary outcomes were better in the switching group. This could be inter­preted as a benefit due to less exposure to potential medication side effects.
OYINDAMOLA I OGUNLAJA, MB BS
Clinical Research Fellow, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK.

Schwedt TJ, et al. Patient­ centered treatment of chronic migraine with medication over­ use: a prospective, randomized, pragmatic clinical trial. Neurology 2022; 98: e1409. 
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

This summary is taken from the following Journal Watch title: Neurology.