Thoughts from our Medical Director on the new NICE guidelines for headache
NICE Headache guidelines: the importance of managing medication overuse
Giles Elrington MD
Medical Director, National Migraine Centre, 22 Charterhouse Sq, London EC1M 6DX
Doctors don’t generally appreciate being told to change practice by NICE; on this occasion NICE is absolutely right to draw attention to the importance of medication overuse in headache. This clinical guideline is better late than never, and misses a few tricks. It is required reading for any healthcare professional who advises people with headache: which is most of us, at one time or another.
The key point is that people who have headache (including pain in the face and neck) who frequently use medication as-required to abort pain that is present more often than not, paradoxically worsen their pain, and at least partly block response to evidence-based treatments. “Medication Overuse Headache” appears to be a specific complication of migraine and of its non-disabling, featureless close relative, tension-type headache. A third, uncommon headache, is lumped into this guidance by NICE: but it is a completely different disease, which, curiously, is not worsened by medication overuse (unless there is by chance co-existent migraine). The point is that migraine and tension-type headache occur on a spectrum rather than being distinct disorders, localising to a “software error” in the brainstem; whereas cluster headache localises to the midbrain. These are neurological diseases: not fundamentally caused by disorder of blood vessels, diet, stress, hormones, the neck, the heart or any other of the usual suspects – though co-morbidity and triggering may involve those other organ systems.
Migraine typically begins with attacks lasting hours or days of pulsating head pain accompanied by a range of gastrointestinal or hypersensitivity phenomena, sometimes heralded or accompanied by transient cortical or brainstem dysfunction known as aura. Experience and evidence leave no doubt that abortive medication is most effective if taken early. Evidence shows that failed acute medication is ineffective when repeated during that attack, but experience shows that patients ignore the maxim “when you’re in a hole, stop digging” and repeat doses of medication that are either ineffective or, as they so often report, “take the edge off the pain”. Thus about 10% of migraineurs mature from episodic to chronic pain. When pain is for at least three months present on more days than not, and triptans, opiates or combination analgesics are taken on ten or more days each month (only one day in three – not a lot) the definition of Medication Overuse Headache is fulfilled. The exception is for single analgesics (aspirin, paracetamol, NSAIDs) where the threshold is 15 days of medication a month (only alternate days) but in fact most such patients have long ago stepped up to “something stronger”.
Obtaining the history of medication overuse is typically challenging. A diary can be invaluable though patients need to record all headache and all medication. Less severe headache and non-prescribed medications are often overlooked: all must be on the daily headache diary. Patients are often uncertain, or dissemble perhaps because of embarrassment at the quantity, when asked about frequency of dosing. It can be helpful to ask the spouse; enquire frequency and size of purchase; probe on number of medication stashes. Patients who describe attack duration in terms of medication response, or who are breaking triptans in half or smaller portions, may be assumed to have medication overuse. It is important to avoid blaming the patient for medication overuse, acknowledging that this is a natural response to frequent pain. Many patients are clinging on to employment in the face of severe headache under threat of dismissal if they have more days off sick, and dosing themselves up to keep going. Addressing this matter may take a number of consultations in primary care: it is not an urgent matter.
NICE recommends abrupt withdrawal of all overused acute headache medications. Others might allow no more than 9 days of treatment a month; though this could (unsympathetically) seem like allowing a former alcoholic to drink 28 units a week. Benefit of withdrawal from triptans is more rapid than from the near-ubiquitous codeine combination drugs, so a switch from an overused codeine and paracetamol combination, to temporary triptan overuse (possibly favouring one with a long half life such as frovatriptan) might be considered. A regular strong long-lasting NSAID (a useful class of drugs scarcely recommended by NICE for headache) such as naproxen 250mg or 375mg taken absolutely regularly three times daily after meals, not as and when required, for a few weeks, is worth considering. Some would go as far as a short course of oral steroids, such as prednisolone 1mg/kg daily for a week or two with brisk taper to zero. Others would simply start a prophylactic such as topiramate and hope that benefit might in time facilitate acute medication withdrawal; NICE lists this lower than simple abrupt cessation .
Medication withdrawal is often poorly tolerated for the first couple of weeks. Nausea may require regular domperidone. The timing should be planned to coincide with a couple of weeks off work, mobilising family or friends for domestic support, just as if an elective surgical procedure is planned. Healthcare support should be available and must emphasise the high but not guaranteed likelihood of improvement that is occasionally rapid within a week or two especially with pure triptan overuse; and is largely complete within a month or two of absolutely complete and total acute headache medication cessation. At this point, residual episodic migraine must be carefully targeted with acute rescue no more than two days a week every week; more frequent migraine with a regular prophylactic: including those in which the benefit may be previously blocked during and soon after the medication overuse phase.
Medication overuse headache is under-recognised, and treatable. NICE rightly draws attention to it. There is useful if insufficient attention to the brain scan question (briefly: not recommended for reassurance) ; the important “incidental finding” agenda, is scarcely mentioned. Sadly, other important and good value treatment strategies such as lifestyle hygiene are ignored.
Headaches. Diagnosis and management of headaches in young people and adults. Clinical Guideline 150. http:// www.nice.org.uk/nicemedia/live/13901/60854/60854.pdf