Neurol Sci (2015) 36 (Suppl 1):S169–S171 DOI 10.1007/s10072-015-2177-2
BRIEF COMMUNICATION
Proposal of a model for multidisciplinary treatment program of chronic migraine with medication overuse: preliminary study L. Grazzi • A. Prunesti • G. Bussone
Ó Springer-Verlag Italia 2015
Abstract The treatment of patients with chronic migraine associated with medication overuse is challenging in clinical practice; different strategies of treatment have been recently developed, multidisciplinary treatment approaches have been developed in academic headache centers. Education and support of patients are necessary to improve patients’ adherence to pharmacological treatments as well as to non-pharmacological therapies. This study reports a clinical experience conducted at our Headache center with a group of female patients, suffering from chronic migraine complicated by medication overuse, treated by a multidisciplinary approach and followed for a period of 1 year after withdrawal. Results confirm the efficacy of a multifaceted treatment to manage this problematic category of patients. Keywords Chronic migraine Medication overuse Multidisciplinary treatment Mindfulness
Introduction The problem concerning treatment of patients with chronic migraine (CM) associated to medication overuse (MO) is challenging in clinical practice and often a single modality of treatment, pharmacological prophylaxis in the most part of cases, can be insufficient for this problematic category of patients. Different strategies of treatment have been recently developed, as new options of pharmacological
therapies, new devices for neurostimulation methods and non-pharmacological approaches [1–3]. Up to now, clinical experiences indicate, when chronic migraine is complicated by medication overuse, withdrawal as the most adequate procedure to help these patients to stop the vicious circle between medication and pain; this procedure is helpful to educate patients how to manage their pain without using medications, also this prospectively helps patients to avoid relapses in overuse by increasing their sense of self-confidence to manage the pain episodes [3, 4]. Nevertheless, after withdrawal, usually patients are not adequately followed: they are treated by pharmacological prophylaxis for migraine according to their characteristics and their migraine history, they are seen with periodic appointments for checking their medical condition at fixed follow-up, but they are not supported to continue the process of detoxication. In particular during the first phase after withdrawal, it has been observed that migraine attacks can be intense: for patients it can be difficult to face up with these new attacks without using medications and, if not well supported and encouraged, the risk of relapse in overuse is high in this critical phase [5]. In the last decades, multidisciplinary treatment approaches have been developed in academic headache centers [5–7]. Education and support of patients are necessary to improve patients’ adherence to pharmacological treatments as well as to non-pharmacological therapies.
Aim of this study L. Grazzi (&) A. Prunesti G. Bussone Headache Center, C. Besta Neurological Institute and Foundation, Via Celoria 11, 20133 Milan, Italy e-mail: [email protected]
This study reports a clinical experience conducted at our Headache center with a group of female patients, suffering from chronic migraine complicated by medication overuse
123
S170
(diagnosis according to IHS 2013-beta criteria [8]); they were submitted to a withdrawal in a day hospital setting; after that, they followed a multidisciplinary treatment program to learn how to manage their migraine after withdrawal and we verified the clinical improvement at long follow-up.
Methods Nineteen female patients (mean age 44.2 ± 6.8) suffering from chronic migraine complicated by medication overuse (diagnosis according to IHS 2013-beta criteria; [8]) were submitted to a withdrawal in a day hospital setting; after that they were followed with pharmacological treatment for prophylaxis; moreover, a physical activity schedule (twice per week, 45 min of aerobic exercise) and cognitive behavioral approach (6 sessions of relaxation training combined with mindfulness practice, twice per month, with CD for home practice) were provided for all patients. Lifestyle modifications were suggested to patients according to their habits and their job and family necessities. Patients were submitted to psychological tests to evaluate disability, quality of life, anxiety, by MIDAS questionnaire, HIT-6 test, Spielberger test in the two forms (STAI X1–X2 for state and trait anxiety). A daily headache diary was given to record pain attacks and their intensity and medication intake every day. Follow-up were fixed at 3, 6 and 12 months after the end of the program to determine the clinical improvement by the analysis of the diary and to repeat the psychological tests.
Neurol Sci (2015) 36 (Suppl 1):S169–S171
Other studies in the literature evidenced the effectiveness of multidisciplinary treatment program for patients with chronic migraine. Harpole [9] included in a specific treatment program headache specialists, psychologists, and human care physicians. He found a significant reduction in MIDAS and headache days after 6 months. Gaul [10] in his report too evidenced significant clinical improvement for patients who followed a multidisciplinary treatment program with behavioral intervention, lifestyle modifications, aerobic exercise. In our report, although we did not record it specifically and the sample size was limited, all patients followed the therapeutic program carefully without missing any appointment; in particular, patients were able to follow the sessions for mindfulness practice and they reported increased of self-confidence in managing pain attack during and after the period of training and increased ability to manage stress situations. As we know [4], stress is considered a trigger for headaches and migraine; consequently, a mind–body intervention including mindfulness practice, lifestyle modifications, readjustment of diet and sleep rhythm can be considered very effective to support patients through their therapeutic program. This kind of multifaceted intervention, including mindfulness and meditation practice, has already shown significant advantages for patients, as emerged from preceding studies [11], and even if our report is a pilot study with a limited population of patients and without a comparison condition, the clinical improvement is significant and maintained until 12 months after the end of the program without relapses in overuse. These results may indicate the efficacy of a multidisciplinary intervention and also larger studies with longer follow-up will be necessary to confirm these preliminary data.
Results Patients improved from the clinical point of view: days of migraine per month decreased significantly (23.4 ± 6.6 vs. 11.7 ± 8.3, p \ 0.0003) and medication intake decreased significantly too (18.1 ± 4.4 vs. 8.8 ± 4.33, p \ 0.005). MIDAS total score decreased significantly (82.3 ± 75.4 vs. 43 ± 55.21, p \ 0.03). Anxiety levels and HIT-6 test score did not change significantly. After 1 year we did not record relapses in medication overuse. Although we did not record it specifically, all patients completed regularly the clinical program and they did not report any adverse event.
Conclusions Although the study lack of a control group or a comparison condition, data obtained suggest that a multidisciplinary strategy seems to be a good option to manage patients with CM and MO instead of pharmacological treatment only.
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Acknowledgments Italy.
This project has been supported by FICEF,
Conflict of interest The authors certify that there is no actual or potential conflict of interest in relation to this article.
References 1. Martin VT (2009) Medication overuse and chronic migraine. Curr Pain Headache Rep 13:337–339 2. Saper JR, Lake AE 3rd, Madden SF, Kreeger C (1999) Comprehensive/tertiary care for headache: a 6-month outcome study. Headache 39:249–263 3. Grazzi L, Andrasik F, Usai S, Bussone G (2009) Treatment of chronic migraine with medication overuse: is drug withdrawal crucial? Neurol Sci 30(S1):85–88 4. Jensen R, Zeeberg P, Dehelndorff C, Olesen J (2010) Predictors of outcome of the treatment programme in a multidisciplinary headache center. Cephalalgia 30:1214–1224 5. Grazzi L (2013) Multidisciplinary approach to patients with chronic migraine and medication overuse: experience at the Besta Headache Center. Headache 34(Suppl 1):S19–S22
Neurol Sci (2015) 36 (Suppl 1):S169–S171 6. Katsarava Z, Holle D, Diener HC (2009) Medication overuse headache. Curr Neurol Neurosci 9:115–119 7. Matchar DB, Harpole L, Samsa GP, Jurgelski A, Lipton RB, Silberstein SD (2008) The headache management trial: a randomized study of coordinated care. Headache 48:1294–1310 8. Headache Classification Committee of the International Headache Society (HIS) (2013) The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 33:629–808 9. Harpole LH, Samsa GP, Jurgelski AE, Ahipley JL, Bernstein A, Matchar DB (2003) Headache management program improves outcome for chronic headache. Headache 43:715–724
S171 10. Gaul C, Van Doorn C, Webering N, Dlugaj M, Katsarava Z, Diener HC, Fritsche G (2011) Clinical outcome of a headachespecific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study. J Headache Pain 12:475–483 11. Wells RE, Burch R, Paulsen R, Wayne P, Houle T, Loder E (2014) Meditation for migraines: a pilot randomized controlled trial. Headache 54:1484–1495
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BRIEF COMMUNICATION
Proposal of a model for multidisciplinary treatment program of chronic migraine with medication overuse: preliminary study L. Grazzi • A. Prunesti • G. Bussone
Ó Springer-Verlag Italia 2015
Abstract The treatment of patients with chronic migraine associated with medication overuse is challenging in clinical practice; different strategies of treatment have been recently developed, multidisciplinary treatment approaches have been developed in academic headache centers. Education and support of patients are necessary to improve patients’ adherence to pharmacological treatments as well as to non-pharmacological therapies. This study reports a clinical experience conducted at our Headache center with a group of female patients, suffering from chronic migraine complicated by medication overuse, treated by a multidisciplinary approach and followed for a period of 1 year after withdrawal. Results confirm the efficacy of a multifaceted treatment to manage this problematic category of patients. Keywords Chronic migraine Medication overuse Multidisciplinary treatment Mindfulness
Introduction The problem concerning treatment of patients with chronic migraine (CM) associated to medication overuse (MO) is challenging in clinical practice and often a single modality of treatment, pharmacological prophylaxis in the most part of cases, can be insufficient for this problematic category of patients. Different strategies of treatment have been recently developed, as new options of pharmacological
therapies, new devices for neurostimulation methods and non-pharmacological approaches [1–3]. Up to now, clinical experiences indicate, when chronic migraine is complicated by medication overuse, withdrawal as the most adequate procedure to help these patients to stop the vicious circle between medication and pain; this procedure is helpful to educate patients how to manage their pain without using medications, also this prospectively helps patients to avoid relapses in overuse by increasing their sense of self-confidence to manage the pain episodes [3, 4]. Nevertheless, after withdrawal, usually patients are not adequately followed: they are treated by pharmacological prophylaxis for migraine according to their characteristics and their migraine history, they are seen with periodic appointments for checking their medical condition at fixed follow-up, but they are not supported to continue the process of detoxication. In particular during the first phase after withdrawal, it has been observed that migraine attacks can be intense: for patients it can be difficult to face up with these new attacks without using medications and, if not well supported and encouraged, the risk of relapse in overuse is high in this critical phase [5]. In the last decades, multidisciplinary treatment approaches have been developed in academic headache centers [5–7]. Education and support of patients are necessary to improve patients’ adherence to pharmacological treatments as well as to non-pharmacological therapies.
Aim of this study L. Grazzi (&) A. Prunesti G. Bussone Headache Center, C. Besta Neurological Institute and Foundation, Via Celoria 11, 20133 Milan, Italy e-mail: [email protected]
This study reports a clinical experience conducted at our Headache center with a group of female patients, suffering from chronic migraine complicated by medication overuse
123
S170
(diagnosis according to IHS 2013-beta criteria [8]); they were submitted to a withdrawal in a day hospital setting; after that, they followed a multidisciplinary treatment program to learn how to manage their migraine after withdrawal and we verified the clinical improvement at long follow-up.
Methods Nineteen female patients (mean age 44.2 ± 6.8) suffering from chronic migraine complicated by medication overuse (diagnosis according to IHS 2013-beta criteria; [8]) were submitted to a withdrawal in a day hospital setting; after that they were followed with pharmacological treatment for prophylaxis; moreover, a physical activity schedule (twice per week, 45 min of aerobic exercise) and cognitive behavioral approach (6 sessions of relaxation training combined with mindfulness practice, twice per month, with CD for home practice) were provided for all patients. Lifestyle modifications were suggested to patients according to their habits and their job and family necessities. Patients were submitted to psychological tests to evaluate disability, quality of life, anxiety, by MIDAS questionnaire, HIT-6 test, Spielberger test in the two forms (STAI X1–X2 for state and trait anxiety). A daily headache diary was given to record pain attacks and their intensity and medication intake every day. Follow-up were fixed at 3, 6 and 12 months after the end of the program to determine the clinical improvement by the analysis of the diary and to repeat the psychological tests.
Neurol Sci (2015) 36 (Suppl 1):S169–S171
Other studies in the literature evidenced the effectiveness of multidisciplinary treatment program for patients with chronic migraine. Harpole [9] included in a specific treatment program headache specialists, psychologists, and human care physicians. He found a significant reduction in MIDAS and headache days after 6 months. Gaul [10] in his report too evidenced significant clinical improvement for patients who followed a multidisciplinary treatment program with behavioral intervention, lifestyle modifications, aerobic exercise. In our report, although we did not record it specifically and the sample size was limited, all patients followed the therapeutic program carefully without missing any appointment; in particular, patients were able to follow the sessions for mindfulness practice and they reported increased of self-confidence in managing pain attack during and after the period of training and increased ability to manage stress situations. As we know [4], stress is considered a trigger for headaches and migraine; consequently, a mind–body intervention including mindfulness practice, lifestyle modifications, readjustment of diet and sleep rhythm can be considered very effective to support patients through their therapeutic program. This kind of multifaceted intervention, including mindfulness and meditation practice, has already shown significant advantages for patients, as emerged from preceding studies [11], and even if our report is a pilot study with a limited population of patients and without a comparison condition, the clinical improvement is significant and maintained until 12 months after the end of the program without relapses in overuse. These results may indicate the efficacy of a multidisciplinary intervention and also larger studies with longer follow-up will be necessary to confirm these preliminary data.
Results Patients improved from the clinical point of view: days of migraine per month decreased significantly (23.4 ± 6.6 vs. 11.7 ± 8.3, p \ 0.0003) and medication intake decreased significantly too (18.1 ± 4.4 vs. 8.8 ± 4.33, p \ 0.005). MIDAS total score decreased significantly (82.3 ± 75.4 vs. 43 ± 55.21, p \ 0.03). Anxiety levels and HIT-6 test score did not change significantly. After 1 year we did not record relapses in medication overuse. Although we did not record it specifically, all patients completed regularly the clinical program and they did not report any adverse event.
Conclusions Although the study lack of a control group or a comparison condition, data obtained suggest that a multidisciplinary strategy seems to be a good option to manage patients with CM and MO instead of pharmacological treatment only.
123
Acknowledgments Italy.
This project has been supported by FICEF,
Conflict of interest The authors certify that there is no actual or potential conflict of interest in relation to this article.
References 1. Martin VT (2009) Medication overuse and chronic migraine. Curr Pain Headache Rep 13:337–339 2. Saper JR, Lake AE 3rd, Madden SF, Kreeger C (1999) Comprehensive/tertiary care for headache: a 6-month outcome study. Headache 39:249–263 3. Grazzi L, Andrasik F, Usai S, Bussone G (2009) Treatment of chronic migraine with medication overuse: is drug withdrawal crucial? Neurol Sci 30(S1):85–88 4. Jensen R, Zeeberg P, Dehelndorff C, Olesen J (2010) Predictors of outcome of the treatment programme in a multidisciplinary headache center. Cephalalgia 30:1214–1224 5. Grazzi L (2013) Multidisciplinary approach to patients with chronic migraine and medication overuse: experience at the Besta Headache Center. Headache 34(Suppl 1):S19–S22
Neurol Sci (2015) 36 (Suppl 1):S169–S171 6. Katsarava Z, Holle D, Diener HC (2009) Medication overuse headache. Curr Neurol Neurosci 9:115–119 7. Matchar DB, Harpole L, Samsa GP, Jurgelski A, Lipton RB, Silberstein SD (2008) The headache management trial: a randomized study of coordinated care. Headache 48:1294–1310 8. Headache Classification Committee of the International Headache Society (HIS) (2013) The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 33:629–808 9. Harpole LH, Samsa GP, Jurgelski AE, Ahipley JL, Bernstein A, Matchar DB (2003) Headache management program improves outcome for chronic headache. Headache 43:715–724
S171 10. Gaul C, Van Doorn C, Webering N, Dlugaj M, Katsarava Z, Diener HC, Fritsche G (2011) Clinical outcome of a headachespecific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study. J Headache Pain 12:475–483 11. Wells RE, Burch R, Paulsen R, Wayne P, Houle T, Loder E (2014) Meditation for migraines: a pilot randomized controlled trial. Headache 54:1484–1495
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