In a recent article published in Neurology Reviews, author Hans-Christoph Diener, MD, PhD said “For a majority of patients with medication overuse headache and chronic migraine, detoxification prior to initiation of preventive therapy is not necessary,” a departure from current nonevidence-based recommendations. Dr. Diener recommends a three-tiered approach to treatment starting with counseling, followed by the use of topiramate or onabotulinum toxin A, concluding with admission to a detoxification program if the other two steps have failed. Medication overuse headache is common throughout the world appearing in women more often than men. “For most patients with medication overuse headache, counseling on how to restrict the intake frequency of medication to treat headache episodes is effective,” said Dr. Diener. Topiramate and onabotulinum toxin A have been shown to be effective in treating patients with medication overuse headache and chronic migraine, but have not been evaluated in patients overusing opioids or barbiturates. In the article a study by Rossi et al. was cited as saying that effective drug withdrawal among patients with migraine and medication overuse headaches was possible with simple advice alone. Both topiramate and onabotulinum toxin A have proven to be valuable preventive options which do not always require detoxification of the patient before initiation of treatment. Dr. Diener concluded that because approximately 50% of medication overuse headache patients respond to counseling and 50% of the remaining patients respond to prophylaxis, his three-tiered approach reduces the percentage of patients who require detoxification to 25%.

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