We know the repeated use of abortive medications, such as triptans and pain relievers (over the counter or prescribed) to treat frequent Migraine attacks can create medication overuse headache or MOH. This happens when we overuse medications to treat our Migraines, leaving many of us without other options. Up to this point, it has been thought that MOH needed to be stopped before preventive treatments would work. There have been a few different ways to look at ending MOH. One was to immediately stop the offending medication, the quickest and sometimes unpleasant way. But this approach may include possible withdrawal side effects that include dizziness, nausea, vomiting, headache, tachycardia, sleep disturbances, anxiety and nervousness. These can last up to 14 days according to Dr. Peter Goadsby, while other Migraine specialists argue the withdrawal period can take weeks or months. One medication that should never be suddenly stopped is butalbital compounds, especially if taken in large doses. In these cases patients need to work with their doctors to follow a titration schedule so tapering off them won't induce any seizure activity. Another method that has been used to stop MOH is detoxification. However,  not all experts think detoxification is necessary for preventive treatment to be effective. At the 53rd annual scientific meeting of the American Headache, Society, Dr. Hans-Chrisotph Diener was the speaker for the presentation, “Controversies in Headache Medicine: Detoxification for Medication Overuse Headache is not Necessary.”

In the process of getting topiramate (Topamax) approved for the prevention of Migraine, two trials (Diener et al., 2007; Silberstein et al., 2007) were conducted using topiramate vs. placebo for the treatment of chronic Migraine (Migraine 15 or more days per month). Most patients (78) of participants in the European trial overused acute medications, the majority of them overusing triptans (Opioids are seldom used for Migraine in Europe.). In the United States trial, anyone using acute medications four days or more a week were excluded, with 37% reporting medication overuse at the beginning of the trial. In both trials, participants showed a significant reduction in Migraines with topiramate vs. placebo. A later analysis of the United States participants with MOH showed significant improvement. In the European trial, 63% of patients met the criteria for MOH at the beginning of the trial, but only 15% met the criteria at week 16 of the trial. Thus, the conclusion drawn is that topiramate is effective in the prevention of chronic Migraine, both in patients with and without MOH.

Study of the PREEMPT studies conducted in the process of getting approval of onabotulinumtoxinA (Botox) for the treatment of chronic Migraine also revealed interesting data about MOH. At the European Headache and Migraine Trust International Congress (EHMTIC) in 2010, Silberstein et al presented the results of a subgroup analysis in patients with medication overuse in the two PREEPMT trials. Of 1384 patients 65.3% (904) met ICHD-II criteria for medication overuse headache. Most of the patients overused triptans or combination analgesics; very few (2.7%) overused opioids. For the subgroup of patients with medication overuse, onabotulinumtoxinA was superior to placebo. Overall intake of acute medications was reduced significantly for both treatment groups. The conclusion of the analysis of the subgroup of participants with MOH in the PREEMPT studies was that onabotulinumtoxinA is also effective in the prevention of chronic Migraine, both in patients with and without MOH, resulting in “clinically meaningful improvements.”