A role for steroids in treating medication overuse headache?

Chronic headache, defined by the presence of headache on at least 15 days per month (1), is a widespread problem affecting approximately 4% of adults (2). Epidemiology studies demonstrate that medication overuse plays a role in a quarter to a third of these cases (3,4), indicating that it is a substantial contributor to the burden of chronic headache. Medication overuse headache (MOH) is identified by the transformation of an episodic headache pattern to chronic headache while a person is taking an acute analgesic for headache on at least 10–15 days per month (1). Essentially any acute medication for headache can be associated with MOH in individuals with an underlying primary headache disorder such as migraine or tension type (5,6). Evidenced by the fact that the United States economy loses US$13 billion per year from the lost 113 million workdays due to headache, managing chronic headache, a condition associated with significant disability and broad societal impact, is an important endeavor (7). As there are no clear guidelines on treating the medication overuse component of this problem, but complete discontinuation of the overused medication remains a vital part of the treatment plan, detoxification strategies can be varied and include inpatient and outpatient methods (8–10). When the offending medication is stopped, however, the headache tends to worsen before it improves and, depending on the medication, patients may also experience other withdrawal symptoms such as nausea, anxiety, sleep problems, agitation, tachycardia, and blood pressure changes. Often, to mitigate the withdrawal headache, patients are given a short course of steroids (11). Although information gathered from the effects steroids and neurosteroids have on neuronal activity (reducing neurogenic inflammation, decreasing vasogenic edema, and acting on central aminergic and serotonergic pathways) (12) suggests that they can be beneficial in reducing withdrawal headache, until now there have been no large-scale high-quality clinical trials on this topic and the few small studies have yielded mixed results (13–15). In this issue of Cephalalgia, Rabe et al. (16) present a prospective, multicenter, randomized, double-blinded, placebo-controlled study evaluating the role of prednisone in managing withdrawal headache in patients with chronic headache occurring as a result of an underlying headache diagnosis of migraine or tension type, complicated by MOH. Ninety-six subjects were enrolled and equally divided into treatment and placebo groups. The subjects received either prednisone 100mg or placebo for 5 days and were monitored for a number of hours with moderate or severe headache for the first 3 days of withdrawal. Secondary end points included number of moderate or severe headaches during the first 5 and 14 days of withdrawal, and the amount of acute analgesics used during each time frame. Interestingly, although there was no difference between the two groups with regards to the number of hours of moderate or severe headache during the first 3, 5, or 14 days of withdrawal, those in the prednisone group opted to use fewer acute analgesics during the first 3 days (p1⁄4 0.021, 1.1 versus 2.3 doses). However, this difference in medication intake was no longer present by days 5 and 14. As expected, patients who had been overusing triptans had a shorter and less complicated withdrawal period, whereas those overusing combination analgesics had a more difficult and protracted withdrawal; however, these differences stemming from the class of overused analgesic were not significant. This study is the first large, randomized, prospective, double-blinded, placebo-controlled study investigating the utility of a short course of steroids in treating MOH. Although no difference was seen between the treatment and placebo groups in terms of headache intensity, it is noteworthy that at least for the first