No additional benefit with detoxification strategies: A real world experience in 200 patients with chronic migraine and either simple or complex MOH treated with CGRP monoclonal antibodies.

Abstract

BackgroundAlthough withdrawal from analgesics with or without detoxification strategy represented a mainstay in medication overuse headache (MOH) management, recent evidence supports that it is no longer beneficial when CGRP-targeting monoclonal antibodies (CGRP-mAbs) are employed. However, MOH could be stratified into simple and complex MOH phenotypes according to different clinical parameters (i.e., amounts and class of analgesics, psychiatric comorbidities, history of relapse after withdrawal, symptoms of central sensitization, and maladaptive anticipatory response to pain experience). Herein, we explored the effectiveness of CGRP-mAbs plus detoxification strategy compared to CGRP- mAbs preventive treatment alone in patients with either simple or complex MOH phenotypes.MethodsThis is a six-month observational study including chronic migraine patients with MOH treated with subcutaneous CGRP-mAbs. Patients were stratified based on both MOH complexity and detoxification strategy to evaluate differences in the changes of monthly headache days, pain intensity and duration, and monthly days with acute medication intake after the first, third and sixth month of preventive treatment with CGRP-mAbs.ResultsTwo hundred patients with migraine and MOH were recruited. A significant reduction of headache attacks frequency, intensity, duration and monthly days with acute medication intake has been observed both in patients sub-classified as complex MOH (58.5%) and in those with simple MOH (41.5%) after the first, third and sixth month of preventive treatment with CGRP-mAbs (p < 0.001). Furthermore, stratifying patients based on the MOH complexity and detoxification strategy, no differences were found in the reduction of monthly headache days as well as in other parameters of disease severity (p > 0.05).ConclusionOur findings might suggest a change in the mind-set of clinicians, still considering the withdrawal with or without detoxification strategy as a "conditio sine qua non" in patients with MOH, towards a novel approach where the reduction of analgesics intake represents the natural consequence of CGRP-mAbs effectiveness.