Withdrawal of analgesic medications combined with preventive therapy such as candesartan appears to have a slight edge over other approaches to the management of medication overuse headache, research shows.

A Danish study randomised 120 patients with medication overuse headache to either withdrawal plus two months of preventive treatment, preventive treatment alone or withdrawal plus an optional delayed preventive treatment after two months.

At baseline, a third of patients had been overusing combination analgesics for around two years, 28.4% were overusing simple analgesics, 17.6% were using triptans and 25.8% were using a combination of different medications. The most widely used preventive treatments were candesartan, amitryptiline and metoprolol.

While all three management approaches had some efficacy, the study found that withdrawal plus preventive treatment resulted in the biggest numerical, but not statistically significant, reduction of headache days per month (12.3 v 9.9 v 8.5 days, respectively).

Change in monthly migraine days (5 v 4.1 v 3.3), days per month with reduced short-term medication use (14.8 v 11.3 v 14.0), and headache pain intensity score reductions (28.1 v 23.7 v 20.8) were also not significantly different between the three groups.

However the study found patients in the withdrawal plus preventive treatment group were significantly more likely to revert to episodic headache (74.2% v 60.0% v 41.7%).

“The RR [relative risk] was 1.8 (95% CI, 1.1-2.8; P = .03) for reverting to episodic headache, corresponding to an 80% higher chance for reverting to episodic headache in the withdrawal plus preventive group compared with the withdrawal group,” the authors wrote in JAMA Neurology.

And at six months, more patients in the withdrawal plus preventive treatment group (96.8%) were cured of medication overuse headache (MOH), compared with 74.3% in the preventive group and 88.9% in the withdrawal group plus delayed prevention group.

“This corresponds to a 30% (RR, 1.3; 95% CI, 1.1-1.6) better chance of being cured of [medication overuse headache] in the withdrawal plus preventive group than in the preventive group (P = .03),” the study said.

The findings are consistent with recently published EAN guidelines on the management of medication overuse headache.

“Patients in whom education is not effective should be withdrawn from overused drugs with the most appropriate program that applies to their clinical condition and the overused drug(s) and should receive preventive treatment with drugs of proven efficacy,” it said.

The study authors said that medication withdrawal without prevention may still be effective when treating less severely affected patients – but is not recommended for more complex medication overuse headache.

“Arguments for postponing the start of preventive treatment could be uncertain headache diagnosis during medication overuse, prior use of ineffective preventive treatment, and fear of adverse effects of ineffective preventive treatments,” they said.