Page 129 - The clinical aspects and management of chronic migraine Judith Anne Pijpers
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Withdrawal was well tolerated and blinding was successful. After withdrawal, mean number of headache days had decreased by 5 days (25% reduction) and of migraine days by 6–7 days (45% reduction). In total 60% of patients had reverted back to episodic migraine. BTA did not afford any additional benefit over acute withdrawal alone, neither on short term (12 weeks) nor long term measurements (up to 48 weeks). These results confirm that acute withdrawal is associated with meaningful improvement and should be tried first before initiating more expensive treatment with BTA.
Chronic conditions are of augmenting prevalence in the population, posing several challenges on both individual care as health care management. Interventions such as behavioural therapy, lifestyle intervention and mindfulness are gaining importance to cope with chronic diseases and reduce its burden. Similarly, in headache disorders psychological treatment seems beneficial, although the available research is of poor quality. A major concern is the risk of bias by unblinding, as it is difficult to perform blinded trials due to the nature of the intervention. Chapter 5 is the first study investigating a behavioural intervention in a double blind, placebo-controlled randomized clinical trial. Intensive support versus minimal support by a specialised headache nurse seems to increase the success rate of withdrawal therapy, and reduces medication intake after withdrawal therapy. By concealing the study within the BTA-trial (chapter 4), the patients were unaware of the two treatments arms, by which blinding of participants was assured. Intensive support by a headache nurse in medication overuse management of chronic migraine patients is effective. A concealed design may also be useful to investigate non-pharmacological therapies in other central nervous system disorders.
Chronic migraine is a highly disabling and difficult to treat disorder, especially in case of concomitant medication overuse. Acute withdrawal is beneficial in most, but not all patients. However, strong predictors for response are lacking. Especially with the emergence of promising but high cost therapies for chronic migraine, the identification of predictors for response is warranted. Chapter 6 shows that absence of cutaneous allodynia is a predictor for good response to withdrawal therapy in patients with chronic migraine and medication overuse. Moreover, the predictive value was even more pronounced when compared with extracephalic allodynia, which is indicative of trigeminothalamic involvement.
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Summary and general discussion
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