Page 139 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

reducing anxiety and depression has never been studied. As for depression, the comorbidity is thought to occur due to shared etiology and even shared heritability.52–55 Hence, treatment of concurrent depression might not eliminate the added risk for chronification. Still, some risk reduction is to be expected. A large cohort study showed a kind of dose-response relationship, in which the risk of chronification increases when the severity of depression symptoms increases,34 implying a risk reduction for migraine chronification when the severity of depression is reduced.
Treatment of chronic migraine
This thesis emphasizes the importance of withdrawal of overused medication. Chapter 2 and 4 show in a retrospective and prospective manner the efficacy of medication withdrawal. In the prospective trial, the mean number of migraine days per month had decreased by 6-7 days after withdrawal, and 60% of patients had reverted back to episodic migraine. Furthermore, over 30% of patients did not need preventatives after withdrawal. Withdrawal therapy was well- tolerated by patients as almost 50% rated their treatment as very good (≥8/10) and almost 70% would recommended this therapy to friends and family. These numbers show that withdrawal therapy is accepted, especially considering that chronic migraine is difficult to treat, and the nature of the intervention is difficult to endure. The hesitance to initiate withdrawal therapy in clinical practice might be dictated by physicians, as ‘we’ tend to have a preference to give, instead of withhold medication. Chapter 2 and 5 also demonstrate the relevance of a multidisciplinary approach, as a headache nurse reduces medication intake, and decreases the potentially higher drop-out rate in an outpatient versus inpatient setting, seen in a previous study.56
Taken together with previous studies, these chapters provide class III level of evidence of acute withdrawal in case of medication overuse. Although class I/II level of evidence (at least one randomized placebo controlled trial) is preferable in evidence-based medicine, obtaining this level of evidence seems inheritably impossible due to the nature of the intervention. Double-blind comparison is hardly attainable, as placebo matching for all types and combinations of overused medication seems an impossible assignment. Besides this practical issue, controlling for the psychological effect of withdrawal is truly impossible. Therefore, it is important to test new therapeutic interventions against withdrawal, and investigate the additional benefit.
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Summary and general discussion
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