Page 23 - The clinical aspects and management of chronic migraine Judith Anne Pijpers
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have a slightly higher drop-out percentage in some studies.63 This might be prevented by additional outpatient support during the withdrawal period, as some studies show effectiveness of education or multidisciplinary involvement during withdrawal therapy.64–67 Withdrawal strategies can also be applied in first care by a general practitioner, as a brief intervention comprising of education and personal feedback seems effective.68
Unfortunately, acute withdrawal is frequently complicated by acute withdrawal symptoms, as patients suffer temporarily aggravation of headache, before experiencing the beneficial effect of withdrawal.69 Supportive medication during this period to endure withdrawal has been studied, such as oral prednisone, amitriptyline and ibudilast, but didn’t have any effect on the endpoints.70–72 Support by non-pharmalogical interventions such as behavioral interventions has not been studied, but could be helpful as it does have effect after withdrawal therapy.73 Nevertheless, most patients manage to endure withdrawal in an outpatient setting, and in observational studies, success rates of 73-85% are observed.57,59 However, due to the disruption of patient’s socio-economic functioning due to these withdrawal symptoms and untreated headaches, many physicians are reluctant to recommend withdrawal,74 despite the potential advantages.58,74,75
Preventatives for chronic migraine
In the past decade, botulinum toxin A (BTA)55,74,76–82 and topiramate56,83 have emerged as therapy for chronic migraine, further stirring up the debate on the necessity of withdrawal therapy as initial step in the treatment of chronic migraine74,75 and leading to a tendency to initiate preventatives before patients are withdrawn from medication. Although these preventatives did show a significant difference in reduction in headache or migraine days in patients with chronic migraine with and without medication overuse compared to placebo, the efficacy remains questionable, as the therapeutic gain was only modest.10 A small RCT (n=59) in chronic migraine (almost 80% with medication overuse), showed a therapeutic gain of topiramate vs placebo of 3.7 migraine days per month (baseline 16 migraine days per month), with a remarkable absence of a placebo effect (increase of 0.2 migraine days per month in the placebo group).56 A second RCT resulted in an additional reduction of 1.7 days per month compared to placebo.83 The follow-op rate in this RCT was only 55% due to discontinuation because of lack of efficacy and adverse events, 83 corresponding to a high adverse event rate in the first trial (75% in the topiramate group).56
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General introduction
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