Page 52 - The clinical aspects and management of chronic migraine Judith Anne Pijpers
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Chapter 3
and from colleague neurologists. Inclusion criteria for participants were: (i) age ≥ 18 years; (ii) diagnosis of MOH, defined by the ICHD-II criteria15, which are similar to the ICHD-III-b criteria on MOH4 (supervised by an experienced headache neurologist (MDF, GMT)); and (iii) receiving an advice to withdraw all acute headache medication (triptans, analgesics, combination of both, other medication comprising opioids, ergots or combinations of those medications with analgesics or triptans), prophylactic medication and caffeine (-containing liquids) during two or three months. Follow up occurred after withdrawal, to determine the final underlying primary headache diagnosis and start further treatment. At the first visit patients were instructed that because of lack of therapeutic options whilst overusing medication, no follow-up visit was offered if they did not succeed to withdraw. Therefore, patients who were lost to follow-up were considered as ‘not successfully withdrawn’. Patients were excluded when the final diagnosis was not migraine, tension-type headache or a combination of both. The treatment protocol for patients included between 1 April 2006 and 31 March 2008 (group A) comprised a withdrawal advice by a resident-in-neurology/neurologist. All physicians involved during the total inclusion period, gave the same instructions and maintained the same conditions of withdrawal, according to the standardised protocol at the LUMC. This encompassed an outpatient detoxification with the advice to instantly stop acute headache medication. The duration of the withdrawal period was two months in case of triptan overuse, three months for other types of medication or combinations of medication, and/or caffeine use of ≥ 5 units/ day. If patients were on preventive treatment this was tapered off, since the present medication was not effective, and preventive medication regains effectiveness after withdrawal.6 New preventive treatment was postponed until successful withdrawal was accomplished. Use of escape medication or caffeine(- containing liquids) was not permitted. During the withdrawal period no facility was provided for additional contacts or support. Due to the employment of specialized headache nurse ever since 1 April 2008, patients included between 1 April 2008 and 31 March 2010 (group B), were advised exactly the same withdrawal protocol, but additionally received support during the withdrawal period by a specialized headache nurse. The headache nurse was trained and experienced in headache care, and received additional training on cognitive behavioural therapy. The support by the headache nurse started immediately during the first visit with a 15-30 minutes consultation consisting of a reprise
































































































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