Page 102 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

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Chapter 5
During the behavioral intervention, the consults were not only used to educate
on medication overuse and to increase intrinsic motivation to initiate medication
withdrawal using motivational interviewing techniques, but also aimed to
enhance acknowledgement and acceptance of the influence of migraine
on the various aspects of life in general. Furthermore, alternative behavioral
strategies to cope with the untreated pain were discussed, and a value-based
approach was introduced to establish activities. We hypothesize that these
latter aspects of the consults induced the effect of the intervention beyond
the withdrawal therapy itself, with significant lowering on use of headache
medication after 24 weeks. As we stopped the behavioral intervention with
the nurse after 12 weeks, this explains the diminishing effect during the long
term follow up of 1 year. Underlying biological factors and comorbidities such
as depressive symptoms and anxiety, e.g. factors that may influence relapse
into chronification of migraine, might have played an important role for this
diminishing effect as well.7,10,28 In the first year after withdrawal therapy, high
rates of relapse into medication overuse up to 40% are reported,29 posing a
challenge to maintain the effect of withdrawal therapy. Prolonged intensified
intervention by a headache nurse after withdrawal might reduce relapse rates. 30,31
Our findings in this randomized and blinded trial affirm previous results on benefit of multidisciplinary care during withdrawal in observational studies. Our previous retrospective study on behavioral intervention by a headache nurse showed an increased rate of successful withdrawal as well, but did not comprise a long term follow-up.13 A Danish observational study suggested that multidisciplinary approaches during withdrawal therapy are effective. In that study, a structured schedule with both group and individual therapy by a nurse, psychologist and physiotherapist, was compared and found not to be superior to a structured schedule with a headache nurse alone. Interpretation from this comparison has to be done with caution though, since both groups also differed in withdrawal strategy.14 In primary care, a cluster-randomized controlled trial amongst general practitioner practices showed effectiveness of an intervention in MOH patients. Feedback on their dependency behavior resulted in reduced medication use.27 This study suggests that behavioral interventions can be implemented in GP practices as well.