Page 22 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

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Chapter 1
to study genetic variants underlying chronic migraine. In a limited number of chronic migraine patients, several pre-defined SNPs were not significantly associated with chronic migraine.17 A recent study did find an association between positive family history of migraine and a higher attack frequency, but only in males, and of a small effect size.31
Treatment of chronic migraine
Withdrawal therapy for chronic migraine an medication overuse
The majority of chronic migraine patients (65-80%)55,56 has medication overuse, which is the major risk factor for chronic migraine, and an important factor in maintaining and aggravating chronification.3,10,30 As such, withdrawal of the acute headache medication has traditionally been the first step in the treatment of chronic migraine with medication overuse.
Withdrawal therapy is a low cost treatment to reduce headache frequency, improve quality of live, halt medication overuse-induced adverse events, and prevent systemic toxicity.10,57–59 After withdrawal therapy most patients experience a reduction in headache frequency, and approximately 50% of patients reverts from chronic to episodic migraine.33,57,58,60 Furthermore, only half of the patients are in need of preventatives after withdrawal therapy, and withdrawal therapy might also improve responsiveness to preventatives in the other half.60 Besides these objective effects, it might help to reduce the feelings of dependency on the medication and lack of control patients experience whilst overusing medication.46
Many withdrawal strategies are being performed internationally. A recent randomized controlled open label trial shows that complete detoxification (no analgesics or acute migraine medication at all) during 2 months is more effective compared to a reduction of medication intake (intake of analgesics or acute migraine medication with a maximum of 2 days a week).59 Outpatient withdrawal therapy by a simple advice to stop the medication is as effective as inpatient withdrawal therapy in uncomplicated medication overuse patients (amongst other things no overuse of opioids and barbiturates)61 and also effective in medication overuse patients with some comorbidity (for instance mild depression) or more complex overuse (for instance daily intake of medication, and previous withdrawal attempt).62 Outpatient withdrawal did