Page 61 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

Support by a headache nurse during withdrawal
the visit could be changed to a 15-30 minute telephonic appointment in case patients definitely could not miss work. Analysis considering lost to follow-up as unsuccessfully withdrawn shows similar result as analysis with lost to follow- up patients as a separate group. Secondly, for the reason of uncertainty about diagnoses before withdrawal, we diagnosed the primary headache disorder only after successful withdrawal, and used this diagnosis. Still, the pre-existing primary headache diagnosis was fairly correlated with final diagnosis. Thirdly, long-term effects of withdrawal were not investigated in this study. Considering the high recidivism rate, it would be interesting in future research to study the long term effect of a headache nurse in patients with MOH after withdrawal. However, the long term effect of a headache nurse on medication overuse was beyond the scope of this study as we specifically wanted to investigate the response to the initial withdrawal period. In many countries patients with MOH are usually unwilling to endure acute withdrawal therapy. Patients in these countries refuse to discontinue their medication on the grounds that the withdrawal symptoms will be too serious or they are afraid to lose their jobs if they will be ill for a longer period because of the withdrawal symptoms. There is usually a drug treatment started with prophylactics although it is recognized that it often fails if the patient continues to overuse acute headache medication. Therefore, it was of our main interest to show the high success rate of acute withdrawal with the support of a headache nurse.
In literature, several withdrawal therapies, sometimes with the support by a headache nurse for MOH patients have been described, but no other study investigated the insulated effect of a headache nurse and uniform endpoints are lacking, hampering direct comparison between studies.11–14,16
Possible explanations and implications
The headache nurse has an unmistakable effect on succeeding withdrawal therapy. Previous studies suggest that patients with (chronic) headache or high headache related disability, are more prone to use unsuitable coping mechanisms,17 score low on pain acceptance18 and high on catastrophizing scales, and experience a low internal pain control.19 In patients with migraine, pain control and self-management can be improved by behavioural therapy.20 We hypothesize that contact with a headache nurse influences the above mentioned factors and thus will help patients to endure the withdrawal period. Patients with tension-type headache and the combination of migraine and tension-type headache seem to benefit less from withdrawal therapy than
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