Page 93 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

Introduction
To reduce the burden of chronic disorders, many non-pharmacological interventions, such as behavioral therapy, lifestyle intervention and mindfulness are being studied and suggested to be effective.1–3 Similarly, in headache disorders psychological treatment seems beneficial, although recommendations on these therapies are hampered due to the quality of available research.3 A major concern about research in this field is the risk of bias by awareness of the received treatment, as it is difficult to perform blinded trials due to the nature of the intervention.3 As such, evidence is mainly based on observational or non-blinded randomized controlled trials. Therefore, it remains difficult to distinguish the specific effect of therapy itself from that of other factors, such as underlying expectations and receiving attention,4 which is especially important in trials on various disorders of the central nervous system.5
Implementation of behavioral interventions might be particularly relevant in care of headache patients with medication overuse headache (MOH). Medication overuse, the use of acute headache medication on 10 or more days per month6, aggravates and maintains chronic headache.7,8 Epidemiological data suggest that up to 4% of the population overuse analgesics and other drugs for the treatment of pain conditions such as migraine, and about 1% of the general population in Europe, North America, and Asia suffers from Medication Overuse Headache (MOH).9 Medication overuse is a major risk factor for transformation from episodic migraine to chronic migraine (CM) (i.e. headache on 15 or more days per month, of which at least 8 days fulfilling migraine criteria).6,7,10 Withdrawal of the overused medication is an important step in medical care, with possibly added effect of preventive medication during the withdrawal process.7,8,11 Overuse of pain medication has a strong biobehavioral component,12 and withdrawal therapy in itself requires significant adjustments in behavior and lifestyle. As such, behavioral and educational interventions during withdrawal therapy are likely beneficial, but have only been studied in observational trials.13,14 We report a concealed double-blinded randomized trial to study the efficacy of a behavioral intervention during acute medication withdrawal, with and without BTX, in MOH patients with underlying migraine using a new study design that ensures blinding.
5
Behavioural intervention: a double blind RCT
91