Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study

DOI: https://doi.org/10.1186/s10194- 018- 0865- z

Abstract-Summary Compared with those not overusing medications, respondents with AMO were sig- nificantly more likely to be taking triptans (31.3% vs 14.2%), opioids (23.8% vs 8.0%), barbiturates (7.8% vs 2.7%), and ergot alkaloids (3.1% vs 0.6%) and signifi- cantly less likely to be taking NSAIDs (63.3% vs 69.8%) (p < 0.001 for all comparisons).

Respondents with AMO had significantly more MHDs (12.9 ± 8.6 vs 4.3 ± 4.3, p < 0.001); higher migraine symptom severity (17.8 ± 2.7 vs 16.4 ± 3.0, p < 0.001), higher pain intensity scores (7.4 vs 6.5, p < 0.001); and higher rates of cutaneous allodynia (53.7% vs 37.5%, p < 0.001).

Adjusted for MHDs, the odds of AMO were increased by each additional year of age (OR 1.02, 95% CI 1.02, 1.03); being married (OR 1.19, 95% CI 1.06, 1.34); smoking (OR 1.54, 95% CI 1.31, 1.81); having psychological symptoms (OR 1.62, 95% CI 1.43, 1.83) or cutaneous allodynia (OR 1.22, 95% CI 1.08, 1.37); and greater migraine symptom severity (OR 1.06, 95% CI 1.04, 1.09) and pain intensity (OR 1.27, 95% CI 1.22, 1.32).

AMO was present in 15% of respondents with migraine. AMO was associated with higher symptom severity scores, pain intensity, and

rates of cutaneous allodynia.

Cutaneous allodynia was associated with AMO in men but not women.

Background According to the International Classification of Headache Disorders, Third Edition (ICHD-3), acute medication overuse (AMO) can accompany and complicate pri- mary and secondary headaches, including migraine, tension-type headache, new daily persistent headache and posttraumatic headache, among others [495].

Overuse of drugs within certain medication classes has been associated with an

increased risk of transformation from episodic to chronic migraine [496–500].

AMO is associated with greater pain intensity and disability and worse 24 h pain relief outcomes in patients with chronic migraine [501, 502], as well as the develop- ment of a secondary headache disorder known as medication-overuse headache (MOH) — at least 15 monthly headache days (MHDs) in patients with a pre- existing primary headache and developing as a consequence of regular overuse of acute headache medication for more than 3 months [495].

We use AMO to describe the behavior of medication taking above a certain

threshold without assumptions about causing headaches.

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3 Diagnosis

In the general population, about 2% of people are believed to have AMO, but headache clinics report that 50% to 70% of their patients overuse medication [498, 503–507].

Many acute headache medications have been associated with AMO and MOH [495], but the highest risks are seen with barbiturate containing combination anal- gesics and opioids [482, 508].

Methods The symptom screening module, employed previously in the American Migraine Study (AMS) and the American Migraine Prevalence and Prevention Study (AMPP), is based on lifetime recall of symptoms associated with respondents’ most severe headaches.

Respondents meeting AMS/AMPP symptom criteria for migraine were assessed for headache frequency, and those reporting 3 or more monthly headache days (MHDs) in the past 3 months and at least 1 MHD in the past 30 days satisfied fre- quency criteria, completed screening, and qualified for inclusion in the study.

Only respondents currently taking medication to treat their headaches who pro- vided self-reported monthly treatment day frequency were included in these analyses.

Percentages were used to report dichotomous variables, including sex, marital status, education, race, health insurance status, psychological symptoms, employ- ment, current smoking status, and cutaneous allodynia.

The first model included the sociodemographic variables sex, age, marital status, race, household income, education, BMI, health insurance status, and smok- ing status.

Results Compared with respondents who did not overuse their headache medication, those in the AMO group were significantly older (45.8 ± 13.2 vs 43.0 ± 13.6 years, p < 0.001) and more likely to be male (29.5% vs 26.6%, p < 0.01), had higher BMI (28.9 ± 8.5 vs 28.1 ± 7.4, p < 0.001) and were more likely to be married (58.6% vs 54.3%, p < 0.001).

Most respondents (58.8%) had at least a 4-year college degree, but persons in the AMO group were significantly less likely than those not overusing medications to have at least a 4-year college degree (51.7% vs 60.0%, p < .001).

Allodynia was present in 40.0% of the total sample, and those in the AMO group were significantly more likely to be allodynic than individuals not overusing medi- cations (53.7% vs 37.5%, p < 0.001).

Discussion This analysis of MAST Study data was conducted to estimate rates of AMO in a representative sample of people with migraine and to determine associations of AMO with individual and migraine characteristics.

The overall rate of AMO in the MAST Study is similar to the results of previous studies reporting that 17% to 18% of adults with migraine met criteria for AMO [509, 510].

3.5 Medication Overuse and Addiction

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The finding that AMO was more likely among MAST Study respondents in higher BMI categories and who currently smoke confirms previous research show- ing a higher prevalence of MOH among individuals with a BMI of at least 30 [511] and smokers [512].

Possibilities include: (1) biologic differences in the way that men and women experience allodynia; (2) variations in how men and women report symptoms of allodynia, including how they respond to questions on the ASC-12; (3) differential effects of having allodynia on the decision to take acute migraine medications; and (4) differential effects of AMO on the development of allodynia.

We expected that AMO would be associated with attack frequency in MAST

Study respondents.

Conclusions Approximately 15% of persons with migraine met criteria for AMO.

Males with allodynia were more likely to meet criteria for AMO than females

with allodynia.

Acknowledgement A machine generated summary based on the work of Schwedt, Todd J.; Alam, Aftab; Reed, Michael L.; Fanning, Kristina M.; Munjal, Sagar; Buse, Dawn C.; Dodick, David W.; Lipton, Richard B. 2018 in The Journal of Headache and Pain.

Enhanced functional connectivity between habenula and salience network in medication-overuse headache complicating chronic migraine positions it within the addiction disorders: an ICA-based resting-state fMRI study