1. Case 36-year old woman. Frequent headaches since age 14, daily headaches for at least 10 years. What to do? Headache diary revealed 16 days with migraine and 14 days with tension-type headache per month. Diagnosis? Chronic daily headache? Migraine and tension-type headache? Chronic migraine? Chronic migraine and medication-overuse headache?

3. Medication-overuse headache ICHD-III beta, 2013 A.Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder B.Regular overuse for >3 months of one or more drugs 1 that can be taken for acute and/or symptomatic treatment of headaches C.Not better accounted for by another ICHD-3 diagnosis Note 1 A. Ergotamine, triptans, opioids, combination analgesics or any combination of analgesics on ≥10 days/month B. Simple analgesics or NSAIDs on ≥15 days/month

4. Case Headache diary also revealed daily intake of NSAIDs and intake of triptans 12 days per month Diagnosis: Chronic migraine and medication-overuse headache What to do? Withdraw NSAIDs and triptans

5. Case

6. Central sensitization in MOH is reverted after detoxification Lower pain thresholds in MOH than healthy controls (p<0.05) Supra-threshold pain scores –Extra-cephalic: no significant difference –Cephalic MOH patients > healthy controls (p<0.05) 6 months and 12 months < baseline (p<0.05) Healthy controls MOH baseline MOH 2 months MOH 6 months MOH 12 months Munksgaard, Bendtsen and Jensen, Cephalalgia 2013

7. Management of MOH in a tertiary headache center 98 refractory MOH patients 90% completed withdrawal and 88% completed follow-up 83% without MOH at 1-year follow-up (cured of MOH) 39% reduction in headache frequency (p<0.001) 60% episodic headache 49% responders Munksgaard, Bendtsen and Jensen, Cephalagia 2012 Days/month

8. Medication-overuse headache Efficacy of detoxification and prophylaxis demonstrated in several individual centers Most experts recommend that withdrawal therapy should be offered (Evers and Marziniak, Lancet Neurology 2010) Some recommend Botox therapy (Dodick et al., Headache 2010) Some recommend topiramate therapy (Silberstein et al., Headache 2009)

9. Medication-overuse headache Percentage of patients seen in headache centers having MOH US more than 50% Chile 55% Argentina 70% MOH is very common in specialized headache centers

10. Treatment of medication-overuse headache Take home messages Always consider MOH in patients with chronic headache Use calendar to monitor intake of analgesics during treatment Educate and prevent Detoxification and prophylactic treatment is highly effective in reducing headache days, disability, depression, anxiety and costs