Headache is a common health problem and the personal burden, social impact and economic cost for both the sufferers and society are substantial
[1, 2]. Most common headaches are episodic tension-type headache (TTH) and migraine
. However, 2–5% of the world’s population have chronic headache
[4–13] defined as 15 or more headache days per month for at least 3 months and/or 180 or more headache days per year.
Headache is mostly self-managed
[14, 15] and headache prescription medications account only partly for the total medication use for headache since most patients buy over-the-counter (OTC) drugs
[5, 6, 16–19]. Headache accounts for 4% of the general practitioners (GPs) consultations
, and is probably the most common reason for referral to neurologists
[19, 20]. Approximately 20–30% of all new referrals to out-patients neurological departments are due to headache
Analgesic use, misuse and overuse represent major health problems associated with numerous adverse health consequences. A population-based study from Norway which included about 50,000 subjects found that 10% reported taking analgesics currently on a daily basis and up to 5% reported taking analgesics on a daily basis for at least six months
. Results from another Norwegian study showed that 28% of men and 13% of women had used analgesics over the preceding 28-day period, mostly to treat headaches
. Frequent intake of analgesics may, however, worsen headache and lead to chronification and Medication Overuse Headache (MOH)
[25–27]. MOH is a condition with chronic headache in combination with overuse of acute headache medication(s)
[25–27]. The prevalence of MOH in the general population is 1–2%
[5, 6, 10, 25–28]. The condition was first described for egotamines in 1951
 and it is now substantiated that all drugs used for the acute treatment of headache can cause MOH in patients with a pre-existant headache disorder
[25–27]. The proportion of MOH is lower in the general population than one sees in clinical settings, and the distribution of the overused medication differs with simple analgesics being most frequently overused in the general population
[7, 9, 17, 28, 30–35].
The aims of MOH management are
withdrawal of the overused drug(s)
to provide the patient with pharmacological and non-pharmacological support
Detoxification from the overused medication often leads to headache improvement
[25, 26, 31, 38], but is often complicated by temporary withdrawal symptoms such as worsening of headache, nausea, vomiting, hypotension, tachycardia, sleep disturbances, restlessness, anxiety and nervousness which typically occur 2–10 days after detoxification
[26, 27, 40, 41]. There is no established optimal withdrawal method for MOH though many different strategies have been suggested
[25, 36, 37, 39]. These include use of antiemetics and/or neuroleptics to reduce abstinence-like symptoms, intravenous administration of ergotamines and substitution of the offending painkiller with another. Steroid treatment has also been used to alleviate withdrawal reactions though this strategy is controversal
[36, 37, 41–43].
Regarding prophylactic headache medication, there is also an ongoing discussion whether this should be initiated immediately at withdrawal or after completed withdrawal therapy
Follow-up studies of various duration have reported relapse rates between 20–60% and findings from these studies suggest that patients have the highest risk of relapse within the first year after withdrawal
MOH is a heterogenous disorder which has been suggested to include both subgroups with simple medication overuse as well as more complex detoxification-resistant cases
[36, 50–52]. Some of these cases may be more “dependency-like” and it has indeed been suggested that MOH shares some common neurobiological pathways with drug dependence and that MOH therefore may represents a kind of addictive behaviour
. Whether this applies to all MOH cases or specific subgroups defined by this particular “dependency-like” behaviour (eg. “complex” MOH) remains to be demonstrated. Two studies have demonstrated that most MOH patients fulfill criteria for dependency according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)
[54–56]. Another study found that the dependency score based on the Leeds Dependency Questionnaire was similarly increased in MOH patients and illegal drug addicts
Over the past decades several dependency assessment scales have been developed. The Severity of Dependence Scale (SDS) is a simple, validated scale which scores psychological dependence on a number of different substances
[58–63]. Previous studies from our group have revealed that the SDS has both high sensitivity, specificity, positive and negative predictive values for detecting persons with MOH among chronic headache patients.
[30, 35, 64]. In addition, the SDS score has been shown to predict likelihood of successful detoxification in a general population
Screening and Brief Intervention (BI) is a well-known approach to identify and treat unhealthy alcohol use
. The SDS and similar scales such as the Alcohol Use Disorders Identification test, have previously been used to identify individuals at risk for addiction-related problems
[58–63, 67–69]. BI involves the use of such an identification tool followed by feedback to the identified individual as being “at risk”. The final step, in this very short and simple intervention is to give information suggesting to cut down the use of the particular substance to predecided “acceptable” levels
. BI includes clear directive advice, but focus is also on increasing patients insight and awareness regarding overuse as described in more detail elsewhere
[66, 70]. The BI method has shown promising results with both short- and longlasting reduction of alcohol intake and levels of related biochemical markers such as liver transferase levels
[66, 71–73]. Similar methods have also been successfully applied for various other addictive drugs
[70, 74, 75].
We have previously reported data from an open, un-controlled study of medication overuse headache in the general population, which suggested that three out of four MOH subjects had managed to reduce their medication intake after short information
. Similar simple advice also works in clinic settings
[77, 78]. One population- and one clinic-based study suggest that MOH can be successfully managed in a primary care setting after an initial collaboration with headache specialists
The common headache disorders require no high-tech investigations and may therefore be diagnosed and managed by all skilled physicians. Most headaches are therefore probably best managed in primary care. Focus on MOH in primary care is therefore important both in order to prevent MOH from developing and for early diagnosis and treatment.
We have designed a BI for treatment of MOH in primary care and planned a double-blinded cluster randomized parallel controlled trial (RCT) to evaluate effects of the intervention.
The primary objective is to evaluate the effects of a brief intervention (BI) versus business as usual (BAU) in the management of MOH in primary care.