Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178
110
ASAA
DOI: 10.48208/HeadacheMed.2021.21
Headache Medicine
© Copyright 2021
Original
Analgesic abuse headache: risk factors and causes of poor adherence
in the detox process
Klairton Duarte de Freitas , Raimundo Neudson Maia Alcantara
Hospital Geral de Fortaleza, Ceará, Brazil
Abstract
Background
Medication overuse headache (MOH) is characterized by a pre-existing primary or secondary
headache associated with medication overuse.
Aims
To identify the clinical, epidemiological, and therapeutic proles associated with MOH and
poor adherence to treatment.
Methods
A cross-sectional, comparative, descriptive, analytical study was carried out to assess the
characteristics of patients with MOH treated at the Hospital Geral de Fortaleza (HGF).
Results
103 patients participated, 95 (92.2%) women and 8 (7.8%) men. Of these, 55 (53.4%)
patients answered that had already been instructed about the MOH, however they continue
to abuse medication for many reasons, i.e.: difculty in bearing pain, and fear of worsening
the pain. When asked about what could be done to improve adherence to treatment, in a
general way, 28 (27.2%) were unable to inform, 37 (35.9%) answered that most frequent
consultations could help. Furthermore, 19 (18.4%) believe that psychological counseling
wound bring benets.
Conclusion
The lack of guidance or interest in the guidelines provided are real and important obstacles to
treat MOH. Changes in the care model that include effective communication, more frequent
return, family and psychotherapy support and close monitoring by the physician or nurses
are factors that should be considered in headache clinics.
Klairton Duarte de Freitas
Departamento de Neurologia,
Hospital Geral de Fortaleza
Rua Ávila Goulart, 900, Papicu,
Fortaleza, CE, Brazil
CEP: 60175-295
Phone +55 85 99690-1485
klairton-duarte@hotamil.com
Edited by:
Marcelo Moraes Valença
Keywords:
Medication-overuse headache
Risk factors
Comorbidities
Poor adherence
Dependence
Headache Disorders
Received: August 1, 2021
Accepted: October 3, 2021
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Analgesic abuse headache: risk factors and causes of poor adherence in the detox process
Introduction
H
eadaches are a major public health concern given
their high prevalence (46% of the population), usually
occurring episodically, but 2% to 5% of the population have
chronic headache. In these patients the excessive or pro-
longed use of drugs for symptomatic treatment of headaches
can be the cause of headache by abuse of painkillers.
1,2
Medication overuse headache (MOH) is characterized in a
patient with pre-existing primary or secondary headache,
in which, associated with the excessive use of medication,
a new type of headache develops, or pre-existing
headache worsens, the following criteria being present:
a) headache present for more than 15 days per month;
b) regular overuse of analgesics for more than 3 months,
c) headache is not better explained by another diagnosis
and developed or worsened during the excessive use of
medication. Ingestion of 15 days or more per month of
simple analgesics and combination acute medications
is considered for a diagnosis of MOH, and for triptans,
ergotamine, opioids, and combination analgesics,10 days
per month is sufcient.
3
Prevalence rates of MOH in the European population are
between 1-2%, but in specialized headache centers, they
range from 30% to 70%, a high percentage of abuse, even
for specialized centers.
4-6
An important factor to consider in
the abuse of analgesics is pain prevention. For example, if
there is medical advice for early use at the onset of pain, the
patient may understand that there is freedom to use without
quantity limitation or understand that there is a justication
for use. In this sense, the study of Sousa
7
cites some reasons
for abuse, such as difculty enduring pain, fear of arising
pain if you do not take the medication, reappearance of
pain, not believing in the cure, better performance at work,
help with sleep, and decrease anxiety.
7
However, regardless of individual reasons for symptomatic
drug overuse, there are important risk factors that have been
proposed for the development of MOH. For example, the
ratio between men and women is 1:3-4
8
and the condition
is most prevalent in the fourth decade of life; however it
tends to decrease with age, reaching prevalence between
1.0% and 1.7% in those over 65 years of age.
4,5,8
We
can also cite as associated factors low educational level,
unemployment, marital status, high levels of daily stress,
low socioeconomic level, alcoholism, daily smoking, family
history of MOH or abuse of other substances.
9
Among the primary headaches, migraine was responsible
for 65% of the MOH cases. Regarding the type of
analgesics, it was observed that the use of triptans was
more associated with the development of MOH compared
to simple analgesics. Regarding clinical complaints,
cardiovascular risk factors, as well as respiratory
diseases, gastrointestinal complaints, insomnia, chronic
musculoskeletal pain, and other bodily pain, increase the
risk of abuse. Finally, psychiatric comorbidities and genetic
risk factors, such as homozygous D/D ACE (angiotensin-
converting enzyme) polymorphism, which correlated
positively with MOH duration and Val66Met BDNF
polymorphism which predicted consumption of painkiller
use, are also causes of MOH.
10-12
Given the above, we can see that many psychosocial
and socioeconomic factors are associated with MOH.
However, it is difcult to determine whether these are
directly or indirectly associated, since these ndings are
mainly based on cross-sectional studies. Thus, most of these
factors may merely be markers of a complex situation,
since many aspects of life may be affected by chronic
headache as with other conditions.
13
In this sense, it is important to note that despite the existence
of multiple risk factors associated with MOH, ignorance
about the harmful effects of overuse of analgesics, even
for other clinical conditions, has great potential to cause
MOH. On the other hand, why do people who have
already been educated about the risk of analgesic abuse
continue to do so? Thus, the objective of this study is to
identify the clinical, epidemiological, and therapeutic
prole related to MOH and the poor adherence to its
treatment.
Methods
Research Design
This is a cross-sectional, comparative, descriptive analytical
study that evaluated the characteristics of the population of
patients with MOH, registered and regularly accompanied
in the Headache Outpatient Clinic of the HGF, in the city
of Fortaleza, Ceará, Brazil. A questionnaire was applied
during outpatient consultations and by telemedicine during
the period from March to May 2021.
Research Population
The study population was composed of patients regularly
enrolled and accompanied at the headache outpatient
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Analgesic abuse headache: risk factors and causes of poor adherence in the detox process
clinic of the HGF. The inclusion criteria were: MOH
conrmed by the ICHD-3 criteria, patients over 18 years
of age, of both sexes, registered at the mentioned center.
The study was approved by the Ethics Committee of the
HGF (4.568.755). Due to the pandemic of COVID-19, the
application of the Informed Consent Form (ICF), occurred
through Google forms to facilitate the start of data
collection.
Statistical Analysis
Numerical variables were described by measures of
central tendency and variability. Categorical variables
were represented by frequency distribution. All statistical
analyses were performed using Microsoft Excel version
2010 software.
Results
The study population consisted of 95 (92.2%) women and
8 (7.8%) men, for a total of 103 patients. The patients
were grouped by age intervals, with the groups aged 40-
49 years and 50-59 years having the most participants,
totaling 55 patients (53.4%). Of the 103 patients, 57
(55.3%) had less than complete high school education,
65 (63.1%) were married or in a stable union, and 85
(82.5%) were not employed during the study. The main
type of primary headache was migraine (93 patients,
90.3%), with onset more than 10 years ago (68 patients,
66%) and headache frequency more than ve days a week
(47 patients, 45.6%). For headache control, 47 (46.5%)
patients used common analgesics and 83 (80.6%) did
not use analgesics for any condition other than headache
(Tables 1 and 2).
More than half of the patients who took part in the study
(55 patients, 53.4%), answered that they had already
been oriented about the excessive use of drugs and even
so, they continued to abuse them for various reasons,
among which the difculty in bearing the pain and fear of
worsening their headaches were the most cited. Regarding
therapy for detoxication, of the 103 participants, 67
(65%) did not do it, 5 (4.9%) did not remember, and 31
(30.1%) answered that they had gone through at least
one therapy during their follow-up. When asked about
prophylactic medication, 69 (67%) said they have used
it, with 33 patients citing tricyclic antidepressants and
41 patients citing anti-crisis drugs as the most used,
remembering that the same patient could take more than
one class of drugs. Thus, among those who did not take
prophylactic medication, most of the answers mentioned
side effects (11 answers) and the belief that the medication
Table 1. Sociodemographic variables related to medication overuse head-
ache (MOH)
Variables n %
Sex
Male 8 7. 8
Female 95 92.2
Age (years)
18-30 12 11.7
31-39 20 19.4
40-49 28 27. 2
50-59 27 26.2
≥60 16 15.5
Level of Education
Illiterate 3 2.9
Elementary School (incomplete) 34 33.0
Elementary School (complete) 11 10.7
High School (incomplete) 9 8.7
High School (complete) 32 31.1
Superior (incomplete) 3 2.9
University (complete) 11 10.7
Marital Status
Married 65 63.1
Single 26 25.2
Divorced or Widowed 12 11.7
Employee
Yes 18 17.5
No 85 82.5
Table 2. Variables related to primary headache and analgesics used for
medication overuse headache (MOH)
Variables n %
Type of primary
headache
Migraine 93 90.3
Tension-type headache 0 0
Cluster headache 1 1.0
Others 9 8.7
Duration of
headache (years)
<2 6 5.8
2-10 29 28.2
>10 68 66.0
Frequency of
headache (days/
week)
<3 18 1 7.5
4-5 38 36.4
>5 47 45.6
Type of
analgesics
Simple 47 45.6
Combined 23 22.3
Multiples 32 31.1
Triptans 1 1.0
Opioids 0 0
Ergotamines 0 0
Analgesics
used for other
conditions
Not use 83 80.6
MS* pains 14 13.6
Others 6 5.8
*musculoskeletal
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Analgesic abuse headache: risk factors and causes of poor adherence in the detox process
would have no effect (10 answers). As for habits, there was
no report of illegal drug use, but smoking, drinking alcohol,
and drinking coffee more than 3 times a day were mentioned.
In addition, most of the answers associated MOH with
insomnia, a sedentary lifestyle, obesity, and a family history of
headaches, among others. Regarding psychiatric diagnoses
(based on DSM-V), 8 (7.8%) patients were diagnosed with
depression, 26 (25.2%) with anxiety, and 38 (36.9%) with
depression and anxiety. On the other hand, 31 (30.1%) did
not present depression and/or anxiety. In the same way, from
103 patients, 75 (72.8%) presented some clinical comorbidity,
being cardiovascular, respiratory, and musculoskeletal
diseases the most reported (Table 3) (Figures 1, 2, 3 and 4).
Of the 103 patients, 37 (35.9%) had follow-ups between
6-12 months, 27 (26.2%) had follow-ups between
3-6 months. Only 21 (20.4%) attended the headache
outpatient clinic for less than 3 months. About the follow-up
in primary care, 66 (64.1%) patients did not follow up and
when asked what could be done to improve adherence to
detoxication treatment, 28 (27.2%) did not know, while
37 (35.9%) and 19 (18.4%) answered, respectively, that
more frequent consultations and psychological follow-up
could help (Table 3).
Table 3. Clinical data from the anamnesis
Variables n %
Have you ever been guided about the
abusive use of painkillers?
Yes 55 53.4
No 48 46.6
Have you ever had detox therapy?
Yes 31 30.1
No 67 65.0
Do not remember 5 4.9
Do you use prophylactic medication?
Yes 69 67. 0
No 34 33.0
Psychiatric comorbidities
No 31 30.1
Depression 8 7. 8
Anxiety 26 25.2
DA* 38 36.9
Clinical comorbidities
Yes 75 72.8
No 28 27. 2
Outpatient follow-up (months)
<3 21 20.4
3-6 27 26.2
6-12 37 35.9
>12 18 1 7.5
Follow-up in primary care
<3 22 21.4
3-6 7 6.8
6-12 6 5.8
>12 2 1.9
No 66 64.1
*Depression and anxiety
Figure 1. Cause of the permanent use of analgesics.
Figure 2. Prophylactic drugs.
Figure 3. Causes of non-adherence to prophylactic medication
Figure 4. Risk factors associated with medication overuse headache
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Discussion
MOH is a chronic disorder that can impact the patient's
quality of life both socially and nancially. Prevalence
rates are similar in most populations studied, with a
preponderance of female sex, average age ranging
between fourth and fth decades of life, married, low
educational level when compared to the general population,
and most often without paid occupation.
8,9,14,15
Looking
only at sex, the guideline of the European Academy of
Neurology published a recent study where the majority of
patients with MOH are female, 93%.
6
In the present study it
was no different, most of the patients followed were female,
92.2%, and belonging to the fourth and fth decade of
life, totaling 55 patients, 53.4%. Of the 103 patients, 57
(55.3%) had less than complete high school education,
65 (63.1%) were married or in a stable union, and 85
(82.5%) were not employed during the study.
Another important factor when it comes to risk factors is
the type of primary headache, when it started and the
frequency. A meta-analysis of 29 studies showed that
migraine was the most common type of primary headache,
around 65%, followed by tension-type headache 27%.
5
Further studies
6,16
nd similar data, where 80% of the
patients had migraine as their primary headache. To
Nagen et al.
15
, migraine was also the most frequent
primary headache. These data should be interpreted
depending on where the studies were conducted. For
example, our work, as well as the studies cited above,
were performed in a tertiary hospital, and similar results
were found here (90.3% patients with migraine). On the
other hand, tension-type headache, considered the most
common primary headache, was not mentioned in any of
our patients, and the other 9.7% was distributed between
cluster headache, idiopathic intracranial hypertension,
cervicogenic headache, and post-traumatic headache. In
addition, as expected, long-standing and more frequent
headache at the initial visit is associated with higher risk of
developing MOH than infrequent headache.
17
Our results
showed that most patients, 66% had headache onset more
than 10 years ago and 82.5% reported headache for 4
days or more per week, indicating a higher possibility of
committing abuse.
Besides these risk factors, the easy access to acquire certain
medications and to make combinations of them apply.
In our study, common analgesics (45.6%), followed by
multiple analgesics (31.1%) and then combined analgesics
(22.3%) were the most used. Despite being in a tertiary
hospital, where the use of triptans, or opioids, would be
more common, our patients have low purchasing power,
which justies the use of common analgesics as the main
medication, a fact corroborated by comparative studies
between Europe and Latin America, where 31% versus
6% of patients abuse triptans. Also in our study group,
only 1% of patients abused triptans alone and no patients
abused ergotamine or barbiturates alone. However, for
multiple analgesics, the association of common analgesics
with triptans, opioids and ergotamine predominated.
Thus, when comparing these data with data from other
studies, cultural, economic, and political differences may
contribute to international variation in medication use.
In Spain, simple analgesics are most used, followed by
ergotamine among patients with MOH. Scandinavian
studies show the same trend toward a high preference
for simple analgesics, accompanied by combination
analgesics. In the USA it has been described that patients
with MOH use more opioids and barbiturates than in other
nations.
18
However, excessive consumption of analgesics,
combined or not, may be associated with the presence of
comorbidities.
Thus, in relation to self-reported comorbidities, 20 (19.4%)
patients took analgesics frequently (at least once a week)
for conditions other than headache. Among them, 14
patients related taking them for musculoskeletal and
connective tissue pain, 5 patients for non-neoplastic pain
of abdomino-pelvic origin, and 1 patient was taking
medication not to combat pain but to control chronic daily
cough secondary to lung neoplasm. In our results, the major
associated comorbidities were cardiovascular diseases
(hypertension, dyslipidemia, diabetes, stroke), respiratory
(asthma, allergic rhinitis, COPD), and musculoskeletal
(herniated disc, osteoarthritis, bromyalgia, and
rheumatoid arthritis). Besides comorbidities, the risk
and psychosocial factors most often mentioned in our
study were: smoking, alcoholism, insomnia, obesity,
sedentariness and family history of headache, a fact
corroborated by other studies.
10-12
And when looking at
the amount of psychiatric disorders, MOH patients seem to
be more likely to have multiple psychiatric comorbidities.
5
In this context, our patients showed more pathological
personality characteristics, according to the application of
the DSM V diagnostic criteria for depression and anxiety.
The observed prevalence of the evaluated psychiatric
disorders was 72 (69.9%) patients, of these 8 (7.8%)
patients had depression; 26 (25.2%) anxiety; 38 (36.9%)
both disorders. While 31 (30.1%) patients did not close
criteria for depression nor anxiety but could not be ruled
out from other unevaluated pathological personalities.
Similar results were observed in other studies.
5,9,19
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But the biggest question is why the patient abuses
medication. We know the risk factors, we know that
comorbidities inuence analgesic consumption, that
psychosocial disorders make the patient more susceptible,
and yet the rates seem to increase. It is necessary to
understand if there is any factor related to the patient's
knowledge of what abuse is, or if it is important to determine
to what extent personality disorders are a consequence of
inadequate treatment, or a cause of MOH, and whether
they should be more widely attributed to not only MOH,
but chronic pain in general. And, if there is knowledge
about it, then it is important to understand why the patient
continues to overuse it.
In this sense, in our study, 46.6% of the patients
reported not knowing the effect of the abusive use of the
medications. Other studies have presented similar results.
In the study by Johnson et al.
20
, 50% of patients who had
seen a neurologist in the previous year denied having
been instructed about the abuse of pain medications. In
that same respect, Lai et al.
21
observed that 78% of the
respondents, whether headache sufferers or not, did not
know the relationship between headache and analgesic
abuse, and in the Bekkelund et al.
22
only 2/262 (0.8%)
patients, after consultation with a neurologist, were
informed by the specialist that they suffered from a possible
headache associated with excessive use of analgesics. The
authors suggest that the patients may have been informed
but may not have remembered or fully understood the
information. Thus, we wonder to what extent the patients
were not informed, did not remember, did not understand
the orientations, or due to their own abusive personality
maintained the abuse. On the other hand, in some cases
there is medical advice to start medication early before the
crisis sets in. In our sample, 55 (53.4%) patients continued
to abuse medication, even under counseling. Among the
causes for maintaining abuse, the most cited was difculty
in coping with pain (37 answers), followed by fear of
worsening headache (17 answers), anxiety control (16
answers), not understanding guidelines (8 answers), and
need to work (5 answers). Our results are similar to those
shown by the review study by Sousa
7
, where the difculty in
bearing pain (67%) is the most frequent answer, followed
by the belief that there is no cure (65%), the fear of feeling
pain (62%), the need for painkillers to work better (62%),
medical advice to take painkillers at the right time (57%),
to reduce anxiety (45%), and the fear of worsening pain
(30%).
A fact that draws attention in our study is the number of
patients who report not having received detoxication
therapy (65%) since therapy, either with a complete
two-month cessation of acute medications or only with
reduced medication intake, has been shown to be effective
in reducing the frequency of headache days/month,
converting a chronic migraine into an episodic one.
Studies show a reduction in headache chronicity from 55%
to 18% and in over 80% of cases patients were cured of
MOH after 6 months.
23
Medication adherence is essential to successful treatment
of MOH; analyses indicate that only 56% of patients
adhere to treatment over 6 to 12 months with lower
rates over time. In our survey, 33% of patients were not
currently on any prophylactic medication. The fact is that
the absence of therapy makes it difcult for the patient to
adhere, especially in the rst 10 days of detoxication due
to withdrawal effects.
Another important point to be questioned would be
regarding follow-up. In our study, we observed that most
patients (n=66, 64.1%) had no follow-up in primary
care, and only 22 (21.4%) had a follow-up of less than 3
months. In our view, the lack of return to the consultations
can become a risk factor, because without the ideal follow-
up, the patient cannot renew the prescription, has no
control of side effects or dose adjustment, nor support in
moments of weakness. When we evaluated at the tertiary
level, 55 (53.4%) patients returned in a period longer
than 6 months. That is, regardless of the level of care, the
patients did not follow up optimally.
Conclusion
In our study, we observed that patients continue to abuse
pain medication regardless of where they are seen and
whether the physician is a generalist or a specialist,
despite a clear lack of support from the patient's primary
care. When asked what could be done to improve their
adherence to treatment, the majority answered frequent
return visits and psychological follow-up. In addition, we
associated the lack of orientation or the failure to understand
or interest in the orientations given, and the irregular use of
medications as real and important obstacles.
In this sense, some studies have shown that patients submitted
to drug therapy associated with non-pharmacological
treatments, prevented relapses after 8 weeks of follow-
up, when compared to drug therapy alone.
24
Among the
studies, we highlight those in which the patients received
dynamic psychotherapy, frequent support (possibility of
contacting the physician and/or team nurse), and the use
of an electronic diary, focusing on patient education. Thus,
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the patient becomes more active in the decisions of when
and how to treat and also collaborates in behavioral and
lifestyle changes.
25
Comparing these data with our results,
we suggest changing the model of care by adopting
measures that intensify and improve treatment adherence.
These measures include effective communication, such
as asking the patient to repeat important information,
reinforcing concepts and key words, and making sure
that the patient has understood the main directions. If
necessary, making use of supplementary written material,
more frequent feedback, family and psychotherapy support,
and close follow up with the physician or nurse practitioner
if the feedback is longer.
However, despite similar outcome indicators, the differences
between the populations studied should be considered. For
this, more studies are needed, with a longer follow-up time,
for safer answers that can bring real benet.
Klairton Duarte de Freitas
https://orcid.org/0000-0002-2143-1278
Raimundo Neudson Maia Alcantara
https://orcid.org/0000-0003-1927-926X
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