Prednisolone does not reduce withdrawal headache

Prednisolone has no effect on withdrawal headache in patients with chronic daily headache and medication overuse, an online first paper published in Neurology concludes. Medication overuse headache (MOH) is characterized by headache >14 days per month for at least 3 months and intake of analgesics or acute migraine drugs more than 10 or 15 days per month depending on the substance abused, write Boe and colleagues from the Sorlander Hospital in Norway. "There has been traditional consent that the patient should stop all medication and undergo a medication-free period of weeks to return to the initial headache frequency before medication overuse.""However, because of increased pain during the first days after the abrupt stop of medication, many patients do not achieve this goal and it is sometimes recommended that, for patients to get through this purgatory, steroids in the form of prednisolone should be prescribed during the first 6 days or so," they add.The randomized, double-blind, and placebo controlled study included patients aged 18 to 70 years with probable medication overuse headache. The patients were hospitalized for 3 days to start medication withdrawal. They were randomly assigned to receive prednisolone (n=51) 60 mg on days 1 and 2, 40 mg on days 3 and 4, and 20 mg on days 5 and 6 (Group A) or placebo tablets (n=49) for 6 days (Group B). Headache intensity was recorded in a diary for a month before withdrawal (baseline) and throughout the study period of 28 days. The primary endpoint was a calculated mean headache (MH), based on number of days with headache and mean intensity the first 6 days after withdrawal. Of 100 patients, 65 had migraine, 13 had tension-type headache, and 22 had both migraine and tension-type headache. During the first 6 days after withdrawal, headache was similar in Groups A and B (MH 1.48 [CI 1.28 to 1.68] vs 1.61[CI 1.41 to 1.82], p=0.34).The MH score during the whole study period of 28 days was 1.4 (1.2 to 1.6) in Group A and 1.4 (1.3 to 1.6) in Group B (p=0.9). Days without headache were 7.2 (5.0 to 9.3) in Group A and 7.6 (5.4 to 9.8) in Group B (p=0.79). Improvement score was similar: Group A: MH initial 1.6 (1.5 to 1.7), MH follow-up 1.4 (1.3 to 1.6), I=11.8%;Group B: MH initial 1.6 (1.5 to1.7), MH follow-up 1.4 (1.2 to 1.5),I=12.1%(p=0.86)."The addition of steroids probably does not make a significant change to the outcome of the patient, nor does it provide convincing temporary relief," the researchers conclude. "Because steroids may have adverse effects, we do not recommend the use of steroids in withdrawal therapy for medication overuse headache. The main stay of management should be withdrawal combined with supportive strategies and a tight follow-up by the treating doctor," they add. Reference...