New Insights into Preventing Chronic Migraines: The Role of Medication Underuse
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Migraines are more than just a headache—they can disrupt lives, hinder productivity, and lead to chronic pain if not managed properly. A recent focus on “medication underuse headache” (MUH) is shedding light on how inadequate treatment can pave the way to more severe conditions, such as medication overuse headache (MOH). Alan M. Rapoport, MD, a leading expert in headache medicine, is at the forefront of this emerging field, emphasizing the importance of early intervention to prevent migraine chronification.
Understanding Medication Underuse Headache
“The concept of medication underuse headache is so new that there are no accepted treatments or algorithms available yet,” said Rapoport. “MUH is not a new headache subtype but a warning sign that can lead to migraine chronification and medication overuse headache. It’s crucial to educate both doctors and patients about this issue to prevent the onset of more severe headaches.”
Rapoport explained that MUH occurs when patients fail to take their prescribed medication at the right time or in the correct dosage. This underuse can trigger a cycle of pain, making it harder to manage migraines over time. “Medication underuse headache is the cause of medication overuse headache,” he noted. “Once MOH begins, it becomes incredibly challenging to treat.”
the Road to Chronic Migraines
While the exact causes of migraine chronification are still being studied, Rapoport identified several key risk factors, including medication overuse, increased migraine frequency, obesity, and mental health conditions such as depression and anxiety. Sleep deprivation also plays a role in exacerbating migraines.
to prevent migraines from becoming chronic, Rapoport stressed the importance of timely and effective acute treatment. “The right time to start acute treatment is at the very start of a migraine attack,” he said. “Ideally, within 90 minutes of experiencing symptoms.Waiting too long can make the pain harder to control.”
Patients who experience multiple headache days per week should take action as soon as symptoms intensify. “If the headache starts to feel like a migraine—with unilateral throbbing and associated symptoms—it’s time to take medication,” rapoport advised.
Preventive Medications: A Missed Opportunity
Despite the availability of preventive medications, many patients fail to use them consistently. A 2007 study published in Neurology found that while 38% of patients were eligible for preventive treatment, only 12.4% were actually on these medications. Similarly, a 2015 study in Cephalalgia revealed that only 17%-20% of patients continued using their preventive medications a year after starting them.
“If a patient has four severe headache attacks a month, they should be on preventive medication,” Rapoport said. “Even those with one or two attacks monthly may benefit, especially if the pain is severe or treatment-resistant.”
Common reasons for discontinuing preventive medications include lack of efficacy and tolerability issues, according to a 2013 study in Headache. However, rapoport believes that better education and tailored treatment plans coudl help more patients stick with preventive therapies.
A Call to Action for Doctors and Patients
To address medication underuse, Rapoport and his colleagues recommend that neurologists take a proactive approach.this includes ensuring patients receive the correct medications and dosages, and also educating them on the importance of timely treatment. “We need to empower patients to take control of their migraines,” Rapoport said.”Early intervention is key to preventing chronic pain and improving quality of life.”
As research continues to uncover the complexities of migraines, the focus on medication underuse headache offers a promising avenue for prevention. By addressing this overlooked issue, doctors and patients can work together to break the cycle of chronic pain and restore balance to daily life.
For more insights from Dr. Rapoport and other experts, visit Neurology and Cephalalgia.
Migraine Treatment: Balancing Old and New Medications for Optimal Relief
For patients seeking relief from migraines, understanding the differences between older and newer medications is crucial. Older oral preventive medications, originally developed for conditions like hypertension and heart disease, require time to reach therapeutic levels and may cause mild side effects during the initial 2-3 months of use. Patients are advised to persist through these effects to achieve satisfactory results.
The Rise of Anti-CGRP Medications
While older medications can be effective for both acute and preventive migraine care, they frequently enough fall short in efficacy and are associated with more side effects compared to newer anti-CGRP (calcitonin gene-related peptide) medications, according to Dr. Rapoport.”Preventively, I prefer to use the newer anti-CGRP medicines,” he said. ”However, because they’re expensive and not always approved by insurance companies, sometimes we start with the older, less expensive medicines and progress to CGRP-targeting options if needed.”
The introduction of anti-CGRP medications has revolutionized migraine treatment,offering more targeted and effective options for patients. These newer drugs have gained popularity among physicians for their superior efficacy and reduced side effects, though their cost and insurance approval remain critically important barriers.
Overcoming Barriers to MUH Awareness
One of the primary challenges in adopting the concept of Medication-Overuse Headache (MUH) is the lack of awareness among healthcare providers. Dr. Rapoport noted that when he and Dr. Rattanawong first presented the topic at the Spanish Society of Neurology’s annual meeting in November, they encountered no resistance, only genuine interest in best practices. this positive reception highlights the growing recognition of MUH as a critical issue in migraine management.
On March 22, 2025, Dr. Rattanawong will further explore the validity of MUH during a debate at the 19th Annual World Congress on Controversies in Neurology in Prague, Czech Republic. This event promises to be a pivotal moment in advancing understanding and acceptance of MUH among global neurologists.
Dr. Rapoport serves as the editor in chief of Neurology Reviews. The MUH paper received no external funding.
John Jesitus is a Denver-based freelance medical writer and editor.
As the medical community continues to evolve its approach to migraine treatment, the balance between older and newer medications remains a key discussion point. By addressing the challenges of cost, insurance approval, and awareness, healthcare providers can better support patients in their journey toward effective migraine management.
E evolving landscape of treatment options is crucial. The balance between traditional adn newer medications plays a notable role in managing migraines effectively. In this interview, we sit down with Dr. Alan M. Rapoport, a renowned expert in headache medicine, to discuss the challenges and opportunities in migraine treatment, including the importance of addressing medication underuse and overuse.
The Evolution of Migraine Treatment
Senior Editor: Dr.Rapoport, thank you for joining us today. The medical community has seen a significant shift in migraine treatment over the years. can you provide some insight into how these treatments have evolved?
Dr. Rapoport: Absolutely. Over the past few decades, we’ve moved from primarily using acute medications like triptans and NSAIDs to now having a variety of preventive treatments, including CGRP inhibitors and other novel therapies. This shift has been driven by a better understanding of the underlying mechanisms of migraines and the need for more targeted, effective treatments.
Medication Underuse and Overuse: The Double-Edged Sword
Senior Editor: One of the key topics you’ve been focusing on is medication underuse headache (MUH). Can you explain what this is and why it’s so important?
Dr. Rapoport: Certainly. Medication underuse headache occurs when patients fail to take thier prescribed medication at the right time or in the correct dosage. This can lead to a cycle of pain that makes it harder to manage migraines over time. It’s essentially the opposite of medication overuse headache (MOH), which happens when patients take too much medication. Both conditions can lead to chronic migraines, so it’s crucial to address both underuse and overuse.
Preventive Medications: A Missed Prospect
Senior Editor: You’ve mentioned the importance of preventive medications. Why do you think so many patients fail to use them consistently?
Dr. Rapoport: There are several reasons. Some patients may not see immediate results, while others may experience side effects. Additionally, there’s a lack of awareness about the long-term benefits of preventive medications.Many patients only seek treatment when they’re in the midst of a migraine attack, rather then focusing on prevention. Education and tailored treatment plans can help address these issues.
The Role of Healthcare Providers
Senior Editor: What role do healthcare providers play in addressing these challenges?
Dr. Rapoport: Healthcare providers need to be proactive in educating patients about the importance of both acute and preventive treatments. This includes ensuring patients receive the correct medications and dosages,and also educating them on the importance of timely treatment. By empowering patients to take control of their migraines,we can definitely help prevent chronic pain and improve their quality of life.
Looking Ahead: The Future of Migraine Treatment
Senior Editor: what does the future hold for migraine treatment?
Dr. Rapoport: The future is promising. as research continues to uncover the complexities of migraines, we’re seeing more targeted and effective treatments. The focus on medication underuse headache offers a promising avenue for prevention, and with better education and tailored treatment plans, we can definitely help more patients manage their migraines effectively.
For more insights from Dr. Rapoport and other experts, visit Neurology and Cephalalgia.
