Therapie des Kopfschmerzes bei Medikamentenübergebrauch

Zusammenfassung

Nach der zweiten Ausgabe der Internationalen Kopfschmerzklassifikation (ICHD-II, 2004) wird der Kopfschmerz bei Medikamentenübergebrauch (medication overuse headache – MOH) als chronischer Kopfschmerz definiert, induziert durch den Übergebrauch von Ergotamin, Triptanen, Analgetika, Opioiden, Kombinationspräparaten, Kombinationen einzelner Substanzen oder anderer, nicht näher spezifizierter Medikamente. Obwohl bisher keine epidemiologische Studie die tatsächliche MOH-Prävalenz (incl. erfolgreichen Entzug) untersucht hat, wird seine durchschnittliche Prävalenz auf ca. 1% der Gesamtbevölkerung geschätzt. Die genaue Pathophysiologie ist derzeit noch unklar, eine genetische Prädisposition scheint wahrscheinlich. Die Behandlung besteht in den meisten Fällen aus einem akuten Entzug der Medikation und dem Beginn einer vorbeugenden medikamentösen Therapie. Eine Ausnahme davon stellt der Übergebrauch von Opioiden und Barbituraten (in Europa sehr selten) dar, die schrittweise reduziert werden sollen. Es besteht aktuell keine klare Evidenz für die Bevorzugung einer ambulanten oder stationären Entzugstherapie. Steroide werden zur Begleitung des Entzuges eingesetzt, die Studienlage dazu ist jedoch überwiegend negativ. Topiramat und Onabotulinumtoxin können bei Patienten mit Migräne und MOH die Attackenfrequenz so reduzieren, dass die Kriterien des MOH nicht mehr erfüllt sind, ohne dass vorher ein formaler Entzug durchgeführt worden ist.

Summary

According to the 2nd edition of the International Classification of Headache Disorders (ICHD-II, 2004), medication overuse headache (MOH) is defined as a chronic headache attributed to the overuse of ergotamine, triptans, analgesics, opioids, combination medication, combinations of single drugs or not further specified drugs. Although the real prevalence of MOH (including successful withdrawal) has not been investigated in epidemiological studies, the average prevalence is estimated with 1% of the general population. The pathophysiology of MOH remains indistinct, but a genetic background seems likely. The treatment consists of an acute withdrawal of the medication and the beginning of a prophylactic treatment in most patients. As exception, overuse of opioids or barbiturates (the latter in Europe very rare) is recommended to withdrawal stepwise. There is no convincing evidence to prefer a withdrawal therapy in an out-patient or in-patient setting. Steroids may be an option as concomitant medication during the withdrawal phase but the evidence is negative in the majority of studies. Topiramate and onabotulinumtoxin are able to reduce the number of attacks in migraine patients with MOH so far that the criteria of MOH are not longer fulfilled without a formal withdrawal of analgesics.

Schlüsselwörter

Kopfschmerz bei Medikamentenübergebrauch - Analgetika - Prophylaxe - Leitlinie

Keywords

Medication overuse headache - analgesics - prophylaxis - treatment guidelines

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