Galcanezumab a safer choice than prednisone for medication overuse headache

Both galcanezumab and prednisone effectively relieve pain in people with medication overuse headache (MOH), with combination therapy using both medications yielding the greatest benefit, according to the results of a three-arm, head-to-head observational study. However, the use of prednisone is accompanied by an increased frequency of adverse events.

In a cohort of 75 adult patients (median age 48 years, 77.3 percent female) with MOH (median disease duration 23 months), mean monthly headache days decreased significantly after 3 months across the three treatment arms (p<0.001). The highest reduction was observed with galcanezumab plus prednisone (n=25; from 25 to 7 days), followed by galcanezumab alone (n=25; from 25 to 10 days) and prednisone alone (n=25; from 20 to 15 days). [EAN 2024, abstract EPR-078]

However, patients on prednisone—which was administered at an initial dose of 50 mg daily and then tapered off over 28 days—reported a much higher incidence of side effects (p=0.002).

These data indicate that galcanezumab is a safe and effective option, said presenting author Dr Simone Braca from the Department of Neuroscience, Reproductive Sciences and Odontostomatology, University Federico II in Naples, Italy.

Prednisone, given its side-effect profile, should be used only in unresponsive patients, Braca added.

MOH

“MOH emerges from excessive consumption of acute headache medications, [which is common among] individuals enduring ≥15 headache days monthly,” according to Prof Gisela Terwindt from the Leiden University Medical Centre in Leiden University Medical Center in Leiden, The Netherlands.

In a focused workshop presentation at EAN, Terwindt noted that symptoms of MOH can vary. Specifically, analgesic overuse often manifests as a “diffuse, all-encompassing dull pressure in the head,” whereas excessive triptan intake can result in daily, migraine-like episodes that temporarily subside and quickly recur after medication wears off. [EAN 2024, abstract FW15_1]

“Animal studies indicate that prolonged and repetitive use of analgesics and triptans can heighten susceptibility to evoked cortical spreading depression (CSD), modify pain regulation, and foster central sensitization,” she said.

MOH substantially reduces quality of life but is frequently overlooked, Terwindt said, adding that establishing a direct relationship between excessive medication use and worsening headaches can be challenging. While medication withdrawal can suggest MOH, it’s not definitive, and there’s no standard threshold for defining medication overuse, she pointed out.

Managing MOH, according to Terwindt, involves a combination of preventing headaches and reducing reliance on pain relievers, with the goal of reducing both headache frequency and medication intake. “Behavioural and educational interventions coupled with withdrawal therapy [also] prove beneficial for MOH.”

Clinicians are divided on the best course of action for MOH. One strategy involves a complete withdrawal of overused pain medications, while the other emphasizes preventative measures targeting the root cause of the headache, Terwindt stated.

Notably, emerging evidence indicates that small-molecule CGRP receptor antagonists, or gepants, have a low potential for inducing MOH, she added.