PO-82 | Integrated approach with detoxification, CGRP monoclonal antibodies and psychoeducational support in two patients with complex medication overuse headache

Background: Complex Medication Overuse Headache (or type II MOH) is a secondary chronic headache characterized by daily use of acute headache medications for over one year, multiple psychiatric comorbidities and/or a history of relapse following previous withdrawal attempts. Certain medications as well, including opioids, are associated with poorer prognosis and higher risk of relapse, making management particularly challenging. Methods: We report two cases, a 48-year-old man and a 69-year-old woman, with chronic migraine and MOH, experiencing an average of 45 and 90 acute medications per month respectively, including opioids. Both patients were referred to our Headache Clinic in Alessandria after prior management at other centers. They both shared psychiatric comorbidities such as depression, generalized anxiety disorder, bulimia, and self-harming thoughts. Brain MRI was unremarkable, excluding other secondary causes of headache. They underwent multiple prophylactic treatments (10-5) which were discontinued due to poor tolerability or lack of efficacy, along with several unsuccessful detoxification protocols (5-1). We decided to combine detoxification, prophylactic therapy with eptinezumab and a psychoeducational program in order to gain awareness about pain and medication management. Results: Headache diary monitoring revealed a gradual reduction in both frequency and intensity of attacks, initially without drug withdrawal. Subsequently, patients have learned to attend to their emotional dimension, whereas previously they relied on opioids for mood stabilization. At follow-up, the female patient transitioned to an episodic migraine pattern (4 attacks/month), while the male patient, despite persistent chronic migraine, no longer required the overuse of triptans or opioids. Conclusion: A tailored approach combining detoxification, target therapy and psychoeducational support appears effective in reducing both frequency and intensity of the attacks, while also improving emotional awareness, even in cases involving opioid overuse. There is no universal agreement on the best treatment protocols for complex MOH; therefore, further studies are needed to assess the long-term effectiveness of this combined strategy.