Abstract
Purpose of review
Medication-overuse headache is a secondary chronic headache disorder, evolving from an episodic primary headache type, caused by the frequent and excessive use of headache symptomatic drugs. While gene polymorphisms have been deeply investigated as susceptibility factors for migraine, little attention has been paid to medication-overuse headache genetics. In the present study we conducted a systematic review to identify, appraise and summarize the current findings of gene polymorphism association studies in medication-overuse headache.
Methods
A comprehensive literature search was conducted on PubMed and Web of Knowledge databases of primary studies that met the diagnostic criteria for medication-overuse headache according to the temporally-relevant Classification of Headache Disorder of the International Headache Society.
Results
A total of 17 candidate gene association studies focusing on medication-overuse headache were finally included in the qualitative review. Among these, 12 studies investigated the role of common gene polymorphisms as risk factors for medication-overuse headache susceptibility, six studies focused on the relationship with clinical features of medication-overuse headache patients, and four studies evaluated their role as determinants of clinical outcomes in medication-overuse headache patients.
Conclusion
Results of single studies show a potential role of polymorphic variants of the dopaminergic gene system or of other genes related to drug-dependence pathways as susceptibility factors for disease or as determinants of monthly drug consumption, respectively. In this systematic review, we summarize the findings of gene polymorphism association studies in medication-overuse headache and discuss the methodological issues that need to be addressed in the design of future studies.
Introduction
Medication-overuse headache (MOH) is a daily or almost daily headache that results from the chronicization of a pre-existing primary headache as a consequence of symptomatic drug overuse (1). It is a paradoxical headache disorder, in which the cure for the headache becomes its leading cause in a susceptible patient (2). All acute headache medications have the potential to cause MOH. These include both migraine-specific medications, such as triptans and ergot alkaloids, and other pain-relief medications nonspecific for headache treatment, such as NSAIDs, paracetamol, combination analgesics, opioids and barbiturates (1,3). Epidemiological data indicate that MOH affects approximately 1–2% of the general population, with a similar prevalence in Europe, North America and Asian countries (1,4). It is noteworthy that MOH places a high economic burden on society, the per-person annual costs being estimated to be three times higher than those of migraine and 10 times higher than those of tension-type headache (5). Despite drug withdrawal therapy being performed very differently within and across countries, it represents the first-choice treatment for MOH (6). In most MOH patients, chronic headache improves significantly or is even reverted to its previous episodic pattern within two months of drug withdrawal (7,8). However, 30–45% of MOH patients with successful withdrawal therapy relapse into medication overuse, the majority of them within the first year of follow-up (9).
Various clinical and epidemiological studies suggest that MOH has a probable genetic basis. A hereditary susceptibility to MOH has been suggested, as the risk of developing MOH is greater in individuals with a family history of MOH or other substance abuse (10). In addition, patients overusing analgesics for pain conditions other than headache showed a higher risk of developing MOH only when they had a previous history of migraine (11,12). Furthermore, MOH appears to share some pathogenic mechanisms with other kinds of addictive disorders (13), and genetic factors are established factors that contribute to drug addiction (14). While gene polymorphisms have been deeply investigated as risk factors for migraine (15), less attention has been paid to the role of polymorphic gene variants in MOH susceptibility or as determinants of clinical features and outcomes of MOH patients. In order to assess the strength and quality of the evidence so far accumulated, in the present study we conducted a systematic review to identify, appraise and summarize the current findings of gene polymorphism association studies in medication-overuse headache.
Methods
Search strategy
The present systematic review was conducted in accordance with the PRISMA Statement principles (16) and the protocol published in the International Prospective Register of Systematic Reviews “PROSPERO” (registration number: CRD42017055206). A computerized literature search of PubMed and Web of Science databases was performed up to 13 January 2017 by using the Boolean combination of the following key terms: ((“Medication overuse headache” OR “MOH” OR “chronic headache with medication overuse” OR “chronic daily headache with medication overuse” OR “chronic daily headache with substantial medication overuse” OR “chronic medication overuse headache” OR “chronic daily headache associated with long-term misuse of headache medication” OR “drug abuse headache” OR “drug dependence headache” OR “drug-associated headache” OR “drug-induced headache” OR “drug-induced daily headache” OR “drug-induced chronic daily headache” OR “drug-induced refractory headache” OR “drug-rebound headache” OR “drug-related headache” OR “headache associated with chronic use of substances” OR “headache induced by chronic substance use” OR “headache induced by chronic substance exposure” OR “medication abuse-related headache” OR “medication-induced headache” OR “medication-misuse headache” OR “medication rebound headache” OR “painkiller headache” OR “primary headache diagnosis with medication overuse” OR “rebound headache” OR “rebound-withdrawal headache” OR “withdrawal headache”) AND (polymorphism OR polymorphisms OR SNP OR SNPs OR “single nucleotide polymorphism” OR “single nucleotide polymorphisms” OR “variant” OR “variants”)).
Relevant studies were required to meet the following inclusion criteria:
Human studies, including patients who met the diagnostic criteria for MOH according to the temporally relevant Classification of Headache Disorder of the International Headache Society (IHS) (17–20) Prospective or retrospective original studies investigating the association of common genetic variants with any of the following endpoints: i) susceptibility to MOH; ii) clinical features of MOH patients; iii) clinical outcomes of MOH patients.
Exclusion criteria were:
Studies not conducted in humans Reviews, case studies, editorials, and meeting abstracts.
There were no language or time of publication restrictions. All potentially relevant studies retrieved in the initial screening step were then read in their entirety to assess their appropriateness for inclusion in the systematic review. The reference lists of all included studies and relevant reviews were checked to identify additional studies missed from the original electronic searches. Eligibility assessment of manuscripts was independently performed by two investigators (S.C. and S.T.) and any discrepancies were resolved through consensus.
Data extraction and quality assessment
A standardized form was used for each primary study included in the qualitative analysis, in which the following information was collected: first author’s last name, year of publication, study location, number of patients enrolled for each patients’ cohort, medication(s) overused, gene polymorphism analysed, primary (and, if any) secondary endpoint(s) investigated, statistics used to analyse genotype data, application or not of multiple testing correction, p-value used as cut-off for determining statistical significance and, for each endpoint investigated, the polymorphic variant found to be significantly associated. The scientific quality of studies included in the systematic review was evaluated according to the Strengthening the Reporting of Genetic Association (STREGA) recommendations for reports on genetic association studies (21). Briefly, the quality of the studies was assessed based on the clear definition or evaluation of the following 11 points: 1) Objectives and hypothesis, 2) eligibility criteria for study participants, 3) outcome(s) of interest, 4) power analysis or sample size calculations, 5) quality control of genotyping method, 6) assessment of Hardy-Weinberg equilibrium (HWE), 7) use of adjusted or multivariate analysis, 8) descriptive clinical data (e.g. age, gender), 9) statement of outcome results, 10) multiple testing correction, and 11) consideration of study limitation and potential bias. Studies with a total score of at least eight out of 11 points were considered of high quality. Data extraction and quality assessment were independently performed by two investigators (S.C. and S.T.). Any discrepancies were resolved through consensus.
Results
Characteristics of identified studies
The detailed flowchart of literature review process is reported in Figure 1. The search strategy on PubMed and Web of Knowledge identified a total of 128 studies, of which 16 were duplicates. After the removal of 95 hits not fulfilling the inclusion criteria, 17 studies were finally included in the qualitative review of gene association studies focusing on MOH (22–38). The main characteristics of the identified studies are summarized in Table 1. Briefly, these studies were published between 2006 and 2015 by five research groups, four of which were located in Italy – including our group – and one in Japan, with sample sizes of MOH patients ranging from 22 to 227. Twelve studies had a case-control design (22,25–29,31–34,36,37), while the remaining five were case-only studies (23,24,30,35,38). Thirteen studies were conducted on MOH patients with Caucasian ancestry (22–27,29,30,34–38), while four studies recruited MOH patients with Asian ethnicity (28,31–33). Most of the studies enrolled MOH patients overusing different classes of antimigraine medications, except one study which included MOH subjects overusing exclusively triptans (26). The median total score of study quality was eight (range: 3–11, online supplementary Table S1), indicating that the overall methodological quality was moderate to high. Seven studies (41%) conducted an a priori statistical power analysis (24,27,29,34–37), while six out of 13 studies (46%) applied a method (Bonferroni’s) to correct for testing multiple gene variants (25,27,29,34–36).
Flowchart of the literature review process. Characteristics and findings of studies included in the systematic review. BDI: Beck Depression Inventory; CM: chronic migraine; EM: episodic migraine; HC: healthy controls. MOH: medication-overuse headache; NR: not reported.
Gene polymorphism associations with susceptibility to MOH
Twelve case-control studies investigated the role of common genetic polymorphisms as risk factors for MOH susceptibility (22,25–29,31–34,36,37). Overall, 50 polymorphisms were analysed in 33 genes related to serotoninergic transmission (SLC6A4, 5HT1A, 5HT2A, 5HT1B, GNB3, 5HT6, TPH2), dopaminergic transmission (SLC6A3, COMT, DBH, DRD2 and DRD4), drug dependence (ACE, OPRM1, BDNF, EEAT2), metabolic pathways (CYP1A2, MAOA, MTHFR), oxidative stress (eNOS, nNOS, GTPCH, GSTP1, GSTM1, GSTT1, SOD, CAT, PON, CYBA), CGRP pathway (CALCA, RAMP1), and genes postulated to be relevant for migraine pathophysiology (ESR1, TNF-β). Among the identified studies, seven studies compared genotype or allelic frequencies of MOH patients with healthy controls (HCs) (22,25,27,29,34,36,37), seven considered the comparison of MOH patients with episodic migraineurs (EMs) (22,25,28,31–33,36), and one study compared genotype or allelic frequencies of MOH patients with chronic migraineurs without drug overuse (26).
Among the seven studies assessing genotypic or allelic frequencies of MOH patients in comparison to healthy controls (HCs), three gene variants including 5HT6 C267T (25), SLC6A4 rs1042173 (29) and RAMP1 rs7590387 (36) emerged as nominally significant (p < 0.05) in at least one study. Specifically, an overrepresentation of the C allele of the 5HT6 C267T polymorphism was identified in MOH patients compared to HCs (p = 0.033) (25). In addition, results obtained from our group provided evidence of association between carriers of the minor allele for SLC6A4 rs1042173 (GT + GG) and higher risk of being affected by MOH (GT + GG vs. TT: OR 1.58, 95% CI: 1.05–2.37, p = 0.028) (29), and of association between RAMP1 rs7590387GG genotype and lower risk of MOH (GG vs. CC + CG: OR 0.43, 95% CI: 0.22–0.85, p = 0.011) (36). However, none of these three gene variants remains significant after Bonferroni correction or would be significant after its application.
Among the seven studies comparing genotype distributions between episodic migraineurs (EMs) and MOH patients, nominal associations emerged in five studies (22,25,28,32,36) of which two applied correction for multiple testing (25,36). Specifically, allele 10 of SLC6A3 3’ UTR 40-bp VNTR (p = 0.016) and allele 4 of DRD4 48-bp VNTR (p = 0.0053) were reported to be underrepresented in MOH patients compared to EMs (22). The same research group subsequently reported an association of the G allele of the 5HT1A A82G polymorphism with a lower risk of MOH (p = 0.039) (25). In a recent study (36), we found RAMP1 rs7590387 GG carriers at lower risk of episodic migraine transformation into MOH compared to rs7590387C allele carriers (vs. non-GG, OR: 0.27, 95% CI: 0.13–0.57, p = 0.0002; threshold p-value for Bonferroni significance = 0.0029). Based on results obtained from 22 MOH and 47 EM, one single research group from Japan reported in two studies (28,32) association of a total of three polymorphic gene variants including TNF-β G252A (p = 0.013), MTHFR C677T (p = 0.017) and DRD2 rs6275 (p = 0.015). Among all these nominally significant polymorphisms, only RAMP1 rs7590387 and DRD4 48-bp VNTR remained significant after Bonferroni correction or would be significant after its application. In the only study comparing MOH patients to chronic migraineurs without drug overuse (26), the 163A allele of CYP1A2 A163G was found to be overrepresented in MOH patients (p = 0.029), but statistical significance would be lost if Bonferroni correction were to have been applied.
Gene polymorphism associations with clinical features of MOH patients
Six studies investigated the correlation between candidate gene polymorphisms and clinical features of MOH patients (23,24,27,29,30,38). Overall, five gene variants (WFST His611Arg, BDNF rs6265, HDAC3 rs2530223, 5HT2A C516T, ACE I/D) and haplotype combination of SLC6A4 gene polymorphisms (STin2 VNTR-rs1042173) were reported to be associated to clinical features of MOH patients, in at least one study. Specifically, homozygous carriers of the minor allele of WFST His611Arg (R/R patients) showed significantly higher monthly drug consumption (p = 0.00075) and more severe depressive symptoms on the BDI questionnaire (p = 0.003) than non-R/R (23). The same authors subsequently reported that MOH patients harbouring the A allele (non-G/G) of BDNF rs6265 G > A showed a higher monthly consumption of acute drugs (p < 0.0001) and longer MOH duration (p = 0.004) when compared to G/G patients (24), while no significant differences between G/G and non-G/G patient groups were found in terms of other clinical and socio-demographic features. In a study from another group, the G allele of HDAC3 rs2530223 was significantly associated with the number of acute medications per month and with the number of days per month in which medications were used (p = 0.006 and p = 0.007, respectively), but neither with headache frequency nor with the intensity of pain (38). Results from our group revealed an association of the C516T polymorphism of 5HT2A with monthly drug consumption in MOH patients (p = 0.018; threshold p-value for Bonferroni significance = 0.025) (27), and association of the STin2 VNTR- rs1042173 haplotype of SLC6A4 with the number of headache days per month (global haplotype association p = 0.0056, threshold p-value for Bonferroni significance = 0.00625) (29). It is also noteworthy that angiotensin converting enzyme (ACE) I/D gene polymorphism significantly influenced the cortical response of MOH patients to somatosensory stimulation (30).
Gene polymorphism associations with clinical outcomes of MOH patients
Four studies investigated the role of common genetic variants as determinants of clinical outcomes in MOH patients (26,34,35,38), of which two stemmed from our group. In the first published study (34), we assessed 14 SNPs in eight genes (i.e. DRD2, DBH, COMT, BDNF, OPRM1, EAAT2, 5HT2A, SLC6A4) as predictors of response to drug withdrawal therapy at two months of follow-up. No polymorphism remained of statistical significance when the conservative Bonferroni correction was used for multiple testing. Nevertheless, in the multivariate analysis, carriers of at least four of the six top-ranked gene variants (rs1799971, rs4680, rs6275, rs6265, rs6305, rs1611115) were found to be at higher odds of unsuccessful detoxification than patients with ≤3 high-risk genotypes (OR: 3.40, 95 % CI 1.65–7.01, p = 0.001), an association which remained significant after correction for multiple testing (threshold p-value for Bonferroni significance = 0.00357). In the other study (35), we assessed the correlation between SLC6A4 STin2, COMT rs4680, COMT rs6269 and relapse risk at one-year of follow-up after successful detoxification (threshold p-value for Bonferroni significance = 0.012). COMT rs4680G allele carriers or the COMT rs6269G-rs4680G haplotype carriers were found to be at lower risk of relapsing into MOH when compared, respectively, to homozygous rs4680A allele carriers (OR: 0.17, 95% CI: 0.05–0.61, p = 0.007) or with the COMT rs6269A-rs4680A haplotype (OR: 0.19, 95% CI 0.06–0.54, p = 0.003). Regarding the two other studies investigating gene polymorphisms associations with clinical outcomes of MOH patients, no association was detected between HDAC3 gene polymorphisms and response to valproate treatment (38), while a nominal association was reported between the CYP1A2*1F allele and grade of response to triptan administration (26), which however would have not survived Bonferroni correction after its application.
Discussion
In the last decade, a number of gene association studies have attempted to assess the role of polymorphic gene variants as susceptibility factors for MOH or as determinants of clinical features and outcomes of MOH patients. In the present systematic review, we summarized the evidence accumulated so far by gene association studies focusing on MOH, with the aim of highlighting research clues and methodological issues useful for orienting towards a better design of future studies in the field. First, all the studies identified used a hypothesis-driven approach, based on the selection of polymorphisms in candidate genes postulated to be involved in MOH pathophysiology. Most of the studies so far conducted focused on polymorphic genes of serotonergic and dopaminergic systems, which have been selected on the basis of previous evidence showing abnormalities of serotoninergic and dopaminergic transmission in MOH patients (39–41). In addition, polymorphic genes known to be implicated in drug addiction have been postulated in MOH patients to have a role in monthly drug consumption, which represents the clinical hallmark of the disease and the expression of the drug-seeking behavior (42). The lack of genome-wide association studies in MOH highlights an enormous distance between genetic research in MOH compared to migraine (15), and also suggests limited funds to this field, which is surprising given the high economic and social burden of MOH (5).
Summary of positive findings in gene polymorphism association studies in MOH.
BDI: Beck Depression Inventory; CM: chronic migraine; EM: episodic migraine; MOH: medication-overuse headache.
MOH is a complex disorder that, in most cases, evolves from migraine, less frequently from tension-type headache (8,47) and sporadically from cluster headache (48) in parallel with the transformation of the primary headache from episodic into chronic. Since 2004, the ICHD classifications require the application of the double diagnosis: the primary headache that has chronified, and MOH (ICHD-II e ICHD-3beta). Yet, in many studies, only the MOH diagnosis is considered. This is the case for some of the papers considered in the present review (24–26,30,37) that did not specify the type of primary headache from which MOH evolved, nor provided the double diagnosis. This misconception may of course disturb the comparability of the studies. It might also confound the interpretation of results also in the reverse condition, that is, when genetic factors for migraine chronification are searched without considering the presence or absence of medication overuse (49). In future studies, it is important that all existing diagnoses are specified a priori or, at the very least, that patients are stratified on the basis of the presence or absence of medication overuse.
In conclusion, the present systematic review highlights that genetic research on MOH is still in its infancy. Despite a relevant number of candidate gene association studies having reported positive findings, unequivocal and definitive conclusions cannot be drawn due to some methodological flaws, including weak study design and lack of internal or external replication studies. With the recent advances of high throughput genomic technologies, application of the genome-wide approach and of next-generation sequencing are expected to provide a significant breakthrough in unravelling MOH pathogenesis (50). It is noteworthy that, at the time of writing this article, a first genome-wide study of DNA methylation has been published, which reported association of several loci potentially involved in headache chronification (51). Nevertheless, candidate gene association studies with a better study design, including those with a discovery/replication design, could be still useful to validate previously reported genetic associations or for corroborating novel findings. In addition, GWAS studies are warranted to explore in a hypothesis-free manner the contribution of genetic background to MOH. In this frame, large cohorts of MOH patients appear to be an essential prerequisite to unequivocally identify genetic, epigenetic or pharmacogenetic determinants in MOH. This will undoubtedly benefit from multicenter and international collaborations as well as from a broad consensus on phenotype definition.
Clinical implications
This systematic review highlights the results of single studies showing the potential role of candidate polymorphic variants of the dopaminergic gene system (DRD4, DRD2, SLC6A3), or of other genes related to drug-dependence pathways (WSF1, BDNF, ACE, HDAC3), as risk factors for MOH susceptibility or as determinants of monthly drug consumption, respectively. Nevertheless, unequivocal and definitive conclusions cannot be drawn due to some methodological flaws, including weaknesses of study designs and lack of replication studies. Multicenter and international cooperative efforts are strongly warranted for the recruitment of larger cohorts of MOH patients in order to explore, in a hypothesis-free manner, the contribution of genetic factors to disease susceptibility as well as to variability of clinical features and outcomes of MOH patients.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
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