Medication-Overuse Headache – Withdrawal Management — SCE Neurology MCQ

Correct answer: D — Stopping after an inadequate chronic-migraine frequency reduction

The best answer is “Stopping after an inadequate chronic-migraine frequency reduction”. For chronic migraine, NICE continuation requires at least a 30% reduction after 12 weeks; a fall from 20 to 16 days is 20% and does not meet that threshold. “Continuation because any reduction demonstrates a clinically useful response” is less appropriate because a clinically noticed change does not override the specified continuation criterion “Stopping after failure to achieve a 50% frequency reduction” is less appropriate because the 50% criterion applies to episodic rather than chronic migraine in this guidance “Escalation to another licensed dose before formal response assessment” is less appropriate because unlicensed escalation is not the required response to failing the stopping rule “Codeine augmentation followed by delayed response reassessment” is less appropriate because regular opioid use adds medication-overuse risk and does not validate ineffective preventive therapy

Reference: NICE TA682: Erenumab for preventing migraine. https://www.nice.org.uk/guidance/ta682/chapter/1-Recommendations