Medication overuse headache

Last updated: November 1, 2023

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Summarytoggle arrow icon

Medication-overuse headache (MOH) is a chronic secondary headache disorder caused by regular overuse of analgesics that are used to treat a preexisting chronic headache disorder. The most common underlying headache disorders are migraine followed by tension-type headache. Simple analgesics (e.g., acetaminophen, NSAIDs) alone or in combination with caffeine, followed by triptans, are the most commonly overused medications. Women aged 40–49 years are most commonly affected. The pathophysiology is not completely understood but likely involves dependence processes, central sensitization, and (possibly) genetic predisposition. The diagnosis is based on clinical criteria. Diagnostic studies are usually not necessary unless indicated to investigate the cause of the preexisting chronic headache. Treatment involves patient education, weaning of overused medications, management of withdrawal symptoms, and relapse prevention. MOH typically resolves with discontinuation of the overused medications.

Epidemiologytoggle arrow icon

  • Sex: > [2]
  • Prevalence: estimated to be around 2% of the general population [2][3][4]
    • Women aged 40–49 years are most commonly affected.
    • Prevalence decreases with older age.

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Risk factors [3][5][6]

Pathophysiology [2]

  • Only partially understood. Pathogenesis may involve dependence processes, central sensitization, and possibly genetic predisposition.

Clinical featurestoggle arrow icon

Medication-overuse headache is characterized by an increase in headache frequency and severity, and increasing refractoriness to abortive and prophylactic pain medications in patients with a prolonged history of chronic headache and medication overuse. [7][8][9]

Diagnosticstoggle arrow icon

The diagnosis of medication-overuse headache is based on clinical criteria. Diagnostic studies are usually not necessary unless required to investigate the cause of the underlying chronic headache.

Diagnostic criteria for medication-overuse headache [10]

Medication-overuse headache is a diagnosis of exclusion (i.e., it should be considered after ruling out other headache disorders). Further work-up must be pursued if red flags for headache are present.

Managementtoggle arrow icon

Patient education followed by reduction and discontinuation of overused medications are the mainstays of treatment and typically lead to the resolution of medication-overuse headaches.

General principles [2][7][9][11]

  • Patient counseling should be emphasized.
  • Complete weaning of the overused medication is essential.
  • The rate (abrupt vs. gradual) and setting (outpatient vs. inpatient) of medication withdrawal is determined based on patient characteristics and the overused medication class.
  • Headache medications and analgesics are preferably avoided during the withdrawal period.
  • Supportive interventions may include:
    • Rescue medications for treatment of severe withdrawal symptoms
    • Short-term bridging medications to reduce headache frequency and severity during the withdrawal period
    • Nonpharmacological interventions
    • Initiation of long-term prophylactic medications for the underlying headache
  • Expert consultation is advised for patients who have previously been unable to discontinue medications or have a history of severe withdrawal symptoms.

Key points for patient education and counseling [9][12][13][14]

  • Explain the exacerbating effects of medication overuse.
  • Emphasize the benefits of weaning and nonpharmacological therapy.
  • Review specific treatment goals, including:
  • Manage expectations regarding withdrawal.
  • Ensure regular follow-up.

Discontinuation of overused medications

Avoid medications of the same class as the overused medication. [9]

Management of the underlying chronic headache [2][9][11][15]

Disposition and referrals [2][19][20]

  • Outpatient treatment with primary care provider follow-up and counseling is appropriate for most patients.
  • Consider inpatient supervised withdrawal for patients with any of the following:
    • Overuse of opioids, barbiturates, or benzodiazepines
    • Significant medical or psychiatric comorbidities (e.g., depression)
    • Failed attempts at discontinuation in an outpatient setting
  • Consider short-term psychotherapy and/or other nonpharmacological therapy referrals. [14][21]
  • Consider consulting a neurologist or headache specialist for patients with prior difficulty or inability to discontinue medication.

Preventiontoggle arrow icon

Primary prevention [15]

  • Identify patients at risk and educate on the risk of MOH and recommended headache management strategies.
  • Optimize abortive and preventive management of patients with chronic headache disorders. [9]
  • Address modifiable risk factors (e.g., smoking, physical inactivity, use of tranquilizers).

Prevention of recurrence [11][22]

  • Limit the use of headache symptomatic medications to no more than 2 days per week.
  • Avoid previously overused medication classes.

Referencestoggle arrow icon

  1. Evers S, Jensen R. Treatment of medication overuse headache - guideline of the EFNS headache panel. Eur J Neurol. 2011; 18 (9): p.1115-1121.doi: 10.1111/j.1468-1331.2011.03497.x . | Open in Read by QxMD
  2. Da Silva AN, Lake AE. Clinical Aspects of Medication Overuse Headaches. Headache: The Journal of Head and Face Pain. 2013; 54 (1): p.211-217.doi: 10.1111/head.12223 . | Open in Read by QxMD
  3. Tepper SJ. Medication-Overuse Headache. CONTINUUM: Lifelong Learning in Neurology. 2012; 18: p.807-822.doi: 10.1212/01.con.0000418644.32032.7b . | Open in Read by QxMD
  4. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211.doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  5. Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment.. Therapeutic advances in drug safety. 2014; 5 (2): p.87-99.doi: 10.1177/2042098614522683 . | Open in Read by QxMD
  6. Katsarava Z, Obermann M. Medication-overuse headache. Curr Opin Neurol. 2013; 26 (3): p.276-281.doi: 10.1097/wco.0b013e328360d596 . | Open in Read by QxMD
  7. Westergaard ML, Hansen EH, Glümer C, Olesen J, Jensen RH. Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: A systematic review. Cephalalgia. 2013; 34 (6): p.409-425.doi: 10.1177/0333102413512033 . | Open in Read by QxMD
  8. Hagen K, Linde M, Steiner TJ, Stovner LJ, Zwart J-A. Risk factors for medication-overuse headache: An 11-year follow-up study. The Nord-Trøndelag Health Studies. Pain. 2012; 153 (1): p.56-61.doi: 10.1016/j.pain.2011.08.018 . | Open in Read by QxMD
  9. Limmroth V, Katsarava Z, Fritsche G, Przywara S, Diener H-C. Features of medication overuse headache following overuse of different acute headache drugs. Neurology. 2002; 59 (7): p.1011-1014.doi: 10.1212/wnl.59.7.1011 . | Open in Read by QxMD
  10. Tassorelli C, Jensen R, Allena M, et al. A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study. Cephalalgia. 2014; 34 (9): p.645-655.doi: 10.1177/0333102414521508 . | Open in Read by QxMD
  11. Grande RB, Aaseth K, Benth JŠ, Lundqvist C, Russell MB. Reduction in medication-overuse headache after short information. The Akershus study of chronic headache. European Journal of Neurology. 2010; 18 (1): p.129-137.doi: 10.1111/j.1468-1331.2010.03094.x . | Open in Read by QxMD
  12. Rossi P, Faroni JV, Nappi G. Short-term effectiveness of simple advice as a withdrawal strategy in simple and complicated medication overuse headache. European Journal of Neurology. 2011; 18 (3): p.396-401.doi: 10.1111/j.1468-1331.2010.03157.x . | Open in Read by QxMD
  13. Lipton RB. Risk Factors for and Management of Medication-Overuse Headache. CONTINUUM: Lifelong Learning in Neurology. 2015; 21: p.1118-1131.doi: 10.1212/con.0000000000000216 . | Open in Read by QxMD
  14. Alstadhaug KB, Ofte HK, Kristoffersen ES. Preventing and treating medication overuse headache. PAIN Reports. 2017; 2 (4): p.e612.doi: 10.1097/pr9.0000000000000612 . | Open in Read by QxMD
  15. Diener H-C, Bussone G, Oene JV, Lahaye M, Schwalen S, Goadsby P. Topiramate Reduces Headache Days in Chronic Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Cephalalgia. 2007; 27 (7): p.814-823.doi: 10.1111/j.1468-2982.2007.01326.x . | Open in Read by QxMD
  16. Rizzato B, Leone G, Misaggi G, Zivi I, Diomedi M. Efficacy and Tolerability of Pregabalin Versus Topiramate in the Prophylaxis of Chronic Daily Headache With Analgesic Overuse. Clin Neuropharmacol. 2011: p.74-78.doi: 10.1097/wnf.0b013e318210ecc9 . | Open in Read by QxMD
  17. Silberstein SD, Blumenfeld AM, Cady RK, et al. OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline. J Neurol Sci. 2013; 331 (1-2): p.48-56.doi: 10.1016/j.jns.2013.05.003 . | Open in Read by QxMD
  18. Rossi P, Lorenzo CD, Faroni J, Cesarino F, Nappi G. Advice Alone Vs. Structured Detoxification Programmes for Medication Overuse Headache: A Prospective, Randomized, Open-Label Trial in Transformed Migraine Patients With Low Medical Needs. Cephalalgia. 2006; 26 (9): p.1097-1105.doi: 10.1111/j.1468-2982.2006.01175.x . | Open in Read by QxMD
  19. Créac’h C, Frappe P, Cancade M, et al. In-patient versus out-patient withdrawal programmes for medication overuse headache: A 2-year randomized trial. Cephalalgia. 2011; 31 (11): p.1189-1198.doi: 10.1177/0333102411412088 . | Open in Read by QxMD
  20. Altieri M, Di Giambattista R, Di Clemente L, et al. Combined Pharmacological and Short-Term Psychodynamic Psychotherapy for Probable Medication Overuse Headache: A Pilot Study. Cephalalgia. 2009; 29 (3): p.293-299.doi: 10.1111/j.1468-2982.2008.01717.x . | Open in Read by QxMD
  21. Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache - Report of an EFNS task force. European Journal of Neurology. 2010; 17 (11): p.1318-1325.doi: 10.1111/j.1468-1331.2010.03070.x . | Open in Read by QxMD
  22. $Contributor Disclosures - Medication overuse headache. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  23. Krymchantowski A, Barbosa J. Prednisone as Initial Treatment of Analgesic-Induced Daily Headache. Cephalalgia. 2000; 20 (2): p.107-113.doi: 10.1046/j.1468-2982.2000.00028.x . | Open in Read by QxMD
  24. Drucker P, Tepper S. Daily sumatriptan for detoxification from rebound.. Headache. 1998; 38 (9): p.687-90.doi: 10.1046/j.1526-4610.1998.3809687.x . | Open in Read by QxMD
  25. Krymchantowski AV, Moreira PF. Out-patient detoxification in chronic migraine: comparison of strategies.. Cephalalgia. 2003; 23 (10): p.982-93.doi: 10.1046/j.1468-2982.2003.00648.x . | Open in Read by QxMD
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  27. Grande RB, Aaseth K, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of Primary Chronic Headache in a Population-Based Sample of 30- to 44-Year-Old Persons. Neuroepidemiology. 2008; 30 (2): p.76-83.doi: 10.1159/000116244 . | Open in Read by QxMD
  28. Aaseth K, Grande R, Kvárner K, Gulbrandsen P, Lundqvist C, Russell M. Prevalence of Secondary Chronic Headaches in a Population-Based Sample of 30-44-Year-Old Persons. The Akershus Study of Chronic Headache. Cephalalgia. 2008; 28 (7): p.705-713.doi: 10.1111/j.1468-2982.2008.01577.x . | Open in Read by QxMD

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