Medication Overuse Headache

Background

• Medication overuse headache (MOH) is a secondary headache disorder in which frequent use of acute headache medications paradoxically leads to increased headache frequency and reduced effectiveness of acute medications.
• It can occur with simple analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (paracetamol), or it can occur with other analgesics or combinations of medications.
  • Simple analgesic intake ≥ 15 days/month for > 3 months for headache may lead to MOH.
  • Intake of other analgesics (triptans, ergot alkaloids, or opioids) or combinations of medications from different classes ≥ 10 days/month for > 3 months for headache may lead to MOH.

Evaluation

• Consider diagnosis of MOH in a patient with a history of all of the following:
  • existing primary headache disorder (usually migraine or tension headache)
  • frequency of headaches increases to ≥ 15 days/month
  • acute medication taken on ≥ 10-15 days/month (depending on medication) for > 3 months
  • not better accounted for by another headache diagnosis
• Laboratory investigations are not indicated unless they are needed for evaluation of the primary headache disorder or to evaluate for other conditions.
• Assess for depression, anxiety, and substance dependency because they may coexist with MOH and may require additional management.
• Also assess for and address risk factors and other comorbidities, taking into account non-headache characteristics such as socioeconomic factors, which may help devise better management strategies for the patient and improve outcomes.

Management

• Consider outpatient management for most patients who have overused simple analgesics and do not have significant comorbidities. Inpatient treatment is recommended if withdrawal of the medications that were overused requires tapering (such as benzodiazepines, barbiturates, and opioids), the patient has severe comorbidities, or previous attempts at outpatient management were not successful.
• Consider multidisciplinary and multimodal approaches to address behavioral, psychological, and social aspects of treatment.
• Include advice and education (including encouraging following a healthy lifestyle and identifying and avoiding headache triggers) as a component of management for all patients with MOH.
• Consider incorporating counseling and behavioral therapy, particularly in patients with psychological comorbidities that may lead to medication overuse or make withdrawal of overused medications difficult.
• Consider starting withdrawal of overused medication.
  • Successful withdrawal from overused medication may reduce headache frequency to an episodic pattern (with headaches on < 15 days/week, as opposed to chronic pattern) and reduce medication use.
  • Abrupt withdrawal is recommended for overuse of simple analgesics, ergot derivatives, and triptans.
  • Tapered withdrawal is recommended for overuse of benzodiazepines, barbiturates, and opioids.
  • Withdrawal has been shown to reduce headache frequency, but there may be a temporary exacerbation of headaches and other withdrawal symptoms, particularly with abrupt withdrawal.
  • Consider bridging therapy or rescue therapy with medications from a different class than the overused medication to help address withdrawal-related headaches and other symptoms, but evidence is limited for most options.
• Consider also using preventive headache medication, particularly if patient unable to successfully withdraw from acute medication use at previous attempts.
  • Commonly used options for patients with MOH and primary migraine include topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP)-targeted treatments.
  • Other medications to consider have limited evidence for patients with MOH: amitriptyline, (particularly for primary tension headache), beta-blockers, cannabinoids, flunarizine (not available in the United States), pregabalin, and valproic acid.
  • Preventive headache medication without also requiring withdrawal of overused medication might be a potential option, as reduction in headache frequency by itself may lead to reduced acute medication use.
• Routinely follow-up with patients after withdrawal of overused medication to reduce risk of relapse.