Medication overuse headache is a chronic headache that occurs > 15 days/month in patients who regularly overuse headache medication for > 3 months. It usually develops in people with migraine or tension-type headache. Treatment consists of stopping the overused medication, managing withdrawal symptoms, and using other medications to prevent the underlying headache disorder.
(See also Approach to the Patient With Headache.)
Frequent or daily use of medications to treat acute headaches can increase headache frequency and cause episodic headaches to become chronic.
Prevalence of medication overuse headache is 1 to 2% in the general population. It is more common among women than men; most people with this type of headache have underlying episodic migraine or tension-type headache.
Patients who develop this disorder take frequent or excessive doses of analgesics (eg, triptans for ≥ 10 days/month), often with incomplete relief.
Etiology of Medication Overuse Headache
The most common medications taken by patients with medication overuse headache are
Opioids
Analgesics that contain butalbital
Triptans
Other nonsteroidal anti-inflammatory drugs (NSAIDs) can also cause medication overuse headache.
The mechanism of medication overuse headache is thought to include sensitization of the central nervous system similar to what occurs in migraine.
A greater prevalence of substance dependence in people with medication overuse headache suggests a behavioral component. A genetic predisposition may also be involved.
Symptoms and Signs of Medication Overuse Headache
Headache occurs daily or nearly daily, often on awakening. Nausea, irritability, and difficulty concentrating may be present. Location and characteristics of the pain vary.
Diagnosis of Medication Overuse Headache
Clinical criteria
Rarely CT or MRI to exclude other disorders
Diagnosis of medication overuse headache is clinical and is based upon the frequency of headache and use of medications to relieve it.
According to the International Classification of Headache Disorders (1, 2), the criteria for the diagnosis of medication overuse headache include
Headache that occurs ≥ 15 days a month in a patient with a preexisting headache disorder
No other headache type that better accounts for the clinical presentation
Medication overuse headache must be differentiated from the primary headache disorder, which typically causes concurrent symptoms.
Rarely, CT or MRI is done to exclude other disorders. Routine neuroimaging is unnecessary.
Diagnosis references
1. Headache Classification Committee of the International Headache Society (IHS): The International Classification of Headache Disorders, 3rd edition. Cephalalgia 38 (1):1–211, 2018.
2. Diener H-C, Kropp P, Dresler T, et al: Management of medication overuse (MO) and medication overuse headache (MOH) S1 guideline. Neurol Res Pract 4 (1):37, 2022. doi: 10.1186/s42466-022-00200-0
Treatment of Medication Overuse Headache
Medications to prevent the underlying headache disorder
Withdrawal of the overused headache drug
Cognitive therapy
Biofeedback
Education
A patient with medication overuse headache can be treated in an outpatient or inpatient setting; sometimes IV medications are required. Patients with headache due to opioid overuse should be treated in an inpatient setting.
Early symptoms after stopping opioids, barbiturates, or benzodiazepines include nausea, restlessness, anxiety, and poor sleep. In addition, stopping any kind of analgesic can cause an increase in the frequency, duration, and/or intensity of headaches. These symptoms may last a few days or up to 4 weeks.
A rescue medication is used to treat withdrawal headache; rescue medications are the same as transitional medications.
Transitional (bridge) medications are used to help prevent withdrawal headache symptoms if withdrawal of the overused medication, use of the rescue medication, and preventive medications are unlikely to be successful. Transitional medications include
NSAIDs
Corticosteroids
After medication overuse headache has been treated, patients should be instructed to limit acute use of all headache medications as follows:
For NSAIDs: < 6 days/month
Use of previously overused medications is discouraged.
Cognitive therapy, biofeedback (eg, frontal electromyographic biofeedback), and education are helpful.
Prognosis for Medication Overuse Headache
With treatment, medication overuse headache is probably in remission in about 50% of patients after 10 years.
Fewer headache days/month after 1 year of treatment predicts longer remission.
