Key Points of Medication Overuse:

  1. Medication-overuse headache (MOH) is a chronic daily headache and a secondary disorder in which acute medications used excessively causes headache in a headache-prone patient.1,4
  2. MOH is clinical diagnosis and a history of analgesic use more than two to three days per week in a patient with chronic daily headache is indicatory of this diagnosis.
  3. MOH most commonly occurs in people with primary headache disorders like migraine, cluster, or tension-type headaches using less effective or nonspecific medications resulting in inadequate treatment response and redosing.2
  4. MOH development is linked to baseline frequency of headache days per month, acute medication class ingested, frequency of acute medications ingested, and other risk factors.2
  5. Medication overuse headache has been found to render headaches refractory to both pharmacological and non-pharmacological prophylactic medications, and also reduces the efficacy of acute abortive therapy for migraines.
  6. The most effective method to treat MOH is discontinuation of the medication that is overused and a combination of pharmacological, non-pharmacological, behavioral and physical therapy interventions.
  7. Use of certain classes of acute medications such as opioids, barbiturate-containing analgesics and butalbital, aspirin and caffeine is associated with increased risk of chronic migraine.4

Introduction to Medication Overuse Headaches

Medication-overuse headache is a secondary disorder caused by excessive use of acute medications.1,4 It has been previously termed analgesic rebound headaches, drug-induced headache, and medication misuse headaches. It is defined by the ICDH-3 diagnostic criteria as headache occurring on 15 or more days per month in a patient with a preexisting headache disorder who has been overusing one or more acute treatment drugs for symptomatic treatment of headache for three or more months, and those headaches cannot be accounted for by another diagnosis. MOH is more common in middle-life and the prevalence rages from 1% to 2% with a 3:1 female to male ratio.3 People with higher frequency of headaches and greater disability have increased risk of developing chronic migraine.4

Symptoms of Medication Overuse

The location, character, and severity of medication-overuse headache can vary among individuals, but most of the time occurs daily or nearly daily, and is usually present upon awakening.4 It improves transiently with analgesics and returns as the medication wears off. Other symptoms that may accompany the headaches are nausea, anxiety, irritability, asthenia, restlessness, difficulty concentrating, memory problems and depression.5

What is Medication Overuse?

Medication overuse is defined by the amount of acute medication taken per month by a patient. Each medication class has a specific threshold.3 Use of triptans, ergot alkaloids, combination analgesics, or opioids on ten or more days per month constitute medication overuse. Use of simple analgesics, including non-steroidal anti-inflammatory drugs (NSAIDS) on 15 or more days per month constitutes medication overuse. Use of certain classes of acute medications such as opioids, barbiturate-containing analgesics and butalbital, aspirin and caffeine is associated with increased risk of chronic migraine.

  1. Simple analgesics: Common medications such as aspirin, acetaminophen, NSAIDS (ibuprofen, naproxen, indomethacin,) may contribute to rebound headaches especially when the patient exceeds the recommended daily dosages. These medications cause MOH when used 15 or more days per month.
  2. Combination pain relievers: Over-the-counter pain relievers that contain a combination of caffeine, aspirin and acetaminophen or butalbital commonly cause medication overuse headache as well. All of these medications are high risk for the development of medication-overuse headache if taken for 10 or more days per month.
  3. Triptans and Ergotamines: Triptans and Ergotamines also have a moderate risk of causing medication overuse headache when used for ten or more days per month.
  4. Opioids: Oxycodone, tramadol, butorphanol, morphine, codeine, and hydrocodone among others cause MOH when used 10 or more days per month.
  5. Caffeine use: Caffeine intake of more than 200mg per day increases the risk of MOH.

Diagnosis for Medication Overuse

The diagnosis for medication-overuse headache is clinical, and a history of analgesic use more than two to three days per week in a patient with chronic daily headache is indicatory of this diagnosis. The physician may consider performing extra tests like imaging studies and lab work, especially if the quality of the headaches changes to rule out any other secondary cause. This diagnosis is supported if headache frequency increases in response to increasing medication use, or improves when the overused medication is withdrawn.

Treatment for Medication Overuse Headaches

Discontinuation of overused medication is essential and the treatment of choice for MOH. In addition, preventive treatment aimed at the suspected background primary headache disorders should be initiated either during or immediately following withdrawal.4,5 There are various strategies to help with process of medication withdrawal and bridge therapy may be useful during drug withdrawal to provide symptomatic relief. Apart from discontinuation, a combination of pharmacological therapy, non-pharmacological therapy, biofeedback, and targeted physical therapy is needed for improvement in the patient’s symptoms. Support groups and behavioral techniques have also been found necessary for the success of the treatment in the symptoms.

It is important for the patient to know that when the medication overused is discontinued, they may undergo a period where their headaches will get worse. Some other symptoms caused by the withdrawal of the medication can include nausea, vomiting, insomnia, restlessness or constipation. The headaches eventually will get better.

The physician will decide if the overused medication will be discontinued abruptly or if it needs to be tapered slowly. It may take a couple of months to six months to eventually break the headache cycle.

In certain circumstances, inpatient treatment may be considered so that medication can be tapered in a controlled environment, and prolonged intravenous medications can be used to break the headache cycle.

Other outpatient therapies include biofeedback, psychological counseling, and physical therapy, which help effectively work on changing lifestyle and incorporating non pharmacological therapies for the management of headaches. Biofeedback teaches the patient to control certain responses of the body to effectively help in reducing pain. The patient learns diaphragmatic breathing and how to control temperature, heart rate, and muscle tension to enter into a relaxed state, which may help to better cope with pain.

Conclusion

Medication-overuse headache is caused by frequent use of abortive medications and is well known to cause chronic daily headache. Treatment requires pharmacological and non–pharmacological therapies to effectively break the headache cycle. Hospitalization may be required depending on the medication and dosage that the patient was using.

It is important to know that intake of medications for acute treatment should be limited to less than two times per week. Some methods that can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medication, limit use of simple analgesics to less than 15 days per month, and limit triptans and ergotamines to less than 10 days per month.

Patients should remember to contact their physicians and let them know if they need to take medications for acute treatment frequently so that the appropriate management can be done and the onset of medication overuse headaches can be avoided.

References:

  1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd ediction. Cephalalgia 2004;24(suppl 1):9-160.
  2. Tepper SJ. Medication-Overuse Headache. Continuum. 2012 Aug;18(4):807-22.
  3. Kristoffersen ES, Lundquist C. Medication-overuse headache; epidemiology, diagnosis and treatment. Ther Adv Drug Saf 2014;5(2):87-99. doi:10.1177/2042098614522683.
  4. Lipton, R. Risk Factors for and Management of Medication-Overuse Headache. Continuum. 2015 Aug;21(4): 1118-1131.
  5. Dodick D, Freitag F. Evidence-based understanding of medication-overuse headache: clinical implications. Headache 2006; 46 Suppl 4:S202.
  6. Diener HC, Katsarava Z. Medication overuse headache. Curr Med Res Opin 2001;17:s17-s21.Review on medication overuse headache.
  7. Silberstein SD, Olesen J, Bousser MG, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)-revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005;25:460-465.
  8. Tepper SJ. Debate: analgesic overuse is a cause, not consequence, of chronic daily headache. Analgesic overuse is a cause of chronic daily headache. Headache 2002;42:543-547.
  9. Silberstein, Stephen D.; Lipton, Richard B.; Dodick, David W. Wolff’s Headache and Other Head Pain. New York. Oxford Press. 2008
  10. Wilson M-C. Remember to SNOOP and Improve Your Headache Diagnosis. American Headache Society Newsletter. Vol. 15:2 Summer 2004

Maria-Carmen Wilson, MD
Professor of Neurology
Director, Headache Medicine Fellowship
University of South Florida
Tampa, FL

Rebecca Jimenez-Sanders, MD
Assistant Professor of Neurology
University of South Florida
Tampa, FL