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Medication Overuse Headache


Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Reviewed/Revised Apr 2023

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.

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

  • Aspirin or acetaminophen taken with caffeine

  • Ergotamine

  • 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.

  • Headache that occurs ≥ 15 days a month in a patient with a preexisting headache disorder

  • Regular overuse of one or more medications taken for acute treatment of headache for > 3 months (medications include ergotamine, triptans, opioids, or mixed analgesics taken ≥ 10 days a month or a single nonopioid analgesic such as acetaminophen, aspirin, or another NSAID taken ≥ 15 days/month)

  • 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

Treatment of Medication Overuse Headache

  • Medications to prevent the underlying headache disorder

  • Withdrawal of the overused headache drug

  • Use of rescue medications (eg, antipsychotic medications, corticosteroids, dihydroergotamine) for headache during the withdrawal period

  • 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.

Preventive medications Prevention Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more (eg, topiramate, onabotulinumtoxinA, erenumab, epitinezumab, fremanezumab, galcanezumab) are usually started first, and the overused medication is later stopped, often abruptly; the exception is patients who are taking high doses of opioids, barbiturates, or benzodiazepines; for these patients, the medication may need to be tapered more gradually (over 2 to 4 weeks).

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

  • Dihydroergotamine

  • Prochlorperazine

  • Clonidine (preferred if the overused medication was an opioid)

  • Phenobarbital (used to prevent withdrawal seizures if the overused medication was a barbiturate)

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

  • For triptans, ergotamine, or combination analgesics: < 4 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.

Drugs Mentioned In This Article

Drug Name Select Trade
Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Apra, Children's Acetaminophen, Children's Pain & Fever , Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever
Cafcit, NoDoz, Stay Awake, Vivarin
DHE 45, Migranal, TRUDHESA
EPRONTIA, Qudexy XR, Topamax, Topamax Sprinkle, Topiragen , Trokendi XR
Botox, Botox Cosmetic
Compazine, Compazine Rectal, Compazine Solution, Compazine Syrup, Compro
Catapres, Catapres-TTS, Duraclon, Kapvay, NEXICLON XR
Luminal, Sezaby
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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