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Medication Overuse Headache

By

Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Aug 2021| Content last modified Aug 2021
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Medication overuse headache is a chronic headache that occurs > 15 days/month in patients who regularly overuse headache drugs for > 3 months. It usually develops in people with migraine or tension-type headache. Treatment consists of stopping the overused headache drug, managing withdrawal symptoms, and using drugs to prevent the underlying headache disorder.

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 analgesic (eg, triptans for ≥ 10 days/month), often with incomplete relief.

Etiology of Medication Overuse Headache

The most common drugs 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 drugs to relieve it.

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

  • Regular overuse of one or more drugs taken for acute or preventive treatment of headache for > 3 months (drugs include ergotamine, triptans, opioids, or combination analgesics taken ≥ 10 days/month or a single 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 reference

Treatment of Medication Overuse Headache

  • Drugs to prevent the underlying headache disorder

  • Withdrawal of the overused headache drug

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

  • Cognitive therapy

  • Biofeedback

  • Education

Preventive drugs 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 drug is later stopped, often abruptly; the exception is patients who are taking high doses of opioids, barbiturates, or benzodiazepines; for these patients, the drug 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 drug is used to treat withdrawal headache; it is similar to the transitional drugs.

Transitional (bridge) drugs are used to help prevent withdrawal headache symptoms if withdrawal of the overused drug, use of the rescue drug, and preventive drugs are unlikely to be successful. Transitional drugs include

  • NSAIDs

  • Corticosteroids

  • Dihydroergotamine

  • Prochlorperazine

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

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

After medication overuse headache has been treated, patients should be instructed to limit acute use of all headache drugs to

  • For NSAIDs: < 6 days/month

  • For triptans, ergotamine, or combination analgesics: < 4 days/month

Use of previously overused drugs is discouraged.

Cognitive therapy, biofeedback (eg, frontal electromyographic biofeedback), and education are helpful.

Prognosis of 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
BOTOX
D.H.E. 45, MIGRANAL
COMPRO
TYLENOL
No US brand name
Galcanezumab
Fremanezumab
ERGOMAR
TOPAMAX
Butalbital
CATAPRES
Erenumab
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