Medication Overuse Headache (MOH) is a secondary headache disorder caused by the regular overuse of acute or symptomatic headache medications. This condition can paradoxically worsen headache frequency and intensity, often leading to a cycle of increased medication intake.
Recognizing Medication Overuse Headache
Medication Overuse Headache typically presents as a daily or near-daily headache, often described as persistent or worsening over time. These headaches commonly develop in individuals with pre-existing primary headache disorders, such as migraine or tension-type headache. The headache pattern often becomes more diffuse and less responsive to typical acute treatments.
The types of medications most frequently associated with MOH include triptans, opioids, and combination analgesics containing caffeine. Simple analgesics like acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can also contribute to MOH. The International Classification of Headache Disorders, 3rd edition (ICHD-3), outlines specific diagnostic criteria: headache occurring on 15 or more days per month in a patient with a pre-existing headache disorder, and regular overuse of one or more acute or symptomatic headache medications for more than three months. This includes triptans, opioids, or combination analgesics used on 10 or more days per month, or simple analgesics used on 15 or more days per month. Improvement in the headache typically occurs within two months after discontinuing the overused medication.
The Withdrawal Process
The primary treatment for Medication Overuse Headache involves discontinuing the overused acute medication, a process known as withdrawal. This can be approached through abrupt cessation, where the medication is stopped immediately, or through a gradual tapering schedule.
During withdrawal, individuals may experience temporary worsening of headache, often referred to as a “withdrawal headache,” along with other symptoms. These acute withdrawal symptoms can include nausea, vomiting, anxiety, restlessness, insomnia, and increased blood pressure. These symptoms typically peak within the first few days to a week after cessation and usually resolve within a few weeks.
Management of withdrawal symptoms can involve short-term “bridge therapy” with different classes of medications to ease discomfort. Non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids are sometimes used for a limited period to help manage the acute withdrawal headache. Anti-emetics can address nausea, and anxiolytics might be considered for severe anxiety.
Withdrawal can often be managed in an outpatient setting, especially for overuse of simple analgesics or triptans. However, inpatient admission may be considered for individuals overusing opioids or barbiturate-containing medications due to the potential for more severe withdrawal symptoms, or if there are significant comorbidities.
Preventing Relapse and Long-Term Strategies
After successful withdrawal from overused medications, the focus shifts to preventing the recurrence of MOH and managing the underlying primary headache disorder. This often involves initiating or optimizing prophylactic (preventive) medications. These medications are taken regularly to reduce headache frequency, severity, and duration, thereby decreasing the need for acute treatments.
Non-pharmacological approaches play an important role in long-term management and relapse prevention. Lifestyle modifications, such as maintaining a regular sleep schedule, engaging in consistent physical activity, and adopting stress management techniques, can significantly contribute to headache control.
Behavioral therapies, including cognitive behavioral therapy (CBT) and biofeedback, teach individuals coping mechanisms and relaxation techniques to manage pain and stress. Physical therapy can also be beneficial, particularly for headaches with musculoskeletal components.
Patient education is paramount to prevent future medication overuse. Individuals are taught about appropriate medication use, the risks of overuse, and strategies for recognizing early signs of escalating medication intake. Regular follow-up with healthcare providers helps monitor progress and adjust treatment plans.
References
Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018 Jan;38(1):1-211.
Diener, H. C., & Limmroth, V. (2004). Medication-overuse headache: a worldwide problem. The Lancet Neurology, 3(8), 475-483.
Westergaard, M. L., & Jensen, R. H. (2018). Medication overuse headache: a review of the latest evidence. Therapeutic Advances in Neurological Disorders, 11, 1756286418797967.