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Medication Overuse Headache

By

Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision Apr 2020| Content last modified Apr 2020
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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

The most common causes of medication overuse headache are

  • Opioids

  • Analgesics that contain butalbital

  • Aspirin or acetaminophen taken with caffeine

However, other nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans can also cause medication overuse headache.

The mechanism of medication overuse headache is poorly understood but 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

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

  • 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.

According to the International Classification of Headache Disorders (1), the criteria for the diagnosis of medication overuse headache include

  • 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

  • Withdrawal of the overused headache drug

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

  • Drugs to prevent the underlying headache disorder

  • Cognitive therapy

  • Biofeedback

  • Education

Usually, the drug is stopped 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). If necessary, the overused headache drug is stopped after preventive treatment is started.

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.

Preventive treatment (eg, topiramate, onabotulinumtoxinAerenumab) for the underlying headache disorder can be started before or after stopping the overused drug.

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

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.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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