(See also Approach to the Patient With Headache Approach to the Patient With Headache Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical... read more .)
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.
According to the International Classification of Headache Disorders (1 Diagnosis reference 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... read more ), 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
1. Headache Classification Committee of the International Headache Society (IHS): The International Classification of Headache Disorders, 3rd edition. Cephalalgia 38 (1):1–211, 2018.
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.
