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Practice

Medication-overuse headache

Andrew Micieli and Jennifer Robblee
CMAJ March 12, 2018 190 (10) E296; DOI: https://doi.org/10.1503/cmaj.171101
Andrew Micieli
Division of Neurology (Micieli), University of Toronto; Division of Neurology (Robblee), Krembil Neuroscience Centre Headache Clinic, Toronto, Ont.
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Jennifer Robblee
Division of Neurology (Micieli), University of Toronto; Division of Neurology (Robblee), Krembil Neuroscience Centre Headache Clinic, Toronto, Ont.
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Medication-overuse headache (MOH) is common, disabling and underrecognized in clinical practice

Patients with primary headache disorders who overuse analgesia are at risk for MOH, in which the analgesia leads to the paradoxical effect of increasing headache frequency (Box 1).1 The prevalence of MOH in the general population is 1%–2% and as high as 20.6% in referrals to Canadian headache clinics.2

Box 1: Recommended monthly maximums for commonly used medications in headache
MedicationMaximum monthly use, d (ICHD-3 criteria1)
Opioids10†
Barbiturates (butalbital combinations)10†
Triptans10
Ergotamines10
Acetaminophen15
Combination analgesia10
ASA (less common)*15
Nonsteroidal antiinflammatory drugs (less common)15
  • Note: ASA = acetylsalicylic acid, ICHD-3 = The International Classification of Headache Disorders, 3rd ed, MOH = medication-overuse headache.

  • ↵* Caveat: Do not stop ASA if it has a cardiovascular indication. Consider switching to clopidogrel if appropriate.

  • ↵† Caveat: Opioids and butalbital may lead to MOH in about 5 days.

The headache associated with medication overuse can be different in quality and location from the baseline headache

This can make the diagnosis of the underlying primary headache disorder difficult at initial consultation. Neuroimaging should be reserved for patients with red flags if the clinical history supports MOH (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.171101/-/DC1).1 Clinical cues for MOH include an escalation of headache frequency associated with analgesia usage, morning headaches reflecting analgesia withdrawal, predictable development of a headache when medication is delayed and concussion with headache that is not improving.3

Opioid- and butalbital-containing agents should not be used to treat headaches

Use of opioids and barbiturates can lead to central sensitization, headache relapse, hyperalgesia and abuse.3 Medication-overuse headache can develop in the absence of problematic headaches when opioids are used for chronic pain.3

The cornerstone of treatment is patient education followed by stopping or tapering the offending medication

Cessation of offending analgesia may lead to transient exacerbation of headache (lasting 2–10 days) that can be treated with a bridging two-week course of naproxen, long-acting frovatriptan twice per day or short prednisone taper.4 Abrupt withdrawal of overused medications is recommended, except for barbiturates or opioids, which should be tapered over one month.4

A prophylactic medication should be started to reduce primary headache frequency and severity

Topiramate, β-blockers, amitriptyline and gabapentin are strongly recommended for prophylaxis of the primary headache; choice should be individualized based on the drugs’ adverse-effect profiles.5 For difficult cases, particularly with serious behavioural or medical comorbidities, day-hospital or inpatient treatment for intravenous rescue therapy and psychologic support may be required.3

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

References

  1. ↵
    Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd ed. (beta version). Cephalalgia 2013;33:629–808.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Becker WJ,
    2. Purdy RA
    . Medication overuse headache in Canada. Cephalalgia 2008;28:1218–20.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Saper JR,
    2. Da Silva AN
    . Medication overuse headache: history, features, prevention and management strategies. CNS Drugs 2013;27:867–77.
    OpenUrl
  4. ↵
    1. Dodick DW
    . Chronic daily headache. N Engl J Med 2006; 354: 158–65.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Loder E,
    2. Burch R,
    3. Rizzoli P
    . The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines. Headache 2012; 52:930–45.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 190 (10)
CMAJ
Vol. 190, Issue 10
12 Mar 2018
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Medication-overuse headache
Andrew Micieli, Jennifer Robblee
CMAJ Mar 2018, 190 (10) E296; DOI: 10.1503/cmaj.171101

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Andrew Micieli, Jennifer Robblee
CMAJ Mar 2018, 190 (10) E296; DOI: 10.1503/cmaj.171101
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  • Article
    • Medication-overuse headache (MOH) is common, disabling and underrecognized in clinical practice
    • The headache associated with medication overuse can be different in quality and location from the baseline headache
    • Opioid- and butalbital-containing agents should not be used to treat headaches
    • The cornerstone of treatment is patient education followed by stopping or tapering the offending medication
    • A prophylactic medication should be started to reduce primary headache frequency and severity
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