How is medication overuse headache managed?

Management of Medication Overuse Headache (MOH)

The cornerstone of medication overuse headache management is withdrawal of the overused medication, preferably through abrupt discontinuation, combined with preventive therapy and patient education.1, 2

Diagnosis and Recognition

• MOH is characterized by headache occurring on ≥15 days per month for >3 months in patients with pre-existing primary headache disorder
• Develops due to regular overuse of acute headache medications
• Patients with migraine account for approximately two-thirds of all MOH cases1

Treatment Algorithm

Step 1: Education and Withdrawal of Overused Medication

• Patient education is crucial1, 2

  • Explain the relationship between frequent intake of acute headache medications and MOH
  • Warn patients that withdrawal typically causes temporary worsening of headache before improvement
  • Set realistic expectations about the recovery process

• Medication withdrawal approach1, 2, 3

  • Abrupt withdrawal is preferable to slow withdrawal for most medications1
  • Non-opioids and triptans may be stopped abruptly or weaned down within a month1
  • Opioids should be gradually removed over at least one month1
  • Setting:
    • Outpatient withdrawal is appropriate for most patients1, 3
    • Inpatient withdrawal is recommended for patients overusing opioids, benzodiazepines, or barbiturates3

Step 2: Management of Withdrawal Symptoms

• Pharmacological options for withdrawal symptoms2, 3
  • Corticosteroids (at least 60mg prednisone or prednisolone) are possibly effective3
  • Antiemetics with prokinetic properties for associated nausea1
  • Bridging therapy may help relieve withdrawal symptoms4

Step 3: Initiate Preventive Treatment

• Start preventive therapy immediately1, 2, 3
  • Begin preventive medication on the first day of withdrawal or even before3
  • Topiramate (up to 200mg daily) has the strongest evidence for prophylactic treatment in patients with chronic migraine and medication overuse3
  • Other first-line preventive options include:
    • Beta-blockers (propranolol 80-240 mg/day)
    • Amitriptyline (30-150 mg/day)
    • Valproate (800-1500 mg/day)2
  • For chronic migraine with MOH, consider onabotulinumtoxinA or CGRP monoclonal antibodies if other preventives fail1, 2

Step 4: Establish New Acute Treatment Plan

• Limit use of acute medications to ≤2 days per week or ≤10 days per month1
• First-line acute treatments:
  • NSAIDs (ibuprofen, diclofenac, aspirin)
  • Acetaminophen2
• Second-line acute treatments:
  • Triptans (when taken early while headache is mild)2
• Provide clear guidelines on frequency limits for all acute medications

Step 5: Regular Follow-up and Relapse Prevention

• Schedule regular follow-up appointments to monitor progress3
• Use headache calendars to track frequency and medication use1
• Assess treatment effectiveness by monitoring:
  • Attack frequency
  • Attack severity
  • Migraine-related disability1
• Implement lifestyle modifications:
  • Regular sleep schedule
  • Adequate hydration
  • Regular meals
  • Stress management techniques
  • Regular physical activity2

Prognosis and Outcomes

• Success rate of treatment is approximately 50-70%5
• Higher relapse rates in patients with opioid overuse5
• Relapse can be reduced through continued patient education and regular follow-up5

Special Considerations

• If treatment fails, reassess the diagnosis and consider specialist referral1
• For patients with significant comorbidities, consider multidisciplinary care including psychological support1, 2
• MOH is often conflated with chronic migraine; careful assessment is needed to distinguish between them1

Common Pitfalls to Avoid

• Failing to recognize MOH - Always consider MOH in patients with daily or near-daily headaches who use acute medications frequently
• Continuing overused medication - Without discontinuation of the offending medication, improvement is almost impossible6
• Delaying preventive treatment - Early initiation of preventive therapy improves outcomes3
• Inadequate follow-up - Regular monitoring is essential to prevent relapse3
• Not addressing psychological factors - Behavioral and stress management techniques should be implemented1, 2