Management of Medication Overuse Headache (MOH)
The most effective management of medication overuse headache requires withdrawal of the overused medication, combined with preventive treatment and patient education about the relationship between frequent medication intake and headache. 1, 2
Diagnosis and Definition
- MOH is defined as headache occurring on ≥15 days per month for >3 months in patients with pre-existing primary headache, caused by regular overuse of acute headache medications 2
- Medication overuse thresholds:
Treatment Algorithm
Step 1: Education and Counseling
- Educate patients about the relationship between frequent intake of acute headache medication and MOH 2, 3
- Set clear expectations about withdrawal symptoms and the recovery process
- Explain that improvement may take weeks to months
Step 2: Medication Withdrawal (Detoxification)
Withdrawal approach based on medication type:
- Simple analgesics, triptans, or ergots: Abrupt discontinuation or weaning over 1 month 1, 3
- Opioids, barbiturates, or tranquilizers: Gradual tapering over at least 1 month 1, 3
Setting for withdrawal:
- Outpatient: For most patients overusing simple analgesics, triptans, or ergots 3
- Inpatient/day hospital: Recommended for patients overusing opioids, barbiturates, benzodiazepines, or those with significant comorbidities 4, 3
Step 3: Management of Withdrawal Symptoms
- Corticosteroids: Prednisone or prednisolone (at least 60mg) may help manage withdrawal symptoms 4
- Amitriptyline: Up to 50mg may be effective for withdrawal symptoms 4
- Bridge therapy: Short-term medications to manage withdrawal headache while transitioning to preventive treatment 5
Step 4: Preventive Treatment
- Timing: Start preventive medication on the first day of withdrawal therapy or even before 4
- First-line preventive option: Topiramate up to 200mg daily (has moderate evidence specifically for chronic migraine with medication overuse) 4
- Alternative preventives: Based on underlying primary headache type:
Step 5: Follow-up and Relapse Prevention
- Regular follow-up visits to monitor progress and prevent relapse 4
- Continue effective prophylactic treatment for at least 3-6 months 1
- If discontinuing preventive treatment, taper gradually over several weeks 1
- Limited use of acute medications to prevent recurrence:
- NSAIDs: ≤15 days/month
- Triptans: ≤10 days/month 1
Special Considerations
- Higher relapse risk: Patients with opioid overuse have higher relapse rates (50-70% success rate overall) 2
- Women of childbearing age: Avoid valproate and topiramate due to teratogenicity; discuss effective contraception if these medications are necessary 1
- Comorbidities: Consider psychiatric comorbidities that may affect treatment adherence and outcomes
Non-Pharmacological Approaches
- Regular sleep schedule
- Consistent meal times
- Adequate hydration
- Regular physical exercise
- Stress management techniques 1
- Cognitive behavioral therapy may be beneficial 1
Common Pitfalls to Avoid
- Failing to identify medication overuse in patients with chronic headache
- Inadequate patient education about the relationship between medication overuse and headache
- Adding preventive medications without addressing overuse of acute medications
- Insufficient follow-up after withdrawal, leading to high relapse rates
- Not considering comorbidities that may complicate treatment (depression, anxiety, substance use disorders)
The success of MOH treatment depends on patient education, appropriate withdrawal strategies, preventive treatment, and regular follow-up to prevent relapse. A structured approach with clear expectations improves outcomes in this challenging condition.