What is the treatment for medication overuse headache?

Treatment of Medication Overuse Headache

The most effective treatment for medication overuse headache (MOH) involves abrupt discontinuation or tapering of the overused medication, combined with initiation of appropriate preventive therapy and management of withdrawal symptoms. 1, 2

Diagnosis and Definition

MOH is defined as:

• Headache occurring on ≥15 days per month for at least 3 months
• Developing as a consequence of regular overuse of acute headache medication
• In a patient with a pre-existing headache disorder
• Medication overuse thresholds vary by medication type:
  • Simple analgesics: ≥15 days/month
  • Triptans, combination analgesics, opioids: ≥10 days/month 1, 3

Treatment Algorithm

Step 1: Patient Education and Withdrawal of Overused Medication

• Educate patients about the relationship between frequent intake of acute headache medication and MOH 4
• Implement one of the following withdrawal approaches:
  • Abrupt discontinuation (preferred for most medications)
  • Tapering down of overused medication (for opioids, benzodiazepines, barbiturates)
  • Setting: Outpatient for most cases; inpatient recommended for patients overusing opioids, benzodiazepines, or barbiturates 2

Step 2: Management of Withdrawal Symptoms

• Corticosteroids (prednisone/prednisolone ≥60mg) may help manage withdrawal symptoms 2
• IV hydration, metoclopramide, and benzodiazepines can be used during the withdrawal period (7-15 days) 5
• Withdrawal symptoms typically peak within 2-10 days and resolve within 2 weeks

Step 3: Initiate Preventive Treatment

• Start preventive medication on the first day of withdrawal therapy or even before 2
• Evidence-based options include:
  • Topiramate (up to 200mg/day) - has moderate evidence for chronic migraine with medication overuse 2
  • Amitriptyline (up to 50mg/day) - possibly effective for withdrawal symptoms 2
  • OnabotulinumtoxinA - supported by post-hoc analyses of large RCTs for chronic migraine with medication overuse 6

Step 4: Acute Treatment Restructuring

• After withdrawal period, provide guidelines for limited use of acute medications:
  • NSAIDs or acetaminophen for mild episodes (limit to <15 days/month)
  • Consider CGRP antagonists (gepants) for patients who don't respond to or cannot tolerate triptans + NSAIDs 1
  • Avoid opioids and butalbital for acute headache treatment 1
  • Limit triptans to <10 days/month 1, 3

Step 5: Regular Follow-up

• Schedule follow-up visits at 1,3, and 6 months after withdrawal
• Monitor for relapse and medication use patterns
• Adjust preventive therapy as needed 2, 5

Special Considerations

Treatment Based on Overused Medication

• Triptans: Generally respond well to outpatient withdrawal
• Opioids: Higher relapse rates; may require inpatient detoxification 4
• Combination analgesics: May require more intensive withdrawal support

Lifestyle Modifications

• Implement regular sleep schedule, consistent meals, adequate hydration
• Regular physical activity (moderate to intense aerobic exercise)
• Stress management techniques
• Weight loss for overweight/obese patients 1

Prognosis

• Success rates of 50-70% can be expected with proper treatment
• Relapse rates are higher with opioid overuse
• Regular follow-up reduces relapse rates 4

Common Pitfalls to Avoid

1. Failing to recognize MOH as a cause of chronic daily headache
2. Continuing to prescribe the overused medication
3. Not starting preventive therapy concurrently with withdrawal
4. Inadequate management of withdrawal symptoms
5. Insufficient patient education about medication limits
6. Lack of regular follow-up to prevent relapse

By following this structured approach to MOH treatment, clinicians can effectively address this common and often debilitating condition while minimizing the risk of relapse.