Treatment of Medication Overuse Headache
The primary treatment for medication overuse headache (MOH) involves discontinuation of the overused medication combined with initiation of appropriate preventive therapy. 1
Diagnosis and Definition
MOH is defined as:
- Headache occurring on ≥15 days per month for at least 3 months
- Develops as a consequence of regular overuse of acute headache medication
- Threshold for overuse varies by medication type:
- ≥15 days/month for simple analgesics/NSAIDs
- ≥10 days/month for triptans, combination analgesics, or opioids 1
Treatment Algorithm
Step 1: Education and Withdrawal of Overused Medication
- Abrupt withdrawal or tapering down of overused medication is recommended 2
- Patient education about the relationship between frequent medication intake and MOH is essential
- Setting clear expectations about withdrawal symptoms (may worsen before improving)
- Method of withdrawal:
- Outpatient withdrawal is appropriate for most patients
- Inpatient withdrawal recommended specifically for patients overusing opioids, benzodiazepines, or barbiturates 2
Step 2: Initiate Preventive Treatment
- Start individualized prophylactic treatment on the first day of withdrawal or even before 2
- Topiramate (up to 200mg daily) has the strongest evidence for prophylactic treatment in patients with chronic migraine and medication overuse 2, 3
- For chronic migraine with medication overuse, OnabotulinumtoxinA is also effective 1, 3
- Other options include:
- Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
- Amitriptyline (30-150 mg/day)
- Divalproex sodium/sodium valproate (500-1500 mg/day) 4
Step 3: Management of Withdrawal Symptoms
- Corticosteroids (≥60mg prednisone/prednisolone) and amitriptyline (up to 50mg) may help manage withdrawal symptoms 2
- For breakthrough headaches during withdrawal:
- Use a medication from a different class than the one being withdrawn
- Avoid opioids and butalbital 1
- NSAIDs may be appropriate for short-term use
Step 4: Implement Lifestyle Modifications
- Regular sleep schedule
- Consistent meal times
- Adequate hydration
- Regular physical activity (moderate to intense aerobic exercise)
- Stress management techniques (yoga, cognitive-behavioral therapy, mindfulness)
- Weight loss for overweight/obese patients
- Limit caffeine intake 4
Follow-up and Relapse Prevention
- Regular follow-up is essential to prevent relapse of medication overuse 2
- Monitor for:
- Return to overuse patterns
- Effectiveness of preventive treatment
- Need for adjustment of preventive medications
- Success rate of treatment is approximately 50-70%, with higher relapse rates in patients with opioid overuse 3
Important Considerations and Pitfalls
- Avoid using opioids or butalbital for acute headache treatment as they have high potential for causing MOH 1
- Be aware that the threshold for developing MOH varies by medication class (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
- For patients with chronic migraine and medication overuse who cannot immediately discontinue overused medications, starting preventive treatment with topiramate or onabotulinumtoxinA without immediate discontinuation may still be beneficial 5
- The role of medication overuse in chronic headache may be complex—it may contribute to transformation from episodic to chronic headache, exacerbate existing chronic conditions, or be a consequence rather than cause 1
By following this structured approach to MOH treatment, focusing on medication withdrawal, appropriate preventive therapy, and lifestyle modifications, most patients can achieve significant improvement in their headache burden and quality of life.