Preventing Medication Overuse Headache
To prevent medication overuse headache (MOH), limit acute headache medications to specific thresholds: no more than 10 days per month for triptans and no more than 15 days per month for NSAIDs. 1
Understanding Medication Overuse Headache
Medication overuse headache is defined as headache occurring on 15 or more days per month for at least 3 months in people with a pre-existing headache disorder that develops because of overuse of acute medication 2. This condition affects approximately 1% of the general population but is much more common among those with existing headache disorders, particularly chronic migraine 3.
Risk Factors for MOH
- Pre-existing primary headache disorder (migraine, tension-type headache)
- Female gender
- Comorbid depression and anxiety
- Other chronic pain conditions 4
- Regular or frequent use of analgesics and acute antimigraine drugs 4
Medication-Specific Thresholds for Overuse
Different medications have different thresholds for causing MOH:
- Triptans: ≤10 days per month 2, 1
- NSAIDs: ≤15 days per month 2, 1
- Opioids: Avoid completely 2
- Butalbital-containing medications: Avoid completely 2
Prevention Strategies
1. Patient Education and Counseling
- Educate patients about the relationship between frequent intake of acute headache medication and MOH 3, 5
- Counsel patients to begin treatment of migraine headache as soon as possible after onset to improve efficacy and potentially reduce the need for additional doses 2
- Maintain a headache diary to track frequency of medication use 1
2. Appropriate Acute Medication Use
- Use NSAIDs (aspirin, ibuprofen, diclofenac) as first-line treatment for mild to moderate migraine 2
- Add a triptan to an NSAID or acetaminophen for moderate to severe migraine 2
- Consider combination therapy with a triptan plus NSAID or acetaminophen to improve efficacy and potentially reduce the need for additional doses 2, 1
- Strictly avoid opioids and butalbital-containing medications for migraine treatment 2
3. Consider Preventive Treatment
- Initiate preventive medications when:
- Migraine attacks occur ≥2 times per month with disability lasting ≥3 days
- Acute treatments fail or are contraindicated
- Patients use acute medications more than twice per week 1
- First-line preventive options include:
- Beta-blockers (propranolol)
- Topiramate
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
4. Lifestyle Modifications
- Maintain regular sleep patterns
- Stay well hydrated
- Eat regular meals
- Engage in regular physical activity (moderate to intense aerobic exercise)
- Manage stress with relaxation techniques or mindfulness practices
- Pursue weight loss if overweight or obese 2
- Identify and avoid personal migraine triggers 1
Management of Existing MOH
If MOH has already developed, treatment involves:
- Education and counseling about the need to reduce acute medication intake 5
- Withdrawal from overused medications:
- Abrupt termination for simple analgesics, ergots, or triptans
- Slow tapering for opioids, barbiturates, or tranquilizers 5
- Initiation of preventive treatment with drugs of proven efficacy 5
Common Pitfalls to Avoid
- Failing to recognize early signs of MOH: Increasing headache frequency despite medication use
- Prescribing opioids or butalbital: These medications have the highest risk of causing MOH 6
- Not setting clear limits on acute medication use: Patients need specific guidelines on maximum days of use
- Overlooking the importance of preventive treatment: Prevention is key to reducing reliance on acute medications
- Neglecting lifestyle factors: Sleep, hydration, regular meals, and stress management are crucial components of headache management 2
By implementing these strategies, healthcare providers can help patients effectively manage their headache disorders while minimizing the risk of developing medication overuse headache.