How is medication overuse headache managed?

Management of Medication Overuse Headache

The management of medication overuse headache (MOH) requires withdrawal of the overused medication as the necessary and only remedy, with abrupt withdrawal generally preferred over slow tapering except for opioids. 1

Definition and Epidemiology

• MOH is defined as headache occurring on ≥15 days per month for at least 3 months in people with a pre-existing headache disorder, developing as a result of regular overuse of acute headache medication 1, 2
• The prevalence of MOH in the general population is approximately 1-2%, but is much higher among those with chronic headache disorders 2, 3
• The threshold for medication overuse varies by treatment: ≥15 days per month for NSAIDs and ≥10 days per month for triptans 1

Risk Factors

• Female sex, lower socioeconomic status, psychiatric comorbidities (depression, anxiety), and substance use disorders 3
• Primary headache disorders, particularly migraine, account for approximately two-thirds of MOH cases 1
• Frequent use of acute headache medications, especially opioids, barbiturates, triptans, and combination analgesics containing caffeine or butalbital 1

Treatment Algorithm

Step 1: Education and Withdrawal of Overused Medication

• Patient education is essential about the relationship between medication overuse and headache chronification 2, 4
• Abrupt withdrawal is generally preferred over tapering, except for opioids, benzodiazepines, and barbiturates 1, 5
• For opioids, benzodiazepines, and barbiturates, inpatient withdrawal therapy is recommended 5
• Withdrawal symptoms typically include worsening headache, nausea, vomiting, hypotension, tachycardia, sleep disturbances, and anxiety, usually lasting 2-10 days 2

Step 2: Management of Withdrawal Symptoms

• Corticosteroids (at least 60mg prednisone or prednisolone) may help manage withdrawal symptoms 5
• Amitriptyline (up to 50mg) may also be effective for withdrawal symptoms 5
• Bridge therapies during withdrawal may include antiemetics, NSAIDs (if not the overused medication), and hydration 3

Step 3: Preventive Treatment

• Start individualized prophylactic treatment on the first day of withdrawal therapy or even before 5
• Topiramate (up to 200mg) has moderate evidence for prophylactic treatment in patients with chronic migraine and medication overuse 5, 3
• Other effective preventive options include:
  • Amitriptyline 3
  • OnabotulinumtoxinA (Botox) for chronic migraine 6, 3
  • Candesartan 3
  • Anti-CGRP monoclonal antibodies for patients with migraine and MOH 3

Step 4: Follow-up and Relapse Prevention

• Regular follow-up is essential to prevent relapse of medication overuse 5
• Evaluate treatment responses after 2-3 months and regularly thereafter (every 6-12 months) 1
• Assess attack frequency, severity, and migraine-related disability 1
• Educate patients on lifestyle modifications: hydration, regular meals, sufficient sleep, physical activity, stress management, and identifying triggers 1

Special Considerations

• Avoid opioids and butalbital for acute migraine treatment to prevent MOH 1
• Limit acute therapy to no more than twice per week to guard against MOH 1
• Success rates for MOH treatment are approximately 50-70%, with higher relapse rates in patients with opioid overuse 2
• For patients with chronic migraine after successful withdrawal, consider preventive medications like topiramate, onabotulinumtoxinA, or CGRP monoclonal antibodies 1, 3

Common Pitfalls and Caveats

• Failure to recognize MOH as a distinct entity from the underlying primary headache disorder 1
• Continuing to prescribe the overused medication during withdrawal 5
• Not starting preventive therapy concurrently with withdrawal 5, 3
• Inadequate follow-up leading to high relapse rates (>50% may relapse over a 5-year period) 7
• Confusing chronic migraine with MOH, as they often coexist but require different management approaches 1