What is the treatment for Medication Overuse Headache (MOH)?

Treatment of Medication Overuse Headache (MOH)

Withdraw the overused medication abruptly—this is the necessary and only remedy for MOH. 1

Immediate Management Strategy

Step 1: Abrupt Withdrawal

• Stop all overused acute headache medications immediately (except opioids, benzodiazepines, and barbiturates, which require tapering). 1, 2
• Abrupt withdrawal is superior to gradual tapering for non-opioid analgesics, NSAIDs, triptans, and ergotamines. 2, 3
• For patients overusing opioids, benzodiazepines, or barbiturates, inpatient withdrawal therapy is recommended due to risk of severe withdrawal symptoms. 3
• Require at least 1 month medication-free to determine treatment effectiveness. 2

Step 2: Patient Education (Critical Component)

• Warn patients explicitly that headaches will worsen before improving during withdrawal—this temporary worsening is expected and does not indicate treatment failure. 1, 2
• Educate on lifestyle modifications: maintain hydration, eat regular meals, ensure sufficient sleep, engage in physical activity, manage stress, and identify personal triggers. 2
• Explain that frequent use of acute medications (≥10 days/month for triptans, ≥15 days/month for NSAIDs) causes MOH to prevent future recurrence. 2

Step 3: Manage Withdrawal Symptoms

• Use corticosteroids (at least 60mg prednisone or prednisolone) to treat withdrawal headache—this has moderate evidence for effectiveness. 3
• Consider amitriptyline up to 50mg for withdrawal symptom management. 3
• Use prokinetic antiemetics (domperidone or metoclopramide) for nausea/vomiting rather than additional analgesics. 1, 2

Preventive Therapy Initiation

Timing

• Start preventive medication on the first day of withdrawal therapy or even before withdrawal begins—do not wait for withdrawal to complete. 3, 2
• This parallel approach is recommended by expert consensus, though some debate exists about optimal timing. 1

First-Line Preventive Options

• Topiramate up to 200mg is the only drug with moderate evidence specifically for chronic migraine with medication overuse. 3, 4
• Candesartan offers dual benefit for patients with comorbid hypertension and has strong evidence for migraine prevention. 2
• OnabotulinumtoxinA for patients who fail oral preventives (assess efficacy after 6-9 months). 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) for patients who have failed at least two other preventive medications (assess efficacy after 3-6 months). 1

Follow-Up and Relapse Prevention

Monitoring Schedule

• Assess treatment effectiveness after 2-3 months, then regularly every 6-12 months. 1, 2
• Evaluate attack frequency, attack severity, and migraine-related disability at each visit. 1, 2
• Maintain headache diaries to monitor medication use patterns and detect early signs of overuse. 2

Expected Outcomes

• Success rate is 50-70% at 6-12 months follow-up. 2, 4
• Relapse occurs in ≥50% of patients over initial 5-year follow-up, making close monitoring essential. 5, 4
• Patients with opioid overuse have higher relapse rates compared to other medication classes. 4

Setting of Care

Primary Care Management

• Most patients with MOH can be managed in outpatient primary care settings unless addictive drugs are involved. 1
• Complete cessation of analgesics is more feasible and effective than restricted intake, with 44% reduction in medication dependence. 2

Specialist Referral Indications

• Opioid, benzodiazepine, or barbiturate overuse requiring inpatient detoxification. 3
• Chronic migraine that persists after successful MOH treatment. 1
• Serious medical or behavioral comorbidities requiring multidisciplinary care. 6
• Treatment failure after appropriate primary care management. 7

Critical Pitfalls to Avoid

• Do not confuse chronic migraine with MOH—they often coexist but require different management approaches; MOH requires withdrawal first. 2
• Do not prescribe opioids or butalbital-containing compounds for acute migraine treatment, as these have the highest risk for MOH development and dependency. 1, 2, 6
• Do not abandon preventive therapy prematurely—efficacy requires several weeks to months to manifest. 1, 2
• Do not allow patients to use acute medications more than twice per week (approximately 8-10 days/month) to prevent MOH recurrence. 2