Medicines Q&As
Q&A 126.3
Medication-overuse headache: What is it and how do you treat it?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals
Date prepared: October 2011
Summary
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Medication-overuse headache (MOH) is defined as a headache that is present on 15 or more days of
the month and has developed or worsened whilst the patient has been regularly using analgesic or
anti-migraine medicines for more than three months. It occurs only in patients with a pre-existing
primary headache disorder, usually migraine or tension-type headache.
All medicines used for treating headache can cause MOH. This includes simple analgesics (aspirin,
paracetamol), opioids, triptans, non-steroidal anti-inflammatory drugs and ergots, alone or in
combination with caffeine, barbiturates or benzodiazepines.
Abrupt withdrawal of the overused medication is the treatment of choice for most patients, although
there are no prospective randomised trials comparing abrupt with gradual withdrawal. Patients can be
managed in primary care with abrupt withdrawal, provided sudden cessation of their overused
medicine is not contraindicated, they have sufficient support and are well informed about the cause of
MOH and prognosis following withdrawal. Those taking opioids, benzodiazepines or barbiturates, and
those who are poorly motivated, pregnant or have a significant co-existing medical or psychiatric
disorder should be referred to a specialist.
Patients are likely to require drug treatment to alleviate withdrawal symptoms. This should include
adequate hydration, anti-emetics and, if unable to tolerate withdrawal headache, short-term regular
agents of a different class to the overused medication.
Relapse may be prevented through education of patients, use of headache diaries, extended close
medical supervision, restrictions on the intake of headache medication, primary headache prophylactic
drugs and use of behavioural therapies.
Background
Chronic headache is a common problem affecting between 2 and 5% of the population [1]. Since the
1940s it has been increasingly reported that one of the causes is overuse of headache-relieving
medication [2]. The prevalence of medication-overuse headache (MOH) is about 1% in adults [1,3] and
0.5% in adolescents [3], and it can occur in children as young as four years old [1]. Women are 3.5 times
more likely to be affected than men [1]. However, MOH is frequently overlooked as a cause of chronic
headache [1,2]. This can be attributed to poor awareness of the condition, widespread confusion over the
definition of MOH and difficulty in diagnosis. There is a lack of high quality randomised controlled trials
(RCTs) to support effective management [1,2,3,4].
This Medicines Q&A defines MOH according to international diagnostic criteria [5,6,7], describes its
features and reviews the evidence for its management.
Answer
What is medication-overuse headache?
The term ‘medication-overuse headache’ was introduced into the International Headache Society’s
classification of headache disorders in 2004 (ICHD-2) [5]. The term was chosen to emphasise the role of
regular intake of medication in causing the condition (single doses of many drugs can cause headache).
It replaces previously used terms such as ‘drug induced’ or ‘medication misuse’ headache, ‘analgesic
rebound’ or ‘analgesic withdrawal’ headache and ‘transformed migraine’ [1,2,8]. The ICHD-2 diagnostic
criteria for MOH are widely considered to be impractical in clinical use [1,3,8] and two revisions have
been proposed [6,7]. The latest definition of MOH is ‘a headache that is present on 15 or more days of
the month and has developed or worsened whilst the patient has been regularly using analgesic or antimigraine medicines for more than three months’ [7].
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
The following clinical features help to confirm the diagnosis:
 MOH only occurs in patients with a pre-existing primary headache disorder, usually migraine or
tension-type headache (TTH), and develops even if taking medicines for relief of pain other than
headache [1].
 All drugs used to treat headache can cause MOH [1,2]. This includes simple analgesics (aspirin,
paracetamol), opioids, triptans and ergots (e.g. Migril®), alone or in combination with caffeine,
barbiturates or benzodiazepines [1,2,4]. Non-steroidal anti-inflammatory drugs (NSAIDs), previously
thought less likely to cause MOH [2,8], are increasingly implicated [9].
 Onset of MOH after starting medication varies between drugs. It develops after a mean duration of 1.7
years with triptans, 2.7 years with ergots and 4.8 years with analgesics [10].
 Headache commonly occurs in the morning upon awakening and can be accompanied by nausea,
weakness, restlessness, anxiety, irritability, depression, concentration difficulties and forgetfulness
[1,8]. Patients with migraine (but not TTH) on triptans may describe migraine-like daily headaches and
patients taking ergots also describe cardiac and neuromuscular problems [1].
 The severity, location and type of headache can vary but it occurs on a daily or near-daily basis.
Patients appear to have a lowered threshold for headache which can be triggered by physical or
mental effort [8].
 Withdrawal of medication results in exacerbation of the headache (withdrawal headache) and nausea,
vomiting, hypotension, tachycardia, sleep disturbances, restlessness, nervousness and anxiety [1].
Symptoms typically last two to ten days [1] but can be prolonged up to four weeks [4].
The mechanisms leading to development of MOH are not well understood [11,12]. Current theories
include central sensitisation, abnormalities in serotonin receptor expression and function, abnormal
signal transduction and decreased cerebral metabolism [11,12]. Drug dependence and addiction are
accompanied by similar metabolic changes in several brain regions; these abnormalities may predispose
patients with migraine to addictive behaviour and to develop MOH or relapse after withdrawal of
overused medication [12,13].
How should MOH be managed?
Several guidelines for managing MOH are available [14-17]. The guideline from the British Association
for the Study of Headache (BASH) lists four objectives: withdraw the overused medication, achieve
recovery from MOH, prevent relapse and review the underlying primary headache disorder [14]. The key
steps to achieving these objectives are summarised in an algorithm (Appendix One).
1.
Withdraw the overused medication
Withdrawing the overused medication is the treatment of choice and in the majority of patients is
most successful if done abruptly [14-17]. However, abrupt withdrawal has not been compared with
gradual withdrawal in prospective randomised trials [1,4,15-18]. Patients need to have a clear
understanding of the cause of their symptoms, the management of MOH and its prognosis [14,16].
Successful withdrawal has been achieved in inpatient, day-hospital and outpatient settings [8,18-22]
and it is suggested that most people with MOH can be managed in primary care [16]. This
recommendation is supported by a study in 118 patients, without significant co-existent medical or
psychiatric illness, showing no statistically significant difference between the numbers of inpatients
and outpatients whose overused medication was successfully withdrawn [22]. However, it should be
noted that patients were managed by experienced headache specialists and could contact them for
support if necessary.
Abrupt withdrawal is less effective in patients with MOH complicated by medical or psychiatric illness
[23]. Overused medication was successfully withdrawn in 57.1% of 49 outpatients with complicated
MOH compared with 80.3% of 51 patients with simple MOH (p<0.001). Patients overusing opioids,
benzodiazepines or barbiturates should have their medication gradually withdrawn [4,15,17,24]
and/or receive inpatient care [1,2,18]. In addition, many patients with MOH have underlying
psychiatric or behavioural disorders that need to be treated independently [15,25] and those
psychologically dependent on their medication are difficult to manage successfully [14]. These
patients, and anyone who is poorly motivated, pregnant or has a significant underlying medical
condition, especially if they are elderly or frail, should be referred to a specialist unit offering
neurological, clinical psychology or psychiatric services [15,16].
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
2. Achieve recovery from MOH
When the overused medication is stopped abruptly, patients are likely to need drug treatment to
alleviate withdrawal symptoms [2,4], although success can be achieved without drug therapy if
sufficient education and psychological support is provided [4,15,16]. Patients should be advised to
maintain good hydration by drinking at least two litres of fluid daily and prescribed anti-emetics to be
used if necessary [14,16,26]. A wide variety of drug regimens have been reported to be effective in
managing withdrawal symptoms, almost exclusively in uncontrolled, un-blinded studies using a range
of outcome measures (involving amitriptyline, anticonvulsants, anti-emetics, antihistamines,
antipsychotics, benzodiazepines, beta-blockers, central muscle relaxants, clonidine, corticosteroids,
cyclooxygenase-2 inhibitors, intravenous (IV) dihydroergotamine, IV lidocaine, NSAIDs, paracetamol,
piracetam, tramadol, triptans) [1,2,4,18-24,27-39]. Medicines have been used alone or in
combination, regularly or when required, and sometimes with limits on intake.
Two double-blind [27,28] and three open-label RCTs [22,29,30] compared the efficacy of different
regimens following abrupt withdrawal of overused medication in patients with MOH; those overusing
barbiturates, benzodiazepines or opioids were not included in four studies [22,27,28,30], and those
with co-existent psychiatric disease were not included in three studies [22,27,28].
 Pageler et al. randomised 20 inpatients to a five-day course of prednisone 100mg once daily or
placebo after their overused medicine was withdrawn; IV lysine acetylsalicylic acid was given as
rescue medication for severe withdrawal headache [27].
 Rossi et al. randomly allocated 120 patients to three groups – group A received pre-withdrawal
advice and rescue medication (eletriptan, indometacin or naproxen); group B received advice,
rescue medication, an eight-day reducing course of prednisone (60mg daily for two days, 40mg
daily for two days and 20mg daily for four days) and personalised primary headache prophylactic
medication; patients in group C were admitted to hospital and received advice, rescue medication,
prednisone, prophylactic medication, IV anti-emetics and IV fluid replacement [22].
 Boe et al. randomly allocated 100 inpatients to a six-day reducing course of prednisolone (starting
dose 60mg daily) or placebo [28]. Patients received pre-withdrawal advice and were allowed to
take anti-emetics, antihistamines or antipsychotics if necessary. Medication for the relief of
headache or other pain was not permitted.
 Krymchantowski and Moreira randomised 150 outpatients to a reducing course of prednisone
(starting dose 60mg daily), regular naratriptan 2.5mg twice daily or no regular medication for six
days, in addition to advice and rescue medication (indometacin or IV chlorpromazine) [29]. All
patients were started on prophylaxis (atenolol, nortriptyline and flunarizine) on day seven.
 Mathew randomised 22 inpatients with ergotamine MOH to either rescue medication (analgesics,
anti-emetics and sedatives) alone or in combination with regular naproxen 500mg twice daily for
eight days [30]. Three patients were excluded because of naproxen intolerance.
Two of the studies found that patients given drugs (regularly or rescue) to treat withdrawal symptoms
were no more likely to achieve successful withdrawal than those given advice or placebo after a
follow-up period ranging from five weeks to two months. Successful withdrawal was defined as no
headache or fewer than 15 headache days per month, and intake of symptomatic medication on
fewer than ten days per month [22] or a reduction of more than 50% in the number of headache days
per week [29]. Long-term follow-up data (n=83) from the Rossi study [22] also showed no significant
difference in the numbers of patients relapsing at one year (13.8% in group A, 23.1% in group B and
25.0% in group C; p>0.05) [40]. In all but the two smallest studies [27,30] there was no statistically
significant difference in the frequency and/or severity of withdrawal headache during the follow-up
period, regardless of the regimen used [22,28,29]. The duration of follow-up in these two small
studies (five days and eight days, respectively) is insufficient to assess withdrawal symptoms which
can persist for up to a month. In two studies, patients not receiving regular medication were
significantly more likely to experience withdrawal symptoms and need rescue medication than those
given regular drug therapy [29,30].
Evidence from these five RCTs shows that regular and/or rescue drug therapy are equally effective
in supporting patients to achieve successful withdrawal. However in order to break the habit of
responding to pain with medication, it is advised that patients who are unable to tolerate withdrawal
symptoms should be prescribed regular medication taken whether symptoms are present or not
[14,16]. The agent chosen to alleviate withdrawal headache should be of a different class to the
medication being overused. BASH suggests a single course of regular naproxen [14] (see Appendix
One.)
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
3. Prevent relapse
Recovery following withdrawal of the overused medicine is likely to take many months [3,24]. The
mean success rate of withdrawal therapy is 70% within six months and falls to 55 to 60% after four
years [1,41]. The majority of patients who relapse do so in the first year after withdrawal [1,41]. Longterm success depends on the type of primary headache and overused medication [41], although
psychiatric co-morbidity and dependence behaviour may be important [8,34,41,42]. Patients with a
history of migraine are less likely to relapse than those with TTH [24,36,41], as are patients
overusing triptans and ergots rather than other analgesics [1,41,42]. However it may be that disability
associated with the primary headache disorder and its severity, not the type of primary headache,
are predictors of relapse [40,43,44].
Methods of preventing relapse include education of patients, use of headache diaries to detect
changes in headache pattern, close medical supervision particularly in the first year following
withdrawal, restrictions on the intake of headache medication and use of prophylactic drug therapy
[1,2,45]. Anticipatory use of medication should be discouraged and headache triggers identified and
avoided. Non-drug coping skills can be taught using behavioural therapy. Empirically validated
interventions such as cognitive behavioural therapy allow patients to identify and change behaviours
that may cause headache, challenge dysfunctional responses to stress, improve their coping and
problem-solving skills and gain belief in their own self-control [45]. However data on the effectiveness
of all measures in MOH are limited [4]. Several studies have shown the value of patient education
[45]. Short-term psychodynamic psychotherapy (STPP) was effective in an open-label nonrandomised study involving 26 patients undergoing inpatient withdrawal with regular and rescue
medication and migraine prophylaxis; after 12 months, the relapse rate in patients selected to
additionally receive STPP was significantly lower than in those who were not (odds ratio 0.18 [95%
confidence interval 0.03 to 1.0]; p=0.047) [46]. However, in a quasi-randomised controlled trial, the
addition of biofeedback-assisted relaxation therapy to prophylactic medication, after abrupt inpatient
withdrawal of overused medication, did not significantly increase the number of patients with a 50%
or more reduction in the number of headache days per month at three years’ follow-up (69% (11/16)
combined group vs. 58% (22/38) pharmacotherapy-only group) or reduce the number returning to
daily use of analgesics (26.3% (5/19) vs. 47.6% (20/42), respectively; p=0.12 [intention-to-treat
analysis]) [47].
4. Manage the primary headache and/or pain disorder
Once MOH has been treated, the primary headache disorder usually recurs [14,18]. There is no
consensus as to when to start primary headache prophylaxis (tricyclic antidepressants,
anticonvulsants, beta-blockers, etc.) and its use does not appear to influence the success of
withdrawal [1,40,41,48]. Some authors suggest treatment can be started before or immediately after
stopping overused medication [1,4,49] whilst others suggest delaying until necessary [18,22,50]. In a
randomised open-label study involving 37 patients with MOH, those started on prophylaxis but not
explicitly told to stop their overused medication, were no more likely to achieve a significant reduction
of 50% or more in monthly headache days and no medication overuse at 12 months compared to
those started on prophylaxis three months after abrupt withdrawal (53% vs. 25%; p=0.081) [51]. At
three months, there was no significant difference between the groups in the reduction in mean
number of headache days per month (-7.2 [-2.7 to -11.8] days in the early group [baseline 25.2 days]
vs. -4.2 [-3.3 to -7.4] days in the late group [baseline 24.1 days]; p=0.056). The reduction in use of
acute headache medication at three months also did not differ significantly between the groups. A
similar study following 50 patients for four years reported no significant differences in outcomes
between early and late prophylaxis groups [52].
It is probably best to delay starting prophylaxis, but early use can be considered for patients unable
to cope with withdrawal symptoms. Choice of agent should be based on the patient’s primary
headache type, co-morbidities, medication side effect profile and previous response to prophylactic
drugs [2,48]. For patients who continue to have daily headaches after withdrawal it has been shown
that headache frequency can be significantly reduced once prophylaxis is started [18,24,49,50], even
if they previously didn’t respond to prophylactic drugs [24]. For those who have been overusing
medication to relieve pain that is not their underlying primary headache disorder, treatment options
other than analgesics should be explored [53].
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
Limitations
This document provides guidance for the initial management of adults with MOH and is not intended to
provide advice on the treatment of patients who fail to achieve successful withdrawal at the first attempt.
References
1. Diener H-C and Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004; 3:
475-83.
2. Smith TR and Stoneman J. Medication overuse headache from antimigraine therapy. Clinical features,
pathogenesis and management. Drugs 2004; 64: 2503-14.
3. Lake AE. Medication overuse headache: biobehavioral issues and solutions. Headache 2006; 46 (Suppl
3): S88-97.
4. Zed PJ, Loewen PS and Robinson G. Medication-induced headache: overview and systematic review of
therapeutic approaches. Ann Pharmacother 1999; 33: 61-72.
5. Olesen J, Bousser M-G, Diener H-C et al. The international classification of headache disorders, 2nd
edition. Cephalalgia 2004; 24 (Suppl 1): 8-160.
6. Silberstein SD, Olesen J, Bousser M-G et al. The international classification of headache disorders, 2nd
edition (ICHD-II) – revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005; 25: 460-5.
7. Olesen J, Bousser M-G, Diener H-C et al. New appendix criteria open for a broader concept of chronic
migraine. Cephalalgia 2006; 26: 742-6.
8. Dodick D and Freitag F. Evidence-based understanding of medication-overuse headache: clinical
implications. Headache 2006; 46 (Suppl 4): S202-11.
9. Meskunas CA, Tepper SJ, Rapoport AM et al. Medications associated with probable medication overuse
headache reported in a tertiary care headache center over a 15-year period. Headache 2006; 46: 766-72.
10. Limmroth V, Katsarava Z, Fritsche G et al. Features of medication overuse headache following overuse of
different acute headache drugs. Neurology 2002; 59; 1011-4.
11. Katsarava Z, Holle D and Diener H-C. Medication overuse headache. Curr Neurol Neurosci Rep 2009; 9:
115-9.
12. Fumal A, Laureys S, Di Clemente L et al. Orbitofrontal cortex involvement in chronic analgesic-overuse
headache evolving from episodic migraine. Brain 2006; 129: 543-50.
13. Radat F, Creac’h C, Guegan-Massardier E et al. Behavioral dependence in patients with medication
overuse headache: a cross-sectional study in consulting patients using the DSM-IV criteria. Headache
2008; 48: 1026-36.
14. MacGregor EA, Steiner TJ and Davies PTG for the British Association for the Study of Headache.
Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type,
cluster and medication-overuse headache. Third edition (1st revision), 2010. Accessed via:
http://217.174.249.183/upload/NS_BASH/2010_BASH_Guidelines.pdf on 3/10/11.
15. Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. A national
clinical guideline. No.107. November 2008. Accessed via www.sign.ac.uk/pdf/sign107.pdf on 3/10/11.
16. Prodigy. Headache – medication overuse. August 2009. Accessed via
www.prodigy.clarity.co.uk/headache_medication_overuse on 3/10/11.
17. Evers S and Jensen R. Treatment of medication overuse headache – guideline of the EFNS headache
panel. Eur J Neurol 2011; 18: 1115-21.
18. Linton-Dahlof P, Linde M and Dahlof C. Withdrawal therapy improves chronic daily headache associated
with long-term misuse of headache medication: a retrospective study. Cephalalgia 2000; 20: 658-62.
19. Usai S, Grazzi L, D’Amico D, Andrasik F and Bussone G. Reduction in the impact of chronic migraine with
medication overuse after day-hospital withdrawal therapy. Neurol Sci 2008; 29: S176-8.
20. Grazzi L, Andrasik F, Usai S and Bussone G. In-patient vs. day-hospital withdrawal treatment for chronic
migraine with medication overuse and disability assessment: results at one-year follow-up. Neurol Sci
2008: 29: S161-3.
21. Creac’h C, Frappe P, Cancade M et al. In-patient versus out-patient withdrawal programmes for
medication overuse headache: A 2-year randomized trial. Cephalalgia 2011; 31: 1189-98.
22. Rossi P, Di Lorenzo C, Faroni J et al. Advice alone vs. structured detoxification programmes for
medication overuse headache: a prospective, randomized, open-label trial in transformed migraine
patients with low medical needs. Cephalalgia 2006; 26: 1097-105.
23. Rossi P, Faroni JV and Nappi G. Short-term effectiveness of simple advice as a withdrawal strategy in
simple and complicated medication overuse headache. Eur J Neurol 2011; 18: 396-401.
24. Zeeberg P, Olesen J and Jensen R. Discontinuation of medication overuse in headache patients: recovery
of therapeutic responsiveness. Cephalalgia 2006; 26: 1192-8.
25. Saper JR and Lake AE. Medication overuse headache: type I and type II. Cephalalgia 2006; 26: 1262.
26. Anon. Management of medication overuse headache. BMJ 2010: 340: c1305
27. Pageler L, Katsarava Z, Diener HC and Limmroth V. Prednisone vs. placebo in withdrawal therapy
following medication overuse headache. Cephalalgia 2008; 28: 152-6.
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
28. Boe MG, Mygland A and Salvesen R. Prednisolone does not reduce withdrawal headache. A randomized,
double-blind study. Neurology 2007; 69: 26-31.
29. Krymchantowski AV and Moreira PF. Out-patient detoxification in chronic migraine: comparison of
strategies. Cephalalgia 2003; 23: 982-93.
30. Mathew NT. Amelioration of ergotamine withdrawal symptoms with naproxen. Headache 1987; 27: 130-3.
31. Trucco M, Meineri P and Ruiz L. Preliminary results of a withdrawal and detoxification therapeutic regimen
in patients with probable chronic migraine and probable medication overuse headache. J Headache Pain
2005; 6: 334-7.
32. Relja G, Granato A, Bratina A et al. Outcome of medication overuse headache after abrupt in-patient
withdrawal. Cephalalgia 2006; 26: 589-95.
33. Smith TR. Low-dose tizanidine with nonsteroidal anti-inflammatory drugs for detoxification from analgesic
rebound headache. Headache 2002; 42: 175-7.
34. Lu S-R, Fuh J-L, Juang K-D et al. Repetitive intravenous prochlorperazine treatment of patients with
refractory chronic daily headache. Headache 2000; 40: 724-9.
35. Krymchantowski AV and Barbosa JS. Prednisolone as initial treatment of analgesic-induced daily
headache. Cephalalgia 2000; 20: 107-13.
36. Zeeberg P, Olesen J and Jensen R. Probable medication-overuse headache. The effect of a 2-month
drug-free period. Neurology 2006; 66: 1894-8.
37. Sheftell FD, Rapoport AM and Coddon DR. Naratriptan in the prophylaxis of transformed migraine.
Headache 1999; 39: 506-10.
38. Williams DR, Stark RJ. Intravenous lignocaine (lidocaine) infusion for the treatment of chronic daily
headache with substantial medication overuse. Cephalalgia 2003; 23: 963-71.
39. Trucco M, Meineri P, Ruiz L et al. Medication overuse headache: withdrawal and prophylactic therapeutic
regimen. Headache 2010; 50: 989-97.
40. Rossi P, Faroni JV and Nappi G. Medication overuse headache: predictors and rates of relapse in
migraine patients with low medical needs. A 1-year prospective study. Cephalalgia 2008; 28: 1196-1200.
41. Katsarava Z, Muessig M, Dzagnidze A et al. Medication overuse headache: rates and predictors for
relapse in a 4-year prospective study. Cephalalgia 2005; 25: 12-5.
42. Sances G, Ghiotto N, Galli F et al. Risk factors in medication-overuse headache: A 1-year follow-up study
(care II protocol). Cephalalgia 2010; 30: 329-36.
43. Zidverc-Trajkovic J, Pekmezovic T, Jovanovic Z et al. Medication overuse headache: clinical features
predicting treatment outcome at 1-year follow-up. Cephalalgia 2007; 27: 1219-25.
44. Boe MG, Salvesen R and Mygland A. Chronic daily headache with medication overuse: predictors of
outcome 1 year after withdrawal therapy. Eur J Neurol 2009; 16: 705-12.
45. Andrasik F, Buse DC and Grazzi L. Behavioral medicine for migraine and medication overuse headache.
Curr Pain Headache Rep 2009; 12: 241-8.
46. Altieri M, Di Giambattista R, Di Clemente L et al. Combined pharmacological and short-term
psychodynamic psychotherapy for probable medication overuse headache: a pilot study. Cephalalgia
2009; 29: 293-9.
47. Grazzi L, Andrasik F, D’Amico D et al. Behavioral and pharmacologic treatment of transformed migraine
with analgesic overuse: outcome at 3 years. Headache 2002; 42: 483-90.
48. Rossi P, Jensen R, Nappi G and Allena M for the COMOESTAS Consortium. A narrative review on the
management of medication overuse headache: the steep road from experience to evidence. J Headache
Pain 2009: 10: 407-17.
49. Rapoport AM. Medication overuse headache. Awareness, detection and treatment. CNS Drugs 2008; 22:
995-1004.
50. Kossoff EH and Mankad DN. Medication-overuse headache in children: is initial preventative therapy
necessary? J Child Neurol 2006; 21: 45-8.
51. Hagen K, Albretsen C, Vilming ST et al. Management of medication overuse headache: 1-year
randomized multicentre open-label trial. Cephalalgia 2009; 29: 221-32.
52. Hagen K and Stovner LJ. A randomized controlled trial on medication-overuse headache: outcome after 1
and 4 years. Acta Neurol Scand 2011; 124 (Suppl. 191): 38-43.
53. Personal communication. Professor TJ Nurmikko. Professor of Pain Science at the University of Liverpool,
Director of the Pain Research Institute in Liverpool, and Honorary Consultant in Pain Relief at the Walton
Centre NHS Foundation Trust. 06/11/09.
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
Quality Assurance
Prepared by
Joanne McEntee. North West Medicines Information Centre, Pharmacy Practice Unit, 70 Pembroke
Place, Liverpool, L69 3GF.
Contact
druginfo@liv.ac.uk
Date Prepared
October 2011.
Checked by
Justine Howard and Christine Proudlove. North West Medicines Information Centre, Pharmacy Practice
Unit, 70 Pembroke Place, Liverpool, L69 3GF.
Date of check
October 2011.
Search strategy
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Embase 1974 to October 2011 ([exp drug induced headache/disease management; drug
therapy; therapy]) OR ([exp *drug induced headache/] limited to [publication types review and
English language and humans]).
Medline 1950 to October 2011 ([exp headache disorders secondary/drug therapy; therapy]
limited to [English language and humans]) OR ([exp headache disorders secondary] limited to
[review and English language and humans]).
Cochrane Library, Issue 8, 2011 (advanced search all text overuse AND headache).
Evidence in Health and Social Care via www.evidence.nhs.uk (free text [medication overuse]).
www.bash.org.uk
www.i-h-s.org
In-house database/ resources.
Expert opinion:
o Professor Turo Nurmikko [Professor of Pain Science at the University of Liverpool,
Director of the Pain Research Institute in Liverpool, and Honorary Consultant in Pain
Relief at the Walton Centre NHS Foundation Trust].
Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk
UKMi Medicines Q&A 126.3
Appendix One. Algorithm for the management of medication-overuse headache (MOH).
Diagnose MOH
 Headache present on ≥15 days per month AND
 Regular overuse for >3 months of medication [ergotamine, triptans, opioids or combination analgesics on ≥10
days/month; simple analgesics or any combination of ergotamine, triptans, opioids on ≥15 days/month without
overuse of any single class alone] AND
 Headache has developed or markedly worsened during medication overuse [7].
Consider
 Type of medication overused.
 Presence of psychiatric/behavioural disturbance, dependence behaviour,
medical conditions, pregnancy.
Overuse of simple analgesics/triptans/ergots/NSAIDs
Plan for withdrawal of overused medicine.
Motivate the patient & agree a stop date
 Explain that overused medication may be causing headache and
needs to be stopped. Describe withdrawal symptoms, time course
and benefits of withdrawal.
 Agree a convenient stop date.
 Introduce a headache diary and plan one to two-week sick leave if
necessary.
 Prescribe anti-emetics for use if needed, e.g. domperidone 10-20mg
tablets four times daily, metoclopramide 10mg tablets three times
daily or prochlorperazine 3-6mg buccal tablets twice daily [16].
 Patient overusing opioids, opioidcontaining analgesics, barbiturates or
benzodiazepines.
 Patients with psychiatric disorders or
behavioural disturbance.
 Patients with dependence behaviour.
 Patients who are poorly motivated.
 Patients who are pregnant or have
underlying medical conditions,
especially if elderly or frail.
Stop overused medication abruptly
 Advise patient to maintain good hydration (drink 2 litres of fluid daily)
and avoid caffeine and acute pain treatments [16].
Review after 7 days (or earlier if necessary)
 If the patient is unable to cope with withdrawal symptoms, prescribe
regular medicines, choosing a drug from a different class from that
overused. For example:
- naproxen 250mg three times daily or 500mg twice daily for three to
four weeks (or 250mg three times daily for two weeks, then twice a
day for two weeks then once a day for two weeks, then stop) [14].
Regular follow-up
 Review weekly for three weeks to ensure withdrawal complete [16].
If withdrawal is successful:
 Consider need for prophylactic headache medication (if not already
started) as most patients revert to their original headache within two
months [14], OR
 Reintroduce overused medicines after two months with clear
instructions on maximum frequency of use (e.g. two days a week or
less) [14,16].
Persistent chronic headache and/or medication
overuse still present
Consider alternative diagnosis/poor compliance.
Refer to a specialist unit offering
neurological, clinical psychology
or psychiatric services.
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Medication-overuse headache: What is it and how do you treat it?
From the NHS Evidence website www.evidence.nhs.uk