Medication overuse headache

What is medication overuse headache (MOH) or medication rebound headache? 

Medication overuse headache MOH or medication rebound is defined as headache occurring on 15 or more days per month and developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months.

It is present in about 1% to 2% of the population who have preexisting migraine or tension-type headache.

MOH can result from the following: combination over-the-counter medications, triptans, or opiates 10 or more days per month.

Some evidence suggests nonsteroidal antiinflammatory drug (NSAID) use 15 or more days per month may cause MOH; however, other evidence suggests NSAIDs may be used for migraine prevention.

Caffeine-withdrawal headache may develop within 24 hours after regular consumption of caffeine in excess of 200 mg/day for more than 2 weeks.

Some migraineurs benefit from avoiding caffeine completely.

5 Interesting Facts of Medication overuse headache

  1. Long-term use of analgesics may lead to medication overuse headache and should be avoided
  2. Subset of chronic daily headache. Occurs 15 days or more per month but with the added criterion of medication overuse
  3. Involves regular overuse of at least 1 acute treatment drug for more than 3 months
  4. Headache worsens in some way, usually frequency, as use of acute medication becomes more frequent
  5. Differentiated based on history

How is Medication overuse headache treated? 

Overused medications can be tapered off. For those taking high-frequency butalbital combinations, phenobarbital 30 mg twice a day (bid) can be substituted for 2 weeks followed by 15 mg bid for 2 weeks (abrupt withdrawal can result in seizures).

For those taking high doses of opioids, clonidine 0.1 to 0.2 mg three times a day titrated up or down based on symptoms or clonidine patch 0.1 to 0.2 mg/24 hours for 1 to 2 weeks. 

Naproxen 500 mg bid may be used alone or can be combined with tizanidine starting at 2 mg at bedtime and titrating up to 16 mg at bedtime (for 6 weeks in one study) as tolerated. Steroids are probably not effective.


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