Of the myriad difficult and frustrating issues that those of us who live with Migraine and other Headache disorders, how to best avoid overusing Migraine and Headache medications, has to top the list. The susceptibility to Medication Overuse Headache (MOH) and which medications cause it can vary from person to person, showing once again that Migraine and other Headache disorders are definitely not one-size-fits-all.
Questions about MOH abound. Perhaps the two most important of those questions are:
- Which medications can cause Medication Overuse Headache?
- How can I avoid overusing Migraine and Headache medications.
We’re going to address both of those questions here. For some time, there was neither adequate evidence nor any true consensus regarding which medications can cause Medication Overuse Headache. That made it nearly impossible to address the second question of how to avoid overusing Migraine and Headache medications. Thankfully, due to the diligent and dedicated researchers, The International Headache Society has gathered research and set diagnostic and classification criteria for MOH that are quite complete in listing which medications can cause MOH in their International Classification of Headache Disorders, 3rd edition (ICHD-3):1
Which medications can cause Medication Overuse Headache?
- Ergotamine Overuse is defined as ergotamine (DHE, Migranal) intake on 10 or more days/month on a regular basis for more than 3 months.
- Triptans Overuse is defined as triptan intake on 10 or more days/month on a regular basis for more than 3 months. Triptans include sumatriptan (Imitrex, Imigran), almotriptan (Axert), eletriptan (Relpax), rizatriptan (Maxalt), frovatriptan (Frova), naratriptan (Amerge), and zolmitriptan (Zomig).
- Analgesics Overuse is defined as intake of simple analgesics on 15 or more days/month on a regular basis for more than 3 months.
- Acetaminophen (Tylenol, Paracetamol) Overuse is regular intake of paracetamol on 15 days per month for more than 3 months.
- Acetylsalicylic acid (aspirin) overuse is defined as regular intake of acetylsalicylic acid on 15 days per month for more than 3 months.
- Non-steroidal anti-inflammatory (NSAIDs such as Aleve, Advil, ketorolac, indomethacin, etc.) overuse is defined as regular intake of one or more NSAIDs other than acetylsalicylic acid on 15 days per month for more than 3 months.
- Opioid (hydrocodone, tramadol, percocet, Demerol, etc.) overuse is defined as intake of opioids on 10 or more days/month on a regular basis for more than 3 months.
** Comment:** Studies show that patients overusing opioids have the highest relapse rate after withdrawal treatment.
- Combination analgesic overuse is defined as intake of ANY analgesic medications (Tylenol, Paracetamol, Aleve, Advil, aspirin, etc.) on 10 or more days/month on a regular basis for more than 3 months.
** Note:** The term combination-analgesic is used specifically for formulations combining drugs of two or more classes, each with analgesic effect or acting as adjuvants.
- Overuse of multiple drug classes not individually overused is the regular intake of any combination of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids on a total of 10 days per month for more than 3 months without overuse of any single drug or drug class alone.
As you can see, any acute medication (medication used to treat a Migraine or headache when it occurs) can, if overused, cause MOH. Even alternating the types of acute medications leaves us vulnerable to MOH (see 8.2.6 and 8.2.7 above). Most headache and Migraine specialists recommend limiting use of any acute medications to no more than two or three days per week to avoid MOH. They have good reasons for that recommendation. Dr. Fred Sheftell formerly of the New England Center for Headache and past president of the American Headache Society and International Headache Society told me:
“MOH continues to be a vexing problem in tertiary care centers and a major challenge to primary care physicians with these patients often requiring referrals to specialists. AMPP data demonstrates that butalbital and opiates are the 2 agents most likely to lead to overuse and are a major risk factor in the genesis of Chronic Daily Headache. Transitioning patients from MOH (10 or more days of combination products, opiates, triptans or 15 or more days of single ingredient OTCs) can be difficult as patients get worse before they improve. Pharmacologic treatment, preventives and behavioral therapies are often required. 80% will improve with a 50% or more decrease in frequency and intensity. Failure to address MOH will likely reduce the potential efficacy of any preventive intervention. Kudrow was the first to point this out in a landmark prospective study more than 30 years ago. Many studies since that time have shown similar results.”3
How can I avoid overusing Migraine and Headache medications?
Simply put, Medication Overuse Headache is avoided by not using medications for the relief of Migraine and/or Headache too frequently. That statement might seem quite simple to someone who doesn’t have frequent Migraines. However, it leaves those of us who have or have had frequent Migraines or Headaches with an obvious and sometimes urgent question:
How can I avoid overusing Migraine and Headache medications?
The long-term answer to that question is an effective preventive regimen, but that can take time and patience, and we need relief during that process. If you’re at risk for MOH, it’s time to have a frank discussion with your doctor. Here are some topics to discuss with your doctor:
- Finding which acute medication works best for you. Finding what works best for you can reduce the number of days you need medication.
- Finding an effective rescue medication, a medication to be used if your primary acute medication fails.
- If nausea is a problem for you, talk with your doctor about how to treat it. It’s possible that you can treat the nausea even on days when you’re beyond your limit on acute Migraine medications.
- Don’t forget that some complementary therapies might be helpful to you. Some insurance companies will even pay for acupuncture or therapeutic massage with a prescription or referral from your doctor.
- thermal therapy: warm or cold packs
- ginger or peppermint tea for nausea
- aromatherapy: Essential oils can be helpful, but use these with caution. They shouldn’t be applied directly to the skin full-strength, and some oils, such as peppermint, should not be used by children or pregnant women.
When taking acute medications stops the pain, it’s tempting to take them despite the risk of developing MOH. Two points helped me resist that temptation:
- Taking the medications was tantamount to sentencing myself to a headache every day.
- The point Dr. Sheftell mentioned in the quote above about MOH reducing the potential efficacy of preventive treatment.
It can be monumentally difficult to avoid overusing Migraine and Headache medications, but it’s imperative if we want to make progress in our efforts to control our Migraines. Our doctors should be not only willing, but enthusiastic about helping and encouraging us. If they’re not, it’s decidedly time for a new doctor, probably a good Migraine and headache specialist.
When considering a Migraine and headache specialist, It’s important to note that neurologists aren’t necessarily Migraine and headache specialists. Take a look at the article Finding a Migraine Specialist: Why, How and Where If you need help finding a Migraine specialist, check the Find a Health Care Professional at the American Migraine Foundation.
- Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd Edition (ICHD-3). Cephalalgia, Volume: 38 issue: 1, page(s): 1-211.
- Goadsby, Peter J., MD, PhD, DSc, FRACP, FRCP; Silberstein, Stephen D., MD, FACP; Dodick, David W., MD, FRCPD, FACP. “Chronic Daily Headache for Clinicians.” Hamilton, Ontario: BC Decker. 2005.
- Interview with Dr. Fred Sheftell; Director of the New England Center for Headache, Past President of the American Headache Society. January 1, 2010.