Medication Overuse Headache – When Medications Become the Problem

You may see this type of Headache, not Migraine, referred to by various names:

• rebound Headache,
• analgesic rebound Headache, or
• Medication Overuse Headache.

The “official” term is “Medication Overuse Headache” (MOH), and that’s what I’ll be using here because it truly does seem to be the most accurate in describing what causes it. Words have power, and some Migraine and Headache patients dislike the term “Medication Overuse Headache” because it feels a bit like blaming the patient. It’s important to realize, however, that nobody is implying misuse or abuse of medications, simply using medications more frequently than is good for us.

Everyone who has Migraine disease or any other Headache disorder should be told about MOH by our doctors because knowing about it and understanding it in advance is the best way to avoid it and us a great deal of pain. Unfortunately, all too often, our doctors don’t tell us about MOH. If your doctor has prescribed any medication such as triptans, ergotamines, pain medications, etc., or recommended that you take over-the-counter medications such as acetaminophen, etc., when you have Headaches or Migraines and has not told you about their potential to cause MOH, ask him or her about it. Find out what the potential for MOH is with the medications they’re prescribing or recommending.

Although we’ve been hearing about MOH for some time now, there used to be questions about and differing opinions on which medications could cause it because there wasn’t a clear enough consensus or evidence. Now, we have enough studies and anecdotal evidence to be clear.

To help us avoid Medication Overuse Headache and deal with it if it occurs, there are issues we need to explore:

1. What is MOH?
2. Which medications can cause it?
3. How can we avoid MOH?
4. How can we distinguish MOH from other Headaches and Migraines?
5. How do we stop MOH?
6. Will taking pain medications for pain other than head pain cause MOH?

What is Medication Overuse Headache?

The best explanation of MOH comes from the The International Classification of Headache Disorders, 3rd Edition (ICHD-3), from the International Headache Society:

“Headache occurring on 15 or more days/month in a patient with a preexisting primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication… It usually, but not invariably, resolves after the overuse is stopped.”¹

Which medications can cause MOH?

This has long been one of the biggest questions about MOH. There is now sufficient research to address many of our questions. According to Goadsby, et al, “There is now substantial evidence that all drugs used for the treatment of headache may cause MOH in patients with primary headache disorders.” When they say, “Headache,” they mean Headache and Migraine both. So, just which medications can cause MOH?

8.2 Medication-overuse headache (MOH)

8.2.1 Ergotamine-overuse headache

Overuse defined as ergotamine intake on 10 or more days/month on a regular basis for more than 3 months.

8.2.2 Triptan-overuse headache

Overuse defined as triptan intake (any formulation) on 10 or more days/month on a regular basis for more than 3 months.

8.2.3 Analgesic-overuse headache

Overuse defined as intake of simple analgesics on 15 or more days/month on a regular basis for more than 3 months.

8.2.3.1 Paracetamol (acetaminophen)-overuse headache

Regular intake of paracetamol on 15 days per month for more than 3 months.

8.2.3.2 Acetylsalicylic acid-overuse headache

Regular intake of acetylsalicylic acid on 15 days per month for more than 3 months.

8.2.3.3 Other non-steroidal anti-inflammatory drug (NSAID)-overuse headache

Regular intake of one or more NSAIDs other than acetylsalicylic acid on 15 days per month for more than 3 months.

8.2.4 Opioid-overuse headache

Overuse 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.

8.2.5 Combination analgesic-overuse headache

Overuse defined as intake of simple analgesic medications 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.<.p>

8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused

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.

8.2.7 Medication-overuse headache attributed to unverified overuse of multiple drug classes

Regular intake of any combination of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids on 10 days per month for more than 3 months.

8.2.8 Medication-overuse headache attributed to other medication

Regular overuse, on 10 days per month for more than 3 months, of one or more medications other than those described above, taken for acute or symptomatic treatment of headache.

Ergotamine medications include DHE-45 and Migranal Nasal Spray.

The triptans include sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova) – as well as Treximet, which is a combination of sumatriptan and naproxen sodium.

There is a bit of confusion about nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs were protective against transition to chronic Migraine at low to moderate monthly headache days (10 – 14 days a month), but were associated with increased risk of transition to chronic Migraine at high levels of monthly headache days (15 or more days a month). This would serve to confirm that NSAID use should be restricted to no more than two or three days per week and should NOT be used for Migraine prevention.

Although caffeine is not specifically listed, it IS a drug, and for some people, it can indeed cause MOH. The caffeine content is one reason that compound medications such as Excedrin and Fioricet can be such horrid MOH culprits. They contain multiple ingredients, including caffeine, that can cause MOH.

How can we avoid MOH?

Medication Overuse Headache is best avoided by not using medications for the relief of Headache and/or Migraine too frequently. Although that statement may look simple, for the chronic sufferer, it’s anything but a simple solution. As you can see, ICHD-3 defines overuse in terms of days per month, which vary from 10 days to 15 days per month, according to the type of medication. Most doctors will advise staying below those numbers by limiting use to two or three days per week. For those who take triptans, doctors will sometimes recommend taking triptans two days a week and another type of medication another two days a week if absolutely necessary. Beyond that, there is no real answer for pain on additional days that week. The long-term answer is, of course, an effective preventive regimen that reduces the need for MOH-causing medications.

How can we distinguish MOH from other Headaches and Migraines?

How do we stop MOH?

Immediately discontinuing the medication causing the MOH is the preferred plan of action for most medications. It’s obviously the quickest, and it doesn’t add more medications to an already confused body.

According to Goadsby, et al, withdrawal symptoms usually last two to 10 days. Those symptoms may include: withdrawal headache, vomiting, arterial hypotension, tachycardia, sleep disturbances, restlessness, anxiety, nervousness. Other experts in the field have written that it can take weeks, a month, or even longer to end the MOH. cycle.

In some cases where the MOH is being caused by medications such as butalbital compounds that have been taken daily in large amounts, seizures can occur if the medication is abruptly withdrawn, so a tapered withdrawal or supervised detoxifications is necessary. The best approach is to ask your doctor for help and advice. When you take these medications for pain, you don’t become addicted, but you may become dependent upon them. This is a medical issue. Don’t be reluctant to discuss it with your doctor. Depending on the medication involved and the situation, some doctors may recommend hospitalization or prescribe medications to help you get out of the MOH cycle.

Will taking pain medications for pain other than head pain cause MOH?

For someone who already has Migraine disease or another Headache disorder, yes.

Comments from Migraine and headache experts:

I asked some Migraine and Headache experts for comments on MOH. Here are those comments:

“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 CDH. 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.” ~ Dr. Fred Sheftell²

“Medication overuse headache is viewed by the International Classification of Headache Disorders, as a secondary headache disorder, as headache attributable to medication taking. In my opinion, it is better considered a complication of primary headache, usually a complication of migraine.” ~Dr. Richard B. Lipton³

 “MOH is usually a complication of Migraine or another headache disorder, a complication that can present huge obstacles to headache treatment. It not only makes it less likely that prophylactic (preventive) medications will work; it can reduce the effectiveness of IV infusions for intractable Migraine and headaches. Unfortunately, well-intentioned clinicians with little knowledge about treating headache disorders too often enable MOH by prescribing opioids or recommending short-acting over-the-counter analgesics as a primary treatment, and this backfires or leads to a situation where there is more headache, not less.” ~Dr. John Claude Krusz⁴

Summary and comments:

Much has been learned about Medication Overuse Headache, aka Rebound Headache, in the last few years. Unfortunately, it seems that any medication we take for Headache or Migraine relief has the potential to cause MOH if used more than two or three days a week. In the long run, a good preventive regimen that will reduce our need for MOH-causing medications is our best weapon against MOH. Until we perfect our preventive regimens to that point, it’s essential to work with our doctors to avoid medication overuse, thus preventing MOH.

Sources:

1. 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.
2. Interview with Dr. Fred Sheftell. January 1, 2010.
3. Interview with Dr. Richard B. Lipton. January 1, 2010.
4. Interview with Dr. John Claude Krusz. January 4, 2010
5. 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.
6. Bigal, Marcelo E., MD, PhD; Serrano, Daniel, MA; Buse, Dawn, PhD; Ann Scher, PhD; Stewart, Walter F., PhD; Lipton, Richard B., MD. “Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study.” Headache2008;48:1157-1168.
7. Harold G. Wolff Lecture Award Presentation. Marcelo E. Bigal, MD, PhD. “Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study: A Longitudinal Population-Based Study.” American Headache Society 50th Annual Scientific Meeting. Boston. June 27, 2008.
8. Sheftell, Fred D. & Bigal, Marcelo (2004) “Clinical Science: Headache Induced by Acute Medication Overuse.” Headache Currents 1 (3), 64-68. doi: 10.1111/j.1743-5013.2004.10109.x.
9. Young, William B. (2004) “Clinical Science: Treatment of Medication Overuse Headache and Long-term Outcome.” Headache Currents 1 (3), 55-59. doi: 10.1111/j.1743-5013.2004.10112.x.
10. Tepper SJ and Dodick DW. “Debate: Analgesic Overuse is a Cause, Not Consequence, of Chronic Daily Headache.” Headache 2002;42:543-554.