Medication Overuse Headache (MOH) is one of the biggest issues Migraine patients must consider when treating our Migraine attacks. Medication Overuse Headache is a secondary headache disorder because it’s “Headache attributed to a substance or its withdrawal.”
The best definition 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
Medication Overuse Headache isn’t simple, so it’s natural that there’s some confusion about it. Most of the confusion centers around two issues that we’re going to address here:
- Which medications can cause MOH?
- How is overuse defined?
Which medications can cause Medication Overuse Headache?
The ICHD-3 breaks MOH into subtypes based on types of medications. Let’s start there and review the medications that fall into the various categories:
- 8.2.1 Ergotamine-Overuse Headache – Ergotamines include:
- DHE-45 (dihydroergotamine) and
- Migranal Nasal Spray
- 8.2.2 Triptan-Overuse Headache – Triptans include:
- almotriptan (Axert)
- eletriptan (Relpax)
- naratriptan (Amerge)
- rizatriptan (Maxalt)
- sumatriptan (Imitrex)
- zolmitriptan (Zomig)
- sumatriptan combined with naproxen (Treximet)
- 8.2.3 Analgesic-Overuse Headache – This is simple analgesics, which include:
- 220.127.116.11 Paracetamol (acetaminophen/Tylenol)- Overuse Headache
- 18.104.22.168 acetylsalicylic Acid (Aspirin)-Overuse Headache
- 22.214.171.124 Other Non-Steroidal Anti-Inflammatory (NSAID)-Overuse Headache – Includes all other NSAIDs, including:
- ibuprofen (Advil)
- ketorolac (Toradol)
- naproxen sodium (Aleve)
- diclofenac potassium (Cambia)
- indomethacin (Indocin)
- 8.2.4 Opioid-Overuse Headache – Opioid medications include:
- butorphanol (Stadol),
- fentanyl (Duragesic, Actiq),
- hydromorphone (Dilaudid),
- meperidine (Demerol),
- morphine (MS Contin, Kadian),
- oxycodone (OxyContin)
- oxymorphone (Opana)
- tramadol (ultram)
- 8.2.5 Combination Analgesic-Overuse Headache – “The term combination-analgesic is used specifically for formulations combining drugs of two or more classes, each with analgesic effect or acting as adjuvants.”¹ Combination analgesic medications include:
- aspirin/acetaminophen/caffeine combinations such as Excedrin Migraine
- simple analgesic and opioid combinations such as acetaminophen/hydrocodone (Vicodin), acetaminophen/oxycodone (Percocet)
- acetaminophen/butalbital/caffeine combinations (Fioricet, Zebutal, Esgic)
- 8.2.6 Medication-Overuse Headache attributed to multiple drug classes not individually overused – Regular intake of any combination of ergotamines, triptans, simple analgesics, NSAIDs and/or opioids without overuse of any single drug or drug class alone.
The question of whether rotating types of medications will avoid MOH is clearly answered by 8.2.6, Medication-Overuse Headache attributed to multiple drug classes not individually overused, and that answer is a resounding, “No.”
How is overuse defined?
The ICHD-3 also clearly defines the how many days of use is overuse for each type of medication:
- 8.2.1 Ergotamine-Overuse Headache: 10 or more days per month
- 8.2.2 Triptan-Overuse Headache: 10 or more days per month
- 8.2.3 Analgesic-Overuse Headache:
- 126.96.36.199 Paracetamol (acetaminophen/Tylenol)- Overuse Headache: 15 or more days per month
- 188.8.131.52 acetylsalicylic Acid (Aspirin)-Overuse Headache: 15 or more days per month
- 184.108.40.206 Other Non-Steroidal Anti-Inflammatory (NSAID)-Overuse Headache: 15 or more days per month
- 8.2.4 Opioid-Overuse Headache: 10 or more days per month
- 8.2.5 Combination Analgesic-Overuse Headache: 10 or more days per month
- 8.2.6 Medication-Overuse Headache attributed to multiple drug classes not individually overused: 10 or more days per month
Summary, implications, and recommendations
- As you can see above, both abortive and rescue medications can cause Medication Overuse Headache.
- Different types of medications can cause medication overuse more quickly than others.
- “Rotating” medications will not avoid medication overuse.
- To avoid medication overuse AND having longer periods when acute treatments need to be avoided, the general recommendation is to limit the use of acute medications that can cause MOH to two or three days a week.
- The best way to avoid a medication overuse situation is to continue working with our doctors to find effective preventive regimens so we need acute treatments less frequently.
“The term Medication Overuse Headache is not intended to indicate that the patient is at fault. It is very normal to take acute medication when pain occurs, and when Migraine attack frequency is low, that is exactly what is recommended. But if you find yourself taking any acute medication two days per week or more, talk to your provider about ways in which you can prevent attacks from occurring in the first place and if there are other acute medication options available. The easiest way to stop MOH is to never start it.”
For more information on medication overuse headache, see:
- Medication Overuse Headache – When Medications Become the Problem
- How to Avoid Overusing Migraine and Headache Medications
- 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.
- Friedman, Deborah. “Medication Overuse Headache.” The American Migraine Foundation. January 15, 2018.
- Interview with Dr. David Watson. September 21, 2018.