Medication overuse headache

Chia-Chun Chiang MD (

Dr. Chiang of the University of California, San Diego, has no relevant financial relationships to disclose.

)
Shuu-Jiun Wang MD, editor. (

Dr. Wang of the Brain Research Center, National Yang-Ming University, and the Neurological Institute, Taipei Veterans General Hospital, received consulting fees from Eli Lilly, Daichi-Sankyo, and Novartis.

)
Originally released February 14, 1994; last updated March 19, 2019; expires March 19, 2022

This article includes discussion of medication overuse headache, medication-induced headache, medication misuse headache, and MOH. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Medication overuse headache is a chronic headache that occurs in people with a pre-existing primary headache, such as migraine or tension-type headache, following overuse of any kind of acute headache medications. In this update, the author provides an update on the definition, pathophysiology, clinical aspects, and treatment strategies of this headache type.

Key points

 

• Medication overuse headache is a common and disabling disorder that affects 1% to 2% of the general population. It is extremely important to recognize and treat this condition.

 

• Overuse of any kind of acute headache medications can lead to the development of medication overuse headache.

 

• In general, treatment of medication overuse headache requires a multidisciplinary setting and includes education of patients, discontinuation of the overused medication, and initiation of preventive treatment. Large randomized controlled trials are underway to determine the best treatment strategy for medication overuse headache.

Historical note and terminology

Chronic headache following overuse of acute migraine drugs was described first by Horton and Peters (Horton and Peters 1963). They reported 52 patients with migraine who took ergotamine daily and developed daily headache, and the authors noted improvement after the ergotamine was withdrawn.

The International Headache Society originally defined drug-induced headache as chronic headache occurring on 15 or more days a month following overuse of any kind of acute headache drugs (Headache Classification Committee of the International Headache Society 1988). This, however, was based on experience with overuse of analgesics and ergots only and did not cover the triptan-induced medication overuse headache. After triptans were introduced, it became clear that they can also lead to medication overuse headache (Kaube et al 1994; Limmroth et al 1999; Limmroth et al 2002). The revised second edition of the classification criteria of the International Headache Society introduced the term “medication overuse headache,” which replaced previous terms such as “drug-induced headache,” “analgesic-induced headache,” and “rebound headache.” It further differentiated between medication overuse headaches induced by analgesics, ergots, triptans, and opioids (Olesen and Lipton 2004). In 2006, an expert board consensus paper introduced of broader concept of medication overuse headache in which the diagnosis of medication overuse headache is based on the headache frequency (greater than or equal to 15 days a month) and overuse of headache medication but does not require the headache to improve after withdrawal (Olesen et al 2006). In 2013, the International Headache Society published a version of the classification criteria, and the ICHD-3 diagnostic criteria was published in 2018. In the ICHD-2, medication overuse headache excluded a concomitant diagnosis of chronic migraine. However, according to the ICHD-3 Beta, as well as the ICHD-3 criteria, because it is unknown whether the overuse of medication is the cause or consequence in an individual case, the patient will receive a diagnosis of both chronic migraine and medication overuse headache when both criteria are met (Headache Classification Committee of the International Headache Society 2013).

In the ICHD-3, medication overuse headache is defined in chapter 8 under section 8.2. The diagnostic criteria is:

(A) Headache occurring on 15 or more days per month in a patient with a preexisting headache disorder

(B) Regular overuse for greater than three months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache.

(C) Not better accounted for by another ICHD-3 diagnosis.

It usually, but not invariably, resolves after the overuse is stopped.

It has eight subforms: medication overuse headache induced by ergotamine, triptans, non-opioid analgesics (including paracetamol, NSAID, and acetylsalicylic acid), opioids, combination analgesic, undefined multiple drug classes, and others. Another new section is 8.3, which defines withdrawal headache due to withdrawal from opioids, caffeine, oestrogens, and other substances.

Table 1. 8.2 Medication-overuse Headache

Diagnostic criteria:

 

(A) Headache occurring 15 or more days per month in a patient with a preexisting headache disorder

 

(B) Regular overuse for more than three months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache

 

(C) Not better accounted for by another ICHD-3 diagnosis

Table 2. Sub-entities of Medication Overuse Headache

 

8.2 Medication-overuse headache
8.2.1 Ergotamine-overuse headache
8.2.2 Triptan-overuse headache
8.2.3 Non-opioid analgesic-overuse headache
8.2.3.1 Paracetamol (acetaminophen)-overuse headache
8.2.3.2 Non-steroidal anti-inflammatory drug (NSAID)-overuse headache
8.2.3.2.1 Acetylsalicylic acid overuse headache
8.2.3.3 Other non-opioid analgesic overuse headache
8.2.4 Opioid-overuse headache
8.2.5 Combination analgesic-overuse headache
8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused
8.2.7 Medication-overuse headache attributed to unspecified or unverified overuse of multiple drug classes
8.2.8 Medication-overuse headache attributed to other medication
8.3 Headache attributed to substance withdrawal
8.3.1 Caffeine-withdrawal headache
8.3.2 Opioid-withdrawal headache
8.3.3 Oestrogen-withdrawal headache
8.3.4 Headache attributed to withdrawal from chronic use of other substance

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