One of the most difficult and frustrating issues facing those of us with frequent Migraines and headaches is that of medication overuse headache (MOH), aka rebound. As with most issues related to Migraines, the susceptibility to MOH and which medications cause MOH can vary from person to person. 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):
8.2 Medication-overuse headache (MOH)1
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.
- 188.8.131.52 Paracetamol (acetaminophen)-overuse headache Regular intake of paracetamol on 15 days per month for more than 3 months.
- 184.108.40.206 Acetylsalicylic acid-overuse headache Regular intake of acetylsalicylic acid on 15 days per month for more than 3 months.
- 220.127.116.11 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.
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 opioids1 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,1 taken for acute or symptomatic treatment of headache.
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 of the New England Center for Headache 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 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."3
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.
Another issue not to overlook is the use of nonprescription complementary therapies and comfort measures. These can be especially important if there are days when you have to forego acute medications to avoid MOH. Often helpful comfort measures include:
- 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 not overuse acute Migraine 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 Migraine and Headache Specialists - What’s So Special? If you need help finding a Migraine specialist, check the Find a Health Care Specialist on the _ACHE web site _.
1 Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders, 3rd edition (beta version)." Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658
2 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.
3 Interview with Dr. Fred Sheftell; Director of the New England Center for Headache, Past President of the American Headache Society. January 1, 2010.
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Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.