Medication Overuse Headache - When the Remedy Backfires
One of the biggest challenges facing people with migraine and other headache disorders is medication overuse headache. The name varies. You'll see these headaches called "rebound headaches," "analgesic rebound headaches," "medication overuse headaches," and other terms. The "official" diagnosis in the International Headache Society's (IHS)International Classification of Headache Disorders, 3rd edition (ICHD-3) medication overuse headache (MOH), and that's what I'll be using here because it truly does seem to be the most accurate. Some patients have mentioned that they feel the term, "medication overuse headache," smacks of blaming the patient. It's important to know that the IHS doctors and researchers who maintain the ICHD do not blame patients for MOH; it's simply a literal diagnosis for this type of headache, which is caused by overusing acute medications.
Every person who has headaches or migraine disease should be told about MOH by our doctors because knowing about it in advance could save us a great deal of pain. Unfortunately, we're not. 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., to be taken when you have a headache or migraine 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:
- What is MOH?
- What medications cause it?
- How can we avoid MOH?
- How can we distinguish MOH from other headaches and migraines?
- How do we stop MOH?
- 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 per month developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more, or 15 or more days per month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped."**** The ICHD-3 diagnostic criteria for MOH:
- Headache occurring on 15 or more days per month in a patient with a per-existing headache disorder.
- Regular overuse for more than 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache.*
- Not better accounted for by another ICHD-3 diagnosis.
- Patients should be coded for one or more subtypes of 8.2 Medication-overuse headache according to the specific medication(s) overused and the criteria for each below. For example, a patient who fulfills the criteria for 8.2.2 Tristan-overuse headache and the criteria for one of the subforms of 8.2.3 Simple analgesic-overuse headache should receive both these codes. The exception occurs when patients overuse combination-analgesic medications, who are coded 8.2.5 Combination-analgesic-overuse headache and not according to each constituent of the combination-analgesic medication.
Patients who use multiple drugs for acute or symptomatic treatment of headache may do so in a manner that constitutes overuse even though no individual drug or class of drug is overused; such patients should be coded 8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused.
Patients who are clearly overusing multiple drugs for acute or symptomatic treatment of headache but cannot give an adequate account of their names and/or quantities are coded 8.2.7 Medication-overuse headache attributed to unverified overuse of multiple drug classes until better information is available. In almost all cases, this necessitates diary follow-up.
What 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?
The answer to that question becomes clear when we look at the most recent revisions to The International Classification of Headache Disorders, 3rd Edition (ICHD-3), where we find not only a classification for MOH, but a further breakdown:
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/months on a regular basis for more than 3 months.
188.8.131.52 Paracetamol (acetaminophen)- overuse headache
184.108.40.206 Acetysalicylic acid (apririn)- overuse headache
220.127.116.11 Other non-steroidal anti-inflammatory drug (NSAID)-overuse headache
8.2.4 Opioid-overuse headache Overuse defined as intake of opioid medications on 10 or more days/months 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.
8.2.6 Medication-overuse headache attributed to combination of acute medications Intake of any combination of ergotamine, triptans, analgesics and/or opioids on 10 or more days/month on a regular basis for more than 3 months without overuse of any single class alone.
8.2.7 Headache attributed to other medication overuse Regular overuse for more than 3 months of a medication other than those described above.
8.2.8 Probable medication-overuse headache
Ergotamine medications include DHE-45 and Migranal Nasal Spray. The triptans include [Imitrex](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/2YTNOCGF/imitrex-oral-11571%5B1%5D) (sumatriptan), [Maxalt](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/IQUOVZ8L/maxalt-oral-8440%5B1%5D) (rizatriptan), [Zomig](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/SK7QKL5H/zomig-oral-5400%5B1%5D) (zolmitriptan), [Amerge](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/J5ZNVEBI/amerge-oral-6423%5B1%5D) (naratriptan), [Relpax](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/YMDUKRPA/relpax-oral-64734%5B1%5D) (eletriptan), [Axert](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/QSGGW9F5/axert-oral-21400%5B1%5D) (almotriptan), and [Frova](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/MZF31NSF/frova-oral-22253%5B1%5D) (frovatriptan) -- as well as Treximet, which is a combination of Imitrex and naproxen sodium.
There is a bit of confusion about nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs were protective against transition to TM at low to moderate monthly headache days (10 - 14 days a month), but were associated with increased risk of transition to TM 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 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, the 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. For more on avoiding MOH, see How Can I Avoid Overusing Migraine and Headache Medications?
How can we distinguish MOH from other headaches and migraines?
Differentiating between a tension-type headache, for example, and MOH can be difficult. There are, however, some very discernible differences between MOH and a migraine attack. Migraine pain is worsened by activity; MOH tends not to be. MOH is also missing other migraine symptoms such as nausea, vomiting, phonophobia (sensitivity to sound), photophobia (sensitivity to light), hot flashes, chills, dizziness, and so on.
How do we stop MOH?
This is a question for which there isn't a single answer. There are different methods suggested by migraine and headache specialists, but at this time, there's no consensus on which works best. Another issue that complicates matters is that many preventives don't seem to work well in the presence of MOH. So far, only topiramate (Topamax) and onabotulinumA (Botox) have evidence showing that they can begin working when patients have MOH.
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 Sheftell
"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. Lipton
"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 Krusz
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.
- 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.
- Interview with Dr. Fred Sheftell. January 1, 2010.
- Interview with Dr. Richard B. Lipton. January 1, 2010.
- Interview with Dr. John Claude Krusz. January 4, 2010
- 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.