Medication Overuse Headache

Authors: Maria-Carmen Wilson, MD and Sonia Lal
 
Key Points:
  1. Medication-overuse headache (MOH) may occur in people who have frequent migraine, cluster, or tension-type headaches, which leads them to overuse pain medications hence causing a vicious cycle in which frequent headaches cause the person to take medication frequently (often non-prescription medication), which then causes a rebound headache as the medication wears off, causing more medication use.
  2. Medication overuse is a risk factor and common cause for chronic daily headache
  3. Medication overuse headache has been found to render headache refractory to both pharmacological and non pharmacological prophylactic medications and also reduce the efficacy of acute abortive therapy for migraines.
  4. Frequent use of analgesic medication is found to be the most common cause of medication overuse headache.
  5. There is a risk of development of medication overuse headache in migreneurs even when the medication is used for other medical problems.
  6. A combination of pharmacological, non-pharmacological, behavioral and physical therapy interventions are usually necessary for treatment of medication overuse headaches along with the discontinuation of medication overuse which is the most effective method.
Introduction
Medication Overuse headaches have previously been termed rebound headaches, drug-induced headache and medication misuse headaches. It is the most common cause of chronic daily headaches. Medication overuse headaches are experienced more than 15 days a month for atleast 3 months and have developed or markedly worsened during medication overuse.
 
According to the International Classification of Headache Disorders, Second Edition (ICHD-II) a diagnosis of medication overuse headache is made when:
  1. the consumption of acute medication is more than the standard dosed prescribed.
  2. Patients have headaches more than 15 days a month for than 3 months.
  3. Secondary disorders that may explain the headache are excluded clinically or through investigation.
 
Symptoms
Medication overuse headaches can present as follows
(i)Occur every day, often waking the patient early in the morning
(ii)Improve with analgesics but then return as the medication wears off
(iii)Persist throughout the day
(iv)Worsen with physical or mental exertion
Other signs and symptoms may include:
(i)Nausea
(ii)Anxiety
(iii)Restlessness and difficulty concentrating
(iv)Memory problems
(v)Irritability
(vi)Depression
 
What is medication overuse?
Overuse is defined in terms of treatment days per month and depends on the drug. The most commonly used drugs include analgesics in combination with barbiturates or other non-narcotic substances , simple analgesics,opioids,  triptans and ergotamine. Patients who have have headaches especially migraines have a tendency to develop medication overuse headaches even if they are using the analgesics for other medical conditions.
 
1. Simple analgesics: Common medications such as aspirin, acetaminophen, NSAIDS (Ibuprofen, others) may contribute to rebound headaches especially when the patient exceeds the recommended daily dosages. These medications cause rebound headaches when used for more than 15 days in a month.
2. Combination pain relievers: Over-the-counter pain relievers that contain a combination of caffeine, aspirin and acetaminophen or butalbitol commonly cause medication overuse headache as well. All of these medications are high risk for the development of medication-overuse headache if taken for more than 10 days in a month.
3. Triptans and Ergotamine: Triptans and Ergotamines also have a moderate risk of causing medication overuse headache when used for more than 10 days in a month. The relapse rate is comparatively less when compared to other medications like combination or simple analgesics.
4. Opioid medications: Medication overuse headaches occur frequently if opioid use is exceeded to more than 10 days in a month.
5. Caffeine use: Patients who drink beverages with caffeine in large amounts are also at a risk for development of rebound headaches. It is important to limit the amount of caffeine to 200mg per day.
 
Diagnosis
The diagnosis for medication overuse headache is usually made from the clinical history and depending on the amount of use of the medications. The physician may consider performing extra tests like imaging studies and lab work especially if the quality of the headaches changes to rule out any other secondary cause.
 
Treatment
Medication overuse headaches are difficult to treat.  One of the most important requirements for the effective treatment of these headaches is to break the headache cycle. Discontinuation of the medication is usually found to be the most effective method. Apart from discontinuation, a combination of pharmacological therapy (in the form of preventatives, intravenous treatments), non –pharmacological therapy, biofeedback and targeted physical therapy is needed for improvement in the patients symptoms. Support groups and behavioral medication techniques have also been found necessary for the success of the treatment in the symptoms.
 
It is important for the patient to know that when a medication which was being overused is discontinued, they may undergo a period where their headaches will get worse. Some other symptoms caused by the withdrawal of the medication can include nausea, vomiting, insomnia, restlessness or constipation. The headaches eventually getter better.
 
The physician decides how the patient would need to stop the medication- in the form of a taper (especially butalbitol combinations or opiods) or just discontinue them. It may take a couple of months to six months to eventually break the headache cycle.
 
Various medications are also prescribed when the patient is being tapered of the medications and occasionally a brief course of steroids may be used. Ambulatory intravenous medications may be used to break the headache cycle. Commonly used medications include intravenous dihydroergotamine (DHE) along with anti nausea medications like zofran, intravenous steroids, muscle relaxants and ketorolac.
 
Sometimes under certain circumstances, inpatient treatment may be considered so that the medication can be tapered in a controlled environment and prolonged intravenous medications can be used to break the headache cycle. A short hospital stay is usually recommended is the patient has not been able to taper of the medications or is on certain medications like opioids or barbiturates.
 
Other outpatient therapies include biofeedback, psychological counseling and physical therapy which help effectively working on changing lifestyle and incorporate non pharmacological therapies for the management of headaches. Biofeedback teaches the patient to control certain responses to the body to effectively help in reducing pain. The patient learns how to control muscle tension and breathing to enter in a relaxed state which may help to better cope with pain.
Once the headache cycle is broken or is under better control, various preventative medications are used to control the frequency and intensity of headaches. The physician will decide the type of medication depending on the type headache the patient suffers from. Botulinum toxin which is an effective treatment which has been recently approved for treatment of chronic migraines may also be considered for the management of the headaches. Certain multivitamins and minerals have also shown efficacy in controlling migraines.
 
Conclusion
Medication overuse headaches are caused by frequent use of abortive medications and are well known to cause chronic daily headaches. Treatment usually is prolonged and extensive. It usually requires pharmacological and non –pharmacological therapies to effectively break the headache cycle. Hospitalization is rarely required.
 
It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbitol combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month.
 
Patients should remember to contact their physicians and let them know if they need to take medications for acute treatment frequently so that the appropriate management can be done and the onset of medication overuse headaches can be avoided.
 
References:
  1.  Diener HC, Katsarava Z. Medication overuse headache. Curr Med Res Opin 2001;17:s17-s21.Review on medication overuse headache.
  2. Silberstein SD, Olesen J, Bousser MG, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II)-revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005;25:460-465.
  3. Tepper SJ. Debate: analgesic overuse is a cause, not consequence, of chronic daily headache. Analgesic overuse is a cause of chronic daily headache. Headache 2002;42:543-547.
  4. Silberstein, Stephen D.; Lipton, Richard B.; Dodick, David W. Wolff's Headache and Other Head Pain. New York. Oxford Press. 2008
  5. Dodick D at al. Onabotulinum toxin for treatment of chronic migraine. Headache. Vol 50 (6) 921-936. June 2010
  6. Wilson M-C, Remember to SNOOP and Improve Your Headache Diagnosis. American Headache Society Newsletter. Vol. 15:2 Summer 2004
Maria-Carmen Wilson, MD
Professor of Neurology
Clinical Professor of Pediatrics
Director, Headache Medicine Fellowship
Associate Director, Neurology Residency Program
Associate Director, Pain Medicine Fellowship
University of South Florida
Tampa, FL
 
Sonia Lal, MD
Headache Medicine Fellow
University of South Florida
Tampa, FL
 
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