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Key reviewer: Dr William Wallis, Neurologist, Auckland
- Recognition of the problem is the key
- Over the counter medications are often overused
- All medications used for immediate relief of headache have the potential to cause medication-overuse headache
- Withdrawal of the overused medication is essential
What is it?
Medication-overuse headache is a complex disorder that is best thought of as an “interaction between a therapeutic
agent used excessively and a susceptible patient”.1
Medication-overuse headache develops in people who have a pre-existing primary headache disorder, usually migraine or
tension-type headache. The type, location and severity of the headache may vary, but the headaches characteristically
occur on a daily or near daily basis. Medication-overuse headache remains one of the most important, frequent, but under-diagnosed
cause of chronic headache.3,4
Medication-overuse headache can be defined as:
“A headache that is present on 15 or more days of the month and has developed or worsened whilst the patient has
been regularly using analgesic or anti-migraine medicines for more than three months.” 5
Box 1: The latest revised diagnostic criteria for medication-overuse headache are: 6
- Headache present on ≥ 15 days/month
- Regular overuse for ≥ 3 months of one or more acute/symptomatic treatment drugs as defined:
- Ergotamine, triptans, opioids or combination analgesics on ≥ 10 days/month on a regular basis for ≥ 3 months.
- Simple analgesics or any combination of ergotamine, triptans, analgesics, opioids on ≥ 15 days/month on a regular
basis for ≥ 3 months without overuse of any single class alone
- Headache has developed or markedly worsened during medication-overuse
Diagnostic criteria are available (see Box 1).
How big is the problem?
Medication-overuse headache is an increasingly common worldwide health problem. It is estimated that up to 2% of the
population have medication-overuse headache.7,8,9
Characteristics of people with medication-overuse headache
Studies have identified a higher prevalence of medication-overuse headache in people with the following characteristics
- Female gender 4,9,10,11
- Age 40 to 50 years 10,11
- Migraine 4,11
- Obesity 12,13
- Low socioeconomic status 14
- A tendency to exhibit a low threshold for head pain7
What medications are involved?
Almost all drugs used to provide immediate treatment of headache have the potential to cause medication-overuse headache,
those used for the prophylaxis of headache do not. 3,18
The crucial factor in the development of medication-overuse headache is the chronic use of medication on both a frequent
and regular basis.1 Individual doses of medication are generally not higher than recommended. Medication-overuse
headache can develop in three months but it may take longer.
Medications known to lead to medication-overuse headache include simple analgesics (e.g. aspirin, paracetamol), caffeine,
ergotamine, combination agents (e.g. paracetamol/codeine, dextropropoxyphene), triptans (sumatriptan, rizatriptan*),
NSAIDs and all opioids including codeine, tramadol, oxycodone and morphine.
People who have headache most commonly use over the counter medications. Sumatriptan has been available over the counter
for the last few months (see BPJ 9). Triptan use is increasing and
these drugs are now regarded as one of the most commonly implicated types of drugs in the development of medication-overuse
headache.9 Triptans cause this type of headache more quickly and with lower doses than other analgesics.10
For more information see: The role of triptans in the treatment of migraine in adults (BPJ62)
How to recognise medication-overuse headache
|What makes some people overuse medications?
Psychological issues that can contribute to the overuse of medications include:2
- Belief that medication is the only solution for a headache
- Fear of pain
- Low tolerance to discomfort
- Belief that medication will help with sleep
- Need to continue to function
- Personality disorder
- Clinical diagnosis of anxiety, depression, panic disorder or substance use disorder
- Dependence on other psychoactive substances including alcohol and nicotine11
- A family history of substance disorders.11,15
- A family history of mood disorders16
- Psychiatric comorbidity15
Not all people with chronic daily headache overuse medications and not all go on to develop medication-overuse headache.
Some people predisposed to headache, may develop medication-overuse headache after frequent use of analgesics for conditions
other than headache, particularly chronic neck and low back pain.7,8,17
Consider this diagnosis in all patients with frequent headache. Direct questions should be asked about patterns of medication
use, including those purchased over the counter. Some patients may be vague or evasive and refuse to disclose an accurate
level of their medication use. Explaining to them the concept of medication-overuse headache and the way in which it develops
may help them understand the importance of your questions. In some cases you may need to check medication use with a partner
or family member, the pharmacist or verify the patient’s medical record. A daily headache diary can be useful when
collecting information on the level of medication use and identifying the extent of overuse.16
In addition, a general medical and neurological history is required to make a correct diagnosis.
Do not assume that:15
- Medication overuse occurs daily - although this is often true, for some people medication use may be much less frequent.
- The medication must be taken in large quantities.
- Medication-overuse headache can be avoided by mixing and matching medications - combinations of medication can frequently
- Medications taken for pain conditions other than headache “don’t count”.
Clinical characteristics of medication-overuse headache
There may be clinical characteristics that can be useful in assisting diagnosis (refer Box 2). It is important that
other forms of headaches, both primary and secondary, are considered when making the diagnosis.
Box 2. Clinical characteristics of medication-overuse headache 3,16
|General observations and symptoms:
- Headaches are refractory to treatments and are usually daily, or nearly daily
- Headaches vary in severity, type and location from time to time, but often manifest as morning headache upon awakening
- Physical or intellectual effort (‘normal’ levels) may bring on headache i.e. the threshold for head
pain seems to be low
- Symptomatic headache medications tend to provide only short-term relief
- Spontaneous improvement of headache occurs after a few days off medication
- Prophylactic drugs are often ineffective while the patient is taking excess amounts of drugs for immediate relief
Symptoms associated with overuse of ergotamine and to a lesser extent with triptans:
- Anxiety, irritability or depression
- Forgetfulness, concentration and memory difficulties
- Gastrointestinal symptoms
- Cold extremities
- Irritable bowel syndrome
- Weakness of the legs and muscle pain in the extremities
- Occasionally bradycardia and lightheadedness
How should medication-overuse headache be managed?
For most people with medication-overuse headache, there is no relief until all medication used for acute relief is withdrawn.19 Patient
education is a crucial element and advice must be non judgemental. Information and support from family members may be
An approach to management may be:
- Explain to the patient that medication overuse is causing their headache and that they need to stop using the medication
in order for the headache to get better. This may not be accomplished in a single consultation.
- Explain to the patient that it may take up to six weeks before there is any benefit from withdrawal of the overused
- Abrupt withdrawal is usually more successful than gradual withdrawal. If this is not tolerated, gradually withdraw
the overused medication over 4 to 6 weeks. Alternatively, start migraine prophylaxis, usually with a TCA, and increase
to the maximum tolerated dose, then withdraw the overused medication gradually. If a TCA is not tolerated consider sodium
valproate or topiramate.*
- Follow up is essential to guard against relapse and to make sure that there is improvement. If there is not, and the
overused medication is withdrawn entirely for at least six weeks, then the diagnosis is wrong. At this stage refer to
Note: For patients over the age of 55 years, a CRP and an ESR test should be requested to help exclude temporal arteritis,
which can mimic medication-overuse headache.
Avoiding medication-overuse headache
The main way to prevent medication-overuse headache is to prevent medication overuse. When a patient presents with headache,
but is not in the category of chronic headache syndrome, it is essential to warn them about the risks posed by excessive
analgesic and triptan treatments. Consider avoiding the use of codeine, dextropropoxyphene or opioids for any headache.
Patients whose headache is severe enough to require these medications, should be considered for headache prophylaxis.
Continuing to prescribe more and more analgesics, particularly those with addictive potential, without educating patients
about the correct use of medications may promote medication-overuse headache.
Withdrawal symptoms which may be physical and psychological may last between two to ten days and include withdrawal
headache (which initially may be worse than the medication-overuse headache), nausea, vomiting, hypotension, tachycardia,
sleep disturbances and anxiety.
Management of withdrawal symptoms
Many people with medication-overuse headache are able to manage withdrawal without additional assistance. However treatments
to ease withdrawal may include fluid replacement, TCAs and steroids. For patients with severe withdrawal headache, analgesics
may be required, but firm limits on use must be set, e.g. regular naproxen 500mg twice per day for two to three weeks
Study results have differed, however a short course of 60-100mg prednisone for five days may be effective in reducing
the duration of withdrawal headache.20,21 Even though this is a short course of prednisone, at this dose tapering
is recommended, e.g. decreasing by 20mg per day until finished. If withdrawal symptoms are intolerable, consider referral
for hospital treatment.
Patient education is important
The greatest risk of relapse is within the first 12 months after withdrawal.3,16
Patient education is important to initiate withdrawal and to reduce the risk of relapse. Encouraging and supporting
the patient towards their goals and appropriate follow up is necessary. Behavioural techniques such as relaxation therapies
and stress management have been shown to enhance outcome over drug treatment alone.16
- Silberstein SD, Olesen J, Bousser M-G, Diener H-C et al. The International classification of Headache Disorders,
2nd Edition (ICHD-II) - revision of criteria for 8.2 Medication-overuse headache Cephalalgia 2005;25(6):460-465.
- Lake AE. Medication Overuse Headache: Biobehavioural Issues and solutions. Headache 2006;46(Suppl 3):S88-S97.
- Diener H-C, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004;3(8):475-483.
- Zidverc-Trajkovic J, Pekmezovic T, Jovanovic Z, et al. Medication-overuse headache: clinical features predicting
treatment outcome at 1-year follow-up. Cephalalgia 2007;27(11):1219-1225.
- McEntee J. UK Medicines Information. Medication-overuse headache: What is it and how do you treat it? Available from
- Olesen J, Bousser M-G, Diener H-C, et al. New appendix criteria open for a broader concept of chronic migraine. Cephalalgia
- Dodick D, Freitag F. Evidence-Based Understanding of Medication-Overuse Headache:Clinical Implications. Headache
- Silberstein SD, Welch KMA. Painkiller headache. Neurology 2002;59(7):972-974.
- Diener H-C, Katsarava Z. Medication overuse headache. Clinical Summary. Available from MedLink Neurology
- Limmroth V, Katsarava Z, Fritsche G. Features of medication overuse headache following overuse of different acute
headache drugs. Neurology 2002;59(7):1011-1014.
- Radat F, Creac’h C, Guegan-Massardier E, et al. Behavioural Dependence in Patients with Medication Overuse
Headache: A Cross-Sectional Study in Consulting Patients Using the DSM-IV Criteria. Headache 2007;48(7):1026-1036.
- Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache
in a population-based study. Pain 2003;106(1-2):81-9.
- Bigal ME, Liberman JN, Lipton RB. Obesity and migraine. A population study. Neurology 2006;66(4):545-50.
- Hagen K, Vatten L, Stovner LJ et al. Low socio-economic status is associated with increased risk of frequent headache:
a prospective study of 22718 adults in Norway. Cephalalgia 2002;22(8):672-679.
- Lake AE. Screening and Behavioural Management: Medication Overuse Headache - the Complex Case. Headache 2008;48(1):26-31.
- Grazzi L, Andrasik F, Usai S, Bussone G. Headache with medication overuse: treatment strategies and proposals of
relapse prevention. Neurol Sci 2008;29(2):93-98.
- Zwart JA, Dyb G, Hagen K, et al. Analgesic use: a predictor of chronic pain and medication overuse headache: the
Head-HUNT study. Neurology 2003;61(2):160-164.
- Ferrari A, Coccia C, Sternieri E. Past, Present and Future Prospects of Medication-Overuse Headache Classification.
- Williams L, O’Connell K, Tubridy N. Headaches in a rheumatology clinic: when one pain leads to another. Eur
J Neurol 2008;15(3):274-277.
- Pageler L, Katsarava Z, Diener H-C, Limmroth V. Prednisone vs. placebo in withdrawal therapy following medication
overuse headache. Cephalalgia 2008;28(2):152-156.
- Krymchantowski AV, Barbosa JS. Prednisone as initial treatment of analgesic-induced daily headache. Cephalgia 2000;2(2):107-113.