Pain Conditions
      Back to home
      1. VCT Resource Library
      2. Pain Conditions

      Medication Overuse Headache

      Brief Overview: According to UpToDate, “Medication overuse headache (MOH) is a secondary condition that occurs when overuse of acute medications to treat other headache disorders results in an increased headache burden with attacks occurring on 15 or more days per month for at least three months. MOH has also been called analgesic rebound headache, drug-induced headache, and medication-misuse headache. It coexists with primary and secondary headache disorders and is a leading cause of neurologic disability worldwide.”

      Prevalence: According to UpToDate, “The prevalence of medication overuse headache (MOH) in the general population is approximately 1 to 2 percent in most studies.”

      Etiology: According to UpToDate, “The precise mechanisms that lead to MOH are still uncertain. However, multiple factors seem to play a role, including the presence of a baseline headache disorder, genetic predisposition, central sensitization (chronic exposure to triptans and other analgesics could lead to downregulation of serotonin receptors and changes in central inhibitory pathways that translate to an impairment of antinociceptive activity and a permanent feeling of head pain), and biobehavioral factors (some patients may have compulsive drug seeking and drug taking behavior despite negative consequences, as the basis of MOH. Other patients may use opiates or other drugs with sedative/anxiolytic effects to treat both pain and a coexistent anxiety disorder).”

      Risk Factors:

      • Female
      • Migraines (compared to other headache types)
      • Greater migraine symptom severeity
      • More intense head pain
      • Medication overuse
      • History of substance disorders
      • Anxiety, depression
      • Older age
      • Smoking

      Commonly Associated Conditions:

      • Migraine or chronic tension-type headache
      • Depression, anxiety, insomnia
      • Substance use disorders
      • Chronic musculoskeletal pain, fibromyalgia

      Common Medications:

      • Analgesics: acetaminophen, NSAIDs (ibuprofen, naproxen)
      • Opioids: oxycodone, hydrocodone, tramadol
      • Combination medications: butalbital-caffeine, acetaminophen-caffeine
      • Migraine-specific drugs: triptans (sumatriptan, rizatriptan), ergotamines

      Common Labs, Imaging, and Tests:

      • Clinical diagnosis based on history of medication use and headache pattern.
      • No specific labs diagnose MOH.
      • Workup may include:
        • Neurological exam
        • MRI or CT brain (if new or atypical headache in seniors to rule out secondary causes)
        • Basic labs to rule out metabolic contributors (thyroid dysfunction, anemia, electrolyte imbalance) or to evaluate organ function before medication adjustment

      Common Symptoms:

      • A previously diagnosed, episodic headache disorder
      • Headaches daily or nearly daily
      • Nausea
      • Asthenia (weakness, lack of energy, loss of strength)
      • Difficulty concentrating
      • Memory problems
      • Irritability

      Common Treatments:

      • Step 1: Withdrawal of Overused Medications
        • Gradual taper or abrupt stop depending on drug (opioids/barbiturates usually tapered). – this will be guided by your healthcare provider
        • Short-term worsening of headaches may occur (“withdrawal headache”).
      • Step 2: Bridge/Transitional Therapy
        • NSAIDs (short course), steroids, or antiemetics may be used temporarily to ease withdrawal – as directed by your healthcare provider
      • Step 3: Preventive Therapy
        • Start/optimize preventive medications (e.g., beta-blockers, topiramate, amitriptyline, CGRP inhibitors in migraine) – as directed by your healthcare provider
      • Step 4: Supportive Care
        • Behavioral therapy, sleep hygiene, stress management.
        • Education on safe limits for acute medication use (e.g., triptans ≤9 days/month, simple analgesics ≤15 days/month).
        • Close follow-up to monitor withdrawal and prevent relapse

      Physical Findings:

      • Usually normal physical exam between headaches.
      • May show nonspecific findings: neck muscle tension, scalp tenderness.
      • Neurological exam typically normal (unless another cause is present).

      Potential Complications and Contraindications:

      • Potential Complications
        • Progression to chronic daily headache
        • Increased disability, reduced quality of life
        • Medication dependence, tolerance, or toxicity
        • GI complications (ulcers, bleeding from NSAIDs)
        • Kidney or liver damage from prolonged use

      General Health and Lifestyle Guidance:

      • Keep a headache diary to track frequency, triggers, and medication use
      • Encourage regular sleep schedule and sleep hygiene
      • Balanced meals, adequate hydration, limit caffeine
      • Gentle physical activity (walking, yoga, stretching) to reduce stress and improve sleep
      • Stress reduction: mindfulness, meditation, deep breathing
      • Avoid alcohol and smoking, which may worsen headaches
      • Regular follow-up with primary care or neurology for headache management and medication review

      Suggested Questions to Ask Patients:

      • How often do you take pain or headache medication?
      • Which medications are you using, and at what dose?
      • How many days per month do you have headaches?
      • How often do you wake up with a headache?
      • Do headaches improve with medication, or do they return quickly?
      • Do you keep a record of when you take medication for headaches?
      • Do you have other chronic pain conditions or stressors?
      • How does headache affect your daily routine, sleep, or mood?
      • When was your last visit with a neurologist or headache specialist?

      Suggested Talking Points:

      • Taking pain medications too often can make headaches worse.
      • Medication overuse headache is common and can be reversed with the right plan.
      • Your provider may suggest stopping or reducing certain medicines — short-term discomfort is possible, but it hopefully will lead to long-term improvement.
      • Preventive medicines and healthy lifestyle habits can reduce headache frequency.
      • Tracking your headaches and medication use helps your care team create a safer plan.
      • Small changes (better sleep, hydration, reduced caffeine) can also help reduce headache burden.
      • Make sure to report any new, worsening, or persistent symptoms to your healthcare provider. Ask your healthcare provider for guidance on symptoms to watch for and when to seek urgent/emergency care.

      Sources:

      This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.