Medication Overuse Induced Headache (MOH)


Article Author:
Dmitri Aleksenko


Article Editor:
Juan Carlos Sánchez-Manso


Editors In Chief:
Evelyn Metz
Julie Sewell
Aditya Arya


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
5/5/2019 10:16:57 PM

Introduction

Medication overuse headache (MOH) is thought to occur when medications intended to relieve a headache are consumed too frequently. This overuse causes a secondary type of headache. It was formerly known as a rebound headache, and when it occurs in a person with a migraine, the overly frequent analgesic use "transforms" an episodic suffering into a chronic one. The exact frequency of taking the pain-relieving drug before developing MOH is variable and depends on the particular type of medication used. Causal agents include both simple and combination analgesics, such as NSAIDs, triptans, ergot derivatives, and opioids, but potentially any painkiller can be the trigger. MOH is common in those patients who are at risk of overusing acute medications. Anyone previously diagnosed with primary headache disorder is at risk for this condition, and the best characterized are those suffering from a migraine and tension-type headache.[1][2][3]

According to the most recent ICHD-3b criteria, MOH is described as a headache occurring 15 or more days per month resulting from overuse of acute headache medication for more than 3 months. MOH tends to resolve when the offending medication is limited.[4][5]

Etiology

For diagnosis of MOH under most recent ICHD-3b criteria the following three points must be met: 

  1. A headache must occur for 15 or more days per month in a patient with previously diagnosed headache disorder.
  2. A patient must have been misusing the acute headache medication for more than 3 months.
  3. A headache cannot be attributed to another ICHD-3 headache condition.

MOH is thought to occur when patients are taking acute headache medication with the following frequencies: 15 days or more per month for simple analgesics (i.e., acetaminophen, NSAIDs); and 10 days or more per month for ergotamine, triptans, opioids, or combination analgesics (i.e., Fioricet).[6][7]

ICHD-3b states that when a combination of different headache medications is used, their combined frequency can lead to MOH, even when the individual medications are not overused separately.

Patients with headaches respond to acute medications differently. The use of an inappropriate headache abortive medication, or less effective medication, can increase the frequency of medication consumption and lead to MOH. For example, given the differences in efficacy in treating migraines between acetaminophen 1000 mg PO (NNT=12) and ibuprofen 400 mg by mouth (NNT= 7.2), the patient using acetaminophen will generally end up requiring more frequent dosages of this medication to control a headache compared to those who are using ibuprofen.

Epidemiology

MOH is considered one of the more prevalent neurological disorders. Based on 2015 Global Burden of Disease (GBD) study, its prevalence was estimated at 1% worldwide (approximately 58.5 million people), which is lower compared to a migraine and tension-type headache. Within the same GBD study, MOH was incorporated into the 20 most debilitating diseases.

It occurs fairly commonly in patients with chronic migraines (CM), with estimates of about 32% of patients within the chronic migraine group has MOH. MOH is believed to be more common in women (M:F ratio ranging from 2:1 to 5:1) and in those with low socioeconomic status.

Pathophysiology

The exact mechanism of MOH is unclear. It is hypothesized that MOH is attributed to depletion of 5-HT by overuse of a headache abortive medications. This leads to neuronal hyperexcitability in the cerebral cortex (which can lead to cortical spreading depression) and trigeminal system (which produces peripheral and central sensitization). The decrease in 5-HT levels leads to increased CGRP release from trigeminal ganglia, which is involved in subsequent sensitization of nociceptive trigeminal neurons.

Other studies demonstrate both structural and functional brain changes which occur in MOH. There are notable changes in metabolism in various brain structures as seen on PET scans of MOH patients. These changes were mostly reversed upon withdrawal of analgesic medication, except for persistent hypometabolism seen in the orbitofrontal area. This particular area is known to be involved in drug dependence and hypothesized to be a risk factor for subsequent relapse in analgesic overuse and recurrent MOH.

History and Physical

Clinical presentation of MOH varies between patients and even changes with time in the same patient. There can be an increase in the frequency of a pre-existing headache or the evolution into a new type of a headache. There are no specific tests to diagnose this condition, and thus it is headache quantity and frequency, and type and frequency of acute medication used that leads to the diagnosis. Although pain location and quality are non-specific in MOH, there are some general features commonly seen in this patient population; these include the following:

  • A headache is usually episodic
  • Frequent acute medication consumption depends on the type of abortive medication used (see Etiology section for more detail)
  • Neck pain is common (often mistaken for a cervicogenic headache, which in turn tends to be resistant to cervicalgia-appropriate treatments)
  • Typically occurs in the morning (presumed related to withdrawal occurring during sleep)
  • Poor sleep
  • Autonomic symptoms (i.e., nasal congestion, rhinorrhea, gastrointestinal [GI] disturbance) are more frequent with overused opioids
  • Comorbid anxiety and depression
  • All headache treatments are generally less effective when MOH is present; efficacy improves after the weaning.

Evaluation

There are currently no specific biomarkers or studies whereby differentiate or point towards MOH. The diagnosis is purely clinical and deserves a special attention not to be overlooked due to the potential consequences of worsening over time.

Treatment / Management

Typical treatment involves weaning the patient off the overused acute headache medication while simultaneously focusing on preventative treatment. Several studies show that complete 100% weaning of overused acute medication shows the best results compared to continuing on the same acute medication responsible for MOH but placing frequency limits on its use. Note that patients can be prescribed a new acute medication from a different class. Patients can wean from the offending medication abruptly ("cold turkey") or gradual over several weeks. Preventative treatment can include prophylactic medication and/or non-pharmaceutical treatments (i.e., cognitive behavioral therapy, biofeedback, relaxation training, lifestyle modification with trigger avoidance).[8][9][10]

Educating the patient and their family on the importance of limiting acute medication use is vital in preventing MOH. Initial worsening of a headache within the first few days of weaning is fairly common. Withdrawal symptoms are thought to typically last up to 10 days then eventually followed by improvement in MOH. Weaning patients off MOH-related medication can be done in an outpatient or an inpatient setting. Most cases can be managed as outpatient mainly through educating patients to cut down their acute medication use. It is important to address and treat co-morbid psychiatric conditions, especially anxiety and depression which are often associated with MOH, but without potentiating the boosting effects of anxiolytic medication has in maintaining the headache.

Following successful weaning, about half of patients relapse after 5 years; thus, it is essential to have the patient follow-up regularly. Once the patient's MOH had resolved, tapering them off of the preventative medication may be considered. There are no specific guidelines, but some professionals suggest tapering prophylactic medication after 1 year. [11][12]

Differential Diagnosis

MOH occurs in patients with an episodic primary headache, and thus chronic versions of an episodic headache are one of the main differentials. Other secondary headaches must be ruled out, with the guide of the clinical picture and the aid of all the necessary tests, and more so when the features of the original episodic headache are different from its chronic counterpart.

Prognosis

The results of a tailored regime are excellent in the long-term, but with an estimated relapse rate of about 30% within 6 months and 50% following a 5-year period.

Pearls and Other Issues

Practitioners contend that frequent use of acute headache medications may be a reflection of poorly controlled headaches, and not necessarily the cause. This idea stems from evidence that not all patients improve when they stop taking headache-relieving medications. Instead of primarily blaming analgesic medication overuse as the reason for the increase in headache frequency, clinicians must be cautious in their approach to managing these patients and not to overlook those in whom headaches are simply poorly controlled. Some studies suggested that other substances, such as the regular use of tranquilizers or other recreational substances abused in the general population, should be considered in conjunction with analgesics.

Enhancing Healthcare Team Outcomes

The diagnosis and management of medication overuse headache is complex and best done with a multidisciplinary team that includes a neurologist, pharmacist, internist and the primary care provider. The key is to educate the patient and family on the importance of limiting acute medication use is vital in preventing MOH. The underlying psychiatric condition must be addressed and a referral to a mental health professional can be helpful.

Following successful weaning, about half of patients relapse after 5 years; thus, it is essential to have the patient follow-up regularly. Once the patient's MOH had resolved, tapering them off of the preventative medication may be considered. There are no specific guidelines, but some professionals suggest tapering prophylactic medication after 1 year. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Medication Overuse Induced Headache (MOH) - Questions

Take a quiz of the questions on this article.

Take Quiz
Select the correct statement about the combination medication acetaminophen 500 mg, aspirin 500 mg, and caffeine 130 mg.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 42 year old female with chronic daily headaches for years, anxiety, and depression presents for an initial visit. She requests a refill on her headache medication, a combination of acetaminophen, butalbital, and caffeine. She states that her last doctor gave her 90 pills with 5 refills and requests the same. She is vague about how many she takes each day. She states she is familiar with medication overuse headache (MOH) but the only way she can function is with this prescription. Select appropriate management.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The International Classification of Headache Disorders, Second Edition outlines diagnostic criteria for medication-overuse headache (MOH). It requires that headaches be present at least half the days of each month for 3 or more months. There must also be intake of certain medication 10 or more days each month. Which of the following would not be one of these medications?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the incorrect statement about medication-overuse headache (MOH).



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the correct statement about cluster headaches (CH) and medication overuse headaches (MOH).



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the correct statement about medication overuse headache (MOH) from triptans.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is false regarding medication overuse headache (MOH)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following medication associated with medication overuse headache (MOH) has the highest relapse rate?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
If the medications listed below are used daily, which of the following has a lower frequency threshold for developing medication overuse headache (MOH)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Over the last few months, a 37-year-old stewardess who covers intercontinental flights and controls her perimenstrual alternating throbbing headache with naproxen starts to obtain less relief from it. Her headaches become more frequent and prolonged. Her headaches usually accompany with nausea and photophonophobia, and she tends to lie flat to wait for it to subside. She uses every so often a small dose of alprazolam to treat her jetlag, which has made her last year somewhat insomniac, and sometimes she adds half a pill to the painkiller. Apart from that, she has not had any other symptoms, and the rest of her medical history and examination is unremarkable. What is the least useful measure to advise her to help improve her almost daily headache?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Medication Overuse Induced Headache (MOH) - References

References

Limmer AL,Holland LC,Loftus BD, Zonisamide for Cluster Headache Prophylaxis: A Case Series. Headache. 2019 Apr 30;     [PubMed]
Mose LS,Pedersen SS,Jensen RH,Gram B, Personality traits in migraine and medication-overuse headache: A comparative study. Acta neurologica Scandinavica. 2019 Apr 30;     [PubMed]
Young NP,Philpot LM,Vierkant RA,Rosedahl JK,Upadhyaya SG,Harris A,Ebbert JO, Episodic and Chronic Migraine in Primary Care. Headache. 2019 Apr 29;     [PubMed]
Sandoe CH,Lay C, Secondary Headaches During Pregnancy: When to Worry. Current neurology and neuroscience reports. 2019 Apr 22;     [PubMed]
Micieli A,Kingston W, An Approach to Identifying Headache Patients That Require Neuroimaging. Frontiers in public health. 2019;     [PubMed]
Grazzi L,D'Amico D, Chronic migraine and medication overuse: which strategy for a complex scenario. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2019 Mar 25;     [PubMed]
Turner DP,Lebowitz AD,Chtay I,Houle TT, Headache Triggers as Surprise. Headache. 2019 Apr;     [PubMed]
Ferini-Strambi L,Galbiati A,Combi R, Sleep disorder-related headaches. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2019 Mar 25;     [PubMed]
Barmherzig R,Kingston W, Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Current neurology and neuroscience reports. 2019 Mar 19;     [PubMed]
Russell MB, Epidemiology and management of medication-overuse headache in the general population. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2019 Mar 19;     [PubMed]
Arca KN,Halker Singh RB, The Hypertensive Headache: a Review. Current pain and headache reports. 2019 Mar 14;     [PubMed]
Bottiroli S,Galli F,Viana M,De Icco R,Bitetto V,Allena M,Pazzi S,Sances G,Tassorelli C, Negative Short-Term Outcome of Detoxification Therapy in Chronic Migraine With Medication Overuse Headache: Role for Early Life Traumatic Experiences and Recent Stressful Events. Frontiers in neurology. 2019;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of NP-Gerontology Primary Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for NP-Gerontology Primary Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in NP-Gerontology Primary Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of NP-Gerontology Primary Care. When it is time for the NP-Gerontology Primary Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study NP-Gerontology Primary Care.