When prescribing acute treatment in primary headache patients should be warned about the risk of medication overuse headache. This is particularly important in patients with migraine. In general the use of simple analgesics and triptans should be restricted to 8-10 days per month. The use of combination analgesics and opioids should be avoided. Preventative treatment should be considered early in patients with frequent headache.

In cluster headache, because the headaches are so severe and the risk of MOH very low, patients should be allowed to use up to 2 doses of a triptan per day (subcutaneous sumatriptan or nasal sumatriptan/ zolmatriptan). 

Before diagnosing MOH it is important to consider other secondary causes of chronic daily headache and investigate appropriately. 

Explanation

Adequate explanation is the key to managing MOH. The patient should be made aware that frequent use of acute medication “winds up” the migraine process making it more likely to happen and results in chronic headache. MOH is a recognised complication of the management of headache and rationalising/stopping medication can improve headache. Patients should be aware that headache can worsen before it improves (re-bound headache) and that this can last for days/weeks. Headache may still require appropriate management with acute and preventative treatment following medication withdrawal. Resuming frequent acute medication use is likely to result in re-emergence of MOH. 

Medication withdrawal

Medication withdrawal is the recommended strategy in patients with MOH. For simple analgesics and triptans abrupt withdrawal is preferable. For combination analgesics (particularly those containing high dose codeine) and opioids gradual withdrawal is recommended. The patient should be warned to expect withdrawal headaches. Other symptoms commonly encountered include: nausea, sleep disturbance and anxiety. Anti-emetics should be considered during the withdrawal phase and patients advised to keep adequately hydrated. Patients overusing triptans can be expected to improve over 7-10 days and those overusing simple analgesics over 2-3 weeks, but improvement can take a few months. For those who cannot manage abrupt withdrawal rationalising acute medication to 2 days per week can be helpful.  

Because medication withdrawal usually results in improvement rather than cessation of headaches adding in or adjusting preventative medication at the same time as initiating withdrawal should be considered. 

Preventative treatment 

The effectiveness of most oral preventative treatments is reduced in MOH and if a preventative treatment is started this should be combined with rationalisation of the overused medication. Topiramate, Botulinum Toxin A and CGRP monoclonal antibodies are less likely to be affected by medication overuse. 

In patients with Medication Overuse Headache an adequate explanation, trial of medication withdrawal and consideration of starting prophylactic treatment should be undertaken prior to referral into secondary care. 

1. Wakerly, B. Medication Overuse Headache. Practical Neurology. 2019;19:399-403 
2. SIGN 155 Pharmacological management of migraine – updated March 2023; includes clinician and patient guidelines Pharmacological management of migraine (sign.ac.uk)  
3. British Association for the Study of Headache (BASH) National Management System 2019; includes clinician and patient portals Headache UK 

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