Ep 220 – Medication overuse headache

Medication overuse headache (MOH) is a common but frequently overlooked cause of chronic daily headache, particularly in people with migraine. In this episode, Dr Roger Henderson explores how regular use of acute headache medications can paradoxically drive increasing headache frequency, creating a cycle of persistent pain and escalating medication use. Clinical features that should raise suspicion and the diagnostic criteria are discussed, along with why asking patients how many days each month they take headache medication is often the most important question in the consultation. This episode also examines the proposed mechanisms underlying MOH, practical approaches to diagnosis and evidence-based management, including medication withdrawal, preventive therapy and patient education. By recognising MOH early, GPs can often achieve substantial improvements in headache control and quality of life without simply prescribing another acute treatment.

Key take-home points

• Always consider MOH when a patient with migraine reports progressively increasing headache frequency rather than assuming their migraine has simply worsened.
• The question "How many days each month do you take medication for your headache?" can be the key to making the diagnosis.
• MOH develops in people with a pre-existing primary headache disorder, most commonly migraine, as a result of regular overuse of acute headache medication over more than 3 months.
• The headache often retains the same migraine or tension-type characteristics, but becomes much more frequent. This gradual increase can easily be mistaken for progression of the underlying headache disorder.
• Overuse is defined by treatment days, not the number of tablets taken.
• Triptans, opioids and combination analgesics are considered overused when taken on 10 or more days per month, while paracetamol and non-steroidal anti-inflammatory drugs generally reach the threshold at 15 or more days per month.
• Patients frequently underestimate how often they use acute medication. Headache diaries are invaluable for accurately documenting both headache frequency and medication use.
• Physical examination is usually normal, and neuroimaging is unnecessary unless there are red flags suggesting an alternative diagnosis.
• The exact mechanisms remain incompletely understood, but central sensitisation and altered pain processing are thought to play key roles in maintaining chronic headache.
• Patients often describe waking with headache, taking medication earlier in the day and finding that treatments become progressively less effective. These features should prompt clinicians to consider medication overuse as a contributing factor.
• Education is the cornerstone of successful management and helps patients understand that withdrawal-related worsening is temporary and that the condition is often reversible.
• Management focuses on reducing or stopping the overused medication while introducing or optimising appropriate preventive therapy. Patients overusing opioids or combination analgesics may require a more gradual withdrawal strategy and additional support.
• Anxiety, depression, poor sleep and chronic pain frequently coexist with MOH and should be addressed alongside headache management to optimise long-term outcomes.
• Most patients experience meaningful improvements in headache frequency, quality of life and responsiveness to acute migraine treatments after successful withdrawal. Regular follow-up is essential to reinforce education, optimise preventive therapy and reduce the risk of relapse.
• MOH is one of the most rewarding headache disorders to treat because recognising it early can dramatically improve a patient's quality of life without necessarily prescribing anything new.

Key references

1. Vandenbussche N, et al. J Headache Pain. 2018;19(1):50. doi: 10.1186/s10194-018-0875-x.
2. Boes CJ, Capobianco DJ. Cephalalgia. 2005;25(5):378-90. doi: 10.1111/j.1468-2982.2005.00868.x.
3. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2018;38(1):1-211. doi: 10.1177/0333102417738202.
4. NICE. 2012. https://www.nice.org.uk/guidance/cg150.
5. Thorlund K, et al. J Headache Pain. 2016;17(1):107. doi: 10.1186/s10194-016-0696-8.