Medication overuse headache

The International Classification of Headache Disorders (ICHD) defines medication overuse headache as:

• Headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of one or more drugs that can be taken for acute and/or symptomatic treatment of headache, for more than 3 months. It usually, but not always, resolves after the overused medication is stopped.
• Ergotamines, triptans, opioids, or combination analgesics are taken on 10 days or more per month.
• Simple analgesics such as paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin (either alone or in any combination) are taken on 15 days or more per month.

Patients overusing simple analgesics or triptans:

• Simple analgesics or triptans can be stopped abruptly.

Patients with medication overuse headache caused by opioids and combination analgesics:

• Warn patients about the potential for withdrawal symptoms, especially if higher doses of opiates are used. Some patients may prefer to gradually reduce medication over two weeks before stopping.

• Evidence for therapeutic interventions is limited, but withdrawal symptoms may be alleviated by antiemetics, tricyclics, short-term naproxen, and a steroid taper. Effective strategies to manage withdrawal may include ensuring regular rest and sleep, staying hydrated, avoiding caffeine, limiting strenuous activities, and using comforting hot or cold packs

Withdrawal Symptoms

• The most common symptom during withdrawal is an increase in headache severity. Other symptoms may include nausea, difficulty sleeping, restlessness, and digestive issues such as stomach upset or diarrhea.
• Withdrawal from medications like ergotamine, triptans, and codeine or morphine-based drugs can be particularly challenging. In comparison, discontinuing paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, or naproxen tends to be less severe, especially when tapered off gradually.

• Referral or advice request to a neurologist should be considered if:
  • There is uncertainty about the diagnosis or atypical symptoms.
  • There is uncertainty about how to manage medication overuse headache in primary care.
  • Previous repeated drug withdrawal attempts have been unsuccessful.
  • A person is overusing strong opioids, barbiturates, or tranquilizers; or has significant comorbidities needing specialist management.