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SIGN decision support

Medication-overuse headache

Pharmacological management of migraine (SIGN)
Healthcare Improvement Scotland

RecommendationIn patients overusing acute treatment, medication overuse should be addressed.

The choice of strategy to address medication overuse should be tailored to the individual patient and may be influenced by comorbidities. Strategies include:

  • abrupt withdrawal alone and considering preventative treatment after a delay
  • abrupt withdrawal and immediately starting preventative treatment
  • starting a preventative treatment without withdrawal.

Good practice point tickConsider withdrawing regular opioids gradually.

RecommendationPrednisolone should not be used routinely in the management of patients with medication-overuse headache.

Good practice point tick Medication overuse headache should be addressed before treatment with atogepant or rimegepant, however, in patients where treatment of medication overuse headache has been
unsuccessful, atogepant or rimegepant can still be considered. 

Good practice point tick Careful consideration should be given to the potential risks and benefits for patients at high risk of
ischaemic cardiovascular disease, including uncontrolled hypertension, before prescribing atogepant or rimegepant. 

Good practice point tick Avoid use of atogepant or rimegepant during pregnancy.