Management of medication overuse headache

doi:10.1136/bmj.c1305

From trainee to consultant, BMJ Group offers doctors around the world tailored information, special events, learning resources and recruitment services at every step along their career path.

... by doctors, for doctors, for patients
We are open for entries!

Online learning

BMJ Learning

High-quality CME / CPD for doctors and other healthcare professionals. BMJ Learning features hundreds of accredited, peer-reviewed learning modules in text, video, and audio formats. Find out more

Courses and Qualifications

BMJ Masterclasses

BMJ Masterclasses, led by experts, help clinicians to use the latest evidence and recent guidelines in practice and meet their CPD/CME requirements. Find out more

Exam Preparation

The leading provider of online exam preparation, helping over 167,000 healthcare professionals to pass their exams. Find out more

onExamination

Search all BMJ education articles:

From

Limit by

The BMJ iPad app brings you the best of print and online, including live links to the latest news, blogs, video, and podcasts. Get the BMJ iPad app.
You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles
Keep up to date with cardiology: Access the latest cardiovascular medicine resources from across BMJ Group.
Countdown to London 2012: BMJ Group's Olympics portal highlights latest Olympics and sports medicine-themed research, comment and learning

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

Drug and Therapeutics Bulletin

¹Drug and Therapeutics Bulletin Editorial Office, London WC1H 9JR

dtb{at}bmjgroup.com

Headache is one of the most frequent reasons for medical consultation in both general practice and specialist neurology clinics.1 Prescribed and over-the-counter medications are taken to alleviate headaches, but may be used incorrectly.2 In particular, use of some drugs both frequently and regularly can have a paradoxical effect, causing headaches rather than relieving them, and leading to medication overuse headache (MOH).3 Such overuse is a common cause of frequent headache. Here we review MOH and its management.

About MOH

The International Classification of Headache Disorders, 2nd edition states that for a diagnosis of MOH, all of the following criteria must be present:

headache occurring on 15 or more days per month;
regular overuse for more than 3 months of one or more acute/symptomatic treatment drugs (ergotamine, triptans, opioids or combined analgesic medications [typically simple analgesics plus opioids or caffeine] on 10 or more days per month; or simple analgesics alone or any combination of ergotamine, triptans and analgesic opioids on 15 or more days per month); and
development or marked worsening of headache during medication overuse.4

The preceding headache problem

Headaches may be primary (eg, migraine, tension-type headache, cluster headache) or secondary (eg, associated with trauma, subarachnoid haemorrhage, intracranial neoplasm, infection or the use or withdrawal of substances such as alcohol or drugs).3 5 MOH occurs only in patients with a history of primary headache.6 7 It is most likely to affect patients with migraine and/or tension-type headache,7 8 but can also arise in association with cluster headache, particularly if there is a personal or family history of migraine or regular headache.9

Epidemiology

Studies from various countries suggest that the prevalence of MOH is around 1% of adults and 0.5% of adolescents (aged 13–18 years) in the general population;10 around 25–64% in those attending tertiary care headache …