Intended for healthcare professionals

Clinical Review From Drug and Therapeutics Bulletin

Management of medication overuse headache

BMJ 2010; 340 doi: (Published 28 April 2010) Cite this as: BMJ 2010;340:c1305
  1. Drug and Therapeutics Bulletin
  1. 1Drug and Therapeutics Bulletin Editorial Office, London WC1H 9JR
  1. dtb{at}

    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


    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 …

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