Addressing Medication Overuse Headache (MOH) in Clinical Practice

Addressing Medication Overuse Headache (MOH) in Clinical Practice

Medication overuse headache (MOH), formerly known as rebound headache, is a prevalent and disabling headache disorder commonly encountered in clinical practice. Globally, more than 60 million people are affected.1 Per the ICHD-3 criteria, MOH is defined as “headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped.”2

IHS Diagnostic criteria:
Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache.1,2,3
Not better accounted for by another ICHD-3 diagnosis

The Global Burden of Disease studies consistently rank medication overuse headache in the top 20 disorders causing years of life lost due to disability.1

Medication overuse headache occurs in up to 70% of people with chronic headache and may be a result of poorly treated pre-existing headache (ex. migraine or tension-type headache).1,3 It is one of the most important risk factors for headache chronification.1

Medication overuse headache is characterized by:1

  • Escalating frequency of headache attacks
  • Progressive use of acute therapies resulting in chronic headache intractable to treatment

Julie is a 55-year-old female who works in healthcare. She has a family history of migraine. She’s had headaches for 30+ years and has seen different primary care and emergency providers throughout the years. She has daily headaches that are worse at the end of the day and spends most of her evenings alone at home avoiding any stimulation. Although she has been diagnosed with both migraine and tension headaches and tried different preventive therapies such as propranolol, topiramate and amitriptyline, she stopped them due to the lack of efficacy and intolerable side effects. She is not on any acute or preventive prescription medications at the time of her visit and manages her headaches only with over-the-counter ibuprofen. Julie reported taking a total of 18 doses of 200 mg ibuprofen per day.

Julie’s primary care provider started her on 100 mg PO of sumatriptan as needed and galcanezumab (Emgality) 120 mg SQ monthly. She reported significant improvement after one month of treatment. She measured her success by decreasing her ibuprofen intake from 18 doses of 200 mg per day to “only” 4 doses of 200 mg per day during the first month.

Obtaining a detailed medical history is key to diagnosing the headache phenotype. Providers should be excluding underlying conditions, identifying the presence of medication overuse headache and addressing comorbidities.

  • Encourage patients to fill out a headache diary and document associated symptoms (nausea, sensitivity to light, noise, or smell etc.), frequency of acute medication intake and treatment response, attacks, triggers (stress, menses, weather changes, airplane travel) and missed work days.
  • Perform a physical examination and neurologic assessment.
  • Conduct a history of the headaches such as associated symptoms, quality, intensity and duration of pain, exacerbating and relieving factors, location, previous assessments, diagnosis and treatments, etc.4
  • Exclude underlying conditions.
  • Medication history should include all prescription and over-the-counter (OTC) analgesics.
    • Suspect Medication Overuse Headache (MOH) in patients presenting with frequent headaches or sinus complaints. 
  • Address comorbid conditions such as:4

Migraine progression is defined as the transition from ≤ 15 to ≥ 15 monthly headache days in patients with migraine.5 Medication overuse headache is a significant risk factor for the chronification of migraine.

Other key risk factors for migraine progression include:5

  • Frequent headache days
  • Suboptimal acute and/or preventive headache treatment
  • Acute medication overuse (especially with barbiturates and opioids)
  • Comorbidities
    • Psychiatric disorders (anxiety, depression)
    • Metabolism-related conditions (obesity)
    • Head and neck injuries (traumatic head injury)
    • Poor sleep quality and sleep disturbances (insomnia)
    • Respiratory conditions (asthma)
    • Chronic pain conditions
  • Low levels of physical activity
  • Former and current high caffeine intake
  • Tobacco use
  • Cutaneous allodynia

Recognizing risk factors for migraine progression will allow clinicians to suggest protective interventions against migraine progression and decrease the likelihood of medication overuse headache.5

When ordering a CGRP inhibitor for migraine, most insurance companies will ask on the prior authorization form, “Has medication overuse headache been ruled out?” Answering “no” will likely lead to the insurance denial of the requested medication. Identifying and appropriately treating MOH would help patients receive therapies they need.

In an open-label, randomized clinical trial of 120 patients with MOH with 6 months of follow-up the following treatment strategies were used:1 

  • Withdrawal of acute medication with optional preventive treatment 2 months after withdrawal
  • Use of preventive medication without withdrawal of acute medication
  • Withdrawal of acute medication and use of preventive medication

The primary outcome was the change in headache days per month after 6 months. 

Headache days per month were reduced by:1 

  • 12.3 (95% CI, 9.3-15.3) in the withdrawal plus preventive group
  • 9.9 (95% CI, 7.2-12.6) in the preventive group without withdrawal
  • 8.5 (95% CI, 5.6-11.5) in the withdrawal group

There was no difference among the 3 groups in the reduction of headache days per month, use of short-term medication, or headache intensity.1 All 3 treatment strategies were effective. 

However, the authors recommend the use of preventive medication at the time of withdrawal to treat medication overuse headache. When preventive therapy was initiated at the time of withdrawal, 74.2% of patients reverted to episodic migraine and 96.8% of patients had no evidence of MOH.1 Regularly scheduled follow-ups are also an important step in monitoring patients.4 

Like Julie, many patients do not think of their migraine and tension headaches as chronic conditions that may require preventive treatments. Clinicians should encourage patients to accept their diagnosis of headache, and educate them on how to manage it preventively rather than searching for a cure or overusing acute medications.6

Preventive therapies can be divided into several groups:

It is important for all first-line health care providers in primary care, women’s health, urgent care and emergency rooms, as well as pharmacists, to be informed about MOH and the best available prophylactic pharmacological and non-pharmacological options. Also, patients should be encouraged to actively participate in managing their headaches by avoiding triggers, adopting positive lifestyle changes (regular exercise, meals, and bedtime), and collaborating with their providers on a long-term treatment strategy.7

Julie reported a significant improvement to 2 headache days per month at her 3-month follow-up. Her treatment regimen includes galcanezumab (Emgality) 120 mg SQ monthly for prevention and 100 mg of sumatriptan as needed. She completely stopped her intake of ibuprofen after 3 months of starting preventive medication.

Overall, many patients who present to primary care or urgent care settings, do not take preventive medications or mention the use of over-the-counter medications like ibuprofen, acetaminophen and combination medications unless specifically asked by a provider. Encouraging clinicians to create a culture of prevention is a crucial step in reducing the burden of medication overuse headache.7

American Headache Society: Medication Overuse Headache: Provider Resource | First Contact

  1. Carlsen LN, Munksgaard SB, Nielsen M, et al. Comparison of 3 Treatment Strategies for Medication Overuse Headache: A Randomized Clinical Trial. JAMA Neurol. 2020;77(9):1069–1078. doi:10.1001/jamaneurol.2020.1179
  2. ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/8-2-medication-overuse-headache-moh/
  3. Fischer MA, Jan A. Medication-Overuse Headache. [Updated 2023 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK538150/
  4. Walling A. (2020). Frequent Headaches: Evaluation and Management. American family physician, 101(7), 419–428.
  5. Lipton, R. B., Buse, D. C., Nahas, S. J., Tietjen, G. E., Martin, V. T., Löf, E., Brevig, T., Cady, R., & Diener, H. C. (2023). Risk factors for migraine disease progression: a narrative review for a patient-centered approach. Journal of neurology, 270(12), 5692–5710. doi.org/10.1007/s00415-023-11880-2
  6. McPhee, D., Brown, C. C., Robinson, W. D., & Jarzynka, K. (2022). Receiving Medical Care for Chronic Migraines: A Phenomenological Study. Southern medical journal, 115(4), 270–275. doi.org/10.14423/SMJ.0000000000001382
  7. Agostoni, E.C., Barbanti, P., Calabresi, P. et al. (2019). Current and emerging evidence-based treatment options in chronic migraine: a narrative review. J Headache Pain (20)92. doi.org/10.1186/s10194-019-1038-4

Vera Gibb, DNP, APRN, FNP-C, AQH, CCTP is a Family Nurse Practitioner in primary care and an Assistant Professor, Graduate Studies Department, School of Nursing, of The University of Texas Medical Branch (UTMB) at Galveston. She holds additional certifications in headache medicine, clinical trauma, and interprofessional education. Vera Gibb serves on the Board of Directors of Coalition for Headache and Migraine Patients (CHAMP) and the Advisory Board of The First Contact – Headache in Primary Care Program of the American Headache Society. She’s actively involved in improving headache education for current and future providers across different healthcare disciplines.

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