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Medication Overuse Headache:
When the Remedy Backfires

   
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The name varies. You'll see these headaches called "rebound headaches," "analgesic rebound headaches," "medication overuse headaches," and other terms. The newer term in use by specialists in the field of headache and Migraine disease treatment is "medication overuse headache" (MOH), and that's what I'll be using here because it truly does seem to be the most accurate.

Every person who has headaches or Migraine disease should be told about MOH by our doctors because knowing about it in advance could save us a great deal of pain. Unfortunately, we're not. If your doctor has prescribed any medication for you to take when you have headaches or Migraines such as triptans, ergotamines, pain medications, etc., or recommended that you take over-the-counter medications such as acetaminophen, etc., and has not told you about their potential to cause MOH, ask him or her about it. Find out what the potential for MOH is with the medications they're prescribing or recommending.

There have been nearly as many questions as answers about MOH for quite some time now, especially regarding which types or classes of medications can cause MOH. Those questions haven't been easy to answer because, for some time, there wasn't a clear enough consensus about which medications could induce MOH. Studies with empirical evidence were lacking, and conflicting opinions among experts easily left us to think one way one day and another way the next. While it's highly unlikely that everyone in any field will ever totally agree, today there's at least a fair consensus regarding the issues related to MOH. To help us avoid medication overuse headache and deal with it if it occurs, there are issues we need to explore:

  1. What is MOH?
  2. What medications cause it?
  3. How can we avoid MOH?
  4. How can we distinguish MOH from other headaches and Migraines?
  5. How do we stop MOH?
  6. Will taking pain medications for pain other than head pain cause MOH?

What is Medication Overuse Headache?
The best explanation of MOH comes from the The International Classification of Headache Disorders, 2nd Edition (ICHD-II), from the International Headache Society:

"MOH is an interaction between a therapeutic agent used excessively and a susceptible patient. The best example is overuse of symptomatic headache drugs causing headache in the headache-prone patient. By far the most common cause of migraine-like headache occurring on more than 15 days per month and of a mixed picture of migraine-like and tension-type-like headaches on more than 15 days per month is overuse of symptomatic antimigraine drugs and/or analgesics...

The diagnosis of MOH is clinically extremely important because patients rarely respond to preventative medications whilst overusing acute medications."1

The ICHD-II diagnostic criteria for MOH:

A. Headachea present on 15 or more days/month fulfilling criteria C and D.

B. Regular overuseb for more than 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache.c

C. Headache has developed or markedly worsened during medication overuse.

D. Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication.

a The headache associated with medication overuse is variable and often has a peculiar pattern with characteristics shifting, even within the same day, from migraine-like to those of tension-type headache.

b Overuse is defined in terms of duration and treatment days per week. What is crucial is that treatment occurs both frequently and regularly, i.e. on 2 or more days each week. Bunching of treatment days with long periods without medication intake, practised by some patients, is much less likely to cause medication-overuse headache and does not fulfill criterion B.

c MOH can occur in headache-prone patients when acute headache medications are taken for other indications.

What medications can cause MOH?
This has long been one of the biggest questions about MOH. There is now sufficient research to address many of our questions. According to Goadsby, et al, "There is now substantial evidence that all drugs used for the treatment of headache may cause MOH in patients with primary headache disorders." When they say, "headache," they mean headache and Migraine both. So, just which medications can cause MOH?

The answer to that question becomes clear when we look at the most recent revisions to The International Classification of Headache Disorders, 2nd Edition (ICHD-II), where we find not only a classification for MOH, but a further breakdown:1

8.2 Medication-overuse headache (MOH)

8.2.1 Ergotamine-overuse headache
Overuse defined as ergotamine intake on 10 or more days/month on a regular basis for more than 3 months.

8.2.2 Triptan-overuse headache
Overuse defined as triptan intake (any formulation) on 10 or more days/month on a regular basis for more than 3 months.

8.2.3 Analgesic-overuse headache
Overuse defined as intake of simple analgesics on 15 or more days/monthd on a regular basis for more than 3 months.

8.2.4 Opioid-overuse headache
Overuse defined as intake of opioids on 10 or more days/monthd on a regular basis for more than 3 months.
Comment:
Studies show that patients overusing opioids have the highest relapse rate after withdrawal treatment.

8.2.5 Combination analgesic-overuse headache
Overuse defined as intake of simple analgesic medicationse on 10 or more days/month on a regular basis for more than 3 months.

8.2.6 Medication-overuse headache attributed to combination of acute medications
Intake of any combination of ergotamine, triptans, analgesics and/or opioids on 10 or more days/month on a regular basis for more than 3 months without overuse of any single class alone.f

8.2.7 Headache attributed to other medication overuse
Regular overuseg for more than 3 months of a medication other than those described above.

8.2.8 Probable medication-overuse headache

d Expert opinion rather than formal evidence suggests that use on 15 or more days/month rather than 10 or more days/month is needed to induce analgesic-overuse headache.

e Combinations typically implicated are those containing simple analgesics combined with opioids, butalbital and/or caffeine.

f The specific subform(s) 8.2.1–8.2.5 should be diagnosed if criterion B is fulfilled in respect of any one or more single class(es) of these medications.

g The definition of overuse in terms of treatment days per week is likely to vary with the nature of the medication.

Ergotamine medications include DHE-45 and Migranal Nasal Spray.

The triptans include Imitrex, Maxalt, Zomig, Amerge, Relpax, Axert, and Frova -- as well as Treximet, which is a combination of Imitrex and Naproxen Sodium.

Analgesics are medications for the relief of pain, medications such as acetaminophen.

There is a bit of confusion about nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs were protective against transition to TM at low to moderate monthly headache days (10 - 14 days a month), but were associated with increased risk of transition to TM at high levels of monthly headache days (15 or more days a month). This would serve to confirm that NSAID use should be restricted to no more than two or three days per week and should NOT be used for Migraine prevention.

Although caffeine is not specifically listed, it IS a drug, and for some people, it can indeed cause MOH. The caffeine content is one reason that compound medications such as Excedrin and  Fioricet can be such horrid MOH culprits. They contain multiple ingredients, including caffeine, that can cause MOH.
  

 
 

How can we avoid MOH?
Medication overuse headache is avoided by not using medications for the relief of headache and/or Migraine too frequently. Although that statement may look simple, for the chronic sufferer, it's anything but a simple solution. As you can see, the ICHD-II defines overuse in terms of days per month, which vary from 10 days to 15 days per month, according to the type of medication. Most doctors will advise staying below those numbers by limiting use to two or three days per week. For those who take triptans, doctors will sometimes recommend taking triptans two days a week and another type of medication another two days a week if absolutely necessary. Beyond that, there is no real answer for pain on additional days that week. The long-term answer is, of course, an effective preventive regimen that reduces the need for MOH-causing medications.

How can we distinguish MOH from other headaches and Migraines?
Differentiating between a tension-type headache, for example, and MOH can be difficult. There are, however, some very discernable differences between MOH and a Migraine attack. Migraine pain is worsened by activity; MOH tends not to be. MOH is also missing other Migraine symptoms such as nausea, vomiting, phonophobia (sensitivity to sound), photophobia (sensitivity to light), hot flashes, chills, dizziness, and so on.

How do we stop MOH?
Immediately discontinuing the medication causing the MOH is the preferred plan of action for most medications. It's obviously the quickest, and it doesn't add more medications to an already confused body.

According to Goadsby, et al, withdrawal symptoms usually last two to 10 days. Those symptoms may include: withdrawal headache, vomiting, arterial hypotension, tachycardia, sleep disturbances, restlessness, anxiety, nervousness. Other experts in the field have written that it can take weeks, a month, or even longer to end the MOH. cycle.

In some cases where the MOH is being caused by medications such as butalbital compounds that have been taken daily in large amounts, seizures can occur if the medication is abruptly withdrawn, so a tapered withdrawal or supervised detoxifications is necessary. The best approach is to ask your doctor for help and advice. When you take these medications for pain, you don't become addicted, but you may become dependent upon them. This is a medical issue. Don't be reluctant to discuss it with your doctor. Depending on the medication involved and the situation, some doctors may recommend hospitalization or prescribe medications to help you get out of the MOH cycle.

Will taking pain medications for pain other than head pain cause MOH?
For someone who already has Migraine disease or another headache disorder, yes.

Comments from Migraine and headache experts:

I asked some Migraine and headache experts for comments on MOH. Here are those comments:

"MOH continues to be a vexing problem in tertiary care centers and a major challenge to primary care physicians with these patients often requiring referrals to specialists. AMPP data demonstrates that butalbital and opiates are the 2 agents most likely to lead to overuse and are a major risk factor in the genesis of CDH. Transitioning patients from MOH (10 or more days of combination products, opiates, triptans or 15 or more days of single ingredient OTCs) can be difficult as patients get worse before they improve. Pharmacologic treatment, preventives and behavioral therapies are often required. 80% will improve with a 50% or more decrease in frequency and intensity. Failure to address MOH will likely reduce the potential efficacy of any preventive intervention. Kudrow was the first to point this out in a landmark prospective study more than 30 years ago. Many studies since that time have shown similar results."  ~ Dr. Fred Sheftell2

"Medication overuse headache is viewed by the International Classification of Headache Disorders, as a secondary headache disorder, as headache attributable to medication taking. In my opinion, it is better considered a complication of primary headache, usually a complication of migraine."  ~Dr. Richard B. Lipton3

"MOH is usually a complication of Migraine or another headache disorder, a complication that can present huge obstacles to headache treatment. It not only makes it less likely that prophylactic (preventive) medications will work; it can reduce the effectiveness of IV infusions for intractable Migraine and headaches. Unfortunately, well-intentioned clinicians with little knowledge about treating headache disorders too often enable MOH by prescribing opioids or recommending short-acting over-the-counter analgesics as a primary treatment, and this backfires or leads to a situation where there is more headache, not less." ~Dr. John Claude Krusz4

Summary and comments:
Much has been learned about Medication Overuse Headache, aka rebound headache, in the last few years. Unfortunately, it seems that any medication we take for headache or Migraine relief has the potential to cause MOH if used more than two or three days a week. In the long run, a good preventive regimen that will reduce our need for MOH-causing medications is our best weapon against MOH. Until we perfect our preventive regimens to that point, it's essential to work with our doctors to avoid medication overuse, thus preventing MOH.

____________
Resources:

1 Silberstein, SD; Oleson, J.; Bousser, MG; Diener, HC; Dodick, D.; First, M.; Goadsby, PJ; Göbel, H; Lainez,MJA; Lance, JW; Lipton, RB; Nappi, G.; Sakai, F.; Schoenin, J.; Steiner, TJ. "The International Classification of Headache Disorders, 2nd Edition (ICHD-II)—revision of criteria for 8.2 Medication-overuse headache." Cephalalgia, 2005, 25, 460–465.

2 Interview with Dr. Fred Sheftell. January 1, 2010.

3 Interview with Dr. Richard B. Lipton. January 1, 2010.

4 Interview with Dr. John Claude Krusz. January 4, 2010

5 The International Headache Society. "The International Classification of Headache Disorders, 2nd Edition, 1st revision." (ICHD-II) May, 2005.

6 Goadsby, Peter J., MD, PhD, DSc, FRACP, FRCP; Silberstein, Stephen D., MD, FACP; Dodick, David W., MD, FRCPD, FACP. "Chronic Daily Headache for Clinicians." Hamilton, Ontario: BC Decker. 2005.

7 Bigal, Marcelo E., MD, PhD; Serrano, Daniel, MA; Buse, Dawn, PhD; Ann Scher, PhD; Stewart, Walter F., PhD; Lipton, Richard B., MD. "Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study." Headache 2008;48:1157-1168.

8 Harold G. Wolff Lecture Award Presentation. Marcelo E. Bigal, MD, PhD. "Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study: A Longitudinal Population-Based Study." American Headache Society 50th Annual Scientific Meeting. Boston. June 27, 2008.

9 Sheftell, Fred D. & Bigal, Marcelo (2004) "Clinical Science: Headache Induced by Acute Medication Overuse." Headache Currents 1 (3), 64-68. doi: 10.1111/j.1743-5013.2004.10109.x.

10 Young, William B. (2004) "Clinical Science: Treatment of Medication Overuse Headache and Long-term Outcome." Headache Currents 1 (3), 55-59. doi: 10.1111/j.1743-5013.2004.10112.x.

11 Tepper SJ and Dodick DW. "Debate: Analgesic Overuse is a Cause, Not Consequence, of Chronic Daily Headache." Headache 2002;42:543-554.
           

Medical review by John Claude Krusz, PhD, MD

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