One of the biggest stumbling blocks for those with migraine is how much medication can you safely take? For those who have taking treatments for migraine for years how do you know if you are risking medication overuse headaches (MOH) or rebound headaches?
MOH is the official classification for the common term “rebound headaches”. These are headaches or potentially migraine attacks which occur because of the medication and drugs taken. Typically it occurs when taking medication too often causing a dependence on the medication or drug. When the medication is stopped withdrawal symptoms are experienced and result in a headache or migraine.
MOH often goes unnoticed. Many doctors fail to ask about the frequency and type of medication you’re taking and if they’re not looking for it, it’s easily missed.
If you experience daily migraine attacks or headaches, there is a 30% to 50% chance you overuse acute medications. (1, 2)
Up to 80% of those who visit migraine headache specialty clinics either overuse acute medication or already have MOH. (2,3)
MOH was previously considered a complication of migraine that was secondary condition as a result of the overuse of treatment for the primary migraine or headache. Today, if an individual has migraine, MOH needs to be addressed to help the underlying migraine condition that may have led to MOH in the first place.
MOH is extremely important to address first and foremost. MOH can block or reduce the effectiveness of other treatments. It can be extremely difficult to reduce your migraine frequency whilst you have MOH.
Most patients don’t realise they have MOH.
They may feel trapped and concerned about withdrawal symptoms. As you’ll discover from this guide below, MOH is very treatable with strong success rates. By addressing MOH, you can improve your migraine condition.
What are the risk factors for MOH?
- caucasian background
- lower education
- previous marriage
- frequent caffeine use
- stressful life events in the previous year
- head injury
- high baseline headache frequency
- overusing medication (no surprises here)
The most common age of those with MOH are 40-45 years. They’ve had migraine, some only have tension-type headache or a combination of both. On average they’ve had headaches for 20 years and migraine overuse headache for 5 years! (5)
Medication overuse occurs when you take too much medication, too frequently.
The following monthly frequency of a single dose treatment is associated with MOH (4):
- Butalbital: 5 days
- Opioids: 8 days
- Triptans: 10 days
- NSAIDS: 10-15 days
- Simple analgesics: 15 days
i.e. if you take a treatment of Triptan 10 different occasions each month, you will likely to develop MOH.
Examples of each of these types of medications are:
- Butalbital: Butalbital
- Opioids: Codeine, Hydrocodone, Oxycodone, Meperidine, Morphine
- Triptans: Sumatriptan, Rizatriptan, Zolmitriptan
- NSAIDS: Ibuprofen
- Simple analgesics: Aspirin, Paracetamol, Acetaminophen
Often people have multiple conditions like arthritis and take simple painkillers for this. But…“The brain does not recognize for what disorder the acute medication is being used” your risk of MOH increases with the frequency of acute medication intake. (4)
Most often they’ve overused simple analgesics like Aspirin, Ibuprofen or Acetaminophen (Paracetamol) or their combination with caffeine. Triptans are the 2nd most commonly overused treatment.
Studies have shown that there is a delay between the frequent medication intake and the development of daily headache. This delay is shortest for the Triptans (1.7 years), followed by the Ergots (2.7 years) and longest for the analgesics (4.8 years). This means you could be overusing or overdosing on analgesics like aspirin and it might be around 5 years until you develop medication overuse headaches. However triptans if overused, are able to cause MOH faster and with lower dosages than other treatment groups. (9)
10 days per month of headache is the tipping point. This is where a marked increase occurs in chronic migraines developing as well as an increased risk of MOH. (4)
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Your headache can change over time. This may be due to range of factors including the headache itself or to the changing amounts or type of medication you’re taking. However there are a few similarities amongst migraineurs with MOH:
Frequency & type of acute medication
Taking acute medications with high headache frequency more than 2 days per week is likely to lead to MOH. Some medications cause MOH at very low frequencies eg. butalbital (5 days per month) or combinations of medications are more likely to accelerate MOH.
MOH generally occurs in the morning. Individuals may be woken from sleep with a headache or experience a quick onset after waking most likely due to nocturnal withdrawal.
Pain location and the neck
Those with MOH have mixed intensities and location of pain. Neck pain occurs in two-thirds of patients with episodic migraine (4) but neck pain is more common in MOH. MOH can be misdiagnosed as cervicogenic (neck originating) headaches and are consequently given neck interventions which that often provide little relief. Once the individual is treated for MOH directly the neck pain can be dramatically improved.
Many of those with MOH report stuffy, runny nose, blocked sinuses and associated symptoms. Sinus symptoms are often attributed to sinus headaches. Many people self-medicate with decongestants which exacerbates MOH. Care providers may prescribe antibiotics worsening antibiotic resistance. These symptoms almost always improve after MOH is treated directly.
Depression and anxiety
Those with migraine are several times more likely at risk of depression and anxiety than the general population. Sadly, the high occurrence of depression and anxiety in migraineurs lead some doctors to think a patients problem is primarily psychological. Treating the depression without dealing with the MOH will be unsuccessful as frequent use of NSAID or analgesics such as ibuprofen, aspirin or acetaminophen (paracetamol) interferes with antidepressant efficacy.
Those with MOH generally have nonrestorative sleep. This may be due to depression or drug withdrawal. Caffeine may also be playing a role (and should not be taken after 2 pm). Like neck pain, MOH sleep issues are not generally a sign of a primary sleep disorder and improve dramatically when MOH is successfully managed.
Reduced effectiveness of all treatments
All treatments both acute and preventative have reduced effectiveness in those with MOH before they have been weaned off their medication. (6) After wean, preventative migraine treatments can be far more effective.
An ounce of prevention is worth more than a pound of cure. Preventing MOH should be one of your primary goals when managing your migraine condition.
Medication overuse can lead to severe medical consequences including gastrointestinal bleeding, kidney disease, more severe depression and chronic migraine.
“Headache diaries are crucial to record the number of headache or migraine days, treatments and treatment response. Clinical decisions cannot be made without quantitate data, and relying on patient recall is inadequate.” (4)
“One and done”
The goal with treatment should be seeking a single treatment that delivers a pain-free response within 2 hours after taking the medication. And to accomplish this without requiring a repeat dose or rescue treatment ie. “one and done”.
Taking the right treatment
You’re more likely to achieve this result if you’re taking a triptan, dihydroergotamine or NSAID. See module 3 which reviews some of the best acute and preventative options for migraine.
Timing your treatment
Taking the right dose at the right time is essential. The timing should follow the recommended protocol for that specific treatment.
Limit your treatments
Limit your treatments to no more than 2 per week. If you are experiencing more than 2 migraines per week, then you are eligible for a preventative migraine medication.
Preventative migraine medication
If eligible, you should consider preventative migraine medication so that you are not relying on treatments which put you at risk of MOH. Preventative medications are designed to be taken daily and do not lead to MOH.
Triggers & Behaviors
Remove the fuel from the fire by identifying key triggers that may be contributing to your migraine attacks. For example, certain foods or poor sleep routines. Also consider certain behavioral and lifestyle factors like diet and exercise. Getting these in order not only helps your overall health, it lays a strong foundation for sustainable migraine control and prevention.
A treatment plan will need to evaluate the following:
- the duration and severity of headaches
- the number of overused medications & their doses
- any additional medical conditions
- any other psychiatric conditions such as anxiety or depression
Treatment involves 4 steps:
- 100% weaning off overused medications
- establishing preventative medication and/or behavioral or nondrug preventatives
- providing acute medications with limits to prevent further overuse
- educating patients and families
This is a fundamental responsibility you share with your doctor. This MUST be done with the help of a medical professional who has diagnosed you with MOH and has agreed to put in place a MOH treatment plan for you.
Prevention strategies and wean should be added at the same time (4).
There are 4 levels of wean.
i) Conventional outpatient slow wean
This is where you visit a hospital for treatment without staying overnight. You gradually wean off your acute medications over several weeks. A quit date is set and new acute medications are provided with strict limits. Botox may be initiated or the addition of another preventative medication.
ii) Conventional outpatient “cold turkey”
This option is similar to the previous option where you’re treated as an outpatient, however it involves going ‘cold turkey’ (rapid wean) off the overused treatments. If the treatments being overused are not barbiturates or narcotics then this may be a viable option.
Again, this must be done under strict medical supervision as this can be dangerous if the wrong medications are abruptly halted.
To help with this cold turkey approach a “bridge” is often used. This is a 5-10 day IV used during withdrawal to reduce withdrawal symptoms and treat headache. Once the bridge is completed, prevention can be added and acute medications can be prescribed for no more than 2 days per week.
iii) Medical model
This is where IV infusion occurs as the bridge and is promptly followed by a preventative option (inpatient).
iv) Multidisciplinary program
If someone has already failed an outpatient treatment plan, has a long history with MOH or has multiple medical and psychiatric conditions or has high medicinal doses that are hazardous to withdraw from, then a multidisciplinary program may be likely.
In this situation, day hospital or full-time hospitalization may be required to ensure a successful recovery. High dose narcotics, barbiturates and benzodiazepines require special weaning skills. Interdisciplinary programs should be formally structured with medical subspecialties including
- Primary care
- Skilled nursing
- Physical therapy
Common preventative options include Botox, Anticonvulsant, Antidepressants or a Beta-blocker. There are also several nonmedicinal alternatives which have evidence for their efficacy. These include biofeedback, relaxation therapy, and cognitive behavioral therapy. This helps shift the balance of control back to you. Trigger management and avoidance where appropriate, lifestyle factors, exercise, diet, sleep and active participation are all useful.
3. Acute Treatments
New acute medications can be prescribed with strict limitations. Typically no more than 2 days per week otherwise relapse can re-occur. View a list of evidence-based acute treatments for migraine.
In all scenarios the patient should be given the support and education required. There is a difference between overuse and dependence from migraine and drug abuse. If you have MOH you are not an addict.
With better education and awareness many cases of MOH could be avoided.
Recovery from Medication Overuse Headache
The rates of success are good. 72-85% improved significantly when weaned off their medications and who also used a preventative. (7) Patients are susceptible to relapse to overuse after withdrawal, especially in the first year (8) so it’s important to remain diligent in your migraine management even if things are going well.
MOH affects 1-2% of the general population. (10) It is nothing to be ashamed or embarrassed about. Often it is the result of another primary condition like chronic pain, migraines or a having more than one chronic condition (comorbidity).
It often takes years for MOH to develop and many of those with MOH have had it for years without releasing it. Fortunately with education MOH can be avoided entirely. For those with MOH it can be effectively treated but must be done under the supervision of a medical doctor or medical team. Until this occurs, little else will improve your migraine condition.
Do you know of anyone (or yourself) that might be taking too medication too frequently? Let me know in the comments below.
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3) Sances, G. Ghiotto, N. et.al. ‘A CARE Pathway In Medication Over-use Headache: The Experience Of The Headache Centre In Pavia.’ J Headache Pain 2005; 6: 307-9.
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5) Katsarava, Zaza, Dagny Holle, and Hans-Christoph Diener. “Medication overuse headache.” Current neurology and neuroscience reports 9.2 (2009): 115-119.
6) Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology 1996;47(4):871Y875.
7) Zed PJ, Loewen PS, Robinson G. Medication-induced headache: overview and systematic review of therapeutic approaches. Ann Pharmacother 1999;33(1):61Y72.
8) Lake III AE. ‘Medication Overuse Headache: Biobehavioral Issues And Solutions.’ Headache 2006; 46 Suppl. 3: S88-97.
9) Limmroth V, Katsarava Z, Fritsche G, et al. Features of medication overuse headache following overuse of different acute headache drugs. Neurology 2002; 59:1011 – 1014.
10) Rapoport, Alan M. “Medication Overuse Headache.” CNS drugs 22.12 (2008): 995-1004.