 Medication overuse Headache (MOH)
Medication overuse headache (MOH)
is a substantial source of patient disability. Officially recognized
by the International Headache Society, MOH is the third most common
headache type after tension headache and migraine.1 MOH
is diagnosed when a migraine-type headache occurs on at least 15
days per month. The main categories of MOH are overuse of
ergotamines, triptans, opioids (used at least 10 days per month), or
analgesics (used at least 15 days per month), or a combination of
medications. Also for the diagnosis, drug overuse needs to have
occurred for at least 3 months, and resolution of the headache
occurs within 2 months of stopping the overused drug(s).1,2
Studies have been conducted to assess MOH in patients: in one study,
analgesics were overused by 34.7% of patients, ergotamines by 22.2%,
opioids by 12.5%, triptans by 2.7%, and combinations by 27.8%.3
Another study found the rate of opioid overuse to be approximately
33% and triptan overuse approximately 17%.4 The
medication type and the amount of overuse seems to be related to the
type of medical setting and the population studied.
Data show that medication overuse is an important, modifiable risk
factor for migraine progression; MOH occurs most frequently in
patients with migraine.4 Once MOH develops, headaches
become refractory both to pain management and to prevention
strategies; therefore, avoiding MOH is important.5,6
Withdrawal of the overused medication is an important element to
management. Some medications, such as opioids and butalbital-containing
regimens, may require tapering of the dose vs abrupt withdrawal, to
prevent or reduce the rest of withdrawal symptoms. Symptoms
associated with withdrawal of some agents may include nausea,
vomiting, severe headache, hypotension, and tachycardia; symptoms
may last for several weeks. Relapse is common and is dependent on
the type of primary headache and the type of medication being
overused.7
Still, most patients with MOH are adequately treated as outpatients.
Patient education on the risks of overuse of both over-the-counter
agents and prescription drugs is an important factor in preventing
the development of MOH. Behavior modification in combination with
use of preventive medications and patient monitoring is an
established multimodal approach to MOH management.
REFERENCES
1. Obermann M, Bartsch T, Katsarava Z. Medication overuse headache.
Expert Opin Drug Saf. 2006;5:49-56.
2. Dowson AJ, Dodick DW, Limmroth V. Medication overuse headache in
patients with primary headache disorders: epidemiology, management
and pathogenesis. CNS Drugs. 2005;19:483-497.
3. Colás R, Muñoz P, Temprano R, Gomez C, Pascual J. Chronic daily
headache with analgesic overuse: epidemiology and impact on quality
of life. Neurology. 2004;62:1338-1342.
4. Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB.
Transformed migraine and medication overuse in a tertiary headache
centre—clinical characteristics and treatment outcomes.
Cephalalgia. 2004;24:483-490.
5. Diener H-C, Katsarava Z. Analgesic/abortive overuse and misuse in
chronic daily headache. Curr Pain Headache Rep.
2001;5:545-550.
6. Dodick D, Freitag F. Evidence-based understanding of
medication-overuse headache: clinical implications. Headache.
2006;46(suppl 4):S202-S211.
7. Dodick DW. Chronic daily headache. N Engl J Med.
2006;354:158-165.
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