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  • Review Article
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Medication-overuse headache: risk factors, pathophysiology and management

Nature Reviews Neurology volume 12, pages 575–583 (2016)Cite this article

Subjects

Key Points

  • Medication-overuse headache (MOH) — headache worsening attributed to overuse of attack-aborting medication — is common: its prevalence in the general population is 1%, and as high as 11–70% in people with chronic daily headache

  • Although overuse of any pain medication can result in MOH, some drugs carry an increased risk of the disorder; combination analgesics, opioids and triptans are the medications that are most commonly associated with MOH

  • Risk factors of MOH include female gender, psychiatric comorbidities, pre-existing pain and medication use, and lifestyle-related factors; identification and education of at-risk patients could help to prevent the development of the disorder

  • The pathophysiology of MOH is not completely understood, but headache seems to make the brain more susceptible to central sensitization; moreover, acute pain medications can interfere with neurotransmitter systems and thereby lead to MOH

  • The most common comorbidities of MOH are depression and anxiety, and up to 50% of patients with MOH show a dependence-type behaviour, such as tolerance or loss of control over pain medication use

  • Treatment includes patient counselling, initiation of prevention therapy and detoxification; in patients with psychiatric comorbidities, history of substance abuse and in patients overusing opioids, inpatient detoxification in a specialist headache centre is recommended

Abstract

Medication-overuse headache (MOH) is defined by the International Classification of Headache Disorders as a headache in patients with a pre-existing primary headache disorder that occurs on ≥15 days per month for >3 months, and is caused by overuse of medication intended for acute or symptomatic headache treatment. The prevalence of MOH in the general population is around 1%, but the condition is much more common in people with headache, in particular chronic migraine. The phenotype of the headache in MOH depends on the initial primary headache and the type of overused acute medication. In this Review, we will discuss the epidemiology, risk factors, pathophysiology, prevention and treatment of MOH. Treatment of MOH is performed in three steps: educating patients about the relationship between frequent intake of acute headache medication and MOH with the aim to reduce intake of acute medication; initiation of migraine prevention (such as topiramate or onabotulinumtoxin A in migraine) in patients who fail step 1; detoxification on an outpatient basis or in a day hospital or inpatient setting, depending on severity and comorbidities. The success rate of treatment is around 50–70%, although patients whose MOH is associated with opioid overuse have higher relapse rates. In all patients with MOH, relapse rates can be reduced by patient education and care in the follow-up period.

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Figure 1: Treatment algorithm in medication-overuse headache.

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Acknowledgements

H.-C.D. acknowledges the support of the German Research Foundation (Deutsche Forschungsgemeinschaft), Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung) and the European Union.

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Authors and Affiliations

  1. Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany

    Hans-Christoph Diener, Dagny Holle, Kasja Solbach & Charly Gaul

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Contributions

H.C.D. drafted the structure of the Review and was the main contributor to Introduction, treatment and prevention of medication overuse headache (MOH), as well as to the section on practical recommendations. K.S. was the main contributor to the section on definition of MOH. D.H. was the main contributor to the section on pathophysiology, and C.G. was the main contributor to the sections on epidemiology and predictors.

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Correspondence to Hans-Christoph Diener.

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Competing interests

H.-C.D. has received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Addex Pharma, Alder, Allergan, Almirall, Amgen, Autonomic Technology, AstraZeneca, Bayer Vital, Berlin Chemie, Böhringer Ingelheim, Bristol-Myers Squibb, Chordate, Coherex, CoLucid, ElectroCore Medical, GlaxoSmithKline, Grünenthal, Janssen-Cilag, Labrys Biologicals, Lilly, La Roche, 3M Medica, Medtronic, Menerini, Minster, MSD, Neuroscore, Novartis, Johnson & Johnson, Pierre Fabre, Pfizer, Schaper and Brümmer, Sanofi, St. Jude Medical, Teva and Weber & Weber. Financial support for research projects was provided by Allergan, Almirall, AstraZeneca, Bayer, Electrocore Medical, GSK, Janssen-Cilag, MSD and Pfizer. He has no ownership interest and does not own stocks of any pharmaceutical company. D.H. has received financial support for research projects from Allergan, Grünenthal, Lilly, and research support from EFIC. K.S. has received honoraria for oral presentation from Allergan and MSD. C.G. has received honoraria from Allergan, Berlin-Chemie, MSD, ElectroCore Medical, St. Jude Medical, Grünenthal, Desitin, Bayer, Böhringer Ingelheim, Autonomic Technologies and Hormosan. He has no ownership interests and does not own any pharmaceutical company stocks.

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Diener, HC., Holle, D., Solbach, K. et al. Medication-overuse headache: risk factors, pathophysiology and management. Nat Rev Neurol 12, 575–583 (2016). https://doi.org/10.1038/nrneurol.2016.124

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