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Medication overuse headache

Nature Reviews Disease Primers volume 9, Article number: 5 (2023) Cite this article

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Abstract

Medication overuse headache (MOH) is a secondary headache disorder attributed to overuse of acute headache medications by a person with an underlying headache disorder, usually migraine or tension-type headache. MOH is common among individuals with 15 or more headache days per month. Although MOH is associated with substantial disability and reductions in quality of life, this condition is often under-recognized. As MOH is both preventable and treatable, it warrants greater attention and awareness. The diagnosis of MOH is based on the history and an unremarkable neurological examination, and is made according to the diagnostic criteria of the International Classification of Headache Disorders third edition (ICHD-3). Pathophysiological mechanisms of MOH include altered descending pain modulation, central sensitization and biobehavioural factors. Treatment of MOH includes the use of headache preventive therapies, but essential to success is eliminating the cause, by reducing the frequency of use of acute headache medication, and perhaps withdrawing the overused medication altogether. Appropriate treatment is usually highly effective, leading to reduced headache burden and acute medication consumption.

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Fig. 1: Proposed neuroanatomical circuits relevant to pathophysiology of medication overuse headache and medication overuse.
Fig. 2: Putative cellular and molecular mechanisms of medication overuse headache.
Fig. 3: Example of an electronic headache diary of a patient with chronic migraine and medication overuse headache.
Fig. 4: Proposed prevention and treatment algorithm of medication overuse headache.

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Acknowledgements

The authors thank T. P. Do for skilful assistance and for providing the initial sketches for Fig. 1.

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Authors and Affiliations

  1. BIDMC Comprehensive Headache Center, Department of Neurology and Department of Anaesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Sait Ashina

  2. Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark

    Sait Ashina

  3. Department of Neurology, Leiden University Medical Center, Leiden, Netherlands

    Gisela M. Terwindt

  4. Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway

    Timothy J. Steiner

  5. Division of Brain Sciences, Imperial College London, London, UK

    Timothy J. Steiner

  6. Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

    Timothy J. Steiner & Rigmor H. Jensen

  7. Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

    Mi Ji Lee

  8. Department of Pharmacology, Arizona Health Sciences Center, University of Arizona, Tucson, AZ, USA

    Frank Porreca

  9. Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy

    Cristina Tassorelli

  10. Headache Science & Neurorehabilitation Center, IRCCS C. Mondino Foundation, Pavia, Italy

    Cristina Tassorelli

  11. Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA

    Todd J. Schwedt

  12. Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany

    Hans-Christoph Diener

  13. Department of Neurology and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA

    Richard B. Lipton

  14. Montefiore Headache Center, Bronx, NY, USA

    Richard B. Lipton

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  1. Sait Ashina
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  2. Gisela M. Terwindt
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Contributions

Introduction (S.A., R.B.L. and T. J. Steiner); Epidemiology (S.A., T. J. Steiner and R.B.L.); Mechanisms/pathophysiology (S.A., G.M.T., F.P. and C.T.); Diagnosis, screening and prevention (S.A., G.M.T., T. J. Schwedt and R.H.J.); Management (S.A., M.J.L., R.H.J. and H.-C.D.); Quality of life (S.A., T. J. Steiner, T. J. Schwedt and R.B.L.); Outlook (S.A., F.P., R.H.J., H.-C.D. and R.B.L.); Overview of Primer (S.A.).

Corresponding author

Correspondence to Sait Ashina.

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Competing interests

S.A. received honoraria for consulting from Allergan/AbbVie, Amgen, Biohaven, Eli Lilly, Impel NeuroPharma, Linpharma, Lundbeck, Novartis, Satsuma, Supernus, Teva, Theranica, Percept. S.A. is an associate editor for Neurology Reviews, Frontiers in Neurology and BMC Neurology, serves on the advisory board for the Journal of Headache and Pain, and is a member of the Education Committee of the International Headache Society. G.M.T. reports consultancy support from Novartis, Allergan, Lilly, Teva, Lundbeck, and independent support from the Dutch Organization for Scientific Research, the Dutch Heart and Brain Foundations, IRRF and Dioraphte. M.J.L. received honoraria as a consultant and/or speaker for Eli Lilly, Teva, Sanofi-Aventis, SK Pharma and YuYu Pharma; has been the principal investigator or co-investigator in trials sponsored by Eli Lilly, Novartis, Teva (Otsuka), Allergan, Biohaven, Yuhan Company, Samjin Pharm, and DongA ST; received research support from National Research Foundation of Korea. M.J.L. is an associate editor of Cephalalgia. F.P. has served as a consultant or received research funding from Amgen, Acadia, Teva, Eli Lilly, Lundbeck, Allergan, AbbVie, AstraZeneca, Ipsen and PeptideLogic and is a founder of Catalina Pharma and Axon Therapeutics. C.T. has received personal fees from AbbVie, Allergan, Biohaven, Eli Lilly, Lundbeck, Novartis and Teva. C.T. has received research funding from the European Commission, the Italian Ministry of Health and Migraine Research Foundation. T. J. Schwedt has received personal income from AbbVie, Allergan, Biohaven, Click Therapeutics, Eli Lilly, Equinox, Lundbeck, Novartis, Tonix and Weber & Weber. T. J. Schwedt holds stock options in Aural Analytics and Nocira and has received royalties from UpToDate. T. J. Schwedt has received research funding from the American Migraine Foundation, Amgen, Henry Jackson Foundation, NIH, Patient Centered Outcomes Research Institute, SPARK Neuro and the US Department of Defense. R.H.J. has received honoraria for lectures and/or patient leaflets from MSD, Berlin-Chemie Menarini, ATI, Novartis, Teva, Allergan, Lundbeck and Pfizer, and has been principal investigator in studies sponsored by Eli Lilly, Lundbeck and ATI. H.-C.D. received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Ipsen, Lilly, Novartis, Pfizer and Teva. The German Research Council (DFG), the German Ministry of Education and Research (BMBF) and the European Union support his headache research. H.-C.D. serves on the editorial boards of Cephalalgia and Lancet Neurology. H.-C.D. is member of the Clinical Trials Committee of the IHS. R.B.L. is the Edwin S. Lowe Professor of Neurology at the Albert Einstein College of Medicine in New York. He receives research support from the NIH and FDA. R.B.L. also receives support from the National Headache Foundation and the Marx Foundation. R.B.L. serves on the editorial board of Neurology, is senior adviser to Headache, and associate editor to Cephalalgia and has reviewed for the NIA and NINDS, holds stock options in Biohaven Holdings, Manistee and CntrlM; serves as consultant, advisory board member, or has received honoraria or conducted research funded by Allergan/AbbVie, American Academy of Neurology, American Headache Society, Amgen, Biohaven, Dr Reddy’s (Promius), Electrocore, Eli Lilly, GlaxoSmithKline, Grifols, Lundbeck, Pernix, Pfizer, Teva, Trigemina, Vector, Vedanta. R.B.L. receives royalties from Wolff’s Headache 7th and 8th Edition, Oxford University Press, 2009, Wiley and Informa. T. J. Steiner declares no competing interests.

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Ashina, S., Terwindt, G.M., Steiner, T.J. et al. Medication overuse headache. Nat Rev Dis Primers 9, 5 (2023). https://doi.org/10.1038/s41572-022-00415-0

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