Medication Overuse Headache

What is a medication overuse headache?

Medication overuse headache is a secondary, drug-induced headache that can stem from any type of primary headache (e.g., migraine [most common], tension, cluster).^1,2

Medication overuse headache occurs ≥15 days per month (even daily) because of regular overuse of acute headache medication for >3 months.^1,2,12

Which acute headache treatments can cause medication overuse headache?

Butalbital and opioids pose the highest risk.^3,7

Triptans are becoming the most frequent cause due to widespread triptan use.² They seem to cause medication overuse headaches with shorter duration of use and at lower doses than ergots.⁴

Acetaminophen and combination analgesics (especially with caffeine)maypose a higher risk than NSAIDs.^3,4

Lasmiditan (Reyvow) may be a culprit, based on its mechanism of action.⁶

What are some other risk factors for medication overuse headache?

Medication overuse headache is more common in

• patients with depression, anxiety, or chronic pain.^1,12
• patients with migraine.⁴
• women (probably because migraine is more prevalent in women).^1,2
• patients who drink more than 200 mg of caffeine/day (~2 cups of coffee).⁸

How do you identify patients with medication overuse headache?

Watch for refill requests suggesting use of triptans, ergots, combination analgesics, or opioids for ≥10 days per month, or NSAIDs for ≥15 days/month.^1,4,12

Patients with ergot or analgesic overuse more commonly report tension-type headaches, while triptan overuse headaches tend to be migraine-like.²

How can medication overuse headache be prevented?

Ensure appropriate use of acute headache medications¹ (e.g., maximum triptan dose taken at the first sign of headache to increase efficacy).See our charts, Comparison of Triptans and Other Drugs for Acute Migraine (US) and Comparison of Triptans (Canada), for help with choice of agent and dosing.

Avoid use of butalbital or opioids to treat headache.³

Recommend NSAIDs over acetaminophen.³

Advise patients to try to limit acute treatment to two headache days per week, on average.⁶

• Limit triptan, ergot, analgesic combination, or opioid use to <10 days/month).⁴
• Limit NSAIDs, acetaminophen, or aspirin use to <15 days/month.⁴

Educate patients that analgesics taken for other conditions (e.g., back pain) can contribute to medication overuse headache.¹

Consider a prophylactic med if patients have frequent headaches (e.g., 4 migraine days/month),¹⁰ or are using analgesics at a frequency that puts them at risk of medication overuse headache.¹²

How is medication overuse headache treated?

Treatment is not based on high-level evidence.¹

Consider adding a prophylactic medication before, during, or after stopping the offending medication.^1,4,6 Patients with medication overuse headache despite prophylactic treatment may need a dosage increase of the prophylactic treatment, a change in prophylactic treatment, or the addition of a second prophylactic agent.⁶

• For migraine prophylaxis options, see our chart, Drugs to Prevent Migraines in Adults.
• Prophylactic medications with at least some evidence of benefit for medication overuse headache include erenumab/galcanezumab [Evidence level B-3],⁵ fremanezumab (Ajovy),topiramate, and onabotulinumtoxinA (Botox).¹
• For tension headache prophylaxis, consider amitriptyline or nortriptyline 10 mg at bedtime, increased by 10 mg weekly (max 100 mg/day).^3,12

Consider reducing or stopping/tapering the offending medication.⁴ See details below.

Consider switching to a different acute med.

• Switch from a triptan to an NSAID (e.g., naproxen)¹ or dihydroergoatmine.¹²
• Switch to a long-acting NSAID (e.g., naproxen, ketoprofen, nabumetone).^8,9 Some experts would avoid if the overused medication was an NSAID.¹⁰
• For migraine, consider rimegepant (Nurtec ODT) or ubrogepant (Ubrelvy),⁶ or a triptan for analgesic overuse.¹²

How should the offending medication be stopped/tapered?

Reduce use of acute medication to ≤2 days per week.¹

Stopping the acute medication may worsen headache or cause nausea, vomiting, irritability, and sleep disruption.⁹ These symptoms may last for four weeks, but usually resolve in two to ten days.⁹

Tapering is not necessary for acetaminophen, NSAIDs, or triptans.¹²

Tapering butalbital or opioids may be needed to prevent withdrawal from these drugs. For help, see our chart, Common Oral Medications that May Need Tapering.

Inpatient treatment may be needed for some patients (e.g., failure of outpatient taper, psychiatric comorbidities, significant medical conditions, seizure disorder, excessive use of butalbital or opioids).¹

Consider adding medications to help the patient with withdrawal headache, nausea, and other symptoms during the transition (i.e., bridging therapy).¹ Examples include (not supported by high-level data; doses are for adults):

• Naproxen 500 mg twice daily for one week, then once daily for one week, or twice daily for two to four weeks while the offending medication is tapered.⁹ Some experts would avoid if the overused drug was an NSAID.¹¹
• Metoclopramide 10 mg oral/parenteral three times daily for seven days.¹¹
• Prednisone 60 mg x 1, then tapered by 10 mg daily or by 20 mg every other day, or 60 to 100 mg once daily for five days.^1,9 (Minimal or no benefit.¹¹)
• Prochlorperazine intravenously 5 to 10 mg every eight hours (max 10 mg every six hours for two or three days), tapered by one dose per day once headache is minimal for >24 hours.⁹
• The “Raskin protocol,” or a modified version, using dihydroergotamine and an antiemetic.⁹ For examples, see:
  • https://www.mitchmedical.us/headache-therapy/dhe-bridge-therapy.html
  • https://fammed.wisc.edu/files/webfm-uploads/documents/outreach/im/module_headache_clinician.pdf