Treating Medication Overuse Headache

Learn more about what treatment options there are and how to decide on which treatment is best for your patient

Medication Overuse Headache (MOH) occurs when a person is regularly overusing acute headache medications, resulting in increased headache. It is important to present the possibility of MOH to the patient in a sensitive, non-accusatory way. Patients may overuse medications for a variety of reasons, but the majority of those who overuse medication do so because the usual preventive approaches have been inadequate.

Here are some options for treating MOH to discuss with your patient.

Decide which approach is best

Deciding which preventive approach to take also depends upon a number of factors. These include the headache history and characteristics, reactions to various medications in the past, psychiatric and medical comorbidities, associated GI comorbidities, weight, sleep, fatigue, family history of response to medication, and other factors including cost and access. The patient’s input is, of course, paramount in choosing different approaches. If the patient has not had onabotulinumtoxin A injections, or the CGRP monoclonal antibodies, these are options to consider.

You should try to limit the acute medications given to patients. We do not want to relapse into MOH once again. Limited amounts of non-addictive medications include triptans, NSAIDs, gepants, DHE, and others.

Education

It is important to educate the patient regarding MOH. Even simple advice and information may be all that is necessary. The patient needs to understand that MOH is very real and that treating the condition will play an active role in improving their headache situation. Each patient requires a personalized approach. Withdrawal of the offending medications may be accomplished slowly, or all at once. Opioids, butalbital compounds, and analgesics with high amounts of caffeine should be tapered. Triptans can often be abruptly discontinued.

The vast majority of patients may be treated as outpatients. Inpatient admission is occasionally necessary. Outside of medications, many approaches to MOH may help the patient. These include psychotherapy, physical therapy, meditation, yoga, exercise, biofeedback, massage, and others. It often “takes a village” to help those with MOH.

Additional acute and preventive medication

In addition to educating the patient and withdrawing from the offending medication, many patients will require additional acute and preventive medications. In the hospital, various IV regimens may be employed though most patients do not require IV treatment. These include IV dihydroergotamine, corticosteroids, antiemetics (such as metoclopramide), and NSAIDs (ketorolac). Patients usually require medication to transition through the withdrawal period. Possibilities include muscle relaxants, NSAIDs, oral corticosteroids, and others.

Deciding whether or not to suggest a patient use preventive medications depends upon many factors. If the patient has simple MOH and is able to transition off of the medication, preventive medication may not be necessary. Most patients do have long-standing headaches and have been on various preventive medications, which may include onabotulinumtoxinA and CGRP monoclonal antibodies. These patients will require preventive medications.

Long-term outlook

At least 50% of patients do well, particularly if they do not relapse into MOH once again. The following increase the risk of relapse: a high amount of acute medication, cigarette smoking, excessive alcohol consumption, opioid or butalbital overuse, insomnia, and moderate to severe anxiety and/or depression. Close follow-up with the patient improves the chance of long-term success.

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.