Understanding Medication Overuse Headache (MOH): Causes, Risks, and Management

Medication Overuse Headache (MOH), often referred to as “rebound headache,” is a condition where frequent use of acute headache medications leads to an increase in headache frequency and severity.

This guide explains what MOH is, how it occurs, and the best strategies for managing and preventing it.

What is Medication Overuse Headache (MOH)?

Medication Overuse Headache occurs when acute headache medications are used too frequently, leading to a cycle of worsening headache:

  • Definition: MOH is defined as having more than 15 headache days per month while overusing acute medications intended for headache relief.
  • Common Culprits: Medications most commonly associated with MOH include triptans, narcotics, and combination analgesics (e.g., medications containing acetaminophen, aspirin, and caffeine). Even over-the-counter medications like ibuprofen and acetaminophen can cause MOH if taken too often.

Why Does Medication Overuse Lead to Headache?

Frequent use of headache medications can change the way the brain processes pain:

  • Pain Pathway Changes: Overuse of medications may alter pain pathways in the brain, making headache more likely to occur and more difficult to manage.
  • Thresholds for Overuse: For triptans, narcotics, and combination analgesics, using them more than 10 days per month is considered overuse. For simple analgesics like acetaminophen and ibuprofen, the threshold is 15 days per month.

Challenges in Managing MOH

Managing MOH can be challenging because patients are often instructed to take their acute medications as soon as they feel a migraine coming on, but frequent use can lead to dependency and worsened symptoms:

  • Patient Dilemma: Many patients feel caught between the need to treat their migraine symptoms and the risk of overuse. This can lead to feelings of guilt or blame when headaches become chronic.
  • Focus on Prevention: The most important strategy in managing MOH is to identify an effective preventive medication, rather than solely focusing on reducing or eliminating the overused medication.

Steps to Manage Medication Overuse Headache

Choose the Right Preventive Medication:

  • Preventive Options: Medications like botulinum toxin A (Botox), topiramate, and CGRP monoclonal antibodies (e.g., erenumab) can help reduce headache frequency and may lower the need for acute medication use.

Gradually Reduce Overused Medications:

  • Controlled Reduction: Gradually taper the use of overused medications rather than stopping abruptly to minimize withdrawal symptoms and anxiety. This approach is particularly useful for those who have developed dependency on acute medications.

Avoid Certain High-Risk Medications:

  • High-Risk Medications: Barbiturates (e.g., butalbital) and narcotics (e.g., oxycodone, hydrocodone) are more likely to cause MOH and are generally best avoided.
  • Consider Safer Options: Use medications with a lower risk of causing MOH, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, but limit their use to less than 15 days per month.

Monitor and Adjust Treatment:

  • Regular Follow-Ups: Regular consultations with a healthcare provider can help adjust preventive and acute treatment plans based on response and changes in headache patterns.

When To Talk With a Healthcare Provider​

Consult a healthcare provider if you:

  • Have frequent headaches and find yourself using acute medications more than 10-15 days per month.
  • Feel that your headaches are getting worse or becoming more frequent despite using medications.
  • Need guidance on selecting and starting a preventive medication to manage chronic migraines.

Episode 118, Medication Overuse Treatment Strategy Trial for Migraine and Headache with Vince Martin, MD
Published, 04/09/2022

Learn More

Episode-118-Medication-Overuse

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