Medication-overuse headache (MOH) – also known as ‘drug-induced headache’, ‘medication-misuse headache’ and ‘rebound headache’ – is classified as a chronic headache disorder associated with regular medication overuse secondary to a pre-existing headache syndrome.1 While MOH is often considered a preventable condition usually resolving once overuse is stopped, it is estimated to affect around 63 million individuals worldwide.2 As part of the educational CME topical symposium on unmet needs in migraine treatment at the 5th Congress of the European Academy of Neurology (EAN), Prof. Zaza Katsarava provided an overview covering the history, diagnosis criteria, and management of MOH.

History of MOH and its diagnosis criteria

In the 1930s, some patients taking ergotamine for migraine reported having more frequent migraine attacks. Interestingly, patients reverted back to their baseline migraine frequency once treatment was discontinued. This was the first observation of the paradoxical association between migraine medication intake and increased migraine frequency. The current diagnostic criteria for MOH are defined by the occurrence of headache on at least 15 days a month in patients with pre-existing headache syndromes who have been regularly using acute/symptomatic headache treatment for more than 3 months.1 Other than ergotamine, triptans, analgesics and opioids are known to induce MOH.

Chronic headache and its implications to MOH

In light of the chronic nature of MOH, Prof. Katsarava discussed the topic of chronicity in headache disorders. Because more frequent migraine attacks (i.e. 13 headache days or more per month) are associated with significant psychosocial impairment,3 defining chronic headache, including MOH, as a disorder in which patient experience 15 headache days or more a month is appropriate. Furthermore, he explained that the impact of chronic headache is not restricted to higher frequency of headache attacks. Indeed, several comorbidities are associated with chronicity including depression and anxiety,4 and stress has been identified as a trigger factor for chronic migraine attacks.5 In Prof. Katsarava’s opinion, moments of intense stress can drive an at-risk patient to acute medication intake that could ultimately lead to MOH.

Management of MOH

Educational materials targeting both at-risk patients and healthcare professionals explaining the risk of developing MOH represent an essential component of MOH management. In terms of treatment discontinuation, it should be known that the complete withdrawal of the treatment causing MOH is generally more effective than restricting its intake.6 Healthcare professionals should focus on monitoring their patients’ medication use and providing them with the necessary information to prevent MOH. In Prof. Katsarava’s opinion, MOH is one of the few conditions in neurology were less medication is more, and optimal patient care relies on a clever understanding and management of the condition. To conclude, he enjoined the audience to think about MOH when choosing the appropriate therapy for their patients, including newly available agents.

“It is important that doctors recognise medication-overuse headache and intervene.” 

Zaza Katsarava (University of Essen, Germany)

  1. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38:1–211.
  2. Vandenbussche N, et al. Medication-overuse headache: a widely recognized entity amidst ongoing debate. J Headache Pain 2018;19:50.
  3. Ruscheweyh R, et al. Correlation of Headache Frequency and Psychosocial Impairment in Migraine: A Cross‐Sectional Study. Headache 2014;54:861–71.
  4. Buse DC, et al. Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers. J Neurol Neurosurg Psychiatry 2010;81:428–32.
  5. Schramm SH, et al. The association between stress and headache: A longitudinal population-based study. Cephalalgia 2015;35:853–63.
  6. Nielsen M, et al. Complete withdrawal is the most effective approach to reduce disability in patients with medication-overuse headache: A randomized controlled open-label trial. Cephalalgia 2019;39:863–72.