Do you have headache days — in addition to migraine attacks — more often than you have pain-free days? If so, you may have medication-overuse headache (MOH).
Also called chronic daily headache or rebound headache, MOH most commonly occurs in people with a primary headache disorder and research suggests it can affect up to half of people with chronic headache. It’s caused by too frequent use of acute medications, although exactly what “too frequent” means can depend on the drug being taken.
Medication-overuse headache isn’t only troublesome because you have near-constant head pain: MOH can also cause headaches that are resistant to preventive migraine medications, making acute therapies less effective as well.
Here’s what to know about medication-overuse headache.
1. Medication-Overuse Headache Has a Precise Definition
Different medications have different guidelines as to what constitutes overuse. The use of triptans, ergot alkaloids, combination analgesics (pain relievers), or opioids for 10 or more days of the month is considered overuse.
Usually medication-overuse headaches resolve after the overuse is stopped, although people may undergo a period when their headaches get worse before they get better.
2. Quantity Matters in Medication-Overuse Headache, Not Quality
Medication-overuse headache can feel different in different people, according to Stewart Tepper, MD, professor of neurology at the Dartmouth Geisel School of Medicine in Hanover, New Hampshire, speaking at the Migraine World Summit in 2021.
“What I tell people is that it doesn’t really matter if it’s front or back, right or left, up or down, mild, moderate, or severe. It’s not the quality of the headache; it’s the quantity of the headache,” he says.
The distinguishing feature of MOH is how often it occurs, he says.
3. Any Day With Any Type of Headache Counts as a ‘Headache Day’
If you aren’t sure if what you’re experiencing is MOH, try keeping a calendar and counting the number of headache days you have. Don’t just count the days when you have symptoms of a migraine attack but rather all days with any type of headache, says Dr. Tepper.
Alternatively, he suggests counting the number of completely headache-free days you have. “How many days are crystal clear from the moment you open your eyes until the minute you go to bed at night, without a twinge of headache? The crystal-clear days should be at least 15 days per month in order to not be in chronic migraine,” he says.
4. Taking Certain Medications Just Once a Week Can Make Migraine Worse
The two pain medications that are most likely to make migraine worse are butalbital — which is a barbiturate that is mixed with other pain medicines and is included in the medications Fioricet and Fiorinal — and opioids of any sort, says Tepper.
These types of medications can be used for emergency relief for a migraine attack but should be used with caution because of their risk for rebound headache, according to the American Migraine Foundation.
Opioids, also called narcotics, such as oxycodone (Oxycontin) and hydrocodone (Hysingla ER, Zohydro ER), can cause headaches to worsen or become more frequent by using them just once a week. Butalbital is linked with overuse when used four times a month or more, according to the American Migraine Foundation.
These medications alter the pain regulatory systems of the brain in a bad way, and they not only worsen migraine attacks in terms of frequency, severity, and duration but also often make them untreatable, says Tepper.
5. Pain Medications Taken for Any Reason Can Lead to MOH
Taking analgesics for reasons besides your migraine can still cause medication-overuse headache.
“Say you’re taking it for low back pain, the brain does not know the difference,” says Tepper, adding that the frequency of use and the type of medication are associated with the transformation to MOH.
6. The More Headache Days You Have, the Higher Your Risk for Chronic Daily Headache
“The more headache days a person has, the more likely they are to transform to chronic migraine,” says Tepper. Studies conducted both in the general population and in clinics show that people who have 10 to 14 headache days per month are 20 times more likely to develop daily headache than people who have fewer than five headache days per month, he says.
“The frequency of the headache days is actually a big risk for transforming, and the frequency of headaches is linked to how many times somebody reaches for an acute medication to treat,” says Tepper, adding that although these are separate risks, they feed each other.
“It’s why we try so hard to reduce the total number of headache days per month, as well as the number of acute medication days per month,” says Tepper.
7. Caffeine Can Contribute to Medication-Overuse Headache
Caffeine at 100 to 200 milligrams (mg) per day is probably enough to contribute to medication-overuse headache, says Tepper.
For reference, 8 ounces of coffee has between 80 and 100 mg of caffeine, and 12 ounces of a caffeinated soft drink has between 30 and 40 mg. The headache medication Excedrin has 65 mg of caffeine per tablet.
However, many people are fond of their caffeine-containing beverages.
“I tend to try to work around the caffeine, as long as it’s not high-dose caffeine, to see if we can help them without taking away one of their pleasures,” says Tepper.
8. Pain Relievers Aren’t the Only Kind of Medication That Can Contribute to MOH
Over-the-counter decongestants and prescription sleeping medications can significantly contribute to MOH, according to Tepper.
“There’s a controversy whether benzodiazepines can cause medication-overuse headaches. I personally think they can interfere with treatment, and so I do not prescribe them for my migraine patients. Even when they have anxiety, I look for other treatments,” he says.
9. MOH May Be Caused by Overusing a Combination of Drugs
The guidelines on medications for MOH are divided into different classes, but almost nobody takes just a single drug to treat migraine, says Tepper.
“You may have some days with triptans, some days with combination analgesics, some days with NSAIDs. It’s probably best to assume that if someone is taking 10 or more days of acute treatment per month, they are likely to develop medication-overuse headache and transformation into chronic migraine,” he says.
10. CGRP Migraine Treatments Don’t Increase the Risk of MOH
Oral medications in this class, known as gepants, can be used to prevent headache. They include:
- atogepant (Qulipta)
- rimegepant (Nurtec ODT)
Ubrogepant (Ubrelvy) is a gepant approved to treat acute headache. And rimegepant can also be taken for acute treatment.
Zavegepant (Zavzpret), a gepant approved for acute treatment, is formulated as a nasal spray.
Another kind of CGRP-blocking medicine, CGRP monoclonal antibodies (MABs), are also used for preventing migraine. In addition to the oral medications, these four CGRP-blocking medications are given by injection:
- epitinezumab (Vyepti)
- erenumab (Aimovig)
- fremanezumab (Ajovy)
- galcanezumab (Emgality)
The Takeaway
- When used too frequently, many drugs taken to treat acute migraine can lead to chronic daily headache.
- This is known as medication-overuse headache (MOH): when headache occurs on 15 or more days per month in someone with a primary headache disorder, resulting from regular overuse of acute or symptomatic headache medication for more than three months.
- Newer migraine medications known as CGRP receptor antagonists haven’t been shown to lead to MOH.
- Check in with your doctor to find the best headache treatment for you.
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