Brief review of diagnosis and management of medication-overuse headache, based on a continuum paper.

1. Medication-overuse
headache
Daniel Vela-Duarte, MD
PGY-3. Department of Neurology
Loyola University Medical Center
August 2013

2. Definition

MOH (Medication-Overuse headache)

Secondary chronic daily headache
Headache induced by the overuse of analgesics,
triptans or other acute headache compounds,
ocurring 15 days/month, 4hrs/day, per 3 months or
more.


Repeated medication reaches a threshold causing
transformation (chronification)

3. Introduction / Epidemiology

Higher preponderance in woman

In a study on episodic migraineurs (n=532), the 1-year
incidence of chronic headache was 14%, with a higher
risk for patients who had a higher headache frequency at
baseline and for patients taking greater amounts of
analgesics.

Ergotamine, analgesics, barbiturates and caffeine

Poorer quality of life (Measured by scales: higher score
on MIDAS: Migraine disability assessment scale)

4. Clinical manifestations




Criteria established by the International Headache
Society (IHS) in 2005
The primary headache disorder leading to MOH is
migraine in most cases.
MOH mainly occurs in patients with a primary headache
disorder
Comorbidities



Subclinical obsessive-compulsive disorder
Anxiety - Mood disorders
Type of medications overused.

5. Symptoms

Circadian periodicity
 Patients
may be awakened from sleep or have onset
upon arising

Neck pain / Cervicogenic pain.

Rhinorrhea, nasal stuffiness, postnasal drip, and
ocular or gastrointestinal symptoms, likely
caused by withdrawal and most evident in opioid
rebound.
Nonrestorative sleep disturbance


6. Diagnostic criteria
Lancet Neurol 2010 Apr; 9(4): 391-401.

8. Diagnostic criteria

There is no certainty whether combined drugs are more
likely to cause MOH or not, compared to single
substances.

The headache features of MOH caused by ergotamine
derivatives are more severe than those caused by
triptans.


Overuse of ergotamine + analgesics: daily tension-type-like
headache,
Overuse of triptans: (daily) migraine-like headache or an
increase in migraine frequency

9. Withdrawal treatment

Detoxification process
 Improve
responsiveness to acute and prophylactic
drugs
 Abrupt discontinuation vs. tapered withdrawal

Main symptoms of withdrawal
 worsening
of the headache
 nausea, vomiting
 arterial hypotension, tachycardia
 sleep disturbances
 restlessness, anxiety, nervousness

10. Withdrawal treatment

Inpatient vs. Outpatient
 Overuse
of opioids, barbiturates, or benzodiazepines
 psychological problems
 severe medical comorbidities
 severe withdrawal
 symptoms (eg, vomiting and status migrainous)
 previous medication withdrawal failure

12. Tepper SJ, Continuum (Minneap Minn). 2012 Aug;18(4):807-22.