How to Prevent or Reverse Medication Overuse Headache

WASHINGTON, DC—Every neurologist who treats headache sees patients who are overusing medication. At the 57th Annual Meeting of the American Headache Society, Stewart J. Tepper, MD, discussed the recognition and diagnosis of medication overuse headache (MOH) and offered practical advice for preventing progression of medication overuse in patients with chronic headache conditions. He also described ways to reverse established medication overuse. Dr. Tepper is Professor of Medicine (Neurology) at the Cleveland Clinic Lerner College of Medicine.

Stewart J. Tepper, MD

Diagnosing Medication Overuse
The clinical picture of medication overuse is fluid; headache frequency and severity vary. The location and quality of pain are likewise variable, as are associated features. “And that’s in the same patient and across patients,” Dr. Tepper noted.

MOH also entails drug-dependent periodicity in which the early-morning onset may be a manifestation of withdrawal. Similarly, the autonomic symptoms of MOH may be a manifestation of withdrawal from opioids. “The variability of what they experience [from] day to day may be the variability of the drugs they are taking two days before, or one day before, as they withdraw at different rates,” Dr. Tepper said.

“Neck pain is an almost invariable feature of MOH and is attributed to cervicogenic headache all the time.” With proper treatment, the neck pain disappears. In patients with MOH nonrestorative sleep disturbance is the rule, and increased depression and anxiety occur frequently. “This all may go back to the idea that there is an emotional and supratentorial aspect to the control system,” Dr. Tepper said, “but, from a clinical standpoint, the more diagnoses made in a daily headache patient, the more treatments fail, the more procedures performed, the larger the chart, the more likely the diagnosis is rebound or MOH. And so, if you use rebound as your default diagnosis in daily headache, you’re usually going to be right. You just have to do the detective work.”

MOH correlates with headache frequency and is comorbid with or mistaken for other chronic headache conditions, including chronic daily headache, chronic migraine, chronic tension-type headache, and new daily persistent headache. The third iteration of the International Classification of Headache Disorders (ICHD-3) offers diagnostic criteria for chronic migraine and for MOH and suggests that patients meeting criteria for chronic migraine and MOH should be given both diagnoses. If the patient manifests episodic or chronic migraine after drug withdrawal, the diagnosis can be revised accordingly. In their approval of onabotulinumtoxinA for chronic headache, the FDA accepted a simplified definition of chronic migraine, which is headache with a duration of four or more hours per day on 15 days or more per month, that could be secondary to MOH.

Preventing Progression to MOH
Progression of low-frequency episodic migraine to high-frequency or chronic migraine with MOH is not a one-way street. “What we are interested in clinically is how to prevent increasing migraine frequency and how to encourage decreasing frequency,” Dr. Tepper said. The average annual incidence of new-onset chronic migraine in patients with episodic migraine is about 2.5% to 3% per year, but other studies have shown decreases in headache frequency. “That [observation] has important clinical implications, including not keeping patients on prophylaxis forever,” Dr. Tepper noted.

According to population-based studies, predictors of escalating frequency include white race, low education level, being previously married, obesity, diabetes, caffeine use, stressful life events in the previous year, head injury, snoring, high baseline headache frequency, medication overuse, history of smoking, other pain conditions, and inadequate acute treatment. Predictors of low likelihood of remission for patients with chronic migraine include less than a high school education, white race, those who were previously married, and a higher baseline frequency of medication overuse for chronic migraine. Remission also is hard to achieve in patients with MOH and baseline allodynia.

Regarding escalating headache frequency, the literature makes two points clear: Opiates and barbiturates should not be used for acute migraine treatment, and all prn treatment of episodic migraine should be limited to two days per week or fewer. “With those two simple rules, you can get very far in prevention of transformation into MOH.” Interventions that can help reduce escalation are losing weight, reducing caffeine use, bringing in behavioral help for stressful life events, addressing snoring, and documenting headache frequency and medication use in a diary.

Optimal acute treatment may prevent progression to chronic migraine or MOH. In the American Migraine Prevalence and Prevention (AMPP) study inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of a year.