“Less is more” in medication-overuse headache

EAN 2019

“Less is more” in medication-overuse headache

6668 2484 Peter Stevenson, PhD

Monitoring, recognition and effective patient education are cornerstones in the diagnosis and prevention of medication-overuse headache (MOH), delegates heard at the 5th Annual Congress of the European Academy of Neurology (EAN) in Oslo, Norway.

In a session tackling the unmet needs in migraine treatment, Zaza Katsarava (University of Essen, Germany) explored the past, present and future of the diagnosis and management of MOH – a condition estimated to affect 63 million people worldwide.1

MOH – also referred to as “rebound headache”, “drug-induced headache” or “medication-induced headache” – is classified as a chronic headache disorder (occurring at least 15 days a month), secondary to a pre-existing headache syndrome that is treated for three months or more.2 Its first descriptions date back to the 1930s, when patients receiving ergotamine vasoconstrictors for primary migraines reported more frequent migraines whilst on medication.1

In the 1970s and beyond, many authors identified the link between headache persistence and analgesics (e.g. barbiturates, codeine, paracetamol), opioids, non-steroidal anti-inflammatories and other drugs.1 By 1988, MOH found its way into the first edition of the International Classification of Headache Disorders (ICHD).

MOH usually resolves once drugs are stopped through complete cessation, which is recommended over gradual restriction.3 That being said, there is great difficulty in predicting who may or may not react to commonly used drugs. To date, little pathophysiological understanding of MOH exists.1

If chronic migraine patients are to be treated with analgesics and the like, the twin pillars of monitoring and education are essential, Professor Katsarava underlined. Doctors must keep a close eye on any patients embarking on therapies, and patients should be well-informed of the manifestation, risks and prognosis of MOH.4

Furthermore, the impact that comorbidities may have in the treatment decision should not be overlooked, continued Professor Katsarava. Anxiety, stress, depression and other psychosocial factors are all potent migraine triggers that may drive a patient to more readily seek out medications for their pain. Thus, a patient’s triggers must be thoroughly understood prior to embarking on any treatment course.

Looking at the road ahead, Professor Katsarava relayed an air of cautious optimism, noting that with close monitoring, patient education and even novel drug therapies, the burden of MOH can be effectively reduced. “It is important that doctors recognise medication-overuse headache and intervene” he said, concluding that when it comes to medication in MOH, perhaps less really is more.


  1. Vandenbussche N, et al. Medication-overuse headache: a widely recognized entity amidst ongoing debate. J Headache Pain. 2018;19:50.
  2. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38:1–211.
  3. 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.
  4. Minen MT, et al. Survey of Opioid and Barbiturate Prescriptions in Patients Attending a Tertiary Care Headache Center. Headache. 2015;55(9):1183–91.
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