Medication-Overuse Headache
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Direct answer
Fifteen or more headache days a month in a patient with a pre-existing headache disorder who has been overusing acute relief medication for more than three months — that is medication-overuse headache: simple analgesics on 15 or more days a month, or triptans, opioids or combination analgesics on 10 or more days a month. Treatment is withdrawal of the overused drug with explanation and support, a bridging strategy for the expected transient worsening, and early initiation of preventive therapy, since simply adding a prophylactic on top of continued overuse is far less effective.
What you must remember
- Diagnostic thresholds: headache at least 15 days per month plus regular intake of simple analgesics (paracetamol, NSAIDs) on 15 or more days per month, or of triptans, opioids or combination analgesics on 10 or more days per month, for more than three months.
- The headache typically transforms: a migraine or tension-type headache accelerates into a near-daily, dull, migraine-like headache, often worst on waking.
- It is the most common secondary headache disorder seen in headache specialty clinics, and the rebound mechanism is central sensitisation, not a new disease.
- Withdrawal is the treatment: abrupt discontinuation for simple analgesics and triptans; structured taper for opioids and barbiturate-containing combinations.
- Expect 2 to 4 weeks of transient worsening (withdrawal headache) before improvement — forewarning the patient is itself therapeutic.
- Bridging options during withdrawal include scheduled naproxen, a short corticosteroid course, or antiemetic and fluid support per local practice; inpatient withdrawal is reserved for failures, opioid overuse, or comorbidity.
- Preventive therapy (amitriptyline, topiramate, propranolol and similar migraine preventives) should start during or shortly after withdrawal rather than waiting for abstinence.
- Education and headache diary follow-up determine relapse; relapse rates are substantial in the first year, so review at one to three months.
One withdrawal plan, worked through
A 42-year-old woman with migraine since college now reports headache "every day"; for two years she has taken a paracetamol-plus-codeine combination, and lately a triptan too, most days of the week. Map the diagnosis to the criteria: 25 headache days a month, triptan and combination analgesic use on 16 days a month for far longer than three months — criteria met, and the pattern (early-morning headache, migrainous days superimposed on a daily background) fits. The plan unfolds in five steps. First, the conversation: name the diagnosis, explain that the painkiller has become the pain, and set the expectation of two to four worse weeks before better ones — without this, almost every withdrawal fails at day five. Second, the stop: abrupt withdrawal of the triptan; the codeine combination is tapered over two weeks since opioids taper, and a written day-by-day schedule replaces "as needed". Third, the bridge: scheduled naproxen twice daily with gastric protection for a fixed two weeks (fixed, not as-required — that is the whole point), plus a short course of prednisolone in severe cases per local practice, antiemetics, fluids and hydration. Fourth, the prevention started the same fortnight — topiramate or amitriptyline chosen to her profile — because waiting for a "clean baseline" wastes the motivational moment. Fifth, the review at four weeks with the diary: headache days falling below 15 confirms the diagnosis retrospectively, and the six-month plan (taper the preventive after sustained control, retain the acute-medication limits of under 10 days a month for triptans and under 15 for simple analgesics) is written down with her.
Where students slip
The thresholds are the trap: candidates blur the 15-day and 10-day cutoffs by drug class, or forget the three-month duration requirement, or the prerequisite of a pre-existing primary headache. The second error is treating MOH by simply adding a prophylactic while the patient keeps taking daily analgesics — trials show withdrawal is what changes outcomes. The third is expecting instant improvement and misreading the withdrawal fortnight as treatment failure; the two-to-four-week worsening window is examinable in its own right.
Frequently asked questions
What analgesic frequency defines medication-overuse headache?
Simple analgesics on 15 or more days per month, or triptans, opioids or combination analgesics on 10 or more days per month, for over three months, in a patient with a pre-existing headache disorder and headache on 15 or more days per month.
How is the overused medication withdrawn?
Abruptly for simple analgesics and triptans, with a structured taper for opioids and barbiturate combinations; expect two to four weeks of transient worsening.
When is prophylaxis started relative to withdrawal?
During or shortly after withdrawal — concurrent initiation outperforms delaying prevention until the patient is analgesic-free.
Which patients need inpatient withdrawal?
Those failing outpatient withdrawal, overusing opioids or barbiturates, or with significant medical or psychiatric comorbidity requiring supervised care.
Why does the headache improve only weeks after stopping the drug?
Central sensitisation from chronic analgesic exposure takes weeks to reverse; the delayed improvement is expected, not a sign of wrong diagnosis.