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{{Infobox disease {{Infobox medical condition (new)
| Name = Medication overuse headache | name = Medication overuse headache
| Image = | synonyms = Rebound headache
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| DiseasesDB = | caption =
| ICD10 = G44.41, G44.83 | pronounce =
| ICD9 = | field = ]
| ICDO = | symptoms =
| OMIM = | complications =
| MedlinePlus = | onset =
| duration =
⚫ | eMedicineSubj =
| types =
⚫ | eMedicineTopic =
| MeshID = | causes =
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'''Medication overuse headache''' (MOH), also known as '''rebound headache''' usually occurs when ] are taken frequently to relieve ]. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as ] or ] that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications. A '''medication overuse headache''' ('''MOH'''), also known as a '''rebound headache''', usually occurs when ] are taken frequently to relieve ].<ref name=Garfinkle2022.102>{{cite book |last1=Garza |first1=Ivan |last2=Robertson |first2=Carrie E.|last3=Smith|first3=Jonathan H.|last4=Whealy|first4=Mark E. |editor1-last=Jankovic |editor1-first=Joseph |editor2-last=Mazziotta |editor2-first=John C. |editor3-last=Pomeroy |editor3-first=Scott L. |title=Bradley and Daroff's Neurology in Clinical Practice |date=2022 |publisher=Elsevier |isbn=978-0-323-64261-3 |page=1756 |edition=8th |chapter-url=https://books.google.com/books?id=b1slEAAAQBAJ&pg=PA1756|language=en |chapter=102. Headache and other craniofacial pain|location=Edinburgh|volume=II. Neurological disorders and their management}}</ref> These cases are often referred to as '''painkiller headaches'''.<ref name="NHS">{{cite web |title=Medically unexplained symptoms |url=https://www.nhs.uk/conditions/medically-unexplained-symptoms/ |website=nhs.uk |access-date=29 March 2021 |language=en |date=19 October 2017}}</ref> Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as ] or ] that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications.
MOH is a serious, disabling and well-characterized disorder, which represents a worldwide problem and is now considered the third-most prevalent type of headache. Population-based studies report the prevalence rate of MOH to be 1% to 2% in the general population, but its relative frequency is much higher in secondary and tertiary care. MOH is a serious, disabling and well-characterized disorder, which represents a worldwide problem and is now considered the third-most prevalent type of headache. The proportion of patients in the population with Chronic Daily Headache (CDH) who overuse acute medications ranges from 18% to 33%. The prevalence of medication overuse headache (MOH) varies depending on the population studied and diagnostic criteria used. However, it is estimated that MOH affects approximately 1-2% of the general population, but its relative frequency is much higher in secondary and tertiary care.<ref>{{Cite journal |last1=Colás |first1=R. |last2=Muñoz |first2=P. |last3=Temprano |first3=R. |last4=Gómez |first4=C. |last5=Pascual |first5=J. |date=2004-04-27 |title=Chronic daily headache with analgesic overuse: Epidemiology and impact on quality of life |url=https://n.neurology.org/content/62/8/1338 |journal=Neurology |language=en |volume=62 |issue=8 |pages=1338–1342 |doi=10.1212/01.WNL.0000120545.45443.93 |issn=0028-3878 |pmid=15111671|s2cid=27740384 }}</ref>


==Classification== ==Classification==
Medication overuse headache is a recognized ICHD (International Classification of Headache Disorders) classification.<ref name=ICHD2>{{cite web |url=http://216.25.100.131/ihscommon/guidelines/pdfs/ihc_II_main_no_print.pdf |title=216.25.100.131 |format=PDF |work=the Headache Classification Subcommittee of the International Headache Society |accessdate=}} {{Dead link |date=July 2012}}</ref> Over the years different sets of diagnostic criteria have been proposed and revised by the major experts of headache disorders. The term MOH first appeared in the ICHD 2nd edition in 2004. It was defined as a secondary headache, with the aim of emphasising excessive drug intake as the basis of this form of headache. The two subsequent revisions of the diagnostic criteria for MOH (2005 and 2006) refined and extended the definition of the condition on the basis of both its chronicity (headache on more than 15 days/month for more than three months) and drug classes, thereby identifying the main types of MOH. In the case of ergotamine, triptans, opioids and combination medications in particular, intake on > 10 days/month for > 3 months is required, whereas simple analgesics are considered overused when they are taken on > 15 days/month for >3 months. Medication overuse headache is a recognized ICHD (]) classification.<ref>{{cite web|title=The International Headache Classification|url=http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.00_substance.html|website=ihs-classification.org|publisher=International Headache Society|access-date=28 June 2014|archive-url=https://web.archive.org/web/20160304023022/http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.00_substance.html|archive-date=4 March 2016|url-status=dead}}</ref> Over the years different sets of diagnostic criteria have been proposed and revised by the major experts of headache disorders. The term MOH first appeared in the ICHD 2nd edition in 2004. It was defined as a secondary headache, with the aim of emphasising excessive drug intake as the basis of this form of headache. The two subsequent revisions of the diagnostic criteria for MOH (2005 and 2006) refined and extended the definition of the condition on the basis of both its chronicity (headache on more than 15 days/month for more than three months) and drug classes, thereby identifying the main types of MOH. In the case of ergotamine, triptans, opioids and combination medications in particular, intake on > 10 days/month for > 3 months is required, whereas simple analgesics are considered overused when they are taken on > 15 days/month for >3 months.<ref>{{Cite journal |last1=Ashina |first1=Sait |last2=Terwindt |first2=Gisela M. |last3=Steiner |first3=Timothy J. |last4=Lee |first4=Mi Ji |last5=Porreca |first5=Frank |last6=Tassorelli |first6=Cristina |last7=Schwedt |first7=Todd J. |last8=Jensen |first8=Rigmor H. |last9=Diener |first9=Hans-Christoph |last10=Lipton |first10=Richard B. |date=2023-02-02 |title=Medication overuse headache |url=https://www.nature.com/articles/s41572-022-00415-0 |journal=Nature Reviews Disease Primers |language=en |volume=9 |issue=1 |page=5 |doi=10.1038/s41572-022-00415-0 |pmid=36732518 |s2cid=43144437 |issn=2056-676X}}</ref>


==Causes== ==Causes==


MOH is known to occur with frequent use of many different medications, including most commonly: ],<ref>{{cite web|title=The International Classification of Headache Disorders|url=http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.02_substance.html|website=ihs-classification.org|publisher=The International Headache Society|access-date=28 June 2014}}</ref> ],<ref>{{cite web|title=The International Classification of Headache Disorders|url=http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.01_substance.html|website=ihs-classification.org|publisher=The International Headache Society|access-date=28 June 2014|archive-url=https://web.archive.org/web/20121118180425/http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.01_substance.html|archive-date=18 November 2012|url-status=dead}}</ref> simple and combination ],<ref>{{cite web|title=The International Classification of Headache Disorders|url=http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.03_substance.html|website=ihs-classification.org|publisher=The International Headache Society|access-date=28 June 2014}}</ref><ref name=":0">{{Cite journal|last1=Chiang|first1=Chia-Chun|last2=Schwedt|first2=Todd J|last3=Wang|first3=Shuu-Jiun|last4=Dodick|first4=David W|date=2016|title=Treatment of medication-overuse headache: A systematic review|journal=Cephalalgia|language=en|volume=36|issue=4|pages=371–386|doi=10.1177/0333102415593088|pmid=26122645|s2cid=36144020|issn=0333-1024}}</ref> and ].<ref>{{cite web|title=The International Classification of Headache Disorders|url=http://ihs-classification.org/en/02_klassifikation/03_teil2/08.02.04_substance.html|website=ihs-classification.org|publisher=The International Headache Society|access-date=28 June 2014}}</ref> Common over-the-counter medicines that can cause headaches when overused include Excedrin Migraine, Cafergot, and Advil.<ref>{{Cite web |title=Excedrin Migraine Is Back on the Shelves — But Is It Good for Migraine? |url=https://www.migraineagain.com/excedrin-migraine-warning/ |website=migraineagain.com}}</ref><ref>{{Cite web |last=MD |first=Sait Ashina |date=2019-11-07 |title=Stopping the vicious cycle of rebound headaches |url=https://www.health.harvard.edu/blog/stopping-the-vicious-cycle-of-rebound-headaches-2019110718180 |access-date=2024-08-20 |website=Harvard Health |language=en}}</ref> Dietary and medicinal caffeine consumption appears to be a modest risk factor for chronic daily headache onset, regardless of headache type.<ref name="Scher2004">{{cite journal |last1=Scher |first1=Ann I. |last2=Stewart |first2=Walter F. |last3=Lipton |first3=Richard B. |year=2004 |title=Caffeine as a risk factor for chronic daily headache: A population-based study |journal=Neurology |volume=63 |issue=11 |pages= 2022–2027|doi=10.1212/01.WNL.0000145760.37852.ED |pmid=15596744 |s2cid=25344474 }}</ref><ref name="BMJ2010">{{cite journal |last1= Bulletin|first1= Drug Therapeutics|year=2010 |title=Management of medication overuse headache |journal=Drug and Therapeutics Bulletin |volume= 340|pages= c1305|doi=10.1136/bmj.c1305 |pmid= 20427444|s2cid= 220110431|url=https://www.bmj.com/content/340/bmj.c1305 |access-date=11 April 2018}}</ref>
⚫ MOH is known to occur with frequent use of many different medications, including most commonly: ], ], ], ].<ref name=ICHD2/> The underlying mechanisms that lead to the development of the condition are still widely unknown and clarification of their role is hampered by a lack of experimental research or suitable animal models. Various pathophysiological abnormalities have been reported and they seem to have an important role in initiating and maintaining chronic headache (genetic disposition, receptor and enzyme physiology and regulation, psychological and behavioural factors, physical dependencies, recent functional imaging results).


A lifelong history of headaches is a major risk factor for MOH.<ref>{{Cite web |title=Medication overuse headaches - Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/medication-overuse-headache/symptoms-causes/syc-20377083 |access-date=2024-08-20 |website=Mayo Clinic |language=en}}</ref> MOH is very rare in patients without a history of recurrent headaches, and it rarely develops in patients who take analgesics for non-headache pain, like ] or ]. Furthermore, MOH is more probable when a family history of MOH is present, thus indicating a genetic susceptibility. It is thought that rebound headaches are caused by a neuronal re-adjustment process. Analgesic intake raises the pain threshold. Thus, lacking pain stimuli for longer times, the brain re-] to experience normal stimuli as pain.<ref>{{Cite journal |title=Medication-overuse headache: a review |journal=Journal of Pain Research |last1=Saxhaug Kristoffersen |first1=Esper |last2=Lundqvist |first2=Christofer |year=2014 |volume=7 |pages=367–378 |doi=10.2147/JPR.S46071|pmid=25061336 |pmc=4079825 |doi-access=free }}</ref>
⚫ ==Treatment==
⚫ MOH is common and can be treated. The overused medications must be stopped for the patient's headache to resolve. Clinical data shows that the treatment of election is abrupt drugs withdrawal, followed by starting prophylactic therapy. However, the discontinuation of overused drugs usually leads to the worsening of headache and the appearance of drug withdrawal symptoms (that greatly depend on the previously overused drugs and typically last from two to ten days and that are relieved by the further intake of the overused medication), which might reinforce the continuation of overuse. Where ] or a ] such as rebound headache is possible, gradual reduction of medication may be necessary.<ref>{{cite journal |author=de Filippis S, Salvatori E, Farinelli I, Coloprisco G, Martelletti P |title=Chronic daily headache and medication overuse headache: clinical read-outs and rehabilitation procedures |journal=Clin Ter |volume=158 |issue=4 |pages=343–7 |year=2007 |pmid=17953286 }}</ref> It is important that the patient's physician be consulted before abruptly discontinuing certain medications as such a course of action has the potential to induce medically significant physical withdrawal symptoms. Abruptly discontinuing ], for example, can actually induce seizures in some patients, although simple ] analgesics can safely be stopped by the patient without medical supervision. A long-acting analgesic/anti-inflammatory, such as ] (500&nbsp;mg twice a day), can be used to ease headache during the withdrawal period.<ref>{{cite journal |author=Silberstein SD, McCrory DC |title=Butalbital in the treatment of headache: history, pharmacology, and efficacy |journal=Headache |volume=41 |issue=10 |pages=953–67 |year=2001 |pmid=11903523 |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0017-8748&date=2001&volume=41&issue=10&spage=953 |doi=10.1046/j.1526-4610.2001.01189.x}}</ref><ref>{{cite journal |author=Loder E, Biondi D |title=Oral phenobarbital loading: a safe and effective method of withdrawing patients with headache from butalbital compounds |journal=Headache |volume=43 |issue=8 |pages=904–9 |year=2003 |month=September |pmid=12940814 |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0017-8748&date=2003&volume=43&issue=8&spage=904 |doi=10.1046/j.1526-4610.2003.03171.x}}</ref> Two months after the completion of a medication withdrawal, patients suffering from MOH typically notice a marked reduction in headache frequency and intensity.<ref>{{cite journal |author=Zeeberg P, Olesen J, Jensen R |title=Probable medication-overuse headache: the effect of a 2-month drug-free period |journal=Neurology |volume=66 |issue=12 |pages=1894–8 |year=2006 |month=June |pmid=16707727 |doi=10.1212/01.wnl.0000217914.30994.bd |url=http://www.neurology.org/cgi/pmidlookup?view=long&pmid=16707727}}</ref>


The time it takes for someone to develop medication overuse headaches (MOH) after taking medication too often depends on the type of medication they are using. If someone is taking triptans (such as Sumatriptan etc.), it may take about 1.7 years for them to develop MOH. If they are taking ergots (such as Ergotamine etc.), it may take about 2.7 years, and if they are taking analgesics (such as Naproxen etc.), it may take about 4.8 years. So, the delay between taking medication too often and developing MOH varies based on the type of medication being used.<ref name=":1">{{Cite web |title=Medication Overuse Headache: What are the Causes, Symptoms, Diagnosis, Treatment, and Prevention |url=https://www.drneuro.co.in/2023/04/medication-overuse-headache-what-are.html |access-date=2023-04-27}}</ref>
⚫ Drug withdrawal is performed very differently within and across countries. Most physicians prefer inpatients programmes, however effective drug withdrawal may also be achieved in an outpatient setting in uncomplicated MOH patients (i.e. subjects without important co-morbidities, not overusing opioids or ergotaminics and who are at their first detoxification attempt). In the absence of evidence-based indications, in MOH patients the choice of preventive agent should be based on the primary headache type (migraine or TTH), on the drug side-effect profile, on the presence of co-morbid and co-existent conditions, on patient’s preferences, and on previous therapeutic experiences.


⚫ The underlying mechanisms that lead to the development of the condition are still widely unknown and clarification of their role is hampered by a lack of experimental research or suitable animal models. Various pathophysiological abnormalities have been reported and they seem to have an important role in initiating and maintaining chronic headache (genetic disposition, receptor and enzyme physiology and regulation, psychological and behavioural factors, physical dependencies, recent functional imaging results).<ref>{{Cite journal |last2= Holland|first2= Philip R.|last3= Martins-Oliveira|first3= Margarida|last4= Hoffmann|first4= Jan|last5= Schankin|first5= Christoph|last6= Akerman|first6= Simon|date=2017-04-01 |title=Pathophysiology of Migraine: A Disorder of Sensory Processing |journal=Physiological Reviews |volume=97 |issue=2 |pages=553–622 |doi=10.1152/physrev.00034.2015 |issn=0031-9333 |pmc=5539409 |pmid=28179394|last1= Goadsby|first1= Peter J.}}</ref>
Following an initial improvement of headache with the return to an episodic pattern, a relevant proportion (up to 45%) of patients relapse, reverting to the overuse of symptomatic drugs.


In some cases, individuals may be genetically predisposed to developing medication overuse headache.<ref>{{Cite journal |last1=Kristoffersen |first1=Espen Saxhaug |last2=Lundqvist |first2=Christofer |date=2014-04-04 |title=Medication-overuse headache: epidemiology, diagnosis and treatment |journal=Therapeutic Advances in Drug Safety |volume=5 |issue=2 |pages=87–99 |doi=10.1177/2042098614522683 |issn=2042-0986 |pmc=4110872 |pmid=25083264}}</ref> A PET study in patients with chronic analgesic overuse showed decreased activity in the orbitofrontal cortex of the brain, which is also seen in substance abuse. This suggests that there may be an underlying neurological susceptibility to addiction in some individuals. However, more research is needed to fully understand the complex interplay of factors that contribute to the development of MOH.<ref name=":1" /><ref>{{Cite journal |last1=Fumal |first1=Arnaud |last2=Laureys |first2=Steven |last3=Di Clemente |first3=Laura |last4=Boly |first4=Mélanie |last5=Bohotin |first5=Valentin |last6=Vandenheede |first6=Michel |last7=Coppola |first7=Gianluca |last8=Salmon |first8=Eric |last9=Kupers |first9=Ron |last10=Schoenen |first10=Jean |date=2005-12-05 |title=Orbitofrontal cortex involvement in chronic analgesic-overuse headache evolving from episodic migraine |journal=Brain |volume=129 |issue=2 |pages=543–550 |doi=10.1093/brain/awh691 |pmid=16330505 |issn=1460-2156|doi-access=free }}</ref>
⚫ Predictors of the relapse, and that could influence treatment strategies, are considered the type of primary headache, from which MOH has evolved, and the type of drug abused (analgesics, and mostly combination of analgesics, but also drugs containing barbiturates or tranquillisers cause significantly higher relapse rates), while gender, age, duration of disease and previous intake of preventative treatment do not seem to predict relapse rate.


===Headache treatment===
MOH is clearly a cause of disability and, if not adequately treated, it represents a condition of risk of possible co-morbidities associated to the excessive intake of drugs that are not devoid of side-effect. MOH can be treated through withdrawal of the overused drug(s) and by means of specific approaches that focus on the development of a close ] in the post-withdrawal period.
] and ] are sometimes inappropriately used as treatment for ] and ] and should be avoided in favor of more effective, migraine-specific treatments.<ref name="BBDMigraine">{{Citation |author1=Consumer Reports Health Best Buy Drugs |author1-link = Consumer Reports |date=21 August 2012 |title=Drugs for Migraine Headaches (AAN) |publisher=Consumer Reports |location=] |url=http://consumerhealthchoices.org/catalog/drugs-for-migraine-headaches-aan/ |contribution=Treating Migraine Headaches: Some Drugs should rarely be used |contribution-url=http://consumerhealthchoices.org/wp-content/uploads/2013/02/ChoosingWiselyMigraineAAN-ER.pdf |access-date=28 October 2013}}</ref><ref name="AANfive">{{Citation |author1 = American Academy of Neurology |author1-link = American Academy of Neurology |date=February 2013 |title = Five Things Physicians and Patients Should Question |publisher = American Academy of Neurology |work = ]: an initiative of the ] |url = http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-neurology/ |access-date = August 1, 2013}}, which cites
* {{Cite journal | last1 = Silberstein | first1 = S. D. | title = Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology | doi = 10.1212/WNL.55.6.754 | journal = Neurology | volume = 55 | issue = 6 | pages = 754–762 | year = 2000 | pmid = 10993991| doi-access = free }}
* {{Cite journal | last1 = Evers | first1 = S. | last2 = Afra | first2 = J. | last3 = Frese | first3 = A. | last4 = Goadsby | first4 = P. J. | last5 = Linde | first5 = M. | last6 = May | first6 = A. | last7 = Sándor | first7 = P. S. | author8 = European Federation of Neurological Societies | doi = 10.1111/j.1468-1331.2009.02748.x | title = EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force | journal = European Journal of Neurology | volume = 16 | issue = 9 | pages = 968–981 | year = 2009 | pmid = 19708964 | s2cid = 9204782 | doi-access = free }}
* {{Citation |author=Institute for Clinical Systems Improvement |year=2011 |title=Headache, Diagnosis and Treatment of |publisher=Institute for Clinical Systems Improvement |url=https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/headache/ }}</ref> Opioid and butalbital use can worsen headaches and cause MOH.<ref name="BBDMigraine"/> When a patient fails to respond to other treatment or migraine specific treatment is unavailable, then opioids may be used.<ref name="AANfive"/>

Regular use of ] (OTC) such as ] and ] can also be a cause of MOH.<ref name="AHSfive">{{Citation |author1 = American Headache Society |author1-link = American Academy of Dermatology |date = September 2013 |title = Five Things Physicians and Patients Should Question |publisher = ] |work = ]: an initiative of the ] |url = http://www.choosingwisely.org/doctor-patient-lists/american-headache-society/ |access-date = 10 December 2013 |url-status = dead |archive-url = https://web.archive.org/web/20131206060123/http://www.choosingwisely.org/doctor-patient-lists/american-headache-society/ |archive-date = 6 December 2013 }}, which cites
* {{Cite journal | last1 = Bigal | first1 = M. E. | last2 = Serrano | first2 = D. | last3 = Buse | first3 = D. | last4 = Scher | first4 = A. | last5 = Stewart | first5 = W. F. | last6 = Lipton | first6 = R. B. | doi = 10.1111/j.1526-4610.2008.01217.x | title = Acute Migraine Medications and Evolution from Episodic to Chronic Migraine: A Longitudinal Population-Based Study | journal = Headache: The Journal of Head and Face Pain | volume = 48 | issue = 8 | pages = 1157–1168 | year = 2008 | pmid = 18808500 | doi-access = free }}
* {{Cite journal | last1 = Bigal | first1 = M. E. | last2 = Lipton | first2 = R. B. | doi = 10.1212/01.wnl.0000335946.53860.1d | title = Excessive acute migraine medication use and migraine progression | journal = Neurology | volume = 71 | issue = 22 | pages = 1821–1828 | year = 2008 | pmid = 19029522 | s2cid = 36285728 }}
* {{Cite journal | doi = 10.1212/01.WNL.0000069924.69078.8D | last1 = Zwart | first1 = J. A. | last2 = Dyb | first2 = G. | last3 = Hagen | first3 = K. | last4 = Svebak | first4 = S. | last5 = Holmen | first5 = J. | title = Analgesic use: A predictor of chronic pain and medication overuse headache: The Head-HUNT Study | journal = Neurology | volume = 61 | issue = 2 | pages = 160–164 | year = 2003 | pmid = 12874392| s2cid = 11357203 }}
* {{Cite journal | last1 = Silberstein | first1 = S. D. | title = Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology | doi = 10.1212/WNL.55.6.754 | journal = Neurology | volume = 55 | issue = 6 | pages = 754–762 | year = 2000 | pmid = 10993991| doi-access = free }}</ref> OTC medication for headache should be limited to use for not more than two days weekly,<ref name="AHSfive"/> and it is recommended to seek medical counsel when any pain lasts more than a few days. Concurrent with MOH, overuse of acetaminophen (known as paracetamol in some countries) for treating headaches risks causing ] and NSAID overuse can cause ].<ref name="AHSfive"/>


==Prevention== ==Prevention==
In general, any patient who has frequent headaches or migraine attacks should be considered as a potential candidate for preventive medications instead of being encouraged to take more and more painkillers or other rebound-causing medications. Preventive medications are taken on a daily basis. Some patients may require preventive medications for many years; others may require them for only a relatively short period of time such as six months. Effective preventive medications have been found to come from many classes of medications including neuronal stabilizing agents (aka anticonvulsants), antidepressants, antihypertensives, and antihistamines. Some effective preventive medications include Elavil (]), Depakote (]), Topamax (]), and Inderal (]). In general, any patient who has frequent headaches or migraine attacks should be considered as a potential candidate for preventive medications instead of being encouraged to take more and more painkillers or other rebound-causing medications. Preventive medications are taken on a daily basis. Some patients may require preventive medications for many years; others may require them for only a relatively short period of time such as six months. Effective preventive medications have been found to come from many classes of medications including neuronal stabilizing agents (aka anticonvulsants), antidepressants, antihypertensives, and antihistamines. Some effective preventive medications include Elavil (]), Depakote (]), Topamax (]), and Inderal (]).{{Medical citation needed|date=July 2015}}<ref>{{Citation |last1=Kumar |first1=Anil |title=Migraine Prophylaxis |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK507873/ |access-date=2024-08-16 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29939650 |last2=Kadian |first2=Renu}}</ref>

⚫ ==Treatment==
⚫ MOH is common and can be treated. The overused medications must be stopped for the patient's headache to resolve, though there is limited evidence to suggest this can be done without using other preventive measures.<ref name=":0" /> Clinical data shows that the treatment of choice is abrupt drugs withdrawal, followed by starting prophylactic therapy.<ref>{{Citation |last1=Fischer |first1=Michelle A. |title=Medication-Overuse Headache |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK538150/ |access-date=2024-08-20 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=30844177 |last2=Jan |first2=Arif}}</ref> However, the discontinuation of overused drugs may lead to the initial worsening of headaches, nausea, vomiting, sleep disturbance, anxiety, and restlessness.<ref name=":0" /> These symptoms greatly depend on the previously overused drugs and typically last from two to ten days. They are relieved by the further intake of the overused medication, which might reinforce the continuation of overuse and noncompliance toward discontinuation. Where ] or a ] such as rebound headache is possible, gradual reduction of medication may be necessary.<ref>{{cite journal |vauthors=de Filippis S, Salvatori E, Farinelli I, Coloprisco G, Martelletti P |title=Chronic daily headache and medication overuse headache: clinical read-outs and rehabilitation procedures |journal=Clin Ter |volume=158 |issue=4 |pages=343–7 |year=2007 |pmid=17953286 }}</ref> It is important that the patient's physician be consulted before abruptly discontinuing certain medications as such a course of action has the potential to induce medically significant physical withdrawal symptoms. Abruptly discontinuing ], for example, can actually induce seizures in some patients, although simple ] analgesics can safely be stopped by the patient without medical supervision. A long-acting analgesic/anti-inflammatory, such as ] (500&nbsp;mg twice a day), can be used to ease headache during the withdrawal period.<ref>{{cite journal |vauthors=Silberstein SD, McCrory DC |title=Butalbital in the treatment of headache: history, pharmacology, and efficacy |journal=Headache |volume=41 |issue=10 |pages=953–67 |year=2001 |pmid=11903523 |doi=10.1046/j.1526-4610.2001.01189.x|s2cid=27684961 }}</ref><ref>{{cite journal |vauthors=Loder E, Biondi D |title=Oral phenobarbital loading: a safe and effective method of withdrawing patients with headache from butalbital compounds |journal=Headache |volume=43 |issue=8 |pages=904–9 |date=September 2003 |pmid=12940814 |doi=10.1046/j.1526-4610.2003.03171.x|s2cid=36000736 }}</ref> Two months after the completion of a medication withdrawal, patients with MOH typically notice a marked reduction in headache frequency and intensity.<ref>{{cite journal |vauthors=Zeeberg P, Olesen J, Jensen R |title=Probable medication-overuse headache: the effect of a 2-month drug-free period |journal=Neurology |volume=66 |issue=12 |pages=1894–8 |date=June 2006 |pmid=16707727 |doi=10.1212/01.wnl.0000217914.30994.bd |s2cid=23088630 }}</ref>

⚫ Drug withdrawal is performed very differently within and across countries. Most physicians prefer inpatients programmes, however effective drug withdrawal may also be achieved in an outpatient setting in uncomplicated MOH patients (i.e. subjects without important co-morbidities, not overusing opioids or ergotaminics and who are at their first detoxification attempt). In the absence of evidence-based indications, in MOH patients the choice of preventive agent should be based on the primary headache type (migraine or TTH), on the drug side-effect profile, on the presence of co-morbid and co-existent conditions, on patient's preferences, and on previous therapeutic experiences.<ref>{{Cite journal |last1=Tassorelli |first1=C |last2=Jensen |first2=R |last3=Allena |first3=M |last4=De Icco |first4=R |last5=Sances |first5=G |last6=Katsarava |first6=Z |last7=Lainez |first7=M |last8=Leston |first8=Ja |last9=Fadic |first9=R |last10=Spadafora |first10=S |last11=Pagani |first11=M |last12=Nappi |first12=G |last13=the COMOESTAS Consortium |date=2014-08-03 |title=A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study |url=http://journals.sagepub.com/doi/10.1177/0333102414521508 |journal=Cephalalgia |language=en |volume=34 |issue=9 |pages=645–655 |doi=10.1177/0333102414521508 |pmid=24558185 |issn=0333-1024}}</ref>

Following an initial improvement of headache with the return to an episodic pattern, a relevant proportion (up to 45%) of patients relapse, reverting to the overuse of symptomatic drugs.<ref>{{Cite journal |last1=Tassorelli |first1=C |last2=Jensen |first2=R |last3=Allena |first3=M |last4=De Icco |first4=R |last5=Sances |first5=G |last6=Katsarava |first6=Z |last7=Lainez |first7=M |last8=Leston |first8=Ja |last9=Fadic |first9=R |last10=Spadafora |first10=S |last11=Pagani |first11=M |last12=Nappi |first12=G |last13=the COMOESTAS Consortium |date=February 20, 2014 |title=A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study |url=http://journals.sagepub.com/doi/10.1177/0333102414521508 |journal=Cephalalgia |language=en |volume=34 |issue=9 |pages=645–655 |doi=10.1177/0333102414521508 |pmid=24558185 |issn=0333-1024}}</ref><ref>{{Cite journal |date=September 5, 2008 |title=Medication Overuse Headache: Predictors and Rates of Relapse in Migraine Patients With Low Medical Needs. A 1-Year Prospective Study |url=https://www.researchgate.net/publication/23194354 |website=researchgate.net}}</ref>

⚫ Predictors of the relapse, and that could influence treatment strategies, are considered the type of primary headache, from which MOH has evolved, and the type of drug abused (analgesics, and mostly combination of analgesics, but also drugs containing barbiturates or tranquillisers cause significantly higher relapse rates), while gender, age, duration of disease and previous intake of preventative treatment do not seem to predict relapse rate.{{citation needed|date=August 2021}}

MOH is clearly a cause of disability and, if not adequately treated, it represents a condition of risk of possible co-morbidities associated to the excessive intake of drugs that are not devoid of side-effect. MOH can be treated through withdrawal of the overused drug(s) and by means of specific approaches that focus on the development of a close ] in the post-withdrawal period.<ref>{{Cite journal |last1=Vandenbussche |first1=Nicolas |last2=Laterza |first2=Domenico |last3=Lisicki |first3=Marco |last4=Lloyd |first4=Joseph |last5=Lupi |first5=Chiara |last6=Tischler |first6=Hannes |last7=Toom |first7=Kati |last8=Vandervorst |first8=Fenne |last9=Quintana |first9=Simone |last10=Paemeleire |first10=Koen |last11=Katsarava |first11=Zaza |date=2018-12-01 |title=Medication-overuse headache: a widely recognized entity amidst ongoing debate |journal=The Journal of Headache and Pain |language=en |volume=19 |issue=1 |page=50 |doi=10.1186/s10194-018-0875-x |doi-access=free |pmid=30003412 |pmc=6043466 |issn=1129-2369}}</ref>


==History== ==History==
Rebound headache was first described by Dr. Lee Kudrow.<ref>{{cite journal |author=Kudrow L |title=Paradoxical effects of frequent analgesic use |journal=Adv Neurol |volume=33 |pages=335–41 |year=1982 |pmid=7055014 }}</ref> Rebound headache was first described by Dr. Lee Kudrow in 1982.<ref>{{cite journal |author=Kudrow L |title=Paradoxical effects of frequent analgesic use |journal=Adv Neurol |volume=33 |pages=335–41 |year=1982 |pmid=7055014 }}</ref>


==See also== ==See also==
* ] * ]
* ]


== References == == References ==
{{reflist}} {{reflist}}


===Bibliography===
'''More bibliography'''

{{refbegin}} {{refbegin}}
*{{cite journal |author=Diener HC, Limmroth V |title=Medication-overuse headache: a worldwide problem |journal=Lancet Neurol |volume=3 |issue=8 |pages=475–83 |year=2004 |month=August |pmid=15261608 |doi=10.1016/S1474-4422(04)00824-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S1474442204008245}} * {{cite journal |vauthors=Diener HC, Limmroth V |title=Medication-overuse headache: a worldwide problem |journal=Lancet Neurol |volume=3 |issue=8 |pages=475–83 |date=August 2004 |pmid=15261608 |doi=10.1016/S1474-4422(04)00824-5 |s2cid=43840120 }}
*{{cite journal |author=Katsarava Z, Limmroth V, Finke M, Diener HC, Fritsche G |title=Rates and predictors for relapse in medication overuse headache: a 1-year prospective study |journal=Neurology |volume=60 |issue=10 |pages=1682–3 |year=2003 |month=May |pmid=12771266 |url=http://www.neurology.org/cgi/pmidlookup?view=long&pmid=12771266}} * {{cite journal |vauthors=Katsarava Z, Limmroth V, Finke M, Diener HC, Fritsche G |title=Rates and predictors for relapse in medication overuse headache: a 1-year prospective study |journal=Neurology |volume=60 |issue=10 |pages=1682–3 |date=May 2003 |pmid=12771266 |doi=10.1212/01.wnl.0000063322.14078.90|s2cid=22923813 }}
*{{cite journal |author=International Headache Society |title=The International Classification of Headache Disorders: 2nd edition |journal=Cephalalgia |volume=24 |issue=Suppl 1|pages=9–160 |year=2004 |pmid=14979299 |url=http://cep.sagepub.com/cgi/pmidlookup?view=long&pmid=14979299 |doi=10.1111/j.1468-2982.2004.00653.x}} * {{cite journal |author=International Headache Society |title=The International Classification of Headache Disorders: 2nd edition |journal=Cephalalgia |volume=24 |issue=Suppl 1 |pages=9–160 |year=2004 |pmid=14979299 |doi=10.1111/j.1468-2982.2004.00653.x |doi-access=free }}
*{{cite journal |author=Olesen J, Bousser MG, Diener HC, ''et al.'' |title=New appendix criteria open for a broader concept of chronic migraine |journal=Cephalalgia |volume=26 |issue=6 |pages=742–6 |year=2006 |month=June |pmid=16686915 |doi=10.1111/j.1468-2982.2006.01172.x |url=http://cep.sagepub.com/cgi/pmidlookup?view=long&pmid=16686915}} * {{cite journal |vauthors=Olesen J, Bousser MG, Diener HC, etal |title=New appendix criteria open for a broader concept of chronic migraine |journal=Cephalalgia |volume=26 |issue=6 |pages=742–6 |date=June 2006 |pmid=16686915 |doi=10.1111/j.1468-2982.2006.01172.x |s2cid=4834124 }}
*{{cite journal |author=Ghiotto N, Sances G, Galli F, ''et al.'' |title=Medication overuse headache and applicability of the ICHD-II diagnostic criteria: 1-year follow-up study (CARE I protocol) |journal=Cephalalgia |volume=29 |issue=2 |pages=233–43 |year=2009 |month=February |pmid=19025549 |doi=10.1111/j.1468-2982.2008.01712.x |url=http://cep.sagepub.com/cgi/pmidlookup?view=long&pmid=19025549}} * {{cite journal |vauthors=Ghiotto N, Sances G, Galli F, etal |title=Medication overuse headache and applicability of the ICHD-II diagnostic criteria: 1-year follow-up study (CARE I protocol) |journal=Cephalalgia |volume=29 |issue=2 |pages=233–43 |date=February 2009 |pmid=19025549 |doi=10.1111/j.1468-2982.2008.01712.x |s2cid=7534798 }}
*{{cite journal |author=Silberstein SD, Olesen J, Bousser MG, ''et al.'' |title=The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache |journal=Cephalalgia |volume=25 |issue=6 |pages=460–5 |year=2005 |month=June |pmid=15910572 |doi=10.1111/j.1468-2982.2005.00878.x |url=http://cep.sagepub.com/cgi/pmidlookup?view=long&pmid=15910572}} * {{cite journal |vauthors=Silberstein SD, Olesen J, Bousser MG, etal |title=The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache |journal=Cephalalgia |volume=25 |issue=6 |pages=460–5 |date=June 2005 |pmid=15910572 |doi=10.1111/j.1468-2982.2005.00878.x |s2cid=19666440 }}
{{refend}} {{refend}}


'''Useful and interesting links''' == External links ==
{{Medical resources

| DiseasesDB =
| ICD10 = G44.41, G44.83

| ICD9 =
| ICDO =

| OMIM =
| MedlinePlus =

⚫ | eMedicineSubj =
⚫ | eMedicineTopic =

| MeshID =
}}
{{Headache}} {{Headache}}


{{DEFAULTSORT:Medication Overuse Headache}} {{DEFAULTSORT:Medication Overuse Headache}}
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Latest revision as of 22:22, 1 December 2024

Medical condition
Medication overuse headache
Other namesRebound headache
SpecialtyNeurology

A medication overuse headache (MOH), also known as a rebound headache, usually occurs when painkillers are taken frequently to relieve headaches. These cases are often referred to as painkiller headaches. Rebound headaches frequently occur daily, can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as migraine or tension-type headache that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications. MOH is a serious, disabling and well-characterized disorder, which represents a worldwide problem and is now considered the third-most prevalent type of headache. The proportion of patients in the population with Chronic Daily Headache (CDH) who overuse acute medications ranges from 18% to 33%. The prevalence of medication overuse headache (MOH) varies depending on the population studied and diagnostic criteria used. However, it is estimated that MOH affects approximately 1-2% of the general population, but its relative frequency is much higher in secondary and tertiary care.

Classification

Medication overuse headache is a recognized ICHD (International Classification of Headache Disorders) classification. Over the years different sets of diagnostic criteria have been proposed and revised by the major experts of headache disorders. The term MOH first appeared in the ICHD 2nd edition in 2004. It was defined as a secondary headache, with the aim of emphasising excessive drug intake as the basis of this form of headache. The two subsequent revisions of the diagnostic criteria for MOH (2005 and 2006) refined and extended the definition of the condition on the basis of both its chronicity (headache on more than 15 days/month for more than three months) and drug classes, thereby identifying the main types of MOH. In the case of ergotamine, triptans, opioids and combination medications in particular, intake on > 10 days/month for > 3 months is required, whereas simple analgesics are considered overused when they are taken on > 15 days/month for >3 months.

Causes

MOH is known to occur with frequent use of many different medications, including most commonly: triptans, ergotamines, simple and combination analgesics, and opioids. Common over-the-counter medicines that can cause headaches when overused include Excedrin Migraine, Cafergot, and Advil. Dietary and medicinal caffeine consumption appears to be a modest risk factor for chronic daily headache onset, regardless of headache type.

A lifelong history of headaches is a major risk factor for MOH. MOH is very rare in patients without a history of recurrent headaches, and it rarely develops in patients who take analgesics for non-headache pain, like arthritis or irritable bowel syndrome. Furthermore, MOH is more probable when a family history of MOH is present, thus indicating a genetic susceptibility. It is thought that rebound headaches are caused by a neuronal re-adjustment process. Analgesic intake raises the pain threshold. Thus, lacking pain stimuli for longer times, the brain re-calibrates to experience normal stimuli as pain.

The time it takes for someone to develop medication overuse headaches (MOH) after taking medication too often depends on the type of medication they are using. If someone is taking triptans (such as Sumatriptan etc.), it may take about 1.7 years for them to develop MOH. If they are taking ergots (such as Ergotamine etc.), it may take about 2.7 years, and if they are taking analgesics (such as Naproxen etc.), it may take about 4.8 years. So, the delay between taking medication too often and developing MOH varies based on the type of medication being used.

The underlying mechanisms that lead to the development of the condition are still widely unknown and clarification of their role is hampered by a lack of experimental research or suitable animal models. Various pathophysiological abnormalities have been reported and they seem to have an important role in initiating and maintaining chronic headache (genetic disposition, receptor and enzyme physiology and regulation, psychological and behavioural factors, physical dependencies, recent functional imaging results).

In some cases, individuals may be genetically predisposed to developing medication overuse headache. A PET study in patients with chronic analgesic overuse showed decreased activity in the orbitofrontal cortex of the brain, which is also seen in substance abuse. This suggests that there may be an underlying neurological susceptibility to addiction in some individuals. However, more research is needed to fully understand the complex interplay of factors that contribute to the development of MOH.

Headache treatment

Opioids and butalbital are sometimes inappropriately used as treatment for migraine and headache and should be avoided in favor of more effective, migraine-specific treatments. Opioid and butalbital use can worsen headaches and cause MOH. When a patient fails to respond to other treatment or migraine specific treatment is unavailable, then opioids may be used.

Regular use of over-the-counter drugs (OTC) such as paracetamol and NSAIDs can also be a cause of MOH. OTC medication for headache should be limited to use for not more than two days weekly, and it is recommended to seek medical counsel when any pain lasts more than a few days. Concurrent with MOH, overuse of acetaminophen (known as paracetamol in some countries) for treating headaches risks causing liver damage and NSAID overuse can cause gastrointestinal bleeding.

Prevention

In general, any patient who has frequent headaches or migraine attacks should be considered as a potential candidate for preventive medications instead of being encouraged to take more and more painkillers or other rebound-causing medications. Preventive medications are taken on a daily basis. Some patients may require preventive medications for many years; others may require them for only a relatively short period of time such as six months. Effective preventive medications have been found to come from many classes of medications including neuronal stabilizing agents (aka anticonvulsants), antidepressants, antihypertensives, and antihistamines. Some effective preventive medications include Elavil (amitriptyline), Depakote (valproate), Topamax (topiramate), and Inderal (propranolol).

Treatment

MOH is common and can be treated. The overused medications must be stopped for the patient's headache to resolve, though there is limited evidence to suggest this can be done without using other preventive measures. Clinical data shows that the treatment of choice is abrupt drugs withdrawal, followed by starting prophylactic therapy. However, the discontinuation of overused drugs may lead to the initial worsening of headaches, nausea, vomiting, sleep disturbance, anxiety, and restlessness. These symptoms greatly depend on the previously overused drugs and typically last from two to ten days. They are relieved by the further intake of the overused medication, which might reinforce the continuation of overuse and noncompliance toward discontinuation. Where physical dependence or a rebound effect such as rebound headache is possible, gradual reduction of medication may be necessary. It is important that the patient's physician be consulted before abruptly discontinuing certain medications as such a course of action has the potential to induce medically significant physical withdrawal symptoms. Abruptly discontinuing butalbital, for example, can actually induce seizures in some patients, although simple over the counter analgesics can safely be stopped by the patient without medical supervision. A long-acting analgesic/anti-inflammatory, such as naproxen (500 mg twice a day), can be used to ease headache during the withdrawal period. Two months after the completion of a medication withdrawal, patients with MOH typically notice a marked reduction in headache frequency and intensity.

Drug withdrawal is performed very differently within and across countries. Most physicians prefer inpatients programmes, however effective drug withdrawal may also be achieved in an outpatient setting in uncomplicated MOH patients (i.e. subjects without important co-morbidities, not overusing opioids or ergotaminics and who are at their first detoxification attempt). In the absence of evidence-based indications, in MOH patients the choice of preventive agent should be based on the primary headache type (migraine or TTH), on the drug side-effect profile, on the presence of co-morbid and co-existent conditions, on patient's preferences, and on previous therapeutic experiences.

Following an initial improvement of headache with the return to an episodic pattern, a relevant proportion (up to 45%) of patients relapse, reverting to the overuse of symptomatic drugs.

Predictors of the relapse, and that could influence treatment strategies, are considered the type of primary headache, from which MOH has evolved, and the type of drug abused (analgesics, and mostly combination of analgesics, but also drugs containing barbiturates or tranquillisers cause significantly higher relapse rates), while gender, age, duration of disease and previous intake of preventative treatment do not seem to predict relapse rate.

MOH is clearly a cause of disability and, if not adequately treated, it represents a condition of risk of possible co-morbidities associated to the excessive intake of drugs that are not devoid of side-effect. MOH can be treated through withdrawal of the overused drug(s) and by means of specific approaches that focus on the development of a close doctor-patient relationship in the post-withdrawal period.

History

Rebound headache was first described by Dr. Lee Kudrow in 1982.

See also

References

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Bibliography

External links

ClassificationD
Headache
Primary
ICHD 1
ICHD 2
ICHD 3
ICHD 4
Secondary
ICHD 5
ICHD 7
ICHD 8
ICHD 13
Other
Categories: