# Medication-Overuse Headache | Symptoms, Causes, Tests and Treatment | OSANG > Medication overuse headache is a condition in which headaches increase due to taking painkillers too frequently. It occurs when simple painkillers are used more than 15… - Official page: https://osns.co.kr/en/encyclopedia/medication-overuse-headache - Organization: OSANG Neurosurgery ## Page content Headache ## Medication-Overuse Headache Medication Overuse Headache · G44.4 Medication overuse headache (MOH) is a secondary headache in which headaches become chronic when patients with existing headache diseases take acute headache medications excessively and frequently. In approximately 50% of all chronic headache patients, drug overuse is the cause or aggravating factor. ## At a glance Medication overuse headache is a condition in which headaches increase due to taking painkillers too frequently. It occurs when simple painkillers are used more than 15 days a month, and triptans or complex painkillers are used more than 10 days a month for more than 3 months. Approximately 50% of all chronic headaches are accompanied by medication overuse. When the causative drug is stopped, withdrawal headaches appear for the first 2 to 8 weeks, but the frequency of headaches significantly decreases in about 50 to 70% of patients thereafter. Combination of preventive medication and lifestyle modification are essential to prevent recurrence. - 01Definition and Overview - 02causative drug - 03Mechanism of occurrence - 04symptoms - 05diagnosis - 06treatment - 07Elapsed time after interruption - 08Prevention and prevention of recurrence ## Definition and Overview Medication overuse headache (MOH) is a secondary headache in which patients with existing headache disorders, such as migraine or tension-type headache, take acute headache medication excessively and the headache becomes chronic. In the past, it was called rebound headache or drug-induced headache, but in 2004, it was officially named drug-overuse headache in the International Headache Society (IHS) classification. Approximately 1-2% of the world's general population suffers from medication overuse headache, and approximately 50% of chronic headache patients visiting headache clinics suffer from medication overuse. It occurs approximately 3 to 4 times more often in women than in men, and is most common in people in their 30s to 50s. It occurs most frequently in migraine patients, and can also occur in patients with tension-type headaches or cluster headaches. Medication overuse headache forms a vicious cycle between headaches and painkillers. As headaches become more frequent, the number of times you take painkillers increases. If you take painkillers frequently, the brain's pain control system changes, making headaches more frequent. Recognizing this vicious cycle and intervening at the appropriate time is the starting point for treatment. ## causative drug Drugs that can cause medication overuse headache and their criteria are specified in the International Classification of Headache Disorders, Third Edition (ICHD-3). Simple analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, etc.) meet the criteria for medication overuse headache when taken more than 15 days a month for more than 3 months. Triptans (sumatriptan, rizatriptan, etc.), ergotamine, narcotic analgesics (opioids), and complex analgesics (including caffeine or sleeping pills) are taken when taken more than 10 days a month for more than 3 months. In a population-based longitudinal study, the risk of chronicity differed depending on the type of drug. The risk was highest for combination analgesics containing sleeping pills (odds ratio 2.06), followed by narcotic analgesics (odds ratio 1.98) and triptans (odds ratio 1.73). The risk of using simple analgesics alone was relatively low, but with frequent use, medication overuse headaches also occur. Even when multiple types of acute medications are used alternately, medication overuse headache may occur if the total number of days of use is more than 10 days per month, even if the number of days of use of each drug is below the standard. Therefore, it is important to manage the total number of days taken for all acute headache medications, not just one specific medication. ## Mechanism of occurrence Although the mechanism by which medication overuse headache occurs has not been fully elucidated, it is understood that several neurobiological changes play a complex role. Central sensitization is one of the key mechanisms. Repeated analgesic use lowers the excitation threshold of pain neurons at the level of the trigeminal nucleus caudalis and thalamus. As a result, allodynia occurs, in which headaches occur even when stimuli that normally do not cause pain, and allodynia is observed in approximately 60-70% of patients with medication overuse headaches. Serotonin receptor downregulation is also a major mechanism. Repeated use of triptans or ergotamine decreases the density and responsiveness of 5-HT1B/1D receptors. Because serotonin plays a key role in the descending pain inhibitory pathway in the brain, receptor downregulation leads to a weakening of endogenous pain modulation capacity. In brain imaging studies, patients with medication overuse headache were reported to have a decrease in gray matter volume in areas involved in pain processing and decision-making, such as the orbitofrontal cortex, anterior cingulate cortex, and insula. These structural changes are associated with drug-dependent behavior and have been shown to partially recover after successful drug withdrawal. In the case of narcotic analgesics, hyperalgesia through activation of glutamate receptors acts as an additional mechanism. This explains why drug overuse headache caused by narcotic analgesics is more difficult to treat and has more severe withdrawal symptoms than other drugs. Genetic predisposition is also involved. Even if painkillers are taken at the same frequency, there are patients who experience medication overuse headache and those who do not. Polymorphisms in the serotonin transporter gene (SLC6A4) and brain-derived neurotrophic factor (BDNF) gene have been reported to be associated with drug-overuse headache susceptibility. ## symptoms Symptoms of medication overuse headache vary depending on the existing headache type, but there are common characteristics. Headaches occur almost every day or every day, and it is common for people to already have a headache when they wake up in the morning. This is because rebound headaches appear as the blood drug concentration drops during sleep. The characteristics of existing migraines (throbbing pain on one side of the head) often change to bilateral and pressing pain. The intensity of the headache is moderate to severe and worsens with daily activities. It may be accompanied by hypersensitivity to light or sound and nausea, but it tends to be milder than the original migraine attack. Taking painkillers temporarily improves the headache, but once the drug's effect wears off, the headache recurs. The duration of the drug's effect gradually becomes shorter, and a tolerance phenomenon may occur in which a larger dose is needed for the same effect. It is accompanied by decreased concentration, memory loss, fatigue, and poor sleep quality. Depression and anxiety occur in approximately 40-60% of patients with medication overuse headaches, which greatly reduces quality of life. ## diagnosis The diagnosis of medication overuse headache is based on the International Classification of Headache Disorders, Third Edition (ICHD-3) criteria. The diagnostic criteria are as follows. A. Patients with existing headache disorders experience headaches more than 15 days a month. B. Regular overuse of one or more acute headache medications for more than 3 months. c. Not better explained by another ICHD-3 diagnosis. Overdose criteria vary depending on the type of drug. Simple analgesics (acetaminophen, NSAIDs) are used more than 15 days per month, triptans are used more than 10 days per month, ergotamines are used more than 10 days per month, narcotic analgesics are used more than 10 days per month, complex analgesics (including caffeine and sleeping pills) are used more than 10 days per month, and when using a combination of multiple drugs, a total of more than 10 days per month. There are some things to keep in mind when diagnosing. Medication overuse headache is diagnosed at the same time as an existing headache (mostly migraine or tension-type headache). For example, if a migraine patient is accompanied by medication overuse headache, both diagnoses of ‘chronic migraine’ and ‘medication overuse headache’ are given together. If headaches are reduced to less than 15 days per month within 2 months of stopping the causative medication, the diagnosis of medication overuse headache is lifted and only the underlying headache disorder remains. Headache diaries play a key role in diagnosis. If you record the date of headache occurrence, the date of drug use, and the type and dose of the drug for at least 4 weeks, you can objectively determine whether you have overused it. ## treatment ### cause drug discontinuation The key to treating medication overuse headache is stopping the acute medication being overused. There are two methods of withdrawal: abrupt withdrawal and gradual tapering. Abrupt discontinuation is recommended for overuse of simple analgesics, triptans, ergotamine, or complex analgesics. Stop the overused drug at once, and manage withdrawal symptoms with bridge therapy. Most expert guidelines suggest that rapid discontinuation is more effective than gradual tapering. Gradual reduction is recommended in cases of overuse of complex analgesics containing narcotic analgesics or sleeping pills. Sudden discontinuation may cause seizures or severe withdrawal symptoms, so gradually reduce the dose over 2 to 4 weeks. ### bridge therapy Bridge therapy is performed to relieve withdrawal headaches and accompanying symptoms that appear during the period of drug discontinuation. Drugs used in bridge therapy include short-term use (2-3 weeks) of non-steroidal anti-inflammatory drugs such as naproxen, short-term administration of oral steroids such as prednisolone, and antiemetics (metoclopramide, etc.). Bridging therapy is an auxiliary measure to help patients withstand the withdrawal period and is not intended for long-term use. ### Preventative medication concurrently Starting preventive medication simultaneously with or immediately after discontinuation of the causative drug is effective in preventing recurrence. If the underlying headache is migraine, topiramate, valproic acid, and amitriptyline are used as preventive medications. Botox injections (onabotulinumtoxinA) can be used as preventive treatment for chronic migraines. Monoclonal antibodies targeting CGRP (calcitonin gene-related peptide) have also been reported to be effective in patients with chronic migraine accompanied by medication overuse headache. According to the study, the number of headache days was significantly lower at 6 months in the group that stopped the causative drug and started preventive medication at the same time than the group that only stopped the drug. ### Non-pharmacological treatment Cognitive behavioral therapy (CBT) can help change medication-taking behavior and manage headache-related stress. The results of a randomized controlled trial were reported showing that medication overuse headache can be improved with only brief intervention in primary care. ## Elapsed time after interruption When the causative drug is stopped, withdrawal headaches usually begin within 2 to 10 days. The symptoms of withdrawal headaches vary depending on the type of drug you were overusing. Withdrawal headaches were reported to last an average of 4.1 days in case of triptan overuse, 6.7 days in case of simple analgesic overuse, and 9.5 days in cases of narcotic analgesic overuse. In addition to headaches, the withdrawal period may be accompanied by symptoms such as nausea, vomiting, low blood pressure, tachycardia, sleep disorders, anxiety, and nervousness. When stopping narcotic painkillers, more severe withdrawal symptoms such as sweating, muscle pain, and tremors may occur, so close observation is required. After the withdrawal period, headaches improve in most patients. At 2 months after discontinuation, approximately 50-70% of patients experience a significant decrease in headache frequency, and often return to their existing intermittent headache pattern. In patients who respond well, headache frequency begins to decrease 7 to 10 days after discontinuation. In some patients (approximately 20-30%), chronic headaches persist even after discontinuation. In this case, the underlying headache disease itself is chronic, and preventive medication adjustments and additional treatment strategies are necessary. ## Prevention and prevention of recurrence Medication overuse headache is a disease with a high recurrence rate. In a prospective study, it was reported that approximately 30% of patients who successfully discontinued treatment relapsed within 1 year, and approximately 40-50% relapsed within 5 years. Risk factors for recurrence include history of narcotic analgesic overdose, use of multiple analgesics, long-term history of overdose for more than 10 years, depression or anxiety, and past failure to stop. On the other hand, the recurrence rate in patients who overdose on triptan alone is relatively low. Strategies to prevent recurrence are as follows. First, strictly manage the number of days of acute medication administration. Simple analgesics are limited to no more than 10 days per month, and triptan or complex analgesics are limited to no more than 8 to 9 days per month. Second, objectively monitor the frequency of medication use by continuously keeping a headache diary. Third, maintain preventive medication for a sufficient period of time. Continue prophylactic medication for at least 6 to 12 months and then re-evaluate your condition. Fourth, actively treat comorbid conditions (depression, anxiety, sleep disorders). Fifth, changes in drug use patterns are captured early through regular outpatient follow-up. Maintaining regular sleeping, eating, and exercise habits and limiting caffeine intake (less than 200 mg per day) also contribute to preventing recurrence. Non-pharmacological approaches such as relaxation therapy, yoga, and mindfulness meditation for stress management are also effective when combined. ## Frequently asked questions ### Q01What is medication overuse headache? If you take painkillers too often, your headaches will increase, which is called medication overuse headache. It occurs when you take general painkillers for more than 15 days a month, or triptans or combination painkillers for more than 10 days a month for more than 3 months. As headaches become more frequent, you take more medicine, and as you take more medicine, headaches become more frequent, creating a vicious cycle. You don't need to worry too much because you can break this vicious cycle with professional help. ### Q02Why do my headaches get worse if I take a lot of painkillers? If you take painkillers frequently, the pain-suppressing system in your brain gradually becomes dull. When the drug's effectiveness wears off, the brain becomes more sensitive to pain than usual, causing headaches even from small stimuli. This is not because you took the medicine incorrectly, but rather a natural adaptive response of the brain, so you do not need to blame yourself. By adjusting the medication, the brain can return to its original state. ### Q03Which painkillers commonly cause medication overuse headache? All types of headache medications can cause medication overuse headache. In particular, complex analgesics containing narcotic analgesics and sleeping pills are at high risk, and triptans can also occur when used more than 10 days a month. General painkillers (acetaminophen, ibuprofen, etc.) are eligible if taken more than 15 days a month. If you are concerned about the medication you are currently taking, we recommend that you consult with a headache specialist to check your medication pattern. ### Q04How is medication overuse headache diagnosed? According to the diagnostic criteria of the International Headache Society, a person with a pre-existing headache who has regularly overused acute headache medication for more than 3 months and has headaches for more than 15 days a month is diagnosed with medication overuse headache. For an accurate diagnosis, it would be very helpful to keep a headache diary. Please record the days you had a headache for a month, the days you took medication, and the type and dosage of the medication. ### Q05How is medication overuse headache treated? The key to treatment is to stop the drug you are overusing. There are two ways to suddenly stop taking the drug and another to gradually reduce it. Depending on the patient's condition, a specialist will guide you on the appropriate method. We may prescribe other medications for a short period of time as bridge therapy so that you do not have any difficulties during the discontinuation period. At the same time, preventive medication will be started to prevent recurrence of headaches. If you find it difficult to stop on your own, be sure to make a plan with your specialist. ### Q06I heard that it hurts more at first when you stop taking the medicine. How difficult is it? When you stop taking the causing medication, you may experience withdrawal headaches for the first 2 to 10 days. Headaches can become temporarily worse and may be accompanied by nausea, anxiety, or sleep problems, which can be difficult. But this time will surely pass. In most cases, improvement occurs within 2 to 4 weeks, or 8 weeks at the most. We will guide you through bridge therapy and lifestyle management to help you survive the withdrawal period, so please have the courage to take on the challenge. ### Q07Is it easy for medication overuse headaches to recur? Unfortunately, it is a condition with a substantial recurrence risk. Studies show that even after successful discontinuation, recurrence is reported in approximately 30% within 1 year and in approximately 40-50% within 5 years. However, you can greatly reduce the risk of recurrence by consistently taking preventive medications, managing the number of days you take painkillers, and keeping a headache diary. You can manage it together through regular outpatient visits. ### Q08Should I not take painkillers at all? No. Taking painkillers when you have a headache is not a problem in itself. What matters is how often you take it. In general, you can avoid the risk of medication overuse headache by taking simple analgesics within 2-3 times a week (10 days a month) and taking triptans within 8-9 days a month. If you have frequent headaches and need to take painkillers frequently, it is better to start preventive treatment rather than taking more painkillers. We will develop an appropriate treatment plan through consultation. ### Q09Is it possible to treat medication overuse headache at Osang Neurosurgery? Yes, at Osang Neurosurgery, we systematically perform everything from diagnosis of medication overuse headache to discontinuation of the causative medication, withdrawal management, and preventive medication treatment. If the condition is not sufficiently controlled with drug treatment alone, neuromodulation treatment such as transcranial magnetic stimulation or stellate ganglion blockade is combined. Based on the symptoms and test results, headaches and autonomic symptoms are examined together, and a treatment plan is provided after consultation. Reservations can be made by calling 1599-5453. ## Related articles - giant cell arteritis - Hemicrania continua - Hypnic Headache - Idiopathic intracranial hypertension This article provides general medical information and does not replace an individual diagnosis or treatment plan. Please seek a medical assessment if symptoms persist. ## Important notice This Markdown alternative helps search and AI tools understand the public page accurately. It provides general health information and does not replace an individual diagnosis or treatment.