Medication overuse headache: how to recognise and prevent it

Medication overuse headache is headache on 15 or more days a month caused by taking painkillers or triptans too often. It is also called rebound headache or MOH. It is one of the most common, and most overlooked, causes of daily headache: the medicine that helps you during an attack can end up keeping the headache going.

What is medication overuse headache?

Medication overuse headache is a form of chronic headache caused by frequent use of painkillers, triptans or combination medicines. The brain gets used to the medicine and responds with headache when it wears off, so you reach for medication again. This creates a vicious circle.

The limit lies at 10 to 15 days a month:

• Triptans or combination painkillers: use on 10 or more days a month, for at least 3 months
• Paracetamol or anti-inflammatory painkillers (such as ibuprofen, naproxen or diclofenac): use on 15 or more days a month, for at least 3 months

A useful rule of thumb: use acute medication on no more than 2 to 3 days a week. More than that increases the risk of medication overuse headache.

Can paracetamol and other painkillers cause headaches?

A headache from paracetamol sounds contradictory, since you take it to treat headache. Yet it is a common problem with medication overuse. With regular use, the brain adapts and becomes more sensitive to pain once the medicine wears off. The same applies to ibuprofen, naproxen and other anti-inflammatory painkillers.

This explains why some people feel their headache "never goes away": the medication they take keeps the problem going. The pattern shifts from separate migraine attacks to an almost daily, dull headache with occasional more severe migraine attacks on top.

How do you recognise rebound headache?

Rebound headache is another name for medication overuse headache. Signs include:

• you have headache on more than 15 days a month
• you regularly use painkillers or triptans (more than 2 to 3 days a week)
• the headache is already there when you wake up
• your medication works for a shorter time or less well
• you used to have separate migraine attacks, but now the headache is almost daily

If you recognise this, discuss it with a migraine specialist or your GP. Medication overuse headache is treatable, but it needs a different approach from ordinary migraine.

Rebound headache and migraine can exist side by side: migraine comes in attacks with headache-free days in between, while rebound headache is an almost daily, dull headache.

How is medication overuse headache treated?

Treatment has two parts: reducing the overuse of acute medication, and starting suitable preventive treatment. A specialist decides with you which order and approach fit your situation.

Cutting down on acute medication

International guidance often includes a period of stopping or sharply reducing the overused medicine, sometimes called withdrawal or detox. This gives the brain a chance to recover and respond normally to pain again. The first one to two weeks are usually the hardest, as headache can temporarily get worse. Afterwards, most people notice a clear improvement: fewer attacks, and acute medication that works better again.

Have you already tried a detox without enough benefit? Then you do not have to repeat it. A different approach is likely to be needed, such as starting preventive treatment straight away. A migraine specialist can assess which route makes most sense for you.

Preventive treatment

Preventive treatment reduces the number of migraine attacks over time. At The Migraine Clinic, our migraine specialists prescribe the gepants atogepant and rimegepant, and the CGRP antibodies erenumab, fremanezumab and galcanezumab. International research shows that CGRP-targeted treatment can also work without a detox first. This offers hope for people whose earlier detox did not work or who find a detox period too hard.

Other preventive options exist, such as candesartan, beta blockers, topiramate, amitriptyline or botox. We do not offer these, but your GP can discuss them with you.

How can you prevent medication overuse headache?

• Keep a medication diary: note every day you take medication, so you can see quickly if you are approaching the limit
• No more than 2 to 3 days a week of acute medication: this is the most important rule of thumb
• Discuss preventive treatment: if you have more than 4 attacks a month, prevention is a better strategy than taking acute medication more and more often
• Do not manage it alone: always discuss your medication use with a migraine specialist or your GP, especially if you find yourself reaching for medicine more often

When should you see a specialist?

If you think you may have medication overuse headache, or you notice you need painkillers or triptans more and more often, it is wise to see a migraine specialist. At The Migraine Clinic, an online clinic specialised exclusively in migraine, we help you break the vicious circle and draw up a treatment plan that works for you.

About 10 million people in the UK live with migraine. A significant number of them have medication overuse headache, often without knowing it.

All our care takes place online, through video consultations. Take the migraine test, see how to start, or read more about acute medication and preventive medication.

This article was written by the medical team of The Migraine Clinic, an online clinic specialised exclusively in migraine.