Dr. Rahul Chakor Neurologist
Special Interest in Neuroimmunology, Epilepsy

Introduction

Inappropriate use of acute headache medications by patients with frequent migraine or tension-type headache may contribute to the development of a chronic, daily (or almost daily) headache. This headache is caused by the use of the painkilling drugs themselves (which are being used by the patient for headache relief ). This is a very disabling type of headache. It is called medication overuse headache (MOH), drug induced headache, painkiller headache, rebound headache or transformed migraine.

It may affect 1–1.4% of the general population. It is nearly daily (chronic) headache that occurs after the regular intake (overuse) of any kind of anti-headache or anti-migraine drugs.

Thus it is a chronic headache in patients with migraine or tension-type headache that occurrs after overuse of headache medication and stops within 1 month of withdrawal of the overused medications.

The term chronic is defined as occurrence of headache for at least 15 days per month.

Symptoms

About 65% of the patients are primarily suffering from migraines, 27% fro tension-type headache, and 8% a combination of migraine and tension-type headache or other headache. Most of the patients are women (female–male ratio, 3.5:1).

The medications commonly overused are Triptans (Ritza, Suminat, Naratriptan), Ergotamine (Migranil, Vasograin), Diclofenac (Diclogen, Diclonac, Voveran, dynapar, voltaflam), Saridon, other over the counter analgesics like APC, Nimesulide (Nise), tramadol, paracetamol, aspirin, benzodiazepines, barbiturates.
The diagnostic criteria for MOH are as follow:

1. Headache present on ≥15 days per month
2. Regular overuse for >3 months of one or more acute/symptomatic treatment drugs as defined under subforms of 8.2:
   1. Ergotamine, triptans, opioids, or combination analgesic medications on ≥10 days per month on a regular basis for >3 months.
   2. Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on ≥15 days per month on a regular basis for >3 months without overuse of anysingle class alone.
3. Headache has developed or markedly worsened during medication overuse.

The headaches are refractory (do not respond), occur daily, or nearly daily. Headaches vary in severity, type and location from time to time. Physical or intellectual effort may bring on headache i.e. the threshold for head pain seems to be low in these patients. Withdrawal symptoms are observed when patients are taken off pain medication abruptly.

Associated symptoms of asthenia (generalized weakness), nausea and other gastrointestinal Symptoms are common. There may be irritability, anxiety, restlessness or depression. There are other memory problems and difficulty in intellectual concentration, thinking. These symptoms further worsen headache leading to overuse of painkillers and a vicious cycle is set..  

Spontaneous improvement of headache occurs after a few days of discontinuation of the overused medicines.

Differential diagnosis:
The following secondary headache disorders have to be excluded by appropriate investigations like MRI, MRV, MRA brain with contrast in all suspected cases.

Primary headache disorders

• Chronic migraine
• Chronic tension type headache

Secondary headache disorders

• Cerebral venous and sinus thrombosis
• Giant cell arteritis
• Intracranial hypertension/hypotension
• Space occupying lesions
• Chronic Meningitis

Prevention

The most important aspects of helping patients avoid MOH are providing proper instruction about “not to overuse/self-medicate in case of frequent headaches”.

To avoid dependency on pain killers, the intake frequency of headache drugs must be restricted (eg, analgesics, < 15 intake days monthly; triptans, < 10 intake days monthly). Drugs that contain caffeine, opioids, tranquilizers/sedatives or barbiturates should be avoided. FDA is doing a commendable job by putting a ban on giving these medications without prescriptions. Strict actions have been taken on medical/chemist shops in case of dispensing medicines without a valid prescription.

Early migraine prophylaxis by medical and behavioral treatment might be a preventive way to avoid MOH.

Treatment

Abrupt withdrawal of overused medications is the treatment of choice. Most patients improve after discontinuing regular drug intake. Discontinuation of drug intake leads to a reduction of in migraine, tension-type headache, and mixed migraine and tension-type headache. Drug withdrawal can be done in outpatient or inpatient basis depending on the severity of patients symptoms.

Treatment options for the acute withdrawal phase include fluid replacement, analgesics (Naproxyn), tranquilizers, neuroleptics, amitriptyline, valproate, oxygen etc. Steroids (prednisolone): 60 mg on Day 1, tapering by 20mg every 2 days for total 6 days. Clonidine: Start with 0.1 – 0.2mg thrice a day and titrate up / down depending on withdrawal symptoms (esp. for opioid withdrawal), Topiramate: start with 25 mg & target 100 mg/day and Tizanidine: 2 to 6 mg/day are the other medications used during withdrawal.