Also called chronic daily headache or rebound headache, MOH most commonly occurs in people with a primary headache disorder such as migraine, cluster headache, or tension-type headache, according to the American Migraine Foundation. It’s caused by too frequent use of acute medications, although exactly what “too frequent” means can depend on the drug being taken. Medication-overuse headache isn’t only troublesome because you have near-constant head pain: MOH can also cause headaches that are resistant to preventive migraine medications, making acute therapies less effective as well. Stewart Tepper, MD, professor of neurology at the Dartmouth Geisel School of Medicine in Hanover, New Hampshire, spoke about MOH in his talk “Medications That Make Migraine Worse,” as part of the Migraine World Summit, held March 17 to 25, 2021. In addition to explaining how MOH develops and how to reduce your risk, Dr. Tepper observed that the newest type of acute migraine treatment — a drug class called CGRP receptor antagonists, sometimes referred to as “gepants” (pronounced gee-pants) — does not carry the risk of medication-overuse headache. Here’s what to know about medication-overuse headache.
1. Medication-Overuse Headache Has a Precise Definition
The International Headache Society defines MOH as a headache occurring on 15 or more days per month in a person with a preexisting primary headache disorder and developing as a consequence of regular overuse of acute or symptomatic headache medication for more than three months. Different medications have different guidelines as to what constitutes overuse. The use of triptans, ergot alkaloids, combination analgesics (pain relievers), or opioids for 10 or more days of the month is considered overuse, according to the American Migraine Foundation. Taking simple analgesics, including nonsteroidal anti-inflammatories (NSAIDs) — a drug class that includes aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve) — on 15 or more days a month also constitutes overuse. Usually medication-overuse headaches resolve after the overuse is stopped, although people may undergo a period when their headaches get worse before they get better.
2. Quantity Matters in Medication-Overuse Headache, Not Quality
Medication-overuse headache can feel different in different people, according to Tepper. “What I tell people is that it doesn’t really matter if it’s front or back, right or left, up or down, mild, moderate, or severe. It’s not the quality of the headache; it’s the quantity of the headache,” he says. The distinguishing feature of MOH is how often occurs, he says.
3. Any Day With Any Type of Headache Counts as a ‘Headache Day’
If you aren’t sure if what you’re experiencing is MOH, try keeping a calendar and counting the number of headache days you have. Don’t just count the days when you have symptoms of a migraine attack but rather all days with any type of headache, says Tepper. Alternatively, he suggests counting the number of completely headache-free days you have. “How many days are crystal clear from the moment you open your eyes until the minute you go to bed at night, without a twinge of headache? The crystal-clear days should be at least 15 days per month in order to not be in chronic migraine,” he says.
4. Taking Certain Medications Just Once a Week Can Make Migraine Worse
The two pain medications that are most likely to make migraine worse are butalbital — which is a barbiturate that is mixed with other pain medicines and is included in the medications Fioricet and Fiorinal — and opioids of any sort, says Tepper. These types of medications can be used for emergency relief for a migraine attack but should be used with caution because of their risk for rebound headache, according to the American Migraine Foundation. Opioids, also called narcotics, such as oxycodone (Oxycontin) and hydrocodone (Hysingla ER, Zohydro ER), can cause headaches to worsen or become more frequent by using them just once a week. Butalbital is linked with overuse when used four times a month or more, according to the American Migraine Foundation. These medications alter the pain regulatory systems of the brain in a bad way, and they not only worsen migraine attacks in terms of frequency, severity, and duration but also often make them untreatable, says Tepper.
5. Pain Medications Taken for Any Reason Can Lead to MOH
Taking analgesics for reasons besides your migraine can still cause medication-overuse headache, according to StatPearls. “Say you’re taking it for low back pain, the brain does not know the difference,” says Tepper, adding that the frequency of use and the type of medication are associated with the transformation to MOH.
6. The More Headache Days You Have, the Higher Your Risk for Chronic Daily Headache
“The more headache days a person has, the more likely they are to transform to chronic migraine,” says Tepper. Studies conducted both in the general population and in clinics show that people who have 10 to 14 headache days per month are 20 times more likely to develop daily headache than people who have fewer than five headache days per month, he says. “The frequency of the headache days is actually a big risk for transforming, and the frequency of headaches is linked to how many times somebody reaches for an acute medication to treat,” says Tepper, adding that although these are separate risks, they feed each other. “It’s why we try so hard to reduce the total number of headache days per month, as well as the number of acute medication days per month,” says Tepper.
7. Caffeine Can Contribute to Medication-Overuse Headache
Caffeine at 100 to 200 milligrams (mg) per day is probably enough to contribute to medication-overuse headache, says Tepper. For reference, 8 ounces of coffee has between 80 and 100 mg of caffeine, and 12 ounces of a caffeinated soft drink has between 30 and 40 mg, according to the Food and Drug Administration. The headache medication Excedrin has 65 mg of caffeine per tablet. However, many people are fond of their caffeine-containing beverages. “I tend to try to work around the caffeine, as long as it’s not high-dose caffeine, to see if we can help them without taking away one of their pleasures,” says Tepper.
8. Pain Relievers Aren’t the Only Kind of Medication That Can Contribute to MOH
Over-the-counter decongestants and prescription sleeping medications can significantly contribute to MOH, according to Tepper. “There’s a controversy whether benzodiazepines can cause medication-overuse headaches. I personally think they can interfere with treatment, and so I do not prescribe them for my migraine patients. Even when they have anxiety, I look for other treatments,” he says. Amphetamines, which are sometimes used to treat attention deficit hyperactivity disorder but are also used illegally to get high or improve mental or sports performance, can cause medication-overuse headache and daily headache, notes Tepper.
9. MOH May Be Caused by Overusing a Combination of Drugs
The guidelines on medications for MOH are divided into different classes, but almost nobody takes just a single drug to treat migraine, says Tepper. “You may have some days with triptans, some days with combination analgesics, some days with NSAIDs. It’s probably best to assume that if someone is taking 10 or more days of acute treatment per month, they are likely to develop medication-overuse headache and transformation into chronic migraine,” he says.
10. CGRP Migraine Treatments Don’t Increase the Risk of MOH
One type of medicine to treat migraine, CGRP receptor antagonists, doesn’t appear to cause transformation into daily headache, says Tepper. Medications in this class include rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy), both taken orally for acute migraine. CGRP-blocking medicines are also used for preventing migraine. Atogepant (Qulipta) and rimegepant (Nurtec ODT) are available in tablet form. In addition to the oral medications, four CGRP-blocking medications are given by injection:
Epitinezumab (Vyepti)Erenumab (Aimovig)Fremanezumab (Ajovy)Galcanezumab (Emgality)
