Medication Overuse Headaches: How to Identify & Find Relief

Ever taken a painkiller so often that it seems to create more pain than it eases? That paradox is the hallmark of a medication overuse headache (medication overuse headache), a condition where the very drugs meant to stop headaches end up causing them almost daily. Below you’ll learn how to spot this cycle, which meds are the biggest culprits, and practical steps to break free.

What Is Medication Overuse Headache?

Medication Overuse Headache (MOH) is defined by the International Headache Society as a chronic headache occurring on 15 or more days per month for over three months while regularly overusing acute headache medication. It was officially recognized in the ICHD‑3 guide in 2018, although clinicians have been describing “rebound headaches” since Dr. Seymour Kuttner’s 1982 paper.

Who Is Most Affected?

MOH isn’t rare-about 1-2 % of the general population lives with it, and women make up 70-80 % of cases. People who already have migraine (≈12 % of U.S. adults) or tension‑type headache (≈38 % globally) are especially vulnerable because they tend to reach for medication more often.

Which Drugs Can Trigger MOH?

Not all pain relievers carry the same risk. Below is a quick risk‑ranking based on current guidelines:

• Opioids (oxycodone, hydrocodone, tramadol) - overuse risk after just 10 days/month.
• Butalbital‑containing combos (Butapap, Lanorinal) - also 10‑day threshold.
• Triptans (Imitrex, Zomig) - risk begins at ≥10 days/month.
• Combination analgesics with caffeine/acetaminophen/aspirin (e.g., Excedrin) - moderate risk; overuse defined as ≥15 days/month.
• Simple NSAIDs (ibuprofen, naproxen) - lower risk unless daily doses exceed 1,200 mg (ibuprofen) or 660 mg (naproxen) and are taken ≥15 days/month.

Newer acute migraine treatments called gepants (ubrogepant, rimegepant, zavegepant) appear not to cause MOH, making them attractive alternatives.

How Do Doctors Diagnose MOH?

The diagnosis rests on three pillars:

1. Headache frequency ≥15 days per month for >3 months.
2. Regular use of an acute medication that meets the overuse thresholds listed above.
3. Evidence that the headache improves after stopping the overused drug.

Keeping a headache diary for at least four weeks-recording headache days, medication taken, and dose-helps both patient and clinician see the pattern clearly.

Getting Off the Medication: Withdrawal Strategies

The first step is to stop the offending drug. For most NSAIDs, an abrupt halt works fine. Opioids and butalbital‑containing meds usually need a taper to prevent severe withdrawal (nausea, vomiting, low blood pressure, and a spike in headache intensity). A typical taper might reduce the dose by 10 % every 2-3 days under medical supervision.

Withdrawal usually lasts 2-4 weeks, and during this “rebound week” rescue medication should be limited to non‑overused agents (e.g., a short course of a gepant or a low‑dose triptan used no more than two days a week).

Managing Withdrawal Symptoms

About 68 % of patients experience nausea, 42 % vomit, and nearly all (92 %) feel worsened headaches during withdrawal. Simple measures can ease the ride:

• Stay hydrated - aim for 2-3 L of water daily.
• Eat small, frequent meals to calm nausea.
• Use anti‑emetic medication (e.g., ondansetron) prescribed by your doctor.
• Rest in a dark, quiet room during peak headache periods.
• Consider short‑term corticosteroids (e.g., prednisone taper) for severe rebound, as suggested by the Mayo Clinic.

If symptoms become unmanageable, an inpatient program may be recommended, especially for opioid‑dependent patients.

Preventive Therapy After Withdrawal

Once the overused drug is out of the picture, the next goal is to prevent the underlying headache disorder from flaring again. Evidence‑based options include:

• Topiramate - 40-100 mg daily, reduces migraine days in about 50 % of patients.
• Propranolol - 80-160 mg daily, useful for tension‑type headaches.
• CGRP monoclonal antibodies (erenumab/Aimovig) - monthly injection, 50-60 % efficacy in chronic migraine.
• Gepants used preventively (e.g., atogepant/Qulipta) - newly FDA‑approved (2024) for chronic migraine, shown to lower headache days without overuse risk.

Starting preventive therapy right when withdrawal begins cuts relapse risk sharply; studies show a 78 % relapse rate when prevention is delayed.

Key Takeaways

• MOH occurs when acute headache meds are used ≥10-15 days/month for >3 months.
• Opioids, butalbital combos, and triptans have the highest overuse risk.
• Diagnosis relies on headache frequency, medication overuse, and improvement after cessation.
• Withdrawal may need tapering for opioids and butalbital; expect 2-4 weeks of rebound symptoms.
• Preventive treatments (topiramate, propranolol, CGRP antibodies, gepants) are essential to keep headaches at bay.

Frequently Asked Questions