People with a primary headache disorder, such as migraine or tension-type headache, might be experiencing undesirable pain secondary to the intake of acute headache medication. This is called a medication overuse headache (MOH) or transformed headache. MOH is a chronic condition occurring on more than 15 days in a month, which is no longer responding to previously effective analgesics. Most patients have a background of migraine, which has slowly transformed over months and years from the episodic to chronic form, (Wakerly, 2019) losing the characteristics of migraine (such as photophobia, osmophobia, phonophobia, and the gastrointestinal symptoms of nausea and vomiting). (Krymchantowski et al, 2020)
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Who is more likely to have MOH?
In the general population, the likelihood of developing MOH ranges from 0.5 to 2.5 % in adults (with more females than males), but that percentage is higher in headache centers, where up to 30% of headache patients in Europe and 50 % in the USA have MOH. If the patient has depression, anxiety, or chronic pain conditions the numbers are even higher. MOH is seen most in those aged 40 to 45, but other age groups can be affected. Interestingly, patients with MOH are also more likely to have relatives who overuse drugs or have substance abuse problems, so a link between both conditions has been studied. (Cheung et al, 2015; Diener
et al, 2019)
Is MOH a drug-seeking behavior?
Certain characteristics of MOH share similarities with drug dependence, suggesting that there might be common underlying biological and behavioral mechanisms. The patients exhibit compulsive drug-seeking behavior, withdrawal headaches, and high relapse rates. Studies have shown that there might be a maladaptive reward system in both disorders, related to changes in the dopaminergic system. (Lau et al, 2020) A genetic predisposition seems likely, but locating specific genes and associations is still under review. (Cargnin et al, 2018)
Examples of headache medications that can trigger MOH
- Over-the-counter pain relievers, such as ibuprofen (ex: Advil) or acetaminophen (ex: Tylenol).
- Combination over-the-counter pain relievers, such as Excedrin (combines caffeine, aspirin, and acetaminophen).
- Prescription migraine medications, such as triptans (ex: Imitrex) and ergots (ex: Ergomar).
- Opioid medications, such as those that include codeine.
No painkillers for MOH!
The evidence supports stopping the analgesic intake reduces the frequency of the headaches, however, this is not an easy task since the patient requires management of the pain. Considering currently available evidence and the systemic toxicity of overusing acute headache medication, discontinuation of the overused medication with the addition of preventive medication seems a logical choice. (Chiang et al, 2016) The patient will require support and understanding that the initial or primary headache will still be present when the MOH is resolved.
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References:
- Wakerley BR. Medication-overuse headache. Pract Neurol. 2019 Oct;19(5):399-403. doi:10.1136/practneurol-2018-002048. Epub 2019 Jul 4. PMID: 31273078.
- Krymchantowski AV, Jevoux CC, Krymchantowski AG, Vivas RS, Silva-Néto R. Medication overuse headache: an overview of clinical aspects, mechanisms, and treatments. Expert Rev Neurother. 2020 Jun;20(6):591-600.
- Cheung V, Amoozegar F, Dilli E. Medication overuse headache. Curr Neurol Neurosci Rep.2015 Jan ;15(1):509. doi: 10.1007/s11910-014-0509-x. PMID: 25398377.
- Diener HC, Dodick D, Evers S, Holle D, Jensen RH, Lipton RB, Porreca F, Silberstein S, Schwedt T. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol. 2019 Sep;18(9):891-902. doi: 10.1016/S1474-4422(19)30146-2. Epub 2019 Jun 4. PMID: 31174999.
- Lau CI, Liu MN, Chen WH, Walsh V, Wang SJ. Clinical and biobehavioral perspectives: Is medication overuse headache a behavior of dependence? Prog Brain Res. 2020;255:371-402. doi: 10.1016/bs.pbr.2020.05.019. Epub 2020 Jun 19. PMID: 33008514.
- Cargnin S, Viana M, Sances G, Tassorelli C, Terrazzino S. A systematic review and critical appraisal of gene polymorphism association studies in medication-overuse headache. Cephalalgia. 2018 Jun;38(7):1361-1373. doi: 10.1177/0333102417728244. Epub 2017 Sep 4. PMID: 28870085.
- Alstadhaug KB, Andreou AP. Caffeine and Primary (Migraine) Headaches-Friend or Foe? Front Neurol. 2019 Dec 3;10:1275. doi: 10.3389/fneur.2019.01275. PMID: 31849829; PMCID: PMC6901704.
- Espinosa Jovel CA, Sobrino Mejía FE. Caffeine and headache: specific remarks. Neurologia. 2017 Jul-Aug;32(6):394-398. English, Spanish. doi: 10.1016/j.nrl.2014.12.016. Epub 2015 Feb 26. PMID: 25728949.
- Chiang CC, Schwedt TJ, Wang SJ, Dodick DW. Treatment of medication-overuse headache: A systematic review. Cephalalgia. 2016 Apr;36(4):371-86. doi: 10.1177/0333102415593088. Epub 2015 Jun 29. PMID: 26122645.
