Managing medication-overuse headache

Q: What is the best treatment for medication-overuse headache?

A: Medication-overuse headache can be caused by prolonged use of any headache medication (e.g. triptans, paracetamol, NSAIDs, combination analgesics).^1.2 Medication withdrawal is the only effective treatment.^2-4

Consider specialist referral and inpatient withdrawal for people who overuse combinations of medications, or medications containing barbiturates, tranquilisers or opioids, as well as those with anxiety or depressive disorders.^3.4

Explain to people that the medication they are taking regularly is the main cause of their headache.³ Ensure that they understand that the outcome of medication withdrawal is usually good (compared with the alternative: ever-increasing headache).³

During withdrawal limited use of naproxen, metoclopramide or nightly low-dose amitriptyline may help to reduce withdrawal symptoms including exacerbation of headache.² Reduce the risk of relapse through planned follow-up and ongoing support.³

The prevalence of medication-overuse headache is about 1% of adults in the general population.¹ People with medication-overuse headache have a history of primary headache (e.g. tension-type, migraine).¹ Diagnosis can only be confirmed once the overused medication is stopped and headaches resolve or revert to their original pattern.²

Prevent medication-overuse headache by advising people not to take medications more than 2–3 days per week and encourage use of a headache diary to record headache frequency and medication use.^1-3

References
1.        Anonymous. Management of medication-overuse headache. DTB 2010;48:2-6.

2.        Neurology Writing Group. Therapeutic Guidelines: Neurology, Version 4 Updated November 2011 [eTG complete CD-ROM]. Melbourne: Therapeutic Guidelines Ltd, 2011.

3.        British Association for the Study of Headache. Guidelines for all health professionals in the diagnosis and management of migraine, tension-type headache, cluster headache and medication overuse headache. Hull: BASH, 2010. http://www.bash.org.uk/ (accessed 13 December 2011).

4.         Scottish Intercollegiate Guidlines Network. Diagnosis and management of headache in adults. Edinburgh: NHS Quality Improvement Scotland, 2008. http://www.sign.ac.uk/pdf/sign107.pdf (accessed 19 December 2011).