The existence of medication overuse headache is debated

Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other).

Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts.

Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS:

“It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month”.

And then she posed a question: How many are being harmed vs helped by this advice?

While Dr. Lipton quoted scientific articles supporting the existence of MOH, Dr. Scher’s conclusions reflected my clinical experience that MOH is not a proven entity as it relates to triptans and NSAIDs. I see it only in those who overuse caffeine or caffeine-containing drugs (Excedrin, Fioricet, etc) or narcotic pain killers (Percocet or oxycodone, Vicodin or hydrocodone, and other).

Dr. Scher concluded that, “Since the existence of MOH has not been proven (and may be non-provable for practical purposes), one is obligated to remain agnostic about this entity. And the corollary is that there is no evidence that undertreating will prevent headache frequency progression and may harm more people than help”.

In fact, the same headache experts who limit abortive therapies to twice a week, recommend aggressive abortive therapy for migraines because undertreatment of episodic migraine can lead to its transformation into chronic migraine.

She also indicated that “Quality of evidence for medication withdrawal alone as treatment for MOH is poor” and “Medication withdrawal alone is not clearly better than doing nothing and may be worse”. Meaning that in addition to withdrawal of the acute medication, patients should be given prophylactic treatment.

Studies indicate that after one year, 60% and after two years, 70% of those with chronic migraines (15 or more headache days in a month) revert to episodic ones (less than 15 headache days a month) regardless of treatment. In 15% headaches decrease to less than one a week. This is because fortunately, migraines often improve with time on their own.

We have evidence that Botox injections and some preventive medications can make discontinuation of acute medications easier. We always try to stop Fioricet (butalbital, acetaminophen, and caffeine), Fiorinal (butalbital, aspirin, and caffeine), Excedrin (caffeine, acetaminophen, aspirin) with the help of regular aerobic exercise, biofeedback or meditation, magnesium and other supplements, Botox injections, and sometimes preventive medications.

However, we do have several dozen patients whose headaches are controlled by the daily intake of triptans. These patients have tried given prophylactic medications, Botox injections and other treatments, but find that only triptans provide good relief and eliminate migraine-related disability. The most commented on post on this blog (with 175 comments to date) is one on the daily use of triptans.

  1. Jack Wehr says: 10/06/20164:02 pm

    Thank you kindly, doctor.

  2. Dr. Mauskop says: 10/06/20162:43 pm

    Yes, it is worth trying a longer-acting triptan such as naratriptan or frovatriptan, but for some of my patients they do not work as well even if thought the do last longer. Frovatriptan is a branded product (Frova) and is very expensive, but naratriptan is generic and is cheaper, but it is still much more expensive than sumatriptan.

  3. Jack Wehr says: 10/06/20168:24 am

    Greetings doctor, and fellow headache survivors. I just wanted to take the opportunity to let Dr Mauskop know how much his expertise and time are so very much appreciated. I have no doubt he has saved lives here, including me.
    Doctor, I do have a question. I have an appointment with University of Cincinnati headache clinic, as you suggested. I am not able to get in till January, as only one doctor specializes in botox. I wish I could make the trip to see you, but I could not handle the drive.
    My question, the daily imitrex works, but I am needing to take 200mg a day. Could you please suggest if it would be appropriate to add a longer acting triptipan, and/or other meds. I am hoping my internist will allow me to continue the 30 fiorinal with codeine a month, at least until the botox trial, as some of the severe pain and vomiting only respond with taking both drugs, but this is only a few times a month.
    I printed out the blog, and faxed to him but do not know if he took your kind offer to call you.
    Thank you for any help you can offer.
    Jack Wehr

  4. Dr. Mauskop says: 07/27/20169:27 pm

    Fortunately, not everyone develops MOH from opioid analgesics. There are exceptions where patients take a narcotic pain killer without worsening of headaches, addiction, tolerance. Or any other side effects. This is more likely when the dose is relatively small, like in your case. I should add that the best treatment for cervical dystonia is Botox injections, which also help prevent migraine headaches.

  5. Ana says: 07/27/20163:35 pm

    Thank you for this post. This is both a comment and question. Could you elaborate on what “overuse” of opiods would look like? I ask because after 5 years with chronic migraine I received a diagnosis of cervical dystonia. In addition to botox, cymbalta and orphenadrine I find that to control pain I need to take about 5mg oxycodone almost daily or twice daily depending on any flares. (NSAIDS are not effective and have led to gastritis. Tramdol and norco lead to a headache when they wear off generally). On the whole my migraines have improved significantly by adequately treating the neck pain….I wonder how long I’ll be able to do this before getting into an MOH pattern?
    Thank you.

  6. Ellen says: 07/15/20162:36 pm

    Thank you for this timely blog post. My neurologist (who is the director of a headache clinic) insists that MOH exists and that triptans can cause MOH. He doesn’t believe that MOH is common, but firmly believes that triptans can cause it. I frequently worry about MOH (I take triptans 4-5 times per week), so I take some comfort in knowing that this topic remains unsettled at this point.

Submit comment