Medication Overuse Headache
Medication overuse headache (MOH) is a chronic daily headache caused by the use of too much acute medication. It generally occurs in people with migraine or tension-type headaches who take drugs too often. When the effect of one dose wears off, a withdrawal reaction occurs, triggering the next headache and another round of medication. This results in a vicious cycle of daily headaches and increasingly frequent medication intake. MOH was previously called rebound headache, drug-induced headache, and medication-misuse headache. The most common cause of medication overuse headache is overuse of dietary caffeine or caffeine-containing drugs.
MOH is likely to occur if you are taking opioid (narcotic), barbiturate (butalbital) or caffeine-containing medications on 2 or more days each week. Many doctors and even headache specialists think that over-the-counter pain medications, such as Tylenol or Advil can also cause medication overuse headaches, but scientific research conducted by Dr. Richard Lipton and his colleagues proved that these medications are very unlikely to worsen headaches. In his study thousands of people were followed for one year and had the frequency of migraine headaches and medications they were taking recorded. As little as one dose of a narcotic medication a week appears to increase the risk of worsening of headaches. Medications in the opioid (narcotic) category are codeine, hydrocodone (Vicodin), oxycodone (Percocet, Oxycontin), and many other. Taking aspirin actually makes it less likely that headaches will worsen over time. In fact, daily use of naproxen (Aleve, Naprosyn, Anaprox) has been shown to be effective in prevention of migraine headaches.
You should definitely avoid frequent use of over-the-counter combination pain medications containing caffeine, such are Excedrin, Anacin, BC Powder. Prescription drugs containing a barbiturate, butalbital, such as Fiorinal, Fioricet, and Esgic (which also contain caffeine) also increase the risk of developing medication overuse headaches. Fiorinal and similar drugs have never been proven or approved for the treatment of migraines since they only work for tension-type headaches. Triptans (sumatriptan/Imitrex, zolmitriptan/Zomig, rizatriptan/Maxalt, naratriptan/Amerge, almotriptan/Axert, frovatriptan/Frova, eletriptan/Relpax) have not been proven to increase the risk of developing medication overuse headaches.
If you previously had occasional migraines or tension-type headaches that have gradually increased into a daily or near-daily headache in the setting of frequent medication intake, you probably have MOH. As the headache frequency increases, you may notice that your acute medications do not work as well as they previously did. It is important to recognize MOH because it can worsen your prior headache pattern. The overuse of acute medications can also decrease the effectiveness of your headache prevention medication. Other potentially dangerous effects of medication overuse include the development of physical dependence, addiction (with barbiturates and narcotics) as well as liver and kidney problems.
The best way of treating MOH is to stop or wean off the offending medication under the guidance of your doctor. Though doing so may result in a period of worsened headaches, you will be given a substitute medication to help you through this difficult time. If you take more than 4 – 5 tablets of medications with butalbital (Fiorinal, Fioricet or Esgic) daily you may be given additional short-term medication, phenobarbital to prevent potentially serious withdrawal symptoms, such as seizures. In case of narcotic medications, it may take a month or even longer before detoxification from the acute medication is complete and your headaches improve. Withdrawal from caffeine and caffeine-containing drugs is much quicker and usually easier. People who continue to have daily headaches despite stopping overused medications may require daily preventative medications or Botox injections. Non-drug therapy also plays a role in the treatment of MOH. Acupuncture, biofeedback, meditation or relaxation training and cognitive-behavioral therapy can be very effective, particularly when used in conjunction with medications. Many people are very afraid to stop taking a medication they’ve taken for years and this leads to anxiety and paralysis. Cognitive-behavioral therapy can be the only way such patients can succeed in stopping the MOH. Magnesium, especially given intravenously, CoQ10, boswellia, feverfew, and other supplements can also be of great help.
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This “book” appears to have largely been born out of his blog from the New York Headache Center. For years, he has regularly put up information, scientific and clinical, for his headache followers. He has created this “book,” actually an e-book, which takes relevant information from his experience and knowledge of migraine. There is no need for an index and chapter references. He uses hyperlinks, embedded in the e-book, to connect to material online, which he puts in context for the reader. This works very well as one hyperlink may go to an original paper or publication or a resource site.
He links to major medical journals including headache journals and his own publications, when helpful, as well as nonmedical literature and other sites. This format allows the e-book to be updated from time to time, which is easy to do with this approach.
The book has a very interesting introduction and deals with evidence-based medicine and its role in migraine therapy. When he begins the section on 150+ treatments, he starts with a very interesting comment. Many of the treatment ideas that I describe in this book are not just off-label (that is, not approved by the FDA) but may appear to be off-the-wall. It is refreshing to hear such intellectual honesty from a practicing neurologist.
There is a great section on supplements and finding someone to help with your migraine, such as coach, a partner, or a sympathetic friend. A diagnostic discussion follows and is most helpful, as proper diagnosis directs treatment, as are the detailed sections on triggers including environment, food, exercise, physical therapies, and sleep. Herbal therapies are covered as is neuromodulation and injections/blocks among others.
In the sections on drugs, he deals with acute therapies and the modern use of triptans and gepants, and a ditan. Preventive therapies start with monoclonal calcitonin gene-related peptide antibodies, tricyclic medications, and many other preventive therapies including beta blockers, anti-seizure drugs, nonsteroidal anti-inflammatory drugs, and botulinum injections. From acupuncture to Feldenkrais methods, he covers the contemporary plethora of migraine “treatments” as he sees it in practice.
He ranks all medications on a 1 to 10 scale regarding his own subjective opinions of the utility of each treatment. He indicates that no treatment gets 10 as a score and any receiving a score of 1 were not rated. He also lists his favorite migraine therapies separately. He includes a lot of data links here, from single case reports to full-scale randomized clinical trials, and detailed reviews. His clinical acumen shines through the volume and one gets the impression that this is a very personal view at times, not always backed by evidence, as there may not be any, but by experience, practice and pragmatism. He carefully notes the general things to be careful of in taking some treatments and warns if there are serious concerns. Nonetheless, he indicates clearly that the advice of a medical professional should be sought before trying the therapies mentioned.
Diagnosing secondary headache that can mimic migraine or vice versa is a useful section but does not go into depth about the disorders/diseases mentioned, as this is not the intention of the book. Special circumstances are given sections including menstrual migraine, pregnancy, resistant/refractory headache, aura and headache, and many others.
The author is a senior, highly experienced neurologist and has a high degree of interest in migraine and other headache disorders. He has a sense of curiosity about the brain and migraine and that comes through to the reader of this small volume. I count 23 endorsements, including the excellent foreward of the book from a wide range of well-known people, which includes two prior editors of this journal. He is well liked and highly respected by his colleagues.
In many ways, this book does what online databases on diseases cannot do most times. He tells the reader what he knows and how to use that knowledge. He directs the novice and experts to the right literature and takes the reader on a personal journey through the field of migraine treatments. He tells people, “…keep seeking relief, not to give up on or blame yourself for the pain you experience from migraine.”
There is a printed version of the book; however, the e-book is ideal for the intended purpose. I would recommend it the first instance. It is available via a commercial site and inexpensive.
I would recommend this book to anyone who has migraine or cares for people with migraine and wants a broad and sometimes detailed overview of the treatments. Available in the e-book format, it represents a lot of work for one person, but his passion, occasional humor, and historical perspectives are evident in this work. You don’t have to agree or accept everything the author says to enjoy and benefit from this “book,” and I know he would want people to be critical and skeptical where warranted. However, you will find more than you would usually need to know from this banquet of 150 ways to help your migraines! Enjoy, I did very much. Read it through once and save as reference.
Alexander Mauskop, Director of the New York Headache Center, and Marietta Abrams Brill, a freelance medical writer, have written principally for headache sufferers in North America. They answer questions like “is Rolfing covered by medical insurance?”, and include an excellent resource section in the back. of the book which lists American organizations for the various therapies. But they provide enough background information on both headache and alternative treatments to make their book interesting to readers from other countries, too. In covering most of the more common alternative therapies~like herbs, acupuncture, massage, Ayuverda and Eastern medicine, and qigong-they aim to inform rather than judge, cite research evidence where it exists, and point to potential dangers as well as benefits.
Each of the 10 chapters is introduced with a pithy quote: “Divine is the work to subdue pain” (Hippocrates) heads the first chapter. After general background on pain theories and headache diagnosis, common alternative approaches are covered in turn and there is, of course, oodles of advice on diet and nutrition. A helpful glossary guides readers through words that conventional doctors are familiar with, like Scotoma, and those with which we aren’t, like Qi, Vatta, and Pitta. To round off, a comprehensive resource section and selected bibliography give useful directions to readers wanting more information about specific therapies.
Like all good guides, this one follows a logical structure and so it is relatively simple to go quickly to the information you want to find. It is easy to read. All in all, it is a guide which headache sufferers looking for good information on alternative therapies can be thankful for.