Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
Dallas, Texas 75230
Medication Overuse Headache
The International Classification of Headache II describes medication overuse headache (MOH) as a syndrome related to overtreating. Chronic Daily Headache is a term that implies having headache over 15 days a month. A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly. MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans. Patients typically rotate to different drugs and take many drugs at the same time that may cause MOH. After awhile the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem. It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t. When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going. The patient develops a constant, daily headache problem often times with sensitivity to light, nausea, and irritability. Because serotonin levels in the brain drop, the patient may also develop anxiety, depression, poor concentration, and insomnia, which also are core symptoms.
Drugs that can cause this syndrome are:
Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Wigraine; Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Demerol, MS OxyContin, Darvocet, Darvon, Tylenol with codeine; Drugs with barbiturates– Fiorinal, Fioricet, Phrenilin, Esgic.
The International Headache Society criteria for medication overuse headache are:
Triptans or Ergotamine intake >10 days/month
Non-opioid simple analgesics >15days/month
Opioids or Analgesics combined with barbiturates >10days/month
The only effective treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time. Unless the patient was treated with “Bridge Medication” a terrific headache would come after stopping medication and then the headache would clear. The patient has to stay off any drug on the list above during this time. Bridge medication is: one or two weeks dose of oral cortisone, usually as Medrol Dosepak, for the chemical brain inflammation and Migranol nasal spray every 3 hours as needed for acute treatment of headache. The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of medication abuse. Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume. The patient should limit painkillers to no more than 2 days/ week for the rest of their life. Preventive medications such as topiramate, amitriptyline, or beta-blockers may started, hopefully to reduce the number of monthly migraines. 40% of patients with MOH have generalized anxiety disorder (GAD) and 50% have depression which may need treatment. 50% of patients with MOH get it again.