Medication Overuse Headache (or MOH) is a condition that people who already have a particular type of headache, like migraine or tension-type headache, have an increase in frequency of their episodes due to the medication they are taking. In other words it’s a case of the drugs you are taking to help your headache, actually making it worse.
So how can the Melbourne Headache Centre help you treat it and what are the drugs you need to be aware of?
The key is how many days per month you take these medications. Not how much you take on a given day. Read more on each medication under MOH diagnosis.
Medication Overuse Headache Treatment
The only solution is to get off the medications that are causing the problem, but here’s the trick. When you have a frequent migraine or headaches, you aren’t going to be too happy to stop taking the one thing that gives you some relief and helps you cope, even if it is only for a few hours.
You need an alternative, that’s better than putting up with more pain.
As Dr Larry Charleston advises: “What I would suggest is a comprehensive headache treatment plan and that is going to have the non-pharmacological and behavioral modalities.” (1)
In short the best non-pharmacologic treatment is to treat the most common source of irritation of the brainstem - the three nerves that come in through the top of the neck. Behavioural modalities refers to a plan to 'sow the SEEDS' to good headache health.
This is where we come in. The non-pharmacological modalities should target the underlying problems, rather than mask symptoms like the medications do. The technique we use is the only neck-based technique proven to lower the sensitivity of the ‘headache centre’ in the brainstem where migraine and headache originates. In other words we treat the underlying problem.
It’s no coincidence that the connection between the neck and headpain appears to be stronger in those with medication overuse headache, as Dr Charleston has found:
“ There were more opioid overuse in patients with Medication Overuse Headache and neck pain than in patients with MOH without neck pain. Opioid use was associated with a greater severity of neck spasms in this population.” (2)
That isn’t because the opioids are causing spasms. It is because spasms are painful, and people are using medication to cope with the pain that is coming from their neck.
It isn’t hard to see that if we successfully treat the underlying neck disorder, that the spasm will improve, and medication use (opioid or otherwise), will decrease. This starts to provide a window of opportunity to decrease the medication, allowing the body to ‘cleanse itself’ and affected systems reset.
Research has shown that in about 50-65% of cases withdrawing the medication will see the symptoms revert back to what they were pre-medication overuse, but we need to treat the underlying issues first, otherwise trying to wean off medications will fail as people seek short term relief.
Behavioural interventions include addressing the most common aggravating co-factors, sumarised by the acronym S.E.E.D.S (Sleep, Eating (diet), Exercise, Dehydration, Stress). Click here to read more about a natural approach that includes SEEDS.
Medication Overuse Headache or MOH is not the same as drug abuse. In fact many people are well under the maximum dosages, however, MOH relates to the number of medication days, not individual numbers of tablets. The type and number of medications up until recently has not been well understood, for example someone taking a codeine 2-3 days per week would not think they are taking too many tablets, however more than 10 codeine days per month is in the ‘overuse’ zone. There are a number of terms associated with medication that are often used interchangeably. Medication overuse is not the same as tolerance, dependence and addiction:
Tolerance: your body is ‘getting used’ to the medications your are taking. Over time the same dose doesn’t seem to relieve the pain as well so you take higher doses, and sometimes the medication can become ineffective altogether. In other words your body has built up a tolerance to the medication and it is less effective. It more typically leads to overdosing as people take more medication to achieve the same result. Medication Overuse Headache is defined on the number of medication days per month, and not the amount of medication taken each day, so tolerance is more likely to lead to overdosing than medication overuse headache.
Dependence: This is what happens when people stop taking a medication, most commonly in headache, opioids or caffeine, and they suffer adverse effects from the drug not being in their system. These adverse effects are sometimes referred to as withdrawal symptoms and can lead people to start taking the medication again, not to treat the original ailment, but to avoid the withdrawal symptoms. This can lead to an increase in ‘medication days’ per month and increase the risk of medication overuse headache.
Addiction: This a not merely choosing to take medications to avoid adverse effects, but a compulsion to continue taking a substance despite a lack of positive effect or the harm it may be doing. This is a complex condition involving distorted thinking, and behavior involving a substance to the point where people have intense cravings and find it hard to stop.
Medication Overuse Headache - Diagnosis
Dr Medication Overuse Headache (MOH) is defined by the ICHD-3* as: A. Headache occurring on >15 days/month in a patient with a pre-existing headache disorder B. Regular overuse for > 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache C. Not better accounted for by another ICHD-3 diagnosis
(*ICHD-3: International Classification of Headache Disorders Version 3)
The specified number of days of medication use considered to constitute overuse are based on expert opinion rather than on formal evidence.
Ergotamine/Triptan-Overuse and Opioid-Overuse Headache Regular intake of one or more triptans/opioid/ergotamine in any formulation, on >= 10 days per month for > 3 months.
Paracetamol/NSAID Regular intake of paracetamol/NSAID’s, on >= 15 days per month for > 3 months.
During the 2018 Migraine World Summit Dr Andrew Charles from UCLA highlighted 6 other medications that are seen clinically to exacerbate migraine. "Pretty much any medication is on the table as a possible exacerbator of migraine………you have to always consider even something that may seem innocuous as a potential contributor"
He named the following medications as possible problems, that if you migraines are worsening, and you are taking these, yu should consult your doctor and neurologist for a review of the medications:
SSRI's - Prozac, Zoloft, Lexapro, Celexa, Paxil. These are prescribed for depression, but amazingly up until a few years ago were also prescribed for chronic migraine. This was based on the idea that 'more serotonin good, less serotonin bad' view of migraine, but it's just not that simple.
Proton pump inhibitors (PPI's) - These are prescribed for GORD (GERD in the USA) or reflux. Nexium or protonix being the most common. Alternative are dietary changes and histamine 2 or H2 blocekrs (zantac/pepcid). There's also some evidence they may be bad for things like bone density and possibly involved in cognitive decline in the longer term.
Nasal decongestants - Nasonex, Flixonase, Claratyne D – anything with a decongestant is a potential trigger, especially containing pseudoephedrine which acts as a CNS stimulant.
Caffeine - can interfere with pain transmission in the brainstem. Avoid pandol extra.
Oral contraceptives - high oestrogen can exacerbate but its very individual as in some people they seem to exacerbate the peaks and troughs and others it smooths them out - its very individual.
Butalbital complex - Fiorinal or Esgic – 5 days per month can make migraine worse. These have been taken off the shelf in many countries.
"People kind of make the assumption that because something is ‘over-the-counter’ it’s not going to be problematic in terms of their migraine, and that’s very often not the case"
Charleston, IV, Larry (2017) When Medications Actually Trigger Pain. Migraine World Summit.
Charleston, IV, L (2012) The Incidence of Neck Pain in MOH with Neck Spasm and disability Assessments. Program Abstracts, 54th AHS Annual Scientific Meeting, Los Angeles. Headache, May 2012, 862-914.
Charles, Andrew (2018) 6 Medications that make migraine worse. Migraine World Summit