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Updated: Nov 1 2016

Medication Overuse Headaches

  • Snapshot
    • A 26-year-old female presents with chronic headache. The headache commonly begins in the morning, and persists for most of the day. The headache occurs almost daily and averaging around 20 headaches per month. She reports that abortive therapy with zolmitriptan and acetaminophen are no longer effective. She has taken these medications approximately 15-20 times per month for the last 4 months. Her medical history is significant for migraine with aura. Physical examination is completely normal.
  • Introduction
    • Secondary headache disorder due to medication overuse in patients with a primary headache disorder (e.g., migraine, tension-type headache)
      • also known as rebound headaches
      • headaches occur ≥ 15 times/month
      • medication use ≥ 10-15 times/months for > 3 months
        • medications include:
          • opioids
          • acetaminophen
          • triptans
          • NSAIDs (lowest risk)
  • Epidemiology
    • Prevalence is higher in women
    • Patients with a history of migraine, tension-type headache, or both are at risk
  • Pathophysiology
    • not fully elucidated
      • all medications used for acute treatment of primary headache disorder can lead to medication overuse headaches
      • data suggests it does not happen de novo
        • patients must have a history of primary headache disorder
      • may involve central sensitization
  • Presentation
    • Symptoms
      • headache
        • daily or almost daily
      • nausea
      • irritability
      • problems with memory
  • Evaluation
    • Clinical diagnosis
      • headaches (≥ 15 times/month)
      • medication use (≥ 10-15 times/months for > 3 months)
        • depends on medication
      • history of primary headache
        • e.g., migraine, tension-type headache
  • Differential
    • Chronic migraine
    • Chronic tension-type headache
  • Treatment
    • Discontinue overused headache medication (first-line)
    • Bridge therapy
      • provide symptomatic relief while patient is withdrawing from offending agent
  • Prognosis, Prevention, and Complications
    • Prevention
      • education on medication overuse headaches
      • headache diary
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