Medication Overuse Headaches

Diagnosis

Medication overuse headaches are most often diagnosed based on a detailed headache history and a review of how often pain-relief medicines are used. In most cases, testing is not needed. A diagnosis is usually made when a person already has a headache disorder, experiences headaches on 15 or more days each month for longer than three months, and regularly uses headache medicines more than recommended.

Treatment

Treatment focuses on breaking the cycle of medication overuse and learning safer ways to manage headache pain. Education is a vital part of care. Understanding how frequent use of pain medicine can worsen headaches helps prevent recurrence.

To stop medication overuse headaches, pain medicines must be stopped or reduced. Your healthcare professional may recommend stopping the medicine suddenly or gradually lowering the dose, depending on the type of medication and your overall health.

Breaking the cycle

When pain medicine is stopped, headaches often become worse before they improve. This temporary worsening is expected. Withdrawal symptoms may occur and can include:

• Nervousness

• Restlessness

• Nausea

• Vomiting

• Insomnia

• Constipation

These symptoms usually last between two and ten days but may continue for several weeks in some people.

To manage headache pain and reduce withdrawal effects, your healthcare professional may prescribe short-term treatments known as bridge or transitional therapy. These treatments may include nonsteroidal anti-inflammatory drugs, corticosteroids, nerve blocks, anti-nausea medicines, or dihydroergotamine given through a vein.

Hospitalization

In some situations, stopping pain medicines is safer in a hospital setting. A short hospital stay may be recommended if you have anxiety, depression or other medical conditions, take high doses of medicines containing opioids or butalbital, or use substances such as tranquilizers, opioids or barbiturates.

Preventive medicines

Preventive medicines are often used to help break the cycle of medication overuse headaches and manage the underlying headache condition, such as migraine. These medicines are usually taken daily and prescribed during or after the withdrawal phase. Options may include:

• Anticonvulsants, such as topiramate

• Tricyclic antidepressants, such as amitriptyline or nortriptyline

• Beta blockers, such as propranolol

• Calcium channel blockers, such as verapamil

For people with a history of migraine, injectable CGRP monoclonal antibodies may be recommended. These include erenumab, galcanezumab and fremanezumab, which are given as monthly injections, or eptinezumab, which is given by vein every three months.

Injections

Injections of onabotulinumtoxinA may reduce how often headaches occur each month and may lower headache severity in some people.

Cognitive behavioral therapy

Cognitive behavioral therapy, also known as CBT, is a form of talk therapy that teaches coping strategies for managing headaches. CBT also encourages healthy lifestyle habits and the use of a headache diary to track triggers, symptoms and responses to treatment.