Overusing Medications Can Cause Headaches

What kind of headache is not relieved by pain medications but actually caused by their frequent overuse?

Eight years ago, in the October 2004 issue of Worst Pills, Best Pills News, an article about medication overuse headache (MOH) described how to recognize these headaches and how to significantly reduce, if not stop, their occurrence. Since then, especially in the last three years, much more research has been done concerning this important, drug-induced disease affecting millions of people in the U.S. alone. The following article provides an update to our 2004 work on the topic.

Overview of MOH

First described in a medical journal 23 years ago, MOH may be the cause of a headache that occurs on 15 or more days per month, presents a dull pain of light to moderate intensity, and is on both sides of the head.

It is important to note that “overuse” refers not to excessive dosage (as in a drug overdose) but, even more important, to the frequency of usage. MOH can be caused by regularly using some acute pain-relieving medications a certain number of times per month, for more than three months, as defined here:

• consistent use of ergotamines or triptans (both of which are migraine drugs), opioids, or combination analgesic medications for 10 or more days per month for more than three months; or
• consistent use of simple painkillers such as aspirin or acetaminophen (TYLENOL) or any combination of ergotamine, triptans or opioids for 15 or more days per month for more than three months.

The table below provides a list of drugs in each of these categories.

There is now evidence-based agreement that all drugs used for the treatment of headache can cause MOH, based on the following criteria:

• headache begins or worsens during overuse of medication; and
• headache disappears after successful withdrawal, usually within two months.

Commonly Used Drugs that Can Lead to Medication Overuse Headaches (MOH)*

* Benzodiazepines (such as VALIUM or LIBRIUM) and barbiturates (such as ESGIC-PLUS or FIORICET) are not included in this table, but they are often used in addition to other MOH-causing drugs. These drugs are addicting, and withdrawal from them needs to be gradual. Nonsteroidal anti-inflammatory drugs (NSAIDs, such as ADVIL or MOTRIN) are also used to treat migraines but are generally the least likely drug family to cause MOH.
** Limited Use
*** Do Not Use

How do patients develop MOH?

It is widely agreed that prior to developing MOH, many patients previously have had other common headache disorders, such as tension headaches or migraines. The gradual or acute worsening of these headaches can lead to more frequent use of painkillers, which in turn causes MOH to exist in addition to the original type of headache. An increase in MOH can occur when patients increase the frequency with which they use painkillers — often to daily use — possibly due to the fear of a headache upon abrupt withdrawal.

Treating MOH

A recent study, made up of MOH patients from Norway, began by obtaining a history of subjects’ use of the previously mentioned drugs and a neurological exam to rule out other headache causes. The “treatment” was simple: basic information, tailored to the individual patient, including a discussion with the patient’s doctor of both the role of drugs in developing MOH and the likelihood that cessation of the painkiller overuse would lead to an improvement.

The results were quite striking. This group of people had experienced chronic headaches for an average of 15.5 years, with the duration of medication overuse averaging 8.5 years before the educational intervention. By the time of the follow-up, an average of 1.5 years after the intervention, the average number of days of taking a medication had decreased from 22 days to six days per month. In addition, 76 percent of the patients no longer had MOH, and 42 percent no longer had any type of chronic headaches.

Another recent study reviewing MOH treatment guidelines included evidence concerning the manner in which the previously overused painkillers were discontinued. This study found that there was no overall difference in patient outcome whether patients abruptly withdrew from the overused medication or tapered down its use more gradually. (As noted below, withdrawal from certain classes of medications, such as opioids, benzodiazepenes and barbiturates, must be gradual.) The goal of stopping the medication was to ultimately improve the future effectiveness of the drugs for more intermittent use while also stopping the chronic MOH headaches and getting the drugs out of patients’ systems. The main symptom during withdrawal was temporary worsening of the headache, with other symptoms depending on which drug(s) were used. Most symptoms lasted from two to 10 days.

It is important to note the review’s recommendation that the tapering approach might involve inpatient withdrawal therapy for those patients overusing opioids, benzodiazepines (tranquilizers/sleeping pills) or barbiturates. This is because even in the absence of MOH, these particular groups of drugs can cause classic addiction.

What You Can Do

You should contact your physician if you are using one of the drugs mentioned in the table and you exhibit the characteristics of MOH described at the beginning of the article.

You and your doctor can discuss the important details of MOH and, depending on your individual case, the type of withdrawal from the MOH-causing drugs that is best for you. However, for those drugs that can cause addiction, such as opioids, barbiturates and benzodiazepine tranquilizers, abrupt withdrawal is not recommended.