Avoiding Medication Overuse Headache – Primary Steps for Primary Care

Primary Steps for Primary Care | March 28, 2019 | cookchildrens

Headaches are a common complaint to primary care offices. In children, headaches are frequently transient, related to concurrent illness, inadequate hydration, or other common lifestyle factors. Commonly, over-the-counter treatments (i.e. NSAIDs) are recommended for the treatment of acute headache. While this is often effective, for patients with more frequent headaches – the repeated use of pain medications can worsen the headache disorder and produce a chronic medication overuse headache with extended exposure. Below, we discuss this headache type and some recommendations for preventing the occurrence of analgesic overuse headache in your patients.

Medication Overuse Headache

In patients with primary headache disorders, such as migraine headache and tension headache, a medication overuse headache can significantly increase disability. Frequent headaches can result in frequent intake of acute headache medications, leading to worsening of the headache and unintentionally leading to medication overuse headache. It is thought that medication overuse can have long lasting effects on sensitization of the trigeminal system and therefore increased vulnerability to developing acute headache attacks. In order to prevent medication overuse, it is important to treat chronic headache disorders with appropriate preventive therapies and educate patients regarding overuse of abortive therapies.

What is medication overuse headache?

According to the International Classification of Headache Disorders, medication overuse headache is:

  • Headache occurring on greater than 15 days per month in a patient with a pre-existing headache disorder (such as migraine).
  • Regular overuse for > 3 months of one or more drugs that can be taken for acute symptomatic treatment of headache.

What is “regular overuse” of medication?

  • Using triptans (i.e. Maxalt, Imitrex), ergot alkaloids (i.e. DHE, Migranal), combination analgesics (i.e. Fiorcet, Excedrin Migraine), or opioids on 10 or more days per month.
  • Using a combination of the above medications plus simple analgesics (i.e. Ibuprofen or Tylenol) on more than 10 days per month.
  • Using simple analgesics on 15 or more days per month.

Why does this happen?

  • The exact mechanism of how this happens is unclear. Continued drug exposure is thought to interfere with the neurotransmitter systems and cause sensitization of the trigeminal pathway which plays a role in acute headache.

How do you treat medication overuse?

  • Once in medication overuse, withdrawal of the overused medication is the only treatment. Improvement usually starts to occur within 10-14 days, and long term is associated with significant decline in both pain intensity and frequency of headache in patients with migraine.
  • A “washout” period is typically recommended. There is no consistent guideline regarding how long this period should be, and ranges from two weeks to two to three months in the literature.

How to prevent medication overuse?

  • Acute treatments should be limited to two or fewer days per week.
  • If a third headache happens in a week, recommend trying to treat only with fluids, specifically fluids with electrolytes (Pedialyte, Gatorade, Powerade, etc.) May continue to use anti-emetics as needed for nausea.

Contributing author

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Elora Corbin, MD

Neurology

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Cook Children's Neurosciences team

Great outcomes begin with great input. Having a medical system where every department, doctor, and care team member works together means that your child can have quick access to testing, diagnosis and treatment, and that means better outcomes now and in the future.

Contact the Jane and John Justin Neuroscience Center at Cook Children’s with your questions at 682-885-2500.

Resources:

Lipton, Richard B. “Risk factors for and management of medication-overuse headache.” CONTINUUM: Lifelong Learning in Neurology 21.4, Headache (2015): 1118-1131.

Rizzoli, Paul. “Medication Overuse Headache.” Pain Medicine. Springer, Cham, 2017. 531-532.

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