Medication-Overuse Headache
Medication-overuse headache (MOH), sometimes called rebound headache, usually develops in a person who already has migraine or another primary headache disorder and begins using acute headache medication too frequently.
A self-perpetuating cycle may develop: headaches become more frequent, acute medication is used more often, and headache frequency continues to increase. Episodic migraine may eventually evolve into a pattern of chronic, daily or near-daily headache.
When is medication-overuse headache diagnosed?
According to ICHD-3, MOH develops in a person with a pre-existing headache disorder who develops frequent headache in association with regular overuse of one or more medications used for acute or symptomatic headache treatment.
How many medication days per month are too many?
The threshold depends on the drug class and the number of days on which it is used — not simply on the number of tablets.
| Medication / class | ICHD-3 threshold | Comment |
|---|---|---|
| Triptans | ≥10 days/month | Regular use for more than 3 months. |
| Combination analgesics | ≥10 days/month | Especially products containing several active components, for example an analgesic combined with caffeine or an opioid. |
| Opioids | ≥10 days/month | This group is also associated with a relatively high risk of relapse after withdrawal. |
| Paracetamol / acetaminophen | ≥15 days/month | Regular use for more than 3 months. |
| NSAIDs | ≥15 days/month | For example ibuprofen, naproxen and other non-steroidal anti-inflammatory drugs. |
| Multiple medication classes | combined ≥10 days/month | MOH may occur even when no single drug class is individually overused. |
Why counting medication days matters
A patient may say: “I hardly take anything — only one tablet.” But if that tablet is taken every other day, the medication exposure may be clinically important.
For MOH assessment, the useful question is: on how many days each month do you take medication for headache?
Example
If a patient takes one triptan tablet on 12 separate days in a month, this exceeds the ICHD-3 threshold for triptan overuse.
If two doses are needed during one difficult migraine day, that still counts as one medication-use day.
What does medication-overuse headache feel like?
There is no single characteristic or diagnostic pain pattern. MOH may resemble migraine, tension-type headache, or vary in character from day to day.
Headache becomes more frequent
A typical history is a gradual transition from separate attacks to headache on many days each month.
Medication relief becomes shorter
The acute treatment may appear less durable, and another dose is needed sooner.
The phenotype becomes mixed
Some days resemble migraine, while others feel more dull, pressing or almost continuous.
Medication helps initially, but frequent use may eventually help maintain the headache
MOH is understood as an interaction between frequent exposure to acute headache medication and the nervous system of a person predisposed to headache.
With prolonged overuse, central pain-processing mechanisms may become altered, trigeminal sensitivity may increase, and central sensitisation may help maintain chronic headache.
This does not mean that analgesics or triptans are “bad medications”. They are important for treating migraine attacks. The problem begins when the need for acute treatment becomes too frequent.
The two diagnoses can coexist
A common clinical scenario is a patient with migraine whose headache frequency gradually increases, together with more frequent use of triptans or analgesics.
The patient may eventually fulfil diagnostic criteria for both chronic migraine and medication-overuse headache.
A self-perpetuating cycle
- migraine becomes more frequent;
- acute medication is needed more often;
- overuse contributes to chronification;
- headache frequency increases further;
- medication use rises again.
A headache diary is particularly useful when MOH is suspected
Patients often find it difficult to remember exactly how many days per month they use different medications, especially when paracetamol, NSAIDs, triptans and combination products are all being used.
Headache days
Record every day on which headache occurs, regardless of its severity.
Medication days
Record which medication was used and on which day.
Treatment response
Note whether the medication helped, how quickly headache returned, and whether a repeat dose was required.
Treatment is not simply “stop taking painkillers”
Modern MOH management aims both to reduce excessive use of acute headache medication and to improve control of the underlying headache disorder.
Understand the mechanism
The first step is understanding how frequent use of acute medication can help maintain chronic headache.
Change medication frequency
The strategy depends on the specific drug, dose, duration of use and accompanying medical conditions.
Treat the underlying migraine
When attacks are frequent, effective preventive treatment is often needed to reduce the need for acute medication.
Do not leave the patient without treatment
After changing the previous medication pattern, the patient still needs a clear and effective strategy for future migraine attacks.
Monitor medication days
Headache frequency and acute medication use should be followed over time, not assessed only once.
Prevent relapse
After improvement, the aim is to avoid a gradual return to frequent acute medication use.
Does the medication always need to be stopped immediately?
There is no single strategy that is correct for every patient. Management depends on the drug being overused and the complexity of the clinical situation.
Triptans and simple analgesics
In many cases, they can be stopped abruptly or substantially restricted, while a new headache-treatment plan is introduced.
Opioids, barbiturates and some sedative medications
After prolonged regular use, abrupt self-discontinuation may be inappropriate or unsafe. These medications may require gradual withdrawal under medical supervision.
Headache may temporarily worsen after reducing medication
This is important to discuss in advance. After stopping or sharply reducing a frequently used medication, headache may temporarily worsen during the first days.
Nausea, sleep disturbance, anxiety, dizziness or general discomfort may also occur. The duration depends on the medication used and the individual situation.
Effective migraine prevention can help break the cycle
When frequent or chronic migraine underlies MOH, effective preventive treatment becomes a central part of management.
Traditional preventive treatment
Depending on the clinical situation, traditional migraine preventive medications, including topiramate and other options, may be considered.
Botulinum toxin therapy
OnabotulinumtoxinA is used for prevention of chronic migraine and can also be effective in patients with coexisting medication overuse.
CGRP-targeted treatment
Monoclonal antibodies targeting CGRP or the CGRP receptor have demonstrated efficacy in patients with migraine and coexisting medication overuse.
Why follow-up remains important
After successful treatment, headache frequency may decrease substantially, but the risk of returning to excessive acute medication use remains.
This is particularly likely when the underlying migraine is still poorly controlled: attacks become more frequent, acute medication use gradually increases, and the old cycle can return.
What helps reduce relapse risk?
- effective preventive treatment;
- a headache diary;
- a clear acute-treatment plan;
- monitoring medication-use days;
- early adjustment of treatment if headache frequency rises again.
The main goal
A patient should not live in constant fear of taking a tablet for headache.
The goal is different: to make migraine attacks infrequent and well controlled enough that acute medication does not become a chronic necessity.
What should be assessed when MOH is suspected?
What existed before?
Migraine, tension-type headache or another headache disorder, and what the previous headache frequency was.
How many headache days?
The actual number of headache days per month is important, not only the number of severe attacks.
What is being taken?
Triptans, paracetamol, NSAIDs, combination analgesics and other acute medications.
Count the days
The number of days each medication class is used per month needs to be established.
Why is migraine not controlled?
It is important to assess whether preventive treatment has been used, how effective it was, and whether it is appropriate.
How to break the cycle
A strategy is developed for correcting medication overuse, preventing migraine and safely treating future attacks.
More about migraine and chronic headache
Treatment of chronic migraine and medication-overuse headache with Dr Lidiia Prakhova
Dr Lidiia Prakhova is a specialist neurologist with more than 35 years of clinical experience. Migraine, chronic headache and modern preventive treatment are part of her outpatient neurological practice.
When MOH is suspected, it is important not only to identify frequent medication use, but also to determine which underlying headache disorder led to this pattern and how it can be controlled more effectively.
Frequently asked questions about medication-overuse headache
How many days per month can triptans be used?
How often can ibuprofen or other NSAIDs be used?
Can paracetamol also cause medication-overuse headache?
If I alternate different painkillers, is there no risk?
Do I have to stop all painkillers forever?
Will headache get worse after withdrawal?
Does Botox help chronic migraine with medication overuse?
Can CGRP treatments be used in patients with MOH?
Does medication-overuse headache improve after reducing medication use?
Main medical sources
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202.
- International Headache Society. 8.2 Medication-overuse headache (MOH). ICHD-3.
- Rizzoli P. Medication-Overuse Headache. Continuum (Minneap Minn). 2024;30(2):379–390. doi:10.1212/CON.0000000000001403.
- Diener HC, Antonaci F, Braschinsky M, et al. European Academy of Neurology guideline on the management of medication-overuse headache. Eur J Neurol. 2020;27(7):1102–1116. doi:10.1111/ene.14268.
- Koonalintip P, Phillips K, Wakerley BR. Medication-Overuse Headache: Update on Management. Life. 2024;14(9):1146. doi:10.3390/life14091146.
If acute headache medication is needed too often, the migraine-treatment strategy needs to change
Counting headache days, triptan and painkiller days, assessing the underlying migraine and selecting effective preventive treatment can help break the cycle of frequent headache and frequent medication use.
