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Medication overuse headache
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of medication overuse headache are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2024), the The Scottish Intercollegiate Guidelines Network (SIGN 2023), the German Migraine and Headache Society (GMHS/GSN 2022), the European Academy of Neurology (EAN 2020), the American Academy of Neurology (AAN/AHS ...
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Screening and diagnosis
Identification of at-risk patients: as per GMHS/GSN 2022 guidelines, consider identifying patients at increased risk for developing MOH through general practitioners, pharmacists, or evaluation of prescriptions. Monitor prescription and OTC medications in these patients and refer them to a headache specialist in a timely manner.
E
Diagnostic investigations
Initial assessment: as per DoD/VA 2024 guidelines, consider assessing for the following high-risk factors for MOH in patients with headache:
headache frequency (≥ 7 days per month)
migraine diagnosis
medication use: frequent use of anxiolytics, analgesics (for any condition, including use of opioids or nonopioid analgesics for the short-term treatment of migraine), or sedative hypnotics
history of anxiety or depression, especially in combination with musculoskeletal or gastrointestinal symptoms
physical inactivity
sick leave of > 2 weeks in the past year
self-reported whiplash
smoking (tobacco use).
C
Medical management
Discontinuation of overused medication, advice: as per GMHS/GSN 2022 guidelines, provide counseling and education alone for the treatment of MOH in patients overusing triptans or simple analgesics without severe psychiatric comorbidities.
E
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Discontinuation of overused medication (setting)
Discontinuation of overused medication (protocols)
Management of withdrawal symptoms
Headache prophylaxis
Specific circumstances
Pediatric patients
As per AAN/AHS 2019 guidelines:
Counsel pediatric patients with migraine and their families to use no more than 14 days of ibuprofen or acetaminophen per month, no more than 9 days of triptans per month, and no more than 9 days per month of any combination of triptans, analgesics or opioids for > 3 months to avoid MOH.
B
Discuss the potential role of preventive treatments in pediatric and adolescent patients with migraine and MOH.
B
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Patients with idiopathic intracranial hypertension
Preventative measures
Preventive counseling
As per SIGN 2023 guidelines:
Inform patients starting acute treatment for migraine about the risk of developing MOH.
B
Address medication overuse in patients overusing acute treatment.
A
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Preventive medical therapy
Follow-up and surveillance
Indications for referral: as per GMHS/GSN 2022 guidelines, refer patients overusing opioids or patients with relapse after previous withdrawal treatment to a headache center to receive multimodal care, or manage them as inpatients, with additional psychological counseling.
E
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Follow-up