Makindo Medical Notes

Related Subjects:Migraine |Basilar Migraine |Cluster Headaches |Sumatriptan |Tension Headache |Analgesic Overuse Headache |Headaches in General

Medication Overuse Headache (MOH) = chronic daily headache caused by frequent/excessive use of analgesics or migraine-specific drugs. ⚠️ Typically occurs in patients with pre-existing migraine or tension-type headache who escalate medication use → creating a cycle of dependency & worsening pain.

• 🔑 Primary Cause: Overuse of headache medications (analgesics, triptans, ergotamines, opioids).
• 👩‍⚕️ Commonly Affected: Patients with chronic migraine or tension-type headaches.

📋 Clinical Presentation

Key features of MOH include:

• 📆 Headaches ≥15 days/month.
• 😣 Persistent, dull, daily headache (often present on waking).
• 💊 Temporary relief with analgesics → rapid recurrence → cycle of overuse.
• 🌀 Progression from episodic to chronic headache pattern.

🤔 Suspect MOH If:

• ✅ Headache ≥15 days/month in a patient with known migraine/chronic headache disorder.
• ✅ Regular overuse of acute headache drugs for >3 months:
  • 💉 Ergotamines
  • 💊 Triptans
  • 🩹 Simple analgesics (paracetamol, ibuprofen, etc.)
  • 💊 Opioids

🔎 Investigations

🖥️ Imaging (MRI/CT) is usually normal. Its main role = exclude secondary causes of chronic headache. No specific biomarker exists for MOH → diagnosis is clinical.

• Imaging: Normal (rule out tumour, raised ICP).

🧾 Differential Diagnosis

• 🌩️ Migraine progression: Episodic → chronic, without clear medication link.
• 🧠 Brain tumour: If neurological deficits, seizures, or abnormal imaging.
• 👁️ Benign Intracranial Hypertension (BIH): Daily headache + papilloedema/visual symptoms.

🛠️ Management

Successful management = breaking the cycle of medication overuse + treating the underlying headache disorder.

• 📉 Reduce analgesic use: Gradual tapering or abrupt withdrawal (depending on drug type & risk of withdrawal).
• 🛡️ Prophylaxis for background headache: – Migraine: beta-blockers (propranolol), antiepileptics (topiramate, valproate), CGRP inhibitors. – Tension-type: consider amitriptyline.
• 💊 TCAs: Amitriptyline useful in chronic daily headaches.
• 🎓 Patient education & support: Explain MOH cycle; stress long-term reduction strategies.
• 👩‍⚕️ Follow-up: Essential to prevent relapse; behavioural therapy may help.

💡 Exam Pearl: Think MOH when: “Daily headaches + analgesic overuse + normal imaging”. 👉 Always ask about frequency of analgesic use in a headache history.