Elsevier

The Lancet Neurology

Volume 3, Issue 8, August 2004, Pages 475-483
The Lancet Neurology

Review
Medication-overuse headache: a worldwide problem

https://doi.org/10.1016/S1474-4422(04)00824-5Get rights and content

Summary

Medication overuse and subsequent medication-overuse headache (MOH) is a growing problem worldwide. Epidemiological data suggest that up to 4% of the population overuse analgesics and other drugs for the treatment of pain conditions such as migraine and that about 1% of the general population in Europe, North America, and Asia have MOH. Recent clinical studies gave further insights in clinical and pharmacological features, such as critical monthly doses and frequencies. These features seem to vary significantly and depend on the primary headache disorder and the type of drug that is overused. Along with these findings the new international classification of headache disorders has now incorporated additional criteria and new headache entities that will facilitate the diagnosis of MOH. Withdrawal therapy is the only treatment for this disorder and clear restriction of monthly doses is the central requirement for successful prevention.

Section snippets

Drugs that cause MOH

There is now substantial evidence that all drugs used for the treatment of headache can cause MOH in patients with primary headache disorders. The use of drugs that lead to chronic MOH varies substantially from country to country and is influenced by cultural factors. In many patients it is difficult to identify a single causal substance, because 90% of patients take more than one compound at a time and each component of antimigraine drugs might induce headache. This has been shown even for

Clinical manifestation

Despite the International Headache Society classification and the fact that the diagnosis of MOH does not require any additional examination (only to exclude symptomatic forms of chronic headache) and is made on the basis of the patient's history and the clinical presentation only, MOH is commonly overlooked. Almost no experimental work has been done, and this review is based mainly on clinical series describing patients presenting at headache clinics with this problem and their subsequent

Aetiology and pathophysiology

The mechanisms that lead to MOH are still widely unknown. However, several mechanisms seem to have an important role.

Epidemiology

Cross-sectional, population-based, epidemiological studies indicate that chronic headache is common with prevalence between 2% and 5%36, 37, 38, 39, 40 and the prevalence of chronic headache associated with MOH or probable MOH is about 1%.38, 39, 40, 41 There is increasing evidence that the overuse of analgesics and subsequent MOH is not only prevalent in Europe and North America but is a growing problem in Asian countries—in China and Taiwan the prevalence is the same as in Europe.38, 39

Diagnostic assessment

Medical history, the course of the disorder, the history of drug intake and intake frequency (ideally supported by a well-maintained headache diary) are the only available methods of diagnosis. Some patients may be reluctant to reveal their entire drug consumption. Hence it is important to explain to patients the concept of MOH and the need to know these details.

Many patients take several substances daily despite the fact that their effect is negligible. This behaviour is merely an attempt to

Differential diagnosis

All disorders leading to more than 15 headache days per month must be considered in the differential diagnosis of MOH. A high frequency of drug intake does not necessarily mean that MOH is present but may reflect that patients have another chronic headache disorder or that patients are in the transition phase to MOH.51 A diagnostic diary is often helpful to monitor the precise drug intake and to reveal the extent of overuse (panel 3).

Management

Abrupt drug withdrawal is the treatment of choice for MOH. However, no prospective and randomised trials on the natural course of MOH or the tapering of the causal drug are available. A survey of 22 studies dealing with therapy of drug-induced headache shows that most centres use drug withdrawal as the primary therapy.11 Clinical experience indicates that medical and behavioural headache treatment fails as long as the patient continues to take non-specific-headache drugs daily. The typical

Prevention

The most important preventive measure is proper instruction and appropriate surveillance of patients. Many patients with migraine who are at risk of MOH have a mixture of migraine and tension-type headaches and should be carefully instructed to use specific antimigraine drugs for migraine attacks only. This point about overuse of ergotamine was highlighted in 1951 by Peters and Horton3—ie, complications can be avoided if enough time is taken for proper instruction of the patient, so that he or

Prognosis

The mean success rate of withdrawal therapy within a time window of 1–6 months is 72·4% (17 studies, n=1101 patients). Success is defined as no headache at all or an improvement of more than 50% in terms of headache days. Three studies from before triptans were in use had longer observation period (9–35 months);13, 50, 69 the success rates were 60%, 70%, and 73%. A 5 year follow-up study found a relapse rate of 40%.69 More recent studies included patients with MOH after the misuse of triptans.70

Search strategy and selection criteria

Data for this review were identified from the authors' files and by searches of PubMed with the search terms “medication-overuse headache” or “drug-induced headache” and “chronic daily headache”. Articles and citations were selected for their historical value, importance, representativeness, ease of access, or timeliness. Papers in English and German were included.

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