Medication-Overuse Headache — When Painkillers Perpetuate the Problem

How medication-overuse headache is recognized

MOH typically emerges in a person with an underlying primary headache (most often migraine or tension-type) whose attacks gradually become daily or near-daily. The pattern is characteristic: morning headache, poor response to further doses, and a cycle where more medication leads to more headache. ICHD-3 defines it by the number of days of acute medication use over three months combined with worsening headache — not by any blood test or scan.

• Simple analgesics (paracetamol, NSAIDs): ≥15 days/month for >3 months
• Triptans, opioids, butalbital or combination analgesics: ≥10 days/month for >3 months
• Headache present on ≥15 days/month that developed or worsened during overuse
• Common in Nepal context: over-the-counter analgesic combinations and injectable painkillers are widely available without prescription

Management principles at the clinic

The cornerstone is structured withdrawal of the overused medication alongside education, a bridge plan for rebound symptoms, and — for most patients with migraine as the underlying disorder — introduction of a preventive agent. Withdrawal is usually outpatient-based; symptoms typically improve within 2–8 weeks, though relapse risk persists if the underlying disorder is untreated.

• Complete diary review of every analgesic, including OTC and pharmacy injections
• Gradual or abrupt withdrawal depending on the drug class and comorbidity
• Short bridge therapy for withdrawal symptoms where appropriate
• Preventive treatment started early — treating MOH without treating migraine invites relapse
• Follow-up with the same consultant to track days/month trend and reinforce limits (e.g., acute medication ≤2–3 days/week)

Guidelines referenced:

• ICHD-3 criteria for medication-overuse headache
• European Headache Federation consensus on MOH management
• American Headache Society position papers on acute medication frequency limits