Medication overuse headache: an overview of clinical aspects, mechanisms, and treatments

ABSTRACT

Introduction

Medication-overuse headache (MOH) is a common debilitating neurological disorder, with a prevalence of 1% to 7% in general population. It affects more than 60 million people worldwide and provokes substantial burden. Despite that, most practitioners don’t know MOH. This review aims at presenting MOH clinical features, pathophysiology insights, and recent knowledge and guidance regarding treatments.

Areas covered

A literature search in the major medical databases including the terms ‘medication overuse headache,’ ‘chronic daily headache,’ ‘chronic migraine,’ ‘symptomatic medication overuse’ and others, published between 1990 and 2020, was carried out.

Expert commentary

Primary headache sufferers such as migraineurs and tension-type headache patients may increase the headache frequency and induce the transition from episodic to chronic forms, as well as develop MOH, in the presence of medication overuse. There is evidence of structural and functional changes in some areas of the brain, which may identify those likely to respond or not to treatments. Despite the geographical differences and lack of consensus regarding approaches, to educate the patients about reducing medication intake, to withdraw overused medications and to start prophylaxis in some sufferers are crucial steps. Emerging treatments as monoclonal antibodies to migraine may result in better adherence and tolerability profiles as well as outcomes.

KEYWORDS:

• Medication-overuse headache
• pathophysiology
• withdrawal
• treatment

Article highlights

• MOH is highly prevalent in neurology practice and imposes a heavy burden to sufferers.

• Patients and general physicians are not aware of basic factors about MOH presentation, pathophysiology and treatment, therefore impairing its recognition.

• Treatment varies between countries, cultures, societies, and health professionals, but withdrawal of overused medications seems to be the most effective initial approach.

• Choosing and initiating preventive treatment with drugs, the right time to do it or the superiority of combining medications rather than using monotherapy, still need more evidence.

• Emerging therapies such as monoclonal antibodies may represent better options in comparison to what is currently available.

• Non-pharmacological therapies may also be effective pending further controlled studies.

Acknowledgments

The authors wish to thank Dr Fernando Kowacs MD PhD with his help in suggesting critical issues and checking for overall content with the manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.