Medication overuse headache

When medication becomes the problem, not the solution

I have a bad head almost daily. I use painkillers to keep going at work but really the tablets just take the edge off the pain. I’ve tried every other possible drug and diet but nothing works. This is not like the infrequent migraines I used to get when I was younger.

What is it?

Some people find that their migraine gets more and more frequent, and the natural response may be to take more painkillers. People with migraine know that early treatment of an attack works best, so may consider it’s easier to take medication ‘just in case’.

However, it’s very important to avoid overuse: unlike other headaches and pain conditions, regular use of short-term acute or rescue treatments for migraine can trigger more attacks. This is known as medication overuse headache.

How much medication is too much?

A general rule of thumb would be to limit consumption over three months of head pain to:

• ten days a month of regular over-the-counter painkillers (such as aspirin, paracetamol, or ibuprofen)
• ten days a month of triptans
• always avoid opioids or combination drugs (eg paracetamol with codeine).

But be aware that this is days, not doses: for example, you could be at risk of medication aggravating your headaches if you take painkillers several days every week. It’s better to take repeat doses in one 24 hour period rather than small doses spread over a number of days.

Pattern of use is important. Short-term higher usage might be OK but the steady use of painkillers or triptans over months can cause problems.

Which medications cause medication overuse headaches?

Most people with medication overuse headache will be taking combination drugs, particularly paracetamol with codeine. But any pain medication used inappropriately for migraine can cause medication overuse headache.

Some drugs, such as naproxen, diclofenac and indomethacin, can cause medication overuse headache when used as and when required, but the same medications taken absolutely regularly three times a day, can be helpful for medication overuse headache.

How easy is to fix medication overuse headache?

The simplest solution is just to stop taking the overused medications – but, for many patients, this is not so easy.

Stopping use may involve time off work or school and it can be helpful to ask for the support of family and friends.

Should another drug be added?

Recent studies of topiramate, Botox and anti-CGRP medications show a small benefit from starting these treatments in addition to continuing frequent acute rescue medications. But these benefits are relatively small and the strong consensus is that medication overuse needs to be addressed before other treatments work well.

It can be useful to add the painkiller naproxen, taken absolutely regularly in 250mg doses three times daily after meals, to make stopping acute rescue drugs a little easier. The main side effect of these drugs is indigestion. Normally, they need be taken for no more than six weeks.

Nausea or vomiting can be treated with domperidone 10mg three times daily before meals. Alternatively, preventatives such as amitriptyline, topiramate or Botox could be used. A short course of oral steroids or a greater occipital nerve block can also be considered.

You can learn more about Botox, nerve blocks and anti-CGRP medication in our other factsheets. Speak to a headache specialist to find out more.

How do drugs make migraine worse?

Overuse of painkillers cause the nerves in the brain to become hypersensitive and ‘mis-fire’ without being stimulated by the usual triggers. After stopping these medications, it takes several weeks for the nervous system to recover.

Should I cut out medication suddenly?

Stopping suddenly works best for most people. This is difficult for the first couple of weeks as the pain often increases before it improves.

Stopping more gradually might seem gentler and can be effective but phasing out these drugs gradually can just prolong the pain.

How long do I need to avoid medication for?

Recent research has shown that a period of time taking no medication (usually between six and 12 weeks) is most effective. After that, medication can cautiously be reintroduced, but always within the limits mentioned earlier.

What next?

After two months of addressing medication overuse, ideally with no short-term drugs at all, there are three possible headache outcomes.

1. No headache.

2. Occasional migraine or headache. This requires careful targeting of acute medication, with the right drugs taken at the right time. Avoid medications that are sold as combinations and particularly avoid opioids such as codeine. It is best to avoid paracetamol too as this is a quite a weak drug for migraine compared with aspirin.

3. Frequent migraine or headache. This needs to be treated with regular preventative medication and careful occasional use of acute medication. Regular painkillers that have been ineffective during the medication overuse stage may become effective again.

Medication overuse headache tends to happen to people with severe migraine so there is a high risk of headache recurring. Pay careful attention to lifestyle triggers and restrict your use of acute medication.

Book an appointment with the experts: get on top of medication overuse headache and review the best treatment options for you with a leading headache specialist. Beat the misery of migraine and get back to living. Book your consultation through the National Migraine Centre now.