Ïã½¹ÊÓƵ Guideline
Section 1: The Clinical Approach
Section 2: Primary Headaches
2.2 Medication overuse headache
2.2.3 Management
Practical Management of Medication Overuse Headache
Medication overuse should be addressed in all patients in whom it is identified. However, attempts to reduce or withdraw the overused acute medication should not delay the initiation of migraine preventive treatment where this is clinically indicated.
In many patients, education and withdrawal of the overused medication will lead to significant improvement in headache frequency and treatment response. However, not all patients are able to successfully withdraw acute medication immediately, and some may require preventive treatment to support this process. Accordingly, attempts to address medication overuse are recommended in all patients, but advanced therapies should not be withheld where this is not feasible or achievable, particularly if it would lead to significant delays in initiating high-efficacy migraine preventive therapy.
A pragmatic approach is recommended:
- confirm the diagnosis and quantify acute medication use
- explain the diagnosis clearly and in a non-judgemental manner
- advise reduction or withdrawal of the overused medication
- start preventive treatment when clinically indicated, without unnecessary delay
- provide structured follow-up and relapse-prevention support.
A) Patient education
Top line summary:
- Limit acute headache medications to ≤2 days per week (~10 days per month)
- Avoid regular or near-daily use of acute headache treatments (except during cluster bouts)
- Escalate care early: frequent use should prompt review and consideration of preventative therapy
An important aspect in the management of MOH is to increase awareness of the condition amongst health care providers as well as the general population.
Patients must be advised that restricting their acute headache medications to no more than 2 days in a week minimizes the potential of developing MOH ().
Educational intervention, including simple written information such as information brochures, can help prevent MOH and improve headache outcomes .
Comparison of advice alone with a structured detoxification program in patients with MOH is similarly effective ().
The use of rescue medications, including steroids, does not improve outcomes (; ; ; ).
Acute use of gepants (rimegepant and atogepant) may be helpful during and following withdrawal. Pre-clinical data indicates that repeated exposure to gepants does not cause allodynia (hypersensitivity) and are hence potentially less likely to drive MOH (; ).
B) Medication withdrawal
Top line summary:
- Abrupt vs gradual withdrawal shows no difference in outcomes, the approach should be patient-specific (gradual taper for opioids)
- Withdrawal symptoms (including headache) typically last 2–10 days, with shorter duration in triptan overuse
- Improvement follows withdrawal, with headache frequency and response to acute/preventive treatments improving over weeks (up to ~12 weeks)
MOH is unlikely to resolve unless the offending medication is stopped ().
There is no difference (high quality evidence) in outcome with either abrupt or gradual withdrawal of the causative drug (; ), however gradual tapering is sometimes recommended for opioids whereas simple analgesic and triptans can be abruptly stopped. The decision should be individualised to the patient's circumstances.
Outpatient medication withdrawal is as effective as inpatient detoxification (; ; ).
Withdrawal headache usually lasts for 2-10 days from the time of complete cessation of the overused medication (; ; ).
After medication withdrawal patient’s headaches gradually improved. This improvement can take up to 12 weeks ().
The average duration of withdrawal headache appears to be shortest in patients overusing triptans (4 days) (). A similar timeline is observed with opiate withdrawal, but withdrawal symptoms maybe more severe necessitating a gradual withdrawal from (that may require specialist input and support if withdrawing from high dose chronic opiate use ().
Response to acute and preventive medications improves following withdrawal of the overused medication (; ).
C) Use of preventative medication
Top line summary:
- Start preventive therapy without delay, withdrawal and preventives can proceed in parallel
- Introduce preventive therapy early may reduce disease progression and chronification
- Withdrawal alone may resolve headaches in some patients
- Suboptimal response to migraine preventative medication can be caused by acute analgesic medication overuse
- Response to preventive treatments may improve after withdrawal
The most important step in MOH management is to identify the diagnosis and inform the patient of the importance of reducing or stopping the offending medication, and no further measures may then be required (., 2017; ;).
Response to migraine preventive medications improves following withdrawal of the overused acute headache medication (; ).
Once MOH has developed, there is a lack of randomised placebo-controlled trials looking at simultaneous or postponed preventive treatment in addition to withdrawal of overuse medications. However, if preventive medications are used in patients with MOH, studies have shown that they are effective.
There is a growing awareness that shifting to early introduction of preventive treatment may help prevent disease progression and chronification .
Using topiramate has been shown to be an effective treatment for the treatment of chronic migraine in populations with and without medication overuse (Diener et al., 2009).
RCTs of anti-CGRP monoclonal antibodies in adults with chronic migraine demonstrate reductions in acute medication use and medication overuse, including in participants with concurrent MOH at baseline (; Dodick et al., 2020; ; ).
In chronic migraine with medication-overuse headache, eptinezumab 100 mg IV combined with brief patient education and withdrawal advice reduced migraine/headache days and acute medication use more than education alone, with early benefit from weeks 1–4 sustained to 12 weeks .
In the PREEMPT trials comparing onabotulinum toxin A with placebo injections in patient with chronic migraine about 65% had MOH (excluding patients with opioid overuse) and this showed statistically significant results of benefit of onabotulinum toxin A versus placebo on headache days (; ; ). Subsequent analysis of
data looking at effect of onabotulinum toxin A in this subgroup of patients with MOH showed that efficacy was maintained ().
Other preventive medications such as beta-blockers, candesartan or amitriptyline may be used although their efficacy has not been shown in randomised placebo-controlled trials looking specifically at their use in medication overuse headaches.
There is no difference in outcome if preventive medication is started during or after withdrawal, as long as the acute medication is withdrawn. Preventive treatment is more effective once the overused medication is withdrawn (; ; ; ).
Ïã½¹ÊÓƵ guideline V2.0 2026