Treatment paradigm for patients with medication overuse headache

Component	Treatment strategies	Factors supporting strategy
Wean overused medication	Wean^* or immediately stop (most patients)	Patient willingness Overused agent is nonspecific headache medication (eg, NSAIDs, acetaminophen)
	Continue at lower frequency	History of nonresponsiveness to other classes of acute headache medications
	Initial continuation^¶	Patient unwilling/unable to adhere to wean until alternative acute and preventive therapies take effect No immediate concerns for toxicity/adverse effects with the overused medication
Provide alternative acute treatment	Acute therapy for breakthrough attacks (most patients)	Intermittent breakthrough headache attacks Mild to moderate symptoms
Provide alternative acute treatment	Bridge therapy^Δ	High dose/exposure to overused medication Overuse with barbiturates, opioids, or benzodiazepines Severe symptoms managed in an inpatient setting
Start preventive treatment	Include (most patients)	Patient willingness
Start preventive treatment	Omit	Patient preference to minimize exposure to pharmacotherapy

The management of MOH starts with patient education on how some medications used to treat headache symptoms can lead to an increased headache burden when used to excess. The treatment approach to MOH involves weaning the overused medication, providing appropriate rescue therapy for acute symptoms, and adding preventive therapy to reduce longer-term headache burden and reduce the risk of relapse. Refer to UpToDate topic for additional details on specific medications and options.

MOH: medication overuse headache; NSAID: nonsteroidal antiinflammatory drug.

* The pace of weaning varies by agent and baseline dose. In addition, short-term medications may be added to reduce the risk of withdrawal symptoms associated with these agents. As an example, for patients weaning from high doses of butalbital, we typically add phenobarbital. Refer to UpToDate topics on medication overuse headache for additional details.

¶ Initial continuation refers to delaying weaning the overused medication until other preventive therapies have provided benefit. This strategy is typically used for patients unwilling to follow the preferred strategy of initial weaning when temporary continuation does not constitute immediate risk of toxicity or adverse effects.

Δ Bridge (or transitional) therapy consists of short-term daily therapy given along with preventive treatment used for long-term headache management. Bridge therapy is used as an adjunctive measure for patients with severe symptoms or frequent headaches and those being treated in an inpatient setting.

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Treatment paradigm for patients with medication overuse headache