Case

• 36-year old woman. Frequent headaches since age 14, daily

headaches for at least 10 years. What to do?

• Headache diary revealed 16 days with migraine and 14 days

with tension-type headache per month. Diagnosis?

• Chronic daily headache? Migraine and tension-type

headache? Chronic migraine? Chronic migraine and

medication-overuse headache?

Medication-overuse headacheICHD-III beta, 2013

A. Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder

B.Regular overuse for >3 months of one or more drugs1 that can be taken for acute and/or symptomatic treatment of headaches

C. Not better accounted for by another ICHD-3 diagnosis 

Note 1

A. Ergotamine, triptans, opioids, combination analgesics or any combination of analgesics on ≥10 days/month

B. Simple analgesics or NSAIDs on ≥15 days/month

Case

• Headache diary also revealed daily intake of NSAIDs and

intake of triptans 12 days per month

• Diagnosis: Chronic migraine and medication-overuse

headache

• What to do?

• Withdraw NSAIDs and triptans

Case

Central sensitization in MOH is reverted after detoxification

• Lower pain thresholds in MOH than healthy controls (p<0.05)• Supra-threshold pain scores

– Extra-cephalic: no significant difference– Cephalic

• MOH patients > healthy controls (p<0.05)• 6 months and 12 months < baseline (p<0.05)

27

61

3832

28

Healthy controls

MOH baseline

MOH 2 months

MOH 6 months

MOH 12 months

Munksgaard, Bendtsen and Jensen, Cephalalgia 2013

Management of MOH in a tertiary headache center

• 98 refractory MOH patients• 90% completed withdrawal and 88% completed follow-up• 83% without MOH at 1-year follow-up (cured of MOH)• 39% reduction in headache frequency (p<0.001)• 60% episodic headache• 49% responders

Baseline 2 months 12 months

22.3

16.713.7

Munksgaard, Bendtsen and Jensen, Cephalagia 2012

Day

s/m

onth

Medication-overuse headache

• Efficacy of detoxification and prophylaxis demonstrated in several individual centers

• Most experts recommend that withdrawal therapy should be offered (Evers and Marziniak, Lancet Neurology 2010)

• Some recommend Botox therapy (Dodick et al., Headache 2010)

• Some recommend topiramate therapy (Silberstein et al., Headache 2009)

Medication-overuse headache

• Percentage of patients seen in headache centers having MOH• US more than 50%• Chile 55%• Argentina 70%

• MOH is very common in specialized headache centers

Treatment of medication-overuse headacheTake home messages

• Always consider MOH in patients with chronic headache• Use calendar to monitor intake of analgesics during treatment• Educate and prevent• Detoxification and prophylactic treatment is highly effective in

reducing headache days, disability, depression, anxiety and costs