Guideline sources The following summarized guidelines for the evaluation and management of medication overuse headache (MOH) are prepared by our editorial team based on guidelines from the German Migraine and Headache Society (GMHS/GSN 2022), the The Scottish Intercollegiate Guidelines Network (SIGN 2022), the European Academy of Neurology (EAN 2020), the American Academy of Neurology (AAN/AHS 2019), the Association of British Neurologists (ABN/RCOphth/BASH/SBNS 2018), and the European Federation of Neurological Societies (EFNS 2011; 2010). 1 2 3 4 5 6 7 8 Guidelines 1. Screening and diagnosis Identification of at-risk patients: As per GSN 2022 guidelines, consider identifying patients at increased risk for developing MOH through general practitioners, pharmacists, or evaluation of prescriptions. Monitor prescription and OTC medications in these patients and refer them to a headache specialist in a timely manner. E https://web.pathway.md/diseases/recwl3XRFPj1uH035 1/6 6/30/23, 1:01 AM Medication overuse headache Pathway As per EAN 2020 guidelines, obtain monitoring (by the patient's general practitioner or neurologist) at shorter time intervals, ideally every 3-6 months, in patients at risk of developing MOH. E 2. Medical management Discontinuation of overused medication, advice: As per GMHS/GSN 2022 guidelines, provide counseling and education alone for the treatment of MOH in patients overusing triptans or simple analgesics without severe psychiatric comorbidities. E Show 3 more As per EAN 2020 guidelines, recognize that withdrawal from overused acute medications is effective in ceasing overuse and restoring an episodic pattern of headache for prolonged periods in most patients, and withdrawal is associated with documented improvements in healthcare costs, quality of life, coexisting depression, and anxiety. B Show 3 more As per EFNS 2011 guidelines, provide advice encouraging withdrawal of overuse medications in patients with MOH. B Discontinuation of overused medication, setting: As per GMHS/GSN 2022 guidelines: Offer outpatient withdrawal in patients with MOH without relevant comorbidities. E Offer inpatient withdrawal in patients with MOH with concomitant diseases, such as depression, anxiety, severe internal disease, abuse of other substances, or previous unsuccessful withdrawal from medication. E As per EFNS 2011 guidelines: Recognize that the type/setting of withdrawal treatment (inpatient, outpatient, advice alone) does not influence the success of the treatment and the relapse rate in general. A Offer inpatient withdrawal treatment in patients overusing opioids, benzodiazepines, or barbiturates with severe psychiatric or medical comorbidity or with failure of a previous outpatient withdrawal treatment. E Discontinuation of overused medication, protocols: As per GMHS/GSN 2022 guidelines, offer medication pause, drug withdrawal, or controlled reduction of acute medication, together with good education, for the treatment of MOH. E Show 2 more As per EFNS 2011 guidelines: Offer abrupt withdrawal in patients overusing analgesics, ergotamine derivatives, or triptans. E Offer tapered withdrawal in patients overusing opioids, benzodiazepines, or barbiturates. E Management of withdrawal symptoms: https://web.pathway.md/diseases/recwl3XRFPj1uH035 2/6 6/30/23, 1:01 AM Medication overuse headache Pathway As per GSN 2022 guidelines, offer TCAs, neuroleptics (antiemetics), and corticosteroids for the treatment of withdrawal symptoms or headaches during the medication pause. E As per EFNS 2011 guidelines, consider offering corticosteroids (at least 60 mg prednisone or prednisolone) and amitriptyline (up to 50 mg) for the treatment of withdrawal symptoms. E Headache prophylaxis: As per GSN 2022 guidelines, reassess the indication for migraine or tension headache prophylaxis after successful withdrawal therapy. E Show 5 more As per EAN 2020 guidelines, offer topiramate, onabotulinum toxin A, or a monoclonal antibody targeting calcitonin gene-related peptide or the calcitonin gene-related peptide receptor as preventive medical therapy in patients with chronic migraine and medication overuse. Do not use topiramate in female patients of childbearing potential. B Show 4 more As per EFNS 2011 guidelines, offer individualized preventive medication starting on the first day of withdrawal treatment or even before if applicable. B Consider offering topiramate 100 mg/day, up to 200 mg/day, for the prophylactic treatment of the primary headache. B 3. Specific circumstances Pediatric patients: As per AAN 2019 guidelines: Counsel pediatric patients with migraine and their families to use no more than 14 days of ibuprofen or acetaminophen per month, no more than 9 days of triptans per month, and no more than 9 days per month of any combination of triptans, analgesics or opioids for > 3 months to avoid MOH. B Discuss the potential role of preventive treatments in pediatric and adolescent patients with migraine and MOH. B As per AAN 2019 guidelines, counsel pediatric and adolescent patients with migraine and their families on the avoidance of medication overuse. B Patients with idiopathic intracranial hypertension: inform patients with idiopathic intracranial hypertension, at the earliest opportunity, of the potential issues of analgesic overuse that can lead to MOH (use of simple analgesics on > 15 days/month or opioids, combined preparations or triptan medication on > 10 days/month for > 3 months). E Show 2 more 4. Preventative measures Preventive counseling: As per SIGN 2022 guidelines: Inform patients starting acute treatment for migraine about the risk of developing MOH. B https://web.pathway.md/diseases/recwl3XRFPj1uH035 3/6 6/30/23, 1:01 AM Medication overuse headache Pathway Address medication overuse in patients overusing acute treatment. A As per EAN 2020 guidelines, consider providing information brochures and education about the potential relationship between frequent use of pain medications and the transition from episodic to chronic headache in preventing MOH in at-risk patients with migraine. E As per EFNS 2010 guidelines, advise patients with tension-type headaches to avoid frequent and excessive use of analgesics to prevent the development of MOH. E Preventive medical therapy: insufficient evidence to support the use of preventive medical therapy for the prevention of MOH in patients with frequent migraines. I 5. Follow-up and surveillance Indications for referral: As per GSN 2022 guidelines, refer patients overusing opioids or patients with relapse after previous withdrawal treatment to a headache center to receive multimodal care, or manage them as inpatients, with additional psychological counseling. E As per EAN 2020 guidelines, refer patients overusing opioids, tranquilizers, or barbiturates, experiencing relapses, or failing to stop overuse after advice to a headache specialist or to specialized care. B Follow-up: As per GSN 2022 guidelines, identify patients at high risk of relapse after withdrawal treatment based on their risk profile. E Show 2 more As per EAN 2020 guidelines, attempt to identify risk factors for relapse and obtain regular follow- up in patients with a relatively high relapse rate after initially successful treatment. E Show 2 more As per EFNS 2011 guidelines, obtain regular follow-up in patients after withdrawal therapy to prevent relapse of medication overuse. E 6. Quality improvement Healthcare professional awareness and training: As per GSN 2022 guidelines, consider implementing training programs for headache nurses and pharmacies to improve the identification and care of patients with MOH. E As per EAN 2020 guidelines, ensure an increased awareness among healthcare professionals and in the general population of the relationship between frequent intake of medications to treat acute headache episodes and the possible increase in headache days (MOH). E Clinical findings https://web.pathway.md/diseases/recwl3XRFPj1uH035 4/6 6/30/23, 1:01 AM Medication overuse headache Pathway Symptoms Past medical history Anxiety Cluster-type headache Chronic back pain Depression Facial pain Fibromyalgia Headache Migraine Myalgia Migraine-type headache Neck pain OCD Sleeping disorder Personality disorders Tension-type headache Medication history Social history Barbiturates Benzodiazepines Excessive consumption of caffeine NSAIDs Opioids Triptans Neurological exam Cutaneous allodynia References 1. Hans-Christoph Diener, Peter Kropp, Thomas Dresler et al. Management of medication overuse MO and medication overuse headache MOH S1 guideline. Neurol Res Pract. 2022 Aug 29;4 37 . Open 2. S Evers, R Jensen, European Federation of Neurological Societies. Treatment of medication overuse headache guideline of the EFNS headache panel. Eur J Neurol. 2011 Sep;18 9 1115 21. Open 3. H C Diener, F Antonaci, M Braschinsky et al. European Academy of Neurology guideline on the management of medication-overuse headache. Eur J Neurol. 2020 Jul;27 7 1102 1116. Open 4. L Bendtsen, S Evers, M Linde et al. EFNS guideline on the treatment of tension-type headache Report of an EFNS task force. Eur J Neurol. 2010 Nov;17 11 1318 25. Open 5. Oskoui M, Pringsheim T, Billinghurst L et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93 11 500 509. Open 6. Scottish Intercollegiate Guidelines Network. SIGN 155 Pharmacological management of migraine. SIGN. 2022 Sep. Open 7. Susan P Mollan, Brendan Davies, Nick C Silver et al. Idiopathic intracranial hypertension: consensus guidelines on management. J Neurol Neurosurg Psychiatry. 2018 Oct;89 10 1088 1100. Open 8. Oskoui M, Pringsheim T, Holler-Managan Y et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93 11 487 499. Open https://web.pathway.md/diseases/recwl3XRFPj1uH035 5/6 6/30/23, 1:01 AM Medication overuse headache Pathway https://web.pathway.md/diseases/recwl3XRFPj1uH035 6/6