Medication Overuse Headache
The most common reversible cause of chronic daily headache — and the most under-diagnosed. Specialist withdrawal and preventative strategy at Sydney Headache Centre, Bondi Junction.
Book a ConsultationWhat is Medication Overuse Headache?
Medication Overuse Headache (MOH), also called rebound headache, is a chronic daily headache that develops in people with a pre-existing primary headache disorder (most often migraine) when they use acute pain medications too frequently. It is the paradox that drives many patients deeper into chronic pain: the medications that initially treat the headache, with regular over-use, become the cause of it.
MOH is extremely common. Estimates suggest 1–2% of the general population has MOH at any time — and the proportion is much higher among patients attending specialist headache clinics. It is also the most common reversible cause of chronic daily headache. The good news: identified and managed correctly, the chronic daily pattern often reverts to the original episodic pattern.
The Thresholds — When "Frequent" Becomes "Too Much"
The thresholds for medication overuse differ by drug class. Simple analgesics tolerate slightly more frequent use than triptans, ergots, opioids or combination analgesics — but all of them can cause MOH when used regularly above the relevant threshold for 3 months or more.
| Medication class | Example agents | MOH threshold |
|---|---|---|
| Simple analgesics | Paracetamol, ibuprofen, aspirin, diclofenac | ≥15 days/month |
| Triptans | Sumatriptan, rizatriptan, eletriptan, zolmitriptan, etc. | ≥10 days/month |
| Ergots | Ergotamine, dihydroergotamine | ≥10 days/month |
| Opioids | Codeine, oxycodone, tramadol, morphine | ≥10 days/month |
| Combination analgesics | Mersyndol, Panadeine, Nurofen Plus (paracetamol/ibuprofen + codeine) | ≥10 days/month |
| Multiple drug classes | Any combination from the above | ≥10 days/month combined |
A note on over-the-counter combinations
Many of the most commonly overused medications in Australia are sold over the counter — particularly codeine-containing combinations now restricted to prescription (Panadeine Forte) and earlier formulations still in patients' cupboards. Strong NSAID-codeine and paracetamol-codeine combinations are particularly risk-prone for MOH. Honest review of what is actually being taken is the first step.
How MOH is Diagnosed
The diagnosis requires three things, all present together:
- Headache on ≥15 days per month for ≥3 months
- Regular overuse of acute headache medication beyond the relevant threshold (above)
- A pre-existing primary headache disorder, most often migraine
A headache diary documenting both pain days and medication use is the diagnostic foundation. We provide a simple paper diary or you can use a digital tool — the East Neurology headache diary is available online.
How We Treat MOH
Treatment combines three elements: identifying and stopping the overused medication, supporting the patient through withdrawal, and starting an effective preventative medication so the underlying headache disorder is properly controlled.
Diagnosis and plan
Consultation to confirm MOH, identify the overused medication(s), and plan withdrawal strategy. Headache diary reviewed; comorbidities addressed.
Withdrawal
Complete withdrawal for triptans, simple analgesics and combination analgesics is generally more effective than tapering. For opioids, gradual reduction with bridging may be more appropriate. The choice depends on which medication, doses, duration and individual circumstances.
Bridging therapy
A short course of treatment to reduce the worst of withdrawal headache. Options include a short tapering steroid course, scheduled NSAID, antiemetic, occipital nerve block, or short course of long-acting triptan (e.g. naratriptan or frovatriptan) used as bridge rather than rescue. The right bridge depends on the patient and the medication being withdrawn.
New preventative
An effective migraine preventative is usually started at the same time — oral agent, Botox (if chronic migraine criteria met), or CGRP monoclonal antibody. The goal is to control the underlying disorder so it does not drive the overuse cycle again.
Follow-up
The withdrawal headache typically peaks in the first 1–2 weeks and eases over 4–8 weeks. Close follow-up during this period — and a continuing headache diary — make the difference between success and relapse.
After Successful Withdrawal — What to Expect
About two-thirds of patients respond well to combined withdrawal plus preventative. The chronic daily pattern often reverts to the original episodic migraine pattern (or near it). Acute medications, used at appropriate frequency, can then be reintroduced as needed for individual attacks.
Relapse risk exists, particularly in the first 12 months. Sustained use of an effective preventative, careful tracking of acute medication days per month, and willingness to seek help early if days creep up — these are the practical anchors that protect against returning to the cycle.
Frequently Asked Questions
Recognising MOH in Your Own Headache Pattern?
Book a consultation — we will diagnose, plan structured withdrawal, and start effective prevention.
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