Synopsis
Identify headache made more frequent by regular acute-medicine exposure, explain the diagnosis without blame, and support withdrawal while treating the underlying primary headache disorder.
- Suspect medication-overuse headache when headache is present on at least 15 days per month and one or more acute headache medicines have been overused for more than 3 months.
- Triptans, opioids, ergots and combination analgesics reach the overuse threshold at 10 or more days monthly; paracetamol, aspirin and NSAIDs reach it at 15 or more days.
- Count treatment days rather than tablet numbers, and include over-the-counter cold, pain and caffeine combinations that the patient may not regard as headache medicines.
- The underlying disorder is commonly migraine or tension-type headache; medication overuse is an interaction with that disorder, not evidence that the original headaches were unreal.
- NICE advises stopping all overused acute headache medicines for at least 1 month, usually abruptly, while explaining that headache often worsens temporarily and withdrawal symptoms can occur.
- Provide close follow-up and consider preventive treatment for the underlying primary headache alongside withdrawal according to headache type, comorbidity and preference.
- Do not routinely use inpatient withdrawal; consider specialist referral or inpatient care for strong opioid overuse, major comorbidity or repeated unsuccessful supported attempts.
- Review 4–8 weeks after withdrawal begins, then continue diary follow-up because improvement may evolve and relapse prevention requires a durable acute-treatment limit.
- Use non-judgemental language: repeated prescribing, delayed access to prevention and understandable attempts to remain functional often contribute to the cycle.
Key red flags
Escalating strong opioid use, withdrawal between doses, multiple sedatives, severe mental illness or previous failed detoxification signals need for specialist support and sometimes inpatient care.
A new focal sign, papilloedema, systemic illness, abrupt peak or positional change is not accounted for by overuse and requires an independent urgent work-up.
Investigation priorities
Count total headache days, migraine-feature days and exposure days for every acute medicine class.
Management branches
Headache has become frequent, chronic or progressively less responsive to rescue treatment.
- Ask for total monthly headache days and reconstruct every acute treatment day using prescriptions, purchased products and medicines taken for other pain.
- Apply the correct 10-day or 15-day class threshold over more than 3 months, considering cumulative exposure to several classes.
- Confirm the likely underlying migraine or tension-type phenotype and perform red-flag and neurological assessment before attributing the whole pattern to overuse.
- Explain the mechanism as a reversible treatment-headache interaction, acknowledge prescribing-system contributions and agree that improvement requires a structured change.