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Medication overuse headache

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of medication overuse headache 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), ...
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Screening and diagnosis

Identification of at-risk patients: as per GMHS/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
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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.
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  • Discontinuation of overused medication (setting)

  • Discontinuation of overused medication (protocols)

  • Management of withdrawal symptoms

  • Headache prophylaxis

Specific circumstances

Pediatric patients
As per AAN/AHS 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.
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  • Patients with idiopathic intracranial hypertension

Preventative measures

Preventive counseling
As per SIGN 2022 guidelines:
Inform patients starting acute treatment for migraine about the risk of developing MOH.
B
Address medication overuse in patients overusing acute treatment.
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  • Preventive medical therapy

Follow-up and surveillance

Indications for referral: as per GMHS/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.
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  • Follow-up

Quality improvement

Health professional awareness and training: as per GMHS/GSN 2022 guidelines, consider implementing training programs for headache nurses and pharmacies to improve the identification and care of patients with MOH.
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