Medication-overuse headache

Criteria

ICHD-3 diagnoses medication-overuse headache, also called rebound headache, when all of the following apply:

• headache on 15 or more days a month in a person who already has a headache disorder such as migraine;
• regular overuse of acute headache medicine for more than 3 months;
• no other diagnosis explains the headache better.

The day limits are based on expert opinion.

Limits by medicine

Type of medicine	Days per month, for more than 3 months	ICHD-3
Ergotamines	10 or more	8.2.1
Triptans, in any form	10 or more	8.2.2
Non-opioid painkillers: acetaminophen (paracetamol), aspirin, other NSAIDs	15 or more	8.2.3
Opioids	10 or more	8.2.4
Combination painkillers	10 or more	8.2.5
Several types, none over its own limit	10 or more in total	8.2.6

ICHD-3 treats all non-opioid painkillers as one class. The limits count days, not doses. Count your days.

How common it is

• 1–2% of the general population, and 30–50% of patients seen in specialist headache settings (Vandenbussche 2018).
• More than half of people with headache on 15 or more days a month (ICHD-3).
• In large trials in chronic migraine, about 65% met the criteria in the onabotulinumtoxinA trials and 51.9% overused acute medicine at the start of the HALO-CM trial (Diener 2022).

What guidelines recommend

Medication-overuse headache is managed together with a doctor. Guidelines name these steps:

• Explanation. ICHD-3 notes that most people improve after the overused medicine is stopped, and that preventive treatment then works better. In primary care, simple advice such as a leaflet can be enough.
• Stopping the overused medicine (NICE). NICE advises stopping all overused acute medicines for at least a month, abruptly rather than gradually, and warns that headache and withdrawal symptoms may get worse before they improve. For people who overuse strong opioids, NICE advises considering specialist referral and/or inpatient withdrawal.
• Prevention (NICE). NICE advises considering preventive treatment for the underlying headache.
• Review (NICE). NICE recommends a review 4 to 8 weeks after withdrawal starts.
• A stepped approach (Diener 2022). The German S1 guideline by Diener et al. orders the steps differently from NICE: education first, then preventive treatment, and a pause in acute medicine for people in whom these are not effective, as an outpatient, in a day hospital or as an inpatient. It recommends inpatient withdrawal for opioid overuse and lists topiramate, onabotulinumtoxinA and CGRP antibodies as effective in chronic migraine with medication overuse.

Outcomes reported by Diener et al. (2022): the stepped approach succeeds in 50–70% of people after 6 to 12 months; in the COMOESTAS study two-thirds no longer met the criteria at 6 months. Relapse is most likely in the first year and is high after opioid overuse.

Medicines that contain opioids or barbiturates are not stopped abruptly without medical supervision. Do not stop or change prescribed medicines without medical advice.

Gepants and lasmiditan

ICHD-3 was published in 2018 and does not mention newer acute medicines.

• Gepants (rimegepant, ubrogepant). A 2021 American Headache Society consensus statement found that frequent use of rimegepant or ubrogepant does not appear to lead to medication-overuse headache. The statement did not cover zavegepant. A 2024 commentary called the evidence inconclusive, because trials followed patients for at most 52 weeks (Pellesi 2024).
• Lasmiditan. The 2021 statement noted possible overuse with lasmiditan. Its US prescribing information warns that acute migraine medicines used on 10 or more days a month may lead to medication-overuse headache (section 5.4).

The medication days counter and Aurora do not count gepants or lasmiditan against an ICHD-3 limit. This does not mean any frequency is safe. Record the days you take them, so your doctor sees the whole picture.