Medication Overuse Headache¶

DIAGNOSIS: Medication Overuse Headache (MOH) ICD-10: G44.41 (Drug-induced headache, not elsewhere classified) SCOPE: Diagnosis, withdrawal management, bridge therapy, and preventive therapy for medication overuse headache. Covers simple analgesic, triptan, combination analgesic, opioid, and barbiturate overuse. Excludes acute migraine management (see Migraine plan) and primary headache disorder initial workup.

STATUS: Draft - Pending Review

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC	Rule out anemia contributing to headache; baseline before treatment	Normal	STAT	ROUTINE	ROUTINE	-
BMP	Electrolyte abnormalities; renal function for medication selection	Normal	STAT	ROUTINE	ROUTINE	-
LFTs (AST, ALT, Alk Phos)	Required if acetaminophen or butalbital overuse suspected; baseline for preventives	Normal	URGENT	ROUTINE	ROUTINE	-
TSH	Thyroid dysfunction can worsen headache frequency	Normal (0.4-4.0 mIU/L)	-	ROUTINE	ROUTINE	-

1B. Extended Workup (Second-line)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
ESR, CRP	Rule out giant cell arteritis if age >50 with new or changed headache	Normal	URGENT	ROUTINE	ROUTINE	-
Vitamin D level	Deficiency associated with increased headache frequency	>30 ng/mL	-	ROUTINE	ROUTINE	-
Magnesium (RBC preferred)	Deficiency linked to migraine; common in frequent headache	>4.2 mg/dL	-	ROUTINE	ROUTINE	-
Urine drug screen	If opioid overuse suspected; document substances for treatment planning	Identifies substances	URGENT	ROUTINE	ROUTINE	-
Acetaminophen level	If acute APAP toxicity suspected (>4g/day use or intentional overdose)	<10 mcg/mL	STAT	STAT	-	-

1C. Rare/Specialized (Refractory or Atypical)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Ammonia level	If on valproate and altered mental status	Normal (<35 umol/L)	STAT	URGENT	-	-
INR, PT	If concern for coagulopathy from chronic NSAID use	Normal	-	ROUTINE	EXT	-
Ferritin	Iron deficiency associated with increased headache	>50 ng/mL	-	ROUTINE	ROUTINE	-
HbA1c	Diabetes screening in patients with chronic pain	<5.7% (normal)	-	ROUTINE	ROUTINE	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain without contrast	New headache pattern, atypical features, or first MOH evaluation	Normal; rule out secondary causes	MRI-incompatible devices	URGENT	ROUTINE	ROUTINE	-

2B. Extended¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain with contrast	Focal neurological deficits, papilledema, or suspected mass	No enhancing lesions	Gadolinium allergy; severe renal impairment	URGENT	ROUTINE	ROUTINE	-
MRA Head	Thunderclap headache component or suspected vascular etiology	Patent vessels; no aneurysm	MRI contraindications	URGENT	ROUTINE	EXT	-
MRV Brain	Suspected cerebral venous thrombosis (papilledema, positional)	Patent venous sinuses	MRI contraindications	URGENT	ROUTINE	EXT	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
CT Head non-contrast	Acute severe headache if MRI unavailable; rule out hemorrhage	No hemorrhage	Pregnancy (relative)	STAT	STAT	-	-
Cervical spine MRI	Cervicogenic component suspected	No cord compression or radiculopathy	MRI contraindications	-	ROUTINE	EXT	-

3. TREATMENT¶

3A. Acute/Emergent (Bridge Therapy During Withdrawal)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Prednisone	PO	Bridge therapy during withdrawal; reduces rebound severity	60 mg daily x 5 days; 60 mg daily x 3d then taper :: PO :: :: 60 mg daily x 5 days OR 60 mg x 3d, 40 mg x 3d, 20 mg x 3d	Active infection; uncontrolled diabetes; GI ulcer; psychosis	Glucose if diabetic; mood changes; insomnia	URGENT	URGENT	ROUTINE	-
Methylprednisolone	IV	Severe rebound headache requiring IV therapy	500 mg IV daily x 3-5 days :: IV :: :: 500 mg IV daily for 3-5 days; infuse over 1 hour	Active infection; uncontrolled diabetes	Glucose; BP; mood changes	-	URGENT	-	-
Naproxen	PO	Bridge therapy; standing dose to prevent rebound	500 mg BID x 2-4 weeks :: PO :: :: 500 mg PO BID for 2-4 weeks during withdrawal; not PRN use	Renal impairment; GI bleed; aspirin allergy; third trimester	GI symptoms; renal function if prolonged	URGENT	ROUTINE	ROUTINE	-
Dihydroergotamine (DHE)	IV	Inpatient DHE protocol for severe MOH; status migrainosus	0.5 mg IV q8h; 1 mg IV q8h :: IV :: :: 0.5-1 mg IV q8h for 3-5 days; pretreat with antiemetic; requires cardiac monitoring	Pregnancy; CAD; uncontrolled HTN; peripheral vascular disease; severe hepatic/renal impairment; basilar/hemiplegic migraine	BP; nausea; continuous cardiac monitoring; leg cramping	-	URGENT	-	-
Greater occipital nerve block	SC	Bridge therapy; occipital-predominant pain; opioid overuse	2-3 mL 2% lidocaine + 40 mg triamcinolone :: SC :: :: Inject at greater occipital nerve bilaterally; may repeat q4-6 weeks	Local anesthetic allergy; infection at site	Immediate pain relief; vasovagal reaction	-	ROUTINE	ROUTINE	-
Ketorolac	IV/IM	Acute severe headache during withdrawal	30 mg IV; 15 mg IV :: IV :: :: 30 mg IV x1 (15 mg if age >65, renal impairment, or <50 kg); max 5 days	Renal impairment; GI bleed; aspirin allergy; third trimester	Renal function	STAT	STAT	-	-
Metoclopramide	IV	Nausea during withdrawal; anti-migraine properties	10 mg IV; 20 mg IV :: IV :: :: 10-20 mg IV over 15 min; pretreat with diphenhydramine 25 mg to prevent akathisia	Parkinson's disease; tardive dyskinesia; bowel obstruction	Akathisia; dystonia	STAT	STAT	-	-
Prochlorperazine	IV	Nausea and headache during severe withdrawal	10 mg IV :: IV :: :: 10 mg IV over 2 min; pretreat with diphenhydramine 25 mg	QT prolongation; Parkinson's; neuroleptic hypersensitivity	Akathisia; dystonia; QTc	STAT	STAT	-	-
Ondansetron	IV/PO	Nausea associated with withdrawal or bridge therapy	4 mg IV; 8 mg PO; 4 mg ODT :: IV/PO :: :: 4 mg IV or 8 mg PO/ODT; may repeat q8h	QT prolongation; severe hepatic impairment	QTc if multiple doses	STAT	STAT	ROUTINE	-

3B. Symptomatic Treatments (Withdrawal Support)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Clonidine	PO	Opioid withdrawal symptoms (anxiety, sweating, tachycardia)	0.1 mg BID; 0.1 mg TID; 0.2 mg TID :: PO :: :: Start 0.1 mg BID-TID; titrate to effect; max 0.6 mg/day; taper over 1-2 weeks	Hypotension; bradycardia; heart block	BP, HR; rebound HTN if stopped abruptly	URGENT	ROUTINE	ROUTINE	-
Hydroxyzine	PO	Anxiety and insomnia during withdrawal	25 mg TID; 50 mg qHS; 25 mg q6h PRN :: PO :: :: 25 mg TID or 50 mg qHS; may use 25 mg q6h PRN for anxiety	Glaucoma; urinary retention; QT prolongation	Sedation; QTc	URGENT	ROUTINE	ROUTINE	-
Trazodone	PO	Insomnia during withdrawal period	50 mg qHS; 100 mg qHS; 150 mg qHS :: PO :: :: Start 50 mg qHS; may increase to 100-150 mg qHS	MAOIs; QT prolongation	Sedation; orthostatic hypotension; priapism (rare)	-	ROUTINE	ROUTINE	-
Loperamide	PO	Diarrhea during opioid withdrawal	4 mg initial, then 2 mg PRN :: PO :: :: 4 mg initial, then 2 mg after each loose stool; max 16 mg/day	Toxic megacolon; C. diff colitis	Avoid excessive use	URGENT	ROUTINE	ROUTINE	-
Dicyclomine	PO	Abdominal cramping during opioid withdrawal	20 mg QID; 10 mg QID :: PO :: :: 10-20 mg QID PRN cramping; max 80 mg/day	Glaucoma; GI obstruction; myasthenia gravis	Anticholinergic effects	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory (Opioid/Barbiturate Taper Protocols)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Butalbital taper	PO	Barbiturate-containing medication overuse; requires slow taper	Reduce by 1 tablet every 3-5 days :: PO :: :: Reduce by 1 dose (1 tablet) every 3-5 days; typical taper 2-4 weeks; abrupt stop risks seizure	None (taper required)	Seizure risk; anxiety; tremor; abrupt withdrawal can be fatal	-	ROUTINE	ROUTINE	-
Phenobarbital taper	PO	Severe barbiturate dependence; substitution taper	30 mg q6h; 15 mg q6h; taper by 15-30 mg q3-5d :: PO :: :: Convert butalbital to phenobarbital (30 mg phenobarbital per butalbital dose); taper by 15-30 mg every 3-5 days	Porphyria; severe hepatic impairment	Sedation; ataxia; respiratory depression	-	URGENT	EXT	-
Buprenorphine/naloxone	SL	Opioid overuse with dependence; OUD treatment	2 mg/0.5 mg SL; 4 mg/1 mg SL; 8 mg/2 mg SL :: SL :: :: Start 2-4 mg SL when in mild withdrawal (COWS >8); titrate to 8-16 mg daily; requires X-waiver or OTP	Severe hepatic impairment; respiratory depression	COWS score; precipitated withdrawal; sedation	-	URGENT	EXT	-
Opioid taper (long-acting)	PO	Opioid overuse without OUD; slow outpatient taper	Reduce 10-20% every 1-4 weeks :: PO :: :: Convert to long-acting opioid; reduce by 10-20% every 1-4 weeks; slower if prolonged use	None (taper required)	Withdrawal symptoms; pain control; functional status	-	ROUTINE	ROUTINE	-

3D. Disease-Modifying or Chronic Therapies (Preventive Medications)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Topiramate	PO	First-line prevention; especially if overweight	25 mg qHS; 50 mg BID; 75 mg BID; 100 mg BID :: PO :: :: Start 25 mg qHS; increase by 25 mg/wk; target 50-100 mg BID	None	Glaucoma; kidney stones; pregnancy (teratogen)	Cognitive effects; paresthesias; weight; bicarbonate; kidney stones	-	ROUTINE	ROUTINE	-
Amitriptyline	PO	First-line prevention; comorbid insomnia, depression, TTH component	10 mg qHS; 25 mg qHS; 50 mg qHS; 75 mg qHS :: PO :: :: Start 10 mg qHS; titrate by 10-25 mg q1-2wk; target 25-75 mg qHS	ECG if age >50 or cardiac history	Cardiac conduction abnormality; recent MI; glaucoma; urinary retention	Sedation; weight gain; dry mouth; ECG if dose >100 mg	-	ROUTINE	ROUTINE	-
Nortriptyline	PO	Prevention; less sedating than amitriptyline	10 mg qHS; 25 mg qHS; 50 mg qHS; 75 mg qHS :: PO :: :: Start 10 mg qHS; titrate by 10-25 mg q1-2wk; target 25-75 mg qHS	ECG if age >50 or cardiac history	Cardiac conduction abnormality; recent MI; urinary retention; glaucoma	Less sedation than amitriptyline; ECG if dose >100 mg	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	Prevention; comorbid depression, anxiety	37.5 mg daily; 75 mg daily; 150 mg daily :: PO :: :: Start 37.5 mg daily; increase by 37.5-75 mg q1wk; target 75-150 mg daily	None	Uncontrolled HTN; MAOIs; abrupt discontinuation	BP at higher doses; serotonin syndrome signs	-	ROUTINE	ROUTINE	-
Propranolol	PO	Prevention; comorbid HTN or anxiety	40 mg BID; 80 mg BID; 80 mg daily LA; 160 mg daily LA :: PO :: :: Start 40 mg BID or 80 mg LA daily; titrate q2wk; target 80-240 mg/day	None	Asthma; COPD; bradycardia <50; heart block; decompensated HF	HR, BP; fatigue; depression	-	ROUTINE	ROUTINE	-
Onabotulinumtoxin A (Botox)	IM	Chronic migraine with MOH; failed 2+ oral preventives	155-195 units IM :: IM :: :: 155-195 units across 31-39 injection sites q12wk; PREEMPT protocol	None	Infection at injection sites; myasthenia gravis	Neck weakness; ptosis (rare); effect takes 2-3 cycles	-	-	ROUTINE	-
Erenumab (Aimovig)	SC	CGRP mAb; especially for MOH; no washout period needed	70 mg SC monthly; 140 mg SC monthly :: SC :: :: 70 mg SC monthly; may increase to 140 mg monthly after 3 months	None	Hypersensitivity to erenumab	Constipation (can be severe); injection site reactions; HTN	-	-	ROUTINE	-
Fremanezumab (Ajovy)	SC	CGRP mAb; alternative dosing options	225 mg SC monthly; 675 mg SC quarterly :: SC :: :: 225 mg SC monthly OR 675 mg SC quarterly	None	Hypersensitivity	Injection site reactions	-	-	ROUTINE	-
Galcanezumab (Emgality)	SC	CGRP mAb; proven efficacy in MOH	240 mg SC load; 120 mg SC monthly :: SC :: :: 240 mg SC loading dose (2 x 120 mg), then 120 mg SC monthly	None	Hypersensitivity	Injection site reactions	-	-	ROUTINE	-
Valproate/Divalproex	PO	Prevention; comorbid bipolar or epilepsy	250 mg BID; 500 mg BID; 500 mg ER daily; 1000 mg ER daily :: PO :: :: Start 250 mg BID or 500 mg ER daily; titrate to 500-1000 mg/day	LFTs, CBC	Hepatic disease; pregnancy (teratogen); urea cycle disorders; pancreatitis	LFTs q6mo; weight; hair loss; tremor	-	ROUTINE	ROUTINE	-
Candesartan	PO	Prevention; comorbid HTN; beta-blocker intolerant	8 mg daily; 16 mg daily :: PO :: :: Start 8 mg daily; may increase to 16 mg daily	None	Pregnancy; bilateral renal artery stenosis; hyperkalemia	BP; K+; creatinine	-	ROUTINE	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Headache specialist/Neurology referral for refractory MOH management and preventive optimization	-	ROUTINE	ROUTINE	-
Pain psychology/Behavioral medicine referral for cognitive behavioral therapy addressing medication-seeking behaviors and pain catastrophizing	-	ROUTINE	ROUTINE	-
Addiction medicine consultation for opioid-overuse MOH with features of opioid use disorder	-	URGENT	ROUTINE	-
Primary care physician coordination for chronic disease management and medication reconciliation	-	ROUTINE	ROUTINE	-
Psychiatry referral for comorbid depression, anxiety, or substance use disorder requiring pharmacotherapy	-	ROUTINE	ROUTINE	-
Physical therapy for cervicogenic headache component and postural evaluation	-	-	ROUTINE	-
Social work consultation for disability resources, work accommodations, or financial assistance for medications	-	ROUTINE	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Expect temporary worsening of headaches during the first 1-2 weeks of withdrawal (rebound headache period); this is normal and necessary for improvement	URGENT	ROUTINE	ROUTINE
Most patients experience significant improvement within 2-3 months after successful withdrawal	-	ROUTINE	ROUTINE
Return immediately for severe headache with fever, stiff neck, or altered mental status which may indicate infection requiring emergency evaluation	STAT	-	ROUTINE
Return immediately for sudden severe headache different from usual ("worst headache of life") which may indicate hemorrhage	STAT	-	ROUTINE
Return if experiencing severe withdrawal symptoms including seizure, tremor, or hallucinations (especially with barbiturate or opioid overuse)	STAT	-	ROUTINE
Limit acute headache medication use to maximum 2 days per week to prevent recurrent MOH	ROUTINE	ROUTINE	ROUTINE
Maintain detailed headache diary tracking headache days, medication use days, and triggers	-	ROUTINE	ROUTINE
Do not abruptly stop butalbital-containing medications (Fioricet, Fiorinal) as this may cause seizures; must taper under physician guidance	URGENT	ROUTINE	ROUTINE
Preventive medications may take 4-8 weeks to show full benefit; continue as prescribed even if headaches persist initially	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular sleep schedule (7-8 hours, consistent bedtime/wake time) as irregular sleep triggers headache	-	ROUTINE	ROUTINE
Regular meals to avoid fasting-triggered headache; do not skip meals	-	ROUTINE	ROUTINE
Aerobic exercise (30 min moderate activity 5x/week) shown to reduce headache frequency and improve mood	-	ROUTINE	ROUTINE
Stress management through relaxation techniques, mindfulness, or biofeedback to reduce headache triggers	-	ROUTINE	ROUTINE
Adequate hydration (at least 64 oz water daily) as dehydration can trigger headache	-	ROUTINE	ROUTINE
Caffeine consistency: if using caffeine, maintain consistent daily intake; if tapering, reduce gradually over 2 weeks	-	ROUTINE	ROUTINE
Alcohol avoidance during withdrawal period as it can worsen headaches and interact with medications	-	ROUTINE	ROUTINE
Avoid keeping overused medications at home during withdrawal to reduce temptation and relapse risk	-	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Chronic migraine without MOH	≥15 headache days/month but <10-15 medication days/month; no improvement with medication withdrawal	Headache diary showing medication use <10-15 days/month
Chronic tension-type headache	Bilateral, pressing/tightening quality, mild-moderate intensity, no nausea, minimal photo/phonophobia	Clinical criteria (ICHD-3); no medication overuse pattern
New daily persistent headache (NDPH)	Distinct onset remembered; daily headache from onset; often no prior headache history	Clinical history; MRI to exclude secondary causes; no MOH pattern
Idiopathic intracranial hypertension	Positional headache worse with lying down; papilledema; pulsatile tinnitus; visual obscurations	LP opening pressure >25 cm H2O; MRI/MRV showing empty sella, transverse sinus stenosis
Cervicogenic headache	Unilateral, occipital-frontal radiation, triggered by neck movement or posture	C-spine imaging; diagnostic occipital nerve block
Secondary headache (structural)	Progressive headache, focal neurological deficits, papilledema, new onset >50 years	MRI brain with contrast; consider LP
Chronic subdural hematoma	Elderly, anticoagulation, history of fall/trauma; progressive headache	CT head; MRI brain
Cerebral venous thrombosis	Positional headache; papilledema; hypercoagulable state; pregnancy/postpartum	MRV brain; D-dimer (if negative, unlikely)
Giant cell arteritis	Age >50; scalp tenderness; jaw claudication; visual changes; elevated inflammatory markers	ESR, CRP elevated; temporal artery biopsy

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Headache diary (frequency, severity, medication use)	Daily during withdrawal, then weekly	<4 headache days/month after 3 months	Continue withdrawal protocol; optimize preventive therapy	-	ROUTINE	ROUTINE	-
Acute medication use days	Weekly during withdrawal, then monthly	≤2 days/week (≤8 days/month)	Reinforce limits; address triggers; consider inpatient withdrawal	-	ROUTINE	ROUTINE	-
COWS score (Clinical Opiate Withdrawal Scale)	q4-6h during opioid withdrawal	<8 (mild)	Provide symptomatic treatment; adjust taper if severe	-	URGENT	-	-
Vital signs (HR, BP)	Each visit during withdrawal	Stable; no hypertensive crisis	Treat withdrawal symptoms; hold clonidine if hypotensive	STAT	ROUTINE	ROUTINE	-
Mood assessment (PHQ-9, GAD-7)	Each visit	Stable or improving	Psychiatry referral; adjust antidepressant	-	ROUTINE	ROUTINE	-
LFTs (if on valproate or prior APAP overuse)	Baseline, 3 months, then q6mo	Normal	Discontinue valproate if >3x ULN; evaluate hepatic injury	-	ROUTINE	ROUTINE	-
Weight (if on topiramate, amitriptyline, valproate)	Each visit	Stable	Adjust medication; diet counseling	-	ROUTINE	ROUTINE	-
Bicarbonate (if on topiramate)	Baseline, 3 months	>18 mEq/L	Consider dose reduction or discontinuation	-	ROUTINE	ROUTINE	-
HIT-6 or MIDAS disability score	Every 3 months	50% improvement	Escalate preventive therapy; consider CGRP mAb or Botox	-	-	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Mild-moderate MOH; able to comply with outpatient withdrawal; no opioid/barbiturate dependence requiring medical supervision; support system in place
Admit to floor	Severe rebound headache not controlled with outpatient therapy; opioid or barbiturate withdrawal requiring medical supervision; need for DHE protocol; intractable nausea/vomiting; severe comorbid psychiatric illness
Admit to ICU	Rare; barbiturate withdrawal with seizure risk or autonomic instability; severe opioid withdrawal with hemodynamic instability
Outpatient withdrawal	Most patients; simple analgesic or triptan overuse; reliable follow-up within 1-2 weeks
Outpatient follow-up timing	Initial: within 1-2 weeks of starting withdrawal; then every 2-4 weeks during transition; monthly once stable on preventive

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
ICHD-3 diagnostic criteria for MOH	Consensus	Headache Classification Committee. Cephalalgia 2018
Withdrawal as primary treatment for MOH	Class I, Level A	Diener et al. Lancet Neurol 2019
Abrupt vs gradual withdrawal for simple analgesics/triptans	Class II, Level B	Rossi et al. Cephalalgia 2006
Bridge therapy with corticosteroids during withdrawal	Class II, Level B	Krymchantowski et al. Headache 2000
Preventive therapy initiation during withdrawal	Class II, Level B	Hagen et al. Cephalalgia 2009
Topiramate effective in MOH prevention	Class I, Level A	Silberstein et al. Headache 2012
OnabotulinumtoxinA for chronic migraine with MOH	Class I, Level A	Silberstein et al. Headache 2015
CGRP mAbs effective in MOH without prior withdrawal	Class I, Level A	Tepper et al. Cephalalgia 2019 (erenumab in MOH)
Greater occipital nerve block as bridge therapy	Class II, Level B	Cuadrado et al. Headache 2017
DHE protocol for status migrainosus and refractory MOH	Class II, Level C	Raskin et al. Neurology 1986
Behavioral therapy as adjunct in MOH treatment	Class II, Level B	Katsarava et al. Neurology 2003
Relapse rate up to 40% at 1 year without preventive	Class II, Level B	Katsarava et al. Neurology 2005
Opioid MOH has worst prognosis and highest relapse	Class II, Level B	Bigal et al. Neurology 2008

CHANGE LOG¶

v1.0 (January 27, 2026) - Initial template creation - Comprehensive withdrawal strategies for different medication classes - Bridge therapy options including prednisone, naproxen, DHE, and nerve blocks - Preventive therapy including oral medications and CGRP monoclonal antibodies - Special protocols for opioid and barbiturate overuse - Structured dosing format for order sentence generation

APPENDIX A: ICHD-3 Diagnostic Criteria for Medication Overuse Headache¶

8.2 Medication-overuse headache (MOH)

Diagnostic criteria:

A. Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder B. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache C. Not better accounted for by another ICHD-3 diagnosis

Medication-Specific Thresholds:

Medication Class	Overuse Threshold
Simple analgesics (acetaminophen, ASA, NSAIDs)	≥15 days/month
Triptans	≥10 days/month
Ergotamine	≥10 days/month
Opioids	≥10 days/month
Combination analgesics (butalbital, caffeine combinations)	≥10 days/month
Multiple drug classes (not individually meeting threshold)	≥10 days/month combined

APPENDIX B: Withdrawal Strategy by Medication Class¶

Medication Class	Withdrawal Strategy	Bridge Therapy	Timeline
Simple analgesics (APAP, ibuprofen, naproxen)	Abrupt discontinuation	Prednisone taper; standing naproxen 2 wks; nerve block	Rebound 3-10 days; improvement 2-4 weeks
Triptans	Abrupt discontinuation	Prednisone taper; standing naproxen; nerve block	Rebound 3-10 days; improvement 2-4 weeks
Combination analgesics with caffeine	Abrupt discontinuation (unless butalbital)	Prednisone taper; may need caffeine taper	Rebound 5-14 days; caffeine withdrawal 3-5 days
Butalbital-containing (Fioricet, Fiorinal)	MUST TAPER - seizure risk	Phenobarbital substitution if high doses; slow taper	Taper over 2-4+ weeks
Opioids	Taper preferred; may need inpatient	Clonidine for autonomic symptoms; MAT consideration	Taper over 2-4+ weeks; symptoms 7-14 days
Ergotamine	Abrupt discontinuation	DHE protocol if available; prednisone	Rebound 3-10 days

APPENDIX C: Patient Education Handout Key Points¶

What is Medication Overuse Headache?

Medication overuse headache (MOH) happens when frequent use of headache medications actually causes more headaches. It is sometimes called "rebound headache." The brain becomes dependent on the medication and triggers headaches when the medication wears off.

How did this happen?

MOH can develop in anyone who uses acute headache medications too often: - Pain relievers (Tylenol, Advil, Aleve) used ≥15 days/month - Triptans (Imitrex, etc.) used ≥10 days/month - Combination medications (Excedrin, Fioricet) used ≥10 days/month - Opioids or butalbital used ≥10 days/month

What to expect during withdrawal:

Week 1-2: Headaches may temporarily get WORSE. This is expected and necessary. You may also experience nausea, sleep problems, and anxiety.
Week 3-4: Headaches begin to improve. You start to have more headache-free days.
Month 2-3: Most patients have significant improvement. Preventive medications begin working fully.

Keys to success:

Do not use the overused medication - even for severe headaches
Take your preventive medication every day as prescribed
Keep a headache diary
Follow up with your neurologist as scheduled
Limit acute medications to ≤2 days per week going forward