Medication Overuse Headache¶

VERSION: 1.0 CREATED: January 29, 2026 REVISED: January 29, 2026 STATUS: Approved

DIAGNOSIS: Medication Overuse Headache (MOH)

ICD-10: G44.40 (Drug-induced headache, not elsewhere classified, not intractable), G44.41 (Drug-induced headache, not elsewhere classified, intractable)

CPT CODES: 85025 (CBC), 80053 (CMP), 84443 (TSH), 80076 (LFTs), 82565 (BUN/Creatinine), 85652 (ESR), 80307 (Urine drug screen), 70551 (MRI brain without contrast), 70552 (MRI brain with contrast), 96365 (IV DHE protocol), 96374 (IV ketorolac), J0585 (OnabotulinumtoxinA)

SYNONYMS: Medication overuse headache, MOH, rebound headache, analgesic overuse headache, drug-induced headache, medication-induced headache, chronic daily headache from medication overuse, transformed migraine, analgesic rebound headache, triptan overuse headache, opioid overuse headache, ergotamine overuse headache, butalbital overuse headache, painkiller headache, medication misuse headache, CDH, chronic daily headache

SCOPE: Diagnosis and management of medication overuse headache in adults. Covers identification of offending medications, withdrawal strategies, preventive medication initiation, and relapse prevention. Excludes primary headache disorders without overuse component, and headache due to medication side effects (not overuse).

DEFINITIONS: - Medication Overuse Headache (MOH): Headache occurring ≥15 days/month in a patient with pre-existing headache who regularly overuses acute headache medications for >3 months - Medication Overuse: Use of acute headache medications on ≥10-15 days/month depending on drug class - Chronic Daily Headache: Headache occurring ≥15 days/month for >3 months

DIAGNOSTIC CRITERIA (ICHD-3):

A. Headache occurring on ≥15 days per 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: - Simple analgesics ≥15 days/month - Triptans, ergots, opioids, or combination analgesics ≥10 days/month - Any combination of above ≥10 days/month C. Not better accounted for by another ICHD-3 diagnosis

Drug-Specific Subtypes: - Ergotamine-overuse headache - Triptan-overuse headache - Simple analgesic-overuse headache (acetaminophen, NSAIDs) - Opioid-overuse headache - Combination analgesic-overuse headache (e.g., butalbital-containing)

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

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	-	ROUTINE	ROUTINE	-	Baseline; anemia can contribute to headache	Normal
CMP (CPT 80053)	-	ROUTINE	ROUTINE	-	Electrolytes, renal/hepatic function (chronic NSAID/acetaminophen use)	Normal
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Thyroid dysfunction	Normal

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
LFTs (CPT 80076)	-	ROUTINE	ROUTINE	-	If chronic acetaminophen use	Normal
BUN/Creatinine (CPT 82565)	-	ROUTINE	ROUTINE	-	If chronic NSAID use	Normal
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	If inflammatory/secondary cause suspected	Normal
Urine drug screen (CPT 80307)	-	ROUTINE	ROUTINE	-	If opioid overuse/diversion suspected	Document

1C. Rare/Specialized¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Lumbar puncture	-	EXT	-	-	Only if secondary cause suspected (IIH, infection)	Normal

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	If not previously done; red flags	Rule out secondary causes	Pacemaker, metal

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with contrast (CPT 70552)	-	ROUTINE	ROUTINE	-	If mass, infection suspected	Rule out structural cause	Contrast allergy, renal disease
MRV	-	EXT	EXT	-	If IIH suspected	Patent venous sinuses	Per MRI

3. TREATMENT¶

3A. Withdrawal Strategies - Outpatient¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Abrupt discontinuation (simple analgesics, triptans)	-	-	N/A :: - :: per protocol :: Stop all overused medications immediately; preferred for most patients	None	Headache diary; expect worsening days 2-10	-	ROUTINE	ROUTINE	-
Gradual taper (opioids, barbiturates)	-	-	25% :: - :: - :: Reduce by 10-25% every 1-2 weeks; slower for long-term use	None	Withdrawal symptoms	-	ROUTINE	ROUTINE	-
Bridge therapy during withdrawal	-	-	N/A :: - :: per protocol :: See below	Per agent	Support through withdrawal phase	-	ROUTINE	ROUTINE	-

3B. Bridge Therapy During Withdrawal¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Naproxen sodium (scheduled)	-	-	500 mg :: - :: BID :: 500 mg BID × 2-4 weeks (not PRN - scheduled dosing to prevent rebound)	Renal disease, GI bleeding	Limited to 2-4 weeks	-	ROUTINE	ROUTINE	-
Prednisone (short course)	-	-	60 mg :: - :: daily x 3 days :: 60 mg × 3 days, 40 mg × 3 days, 20 mg × 3 days (total 9 days)	Uncontrolled DM, infection	Glucose	-	ROUTINE	ROUTINE	-
Dexamethasone	PO	-	4-8 mg :: PO :: daily :: 4-8 mg daily × 5-7 days	Same	Same	-	ROUTINE	ROUTINE	-
Nerve block (GON)	-	-	2% :: - :: - :: Lidocaine 2% + steroid, bilateral	Anticoagulation, local infection	May reduce withdrawal severity	-	ROUTINE	ROUTINE	-
Antiemetics PRN	PO	-	10 mg :: PO :: q8h :: Metoclopramide 10 mg q8h PRN or ondansetron 4-8 mg q8h PRN	Per agent	For nausea during withdrawal	-	ROUTINE	ROUTINE	-

3C. Inpatient Withdrawal (Severe Cases)¶

Indication: Failed outpatient withdrawal, severe daily disability, opioid/barbiturate dependence, psychiatric comorbidity, need for intensive monitoring

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV DHE protocol (CPT 96365)	IV	-	0.5-1 mg :: IV :: q8h :: DHE 0.5-1 mg IV q8h × 3-5 days (with metoclopramide 10 mg IV pretreatment)	CAD, CVA, uncontrolled HTN, pregnancy, triptans <24h	BP, nausea, EKG	-	STAT	-	-
IV magnesium	IV	-	1-2 g :: IV :: daily :: 1-2 g IV daily × 3-5 days	Renal failure	Mg levels	-	ROUTINE	-	-
IV ketorolac (CPT 96374)	IV	-	15-30 mg :: IV :: q6h :: 15-30 mg IV q6h × 2-3 days (max 5 days)	Renal disease, GI bleeding	Renal function	-	ROUTINE	-	-
IV valproate	IV	-	500-1000 mg :: IV :: BID :: 500-1000 mg IV BID × 3-5 days	Pregnancy, hepatic disease	Ammonia, LFTs	-	ROUTINE	-	-
IV diphenhydramine	IV	-	25-50 mg :: IV :: q6h :: 25-50 mg IV q6h with antiemetics	Glaucoma	Sedation	-	ROUTINE	-	-
Opioid taper protocol	-	-	N/A :: - :: per protocol :: Structured taper with addiction medicine if significant dependence	N/A	Withdrawal symptoms	-	ROUTINE	-	-
Barbiturate taper	-	-	N/A :: - :: per protocol :: Phenobarbital substitution and taper for butalbital dependence	N/A	Sedation, withdrawal	-	ROUTINE	-	-

3D. Preventive Medication (Start During or After Withdrawal)¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Topiramate	PO	-	25 mg :: PO :: daily :: Start 25 mg daily; titrate to 50-100 mg BID	-	Kidney stones, glaucoma, pregnancy	Cognitive effects, paresthesias	-	ROUTINE	ROUTINE	-
Amitriptyline	-	-	10-25 mg :: PO :: QHS :: Start 10-25 mg QHS; titrate to 50-100 mg QHS	-	Cardiac arrhythmia, glaucoma	QTc, sedation	-	ROUTINE	ROUTINE	-
Propranolol	PO	-	40 mg :: PO :: BID :: Start 40 mg BID; titrate to 80-160 mg/day	-	Asthma, heart block, bradycardia	HR, BP	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	-	37.5 mg :: PO :: daily :: Start 37.5 mg daily; titrate to 75-150 mg daily	-	Uncontrolled HTN, MAOIs	BP	-	ROUTINE	ROUTINE	-
OnabotulinumtoxinA (CPT J0585)	IM	-	155-195 units :: IM :: - :: 155-195 units IM q12 weeks (if chronic migraine criteria met)	-	Infection at site, myasthenia	Spread of effect	-	-	ROUTINE	-
CGRP monoclonal antibodies	SC	-	70-140 mg :: SC :: monthly :: Erenumab 70-140 mg SC monthly; Fremanezumab 225 mg monthly or 675 mg quarterly; Galcanezumab 240 mg load then 120 mg monthly	-	Hypersensitivity	Constipation (erenumab), injection reactions	-	-	ROUTINE	-
Valproate	PO	-	250-500 mg :: PO :: BID :: Start 250-500 mg BID; titrate to 500-1000 mg BID	-	Pregnancy, hepatic disease	LFTs, ammonia, weight	-	ROUTINE	ROUTINE	-

3E. Rescue Medications (Limited Use After Withdrawal)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Triptan (limited)	-	-	N/A :: - :: per protocol :: Max 2 days/week; max 9 days/month	CV disease	Headache diary	-	-	ROUTINE	-
NSAID (limited)	-	-	N/A :: - :: per protocol :: Max 2 days/week; max 14 days/month	Renal/GI disease	Headache diary	-	-	ROUTINE	-
Gepants (preferred rescue)	PO	-	50-100 mg :: PO :: - :: Ubrogepant 50-100 mg or Rimegepant 75 mg; may have lower MOH risk	Per agent	May be safer for frequent use	-	-	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Headache specialist/Neurology	-	ROUTINE	ROUTINE	-	All patients; management and prevention
Pain psychology/Behavioral health	-	ROUTINE	ROUTINE	-	CBT for headache, coping strategies, anxiety/depression
Addiction medicine	-	ROUTINE	ROUTINE	-	Opioid or barbiturate dependence
Psychiatry	-	ROUTINE	ROUTINE	-	Comorbid depression, anxiety
Physical therapy	-	-	ROUTINE	-	Cervicogenic component, tension-type features
Biofeedback specialist	-	-	ROUTINE	-	Non-pharmacologic headache management

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD
MOH is caused by frequent use of pain medications; stopping them is essential for improvement	ROUTINE	ROUTINE	ROUTINE
Expect headaches to WORSEN for 2-10 days during withdrawal before improving	-	ROUTINE	ROUTINE
Most patients improve significantly within 2-3 months of stopping overused medications	-	ROUTINE	ROUTINE
STRICT medication limits going forward: triptans ≤9 days/month, NSAIDs ≤14 days/month	-	ROUTINE	ROUTINE
Keep detailed headache diary tracking medications and headache days	-	ROUTINE	ROUTINE
Preventive medication takes 4-8 weeks to work; be patient	-	ROUTINE	ROUTINE
Relapse is common (~40%); call if headache frequency increasing	-	ROUTINE	ROUTINE
Do NOT restart butalbital-containing medications (Fioricet, Fiorinal)	-	ROUTINE	ROUTINE
Opioids should NOT be used for primary headache disorders	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular sleep schedule (7-8 hours)	-	ROUTINE	ROUTINE
Regular meal schedule (don't skip meals)	-	ROUTINE	ROUTINE
Regular exercise (30 min, 5 days/week)	-	ROUTINE	ROUTINE
Stress management techniques (biofeedback, relaxation, CBT)	-	ROUTINE	ROUTINE
Limit caffeine to consistent moderate intake (<200 mg/day)	-	ROUTINE	ROUTINE
Stay well-hydrated	-	ROUTINE	ROUTINE
Avoid known migraine triggers	-	ROUTINE	ROUTINE
Establish "medication rules" and stick to them	-	ROUTINE	ROUTINE

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Chronic migraine (without MOH)	≥15 headache days/month but NO medication overuse	Medication diary
Chronic tension-type headache	Bilateral, pressing, mild-moderate, no nausea	Clinical; no medication overuse
New daily persistent headache	Distinct onset date; daily from onset; no prior headache history	Clinical history
Hemicrania continua	Continuous unilateral pain; responds to indomethacin	Indomethacin trial
Idiopathic intracranial hypertension	Papilledema, visual obscurations, pulsatile tinnitus	LP with elevated OP, fundoscopy
Secondary headache (tumor, CSF leak, etc.)	Red flags, focal deficits, progressive	MRI brain
Cervicogenic headache	Neck pain, limited ROM, triggered by neck movement	Cervical exam, imaging

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Headache frequency (days/month)	-	Daily	Each visit	-	Monthly	<15 days/month	Adjust preventive
Medication use (days/month)	-	Daily	Each visit	-	Monthly	Triptans <10, NSAIDs <15, total <10	Counsel; adjust strategy
MIDAS or HIT-6 score	-	-	ROUTINE	-	q3 months	Improving disability	Adjust treatment
Headache diary review	-	ROUTINE	Each visit	-	Ongoing	Documented compliance	Reinforce education
Preventive medication adherence	-	-	Each visit	-	Each visit	Taking as prescribed	Address barriers
Depression/anxiety screening	-	ROUTINE	Each visit	-	q3-6 months	Negative or stable	Refer if positive
Weight (if on topiramate/valproate)	-	-	Each visit	-	Each visit	Stable	Adjust medication

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Outpatient management	Most patients; mild-moderate disability, no significant opioid/barbiturate dependence
Admit to hospital	Failed outpatient withdrawal, severe disability, significant opioid/barbiturate dependence, psychiatric comorbidity requiring stabilization, need for IV protocol
Discharge from hospital	Withdrawal completed, preventive started, headache improving, follow-up arranged
Headache specialist follow-up	Within 2-4 weeks of withdrawal; then q1-3 months
Relapse management	May need repeat withdrawal; intensify preventive; consider CGRP mAbs

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
ICHD-3 diagnostic criteria for MOH	Class I	International Headache Society 2018
Abrupt withdrawal effective for simple analgesics/triptans	Class II, Level B	Multiple studies
Bridge therapy with corticosteroids	Class II, Level B	Multiple studies
Preventive medication should be started with withdrawal	Class I, Level A	Expert consensus; multiple guidelines
Topiramate effective for migraine prevention	Class I, Level A	Multiple RCTs
CGRP mAbs may have lower MOH risk	Class II, Level B	Emerging evidence
Gepants may have lower MOH risk	Class II, Level C	Emerging evidence
~40% relapse rate at 1 year	Class II	Observational studies
Opioids and barbiturates have highest MOH risk	Class II, Level B	Multiple studies

NOTES¶

MOH is one of the most common causes of chronic daily headache
Paradoxically, the medications that help acute headaches CAUSE chronic headaches when overused
Triptans, opioids, and barbiturates have LOWER threshold for MOH (≥10 days/month)
Butalbital-containing medications (Fioricet, Fiorinal) are particularly problematic and should be avoided
Opioids should almost NEVER be used for primary headache disorders
Patient education is critical - they must understand the paradox of MOH
Expect worsening during withdrawal ("detox headache") before improvement
Preventive medication should be started during or immediately after withdrawal
CGRP antagonists (gepants, mAbs) may have lower MOH potential - useful in MOH-prone patients
Relapse is common (~40%) - ongoing monitoring and reinforcement needed
Behavioral approaches (CBT, biofeedback) are important adjuncts

CHANGE LOG¶

v1.0 (January 29, 2026) - Initial template creation - ICHD-3 criteria for MOH - Outpatient and inpatient withdrawal protocols - Bridge therapy options - Emphasis on medication limits and patient education - CGRP mAbs and gepants as potentially safer options