Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Medication overuse headache: Etiology, clinical features, and diagnosis

Ivan Garza, MD
Todd J Schwedt, MD, MSCI
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editor
John F Dashe, MD, PhD


Chronic daily headache is a descriptive term that encompasses several different specific headache diagnoses. Chronic daily headache types of long duration (ie, four hours or more) include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Medication overuse headache (MOH), a secondary headache disorder, frequently complicates management of multiple primary headache disorders. (See "Overview of chronic daily headache".)

This topic will review the etiology, clinical features, and diagnosis of MOH. The treatment and prognosis of MOH is discussed separately. (See "Medication overuse headache: Treatment and prognosis".)


Medication overuse headache (MOH) is the term applied to headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped [1]. MOH has also been termed analgesic rebound headache, drug-induced headache, and medication-misuse headache.

Although not a primary type of chronic daily headache, MOH deserves proper coverage since it frequently coexists with primary chronic daily headache. In some cases, MOH may be associated with the development or maintenance of a chronic daily headache syndrome [2].


Available evidence suggests all drugs used for the acute symptomatic treatment of headache can cause medication overuse headache (MOH) in primary headache disorders [3,4]. The precise mechanisms that lead to MOH are still uncertain. However, multiple factors seem to play a role, including genetic predisposition, central sensitization, and biobehavioral factors.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Dec 15, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
  2. Bigal ME, Rapoport AM, Sheftell FD, et al. Transformed migraine and medication overuse in a tertiary headache centre--clinical characteristics and treatment outcomes. Cephalalgia 2004; 24:483.
  3. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004; 3:475.
  4. Abrams BM. Medication overuse headaches. Med Clin North Am 2013; 97:337.
  5. Lance F, Parkes C, Wilkinson M. Does analgesic abuse cause headaches de novo? Headache 1988; 28:61.
  6. Bahra A, Walsh M, Menon S, Goadsby PJ. Does chronic daily headache arise de novo in association with regular use of analgesics? Headache 2003; 43:179.
  7. Katsarava Z, Jensen R. Medication-overuse headache: where are we now? Curr Opin Neurol 2007; 20:326.
  8. Paemeleire K, Bahra A, Evers S, et al. Medication-overuse headache in patients with cluster headache. Neurology 2006; 67:109.
  9. Young WB, Silberstein SD. Hemicrania continua and symptomatic medication overuse. Headache 1993; 33:485.
  10. Dodick D, Freitag F. Evidence-based understanding of medication-overuse headache: clinical implications. Headache 2006; 46 Suppl 4:S202.
  11. Dobson CF, Tohyama Y, Diksic M, Hamel E. Effects of acute or chronic administration of anti-migraine drugs sumatriptan and zolmitriptan on serotonin synthesis in the rat brain. Cephalalgia 2004; 24:2.
  12. Ayzenberg I, Obermann M, Nyhuis P, et al. Central sensitization of the trigeminal and somatic nociceptive systems in medication overuse headache mainly involves cerebral supraspinal structures. Cephalalgia 2006; 26:1106.
  13. De Felice M, Ossipov MH, Wang R, et al. Triptan-induced latent sensitization: a possible basis for medication overuse headache. Ann Neurol 2010; 67:325.
  14. Fumal A, Laureys S, Di Clemente L, et al. Orbitofrontal cortex involvement in chronic analgesic-overuse headache evolving from episodic migraine. Brain 2006; 129:543.
  15. Boes CJ, Black DF, Dodick DW. Pathophysiology and management of transformed migraine and medication overuse headache. Semin Neurol 2006; 26:232.
  16. Saper JR, Hamel RL, Lake AE 3rd. Medication overuse headache (MOH) is a biobehavioural disorder. Cephalalgia 2005; 25:545.
  17. Zwart JA, Dyb G, Hagen K, et al. Analgesic use: a predictor of chronic pain and medication overuse headache: the Head-HUNT Study. Neurology 2003; 61:160.
  18. Radat F, Creac'h C, Swendsen JD, et al. Psychiatric comorbidity in the evolution from migraine to medication overuse headache. Cephalalgia 2005; 25:519.
  19. Fuh JL, Wang SJ, Lu SR, Juang KD. Does medication overuse headache represent a behavior of dependence? Pain 2005; 119:49.
  20. Pascual J, Colás R, Castillo J. Epidemiology of chronic daily headache. Curr Pain Headache Rep 2001; 5:529.
  21. Westergaard ML, Hansen EH, Glümer C, et al. Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review. Cephalalgia 2014; 34:409.
  22. Zwart JA, Dyb G, Hagen K, et al. Analgesic overuse among subjects with headache, neck, and low-back pain. Neurology 2004; 62:1540.
  23. Castillo J, Muñoz P, Guitera V, Pascual J. Kaplan Award 1998. Epidemiology of chronic daily headache in the general population. Headache 1999; 39:190.
  24. Diener HC, Limmroth V, Katsarava Z. Medication-Overuse Headache. In: Chronic daily headache for clinicians, Goadsby PJ, Dodick DW (Eds), Decker, Hamilton 2005. p.117.
  25. Obermann M, Katsarava Z. Management of medication-overuse headache. Expert Rev Neurother 2007; 7:1145.
  26. Diener HC, Dahlof CG. Headache associated with chronic use of substances. In: The Headaches, Second ed, Olesen J, Tfelt-Hansen P, Welch KM (Eds), Lippincott, Williams & Wilkins, Philadelphia 1999. p.871.
  27. Atasoy HT, Unal AE, Atasoy N, et al. Low income and education levels may cause medication overuse and chronicity in migraine patients. Headache 2005; 45:25.
  28. Johnson JL, Hutchinson MR, Williams DB, Rolan P. Medication-overuse headache and opioid-induced hyperalgesia: A review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment. Cephalalgia 2013; 33:52.
  29. Lipton RB, Serrano D, Nicholson RA, et al. Impact of NSAID and Triptan use on developing chronic migraine: results from the American Migraine Prevalence and Prevention (AMPP) study. Headache 2013; 53:1548.
  30. Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008; 48:1157.
  31. Bigal ME, Lipton RB. Excessive acute migraine medication use and migraine progression. Neurology 2008; 71:1821.
  32. Limmroth V, Katsarava Z, Fritsche G, et al. Features of medication overuse headache following overuse of different acute headache drugs. Neurology 2002; 59:1011.
  33. Krymchantowski AV. Overuse of symptomatic medications among chronic (transformed) migraine patients: profile of drug consumption. Arq Neuropsiquiatr 2003; 61:43.
  34. Meskunas CA, Tepper SJ, Rapoport AM, et al. Medications associated with probable medication overuse headache reported in a tertiary care headache center over a 15-year period. Headache 2006; 46:766.