Medication Overuse in Headache
Frequent use of painkillers or acute symptomatic medication for headaches (including paracetamol, triptans, combination products, and NSAID’s) leads to medication overuse (MO). The key factor for defining medication overuse is the number of days per month that acute medication is taken for headache. It does not appear to be relevant in this context whether a single dose or multiple doses of the acute headache medication are used on a particular day.
“Medication Overuse” is formally defined as the use of:
- Simple analgesia (such as paracetamol or NSAID’s) 15 or more days per month for at least three months, OR
- Combination analgesics (often codeine/opiate based, such as solpadine) or triptans 10 or more days a month for at least three months
In my clinical practice, I generally advise our headache patients that analgesics or acute medication should be used no more than 4-6 days per month, in order to avoid medication overuse. Typically, MO begins with patients taking over the counter painkillers more regularly, and this often starts well before the patient consults with their general practitioner. When the practice of MO leads to a change in headache pattern and resistance to conventional migraine prophylactic treatment, the patient is then described as having medication overuse headache or MOH.
The practice of medication overuse is very common. It is a significant problem worldwide, both in primary care and hospital clinics. In addition, MOH appears to be almost exclusive to those who suffer from migraine. Historically, this was called analgesic rebound headache, medication misuse headache, transformed migraine or drug induced headache. A headache diary may be useful for patients to keep a detailed record of medication use.
Medication overuse – When is it time for Prophylactic Migraine Treatment?
MO in the context of more chronic migraine is a worldwide public health problem. Despite repeated public awareness campaigns in internationally over the last two decades, this issue is still a significant cause of disability in a large proportion of high frequency episodic and chronic migraine patients. You may remember the public health campaign which took place in Ireland in 2007. As a result of it, solpadine are available from chemists now
As a general guideline, preventive or prophylactic therapy is indicated in patients with migraine who have headache and associated neurological symptoms:
- on 8-10 days per month or more (usually for a period of at least 3-6 months), and
- have at least moderate disability.
One hopes to treat migraine effectively before MO develops. It should be again emphasised that if there is established MO and chronic migraine, there is strong evidence to suggest that many conventional prophylactic treatments are ineffective or less effective
Strategies for Prevention of MO in Migraine Patients
An integrated care approach to prevention and management of MO in patients with migraine. This often involves primary care physicians, pharmacists, practice nurses, community psychology and psychiatry, and the voluntary patient groups, such as the Migraine Association of Ireland (MAI), accident and emergency doctors, and other hospital-based healthcare professionals (neurologists, specialist nurses, psychologists, etc)
We feel that the following should be considered to try and prevent MO and MOH:
- Headache diaries should record which acute medications are used and how frequently.
- There should be caution in Primary care and in Accident & Emergencies departments when prescribing codeine (which is metabolised as an opiate) or opiate-based analgesia, as they are often responsible for MO, and there is also the potential for dependence and possibly addiction. Opiate based medication may also cause drowsiness, incoordination and possibly impair driving. All patients should be advised of this when they get a prescription. It is generally advised that headache patients should avoid codeine, tramadol and other opiate derivatives (including Tylex, Ixprim, Solpadeine, Solpadol, Palexia, etc).
- Written patient information leaflets/booklets on medication overuse should be given to those migraine patients, in particular when opiate or combination painkillers (e.g solpadine) are prescribed; and who are potentially at risk of progressing to MO.
- Pharmacists are ideally placed in primary care to identify patients who may be at risk of MO. Therefore, it is essential to include and collaborate with pharmacists to highlight this message to patients.
- The value of pharmacy involvement has now been highlighted through their inclusion in the 2020 National Slaintecare headache programme.
- The Migraine Association of Ireland (MAI) also provides information for patients.