Medication Overuse Headache is a type of headache that develops as a result of excessive, frequent, or uncontrolled use of painkiller medications used to relieve headache.
As the person takes medication each time to alleviate their pain, over time these medications begin to trigger new and persistent headaches. This condition is called “Medication Overuse Headache (MOH)” or “Rebound Headache” in medicine.

This headache is most commonly seen in people with migraine or chronic tension-type headache.
Long-term and irregular use of painkillers disrupts the brain’s pain control mechanisms, causing headaches to become more frequent, more resistant, and more severe.
However, with early diagnosis and correct treatment, this condition can be completely corrected and patients’ quality of life significantly increases.

What is Medication Overuse Headache?

Medication Overuse Headache is a type of chronic headache that develops as a result of very frequent or long-term use of painkiller medications used to relieve headache.
This condition is called “Medication Overuse Headache (MOH)” or “Rebound Headache” in medicine.

Normally, painkillers provide relief by temporarily suppressing the brain’s pain centers.
However, when medications are taken at frequent intervals and uncontrollably, the brain adapts to this situation and begins to feel pain more strongly when the medication effect wears off.
This “rebound effect” leads to headache becoming permanent.

Characteristics of Medication Overuse Headache

• Seen in people who experience headache more than 15 days per month.
• The risk of development is high in people who use painkillers more than 10-15 days per month.
• Pain is generally felt every day and is more pronounced in the mornings.
• The person takes medication again to reduce pain, which causes the vicious cycle to continue.
• Over time, the person gets the feeling “I can’t do without medication” and a picture similar to addiction develops.

How Does the Vicious Cycle Form?

1. Headache starts → person takes painkiller.
2. Temporary relief occurs.
3. When medication effect wears off, pain returns.
4. Person takes medication again → cycle starts over.

Unless this cycle is broken, headache becomes chronic, the brain becomes sensitive to pain signals, and the person’s quality of life seriously decreases.

What Causes Medication Overuse Headache?

Both the type of medications used and the change in the brain’s response to pain play a role in the emergence of Medication Overuse Headache.
Over time, medications used to suppress pain cause increased sensitivity in the brain’s pain centers. In this situation, when the medication effect wears off, the brain reproduces pain in a “rebound” manner.

1. Simple Painkillers:
   Over-the-counter medications such as paracetamol, aspirin, ibuprofen can lead to this condition when used long-term and frequently.
   Using these medications more than 15 days per month increases risk. Especially combination painkillers containing caffeine carry higher risk.
2. Migraine Medications (Triptans and Ergot Derivatives):
   Triptan group medications (e.g., sumatriptan, rizatriptan, etc.) used to stop migraine attacks can trigger headache itself when used more than 10 days per month.
   Ergot derivatives are the riskiest medication group; rebound headache almost always develops with use exceeding 10 days.
3. Opioid Group Painkillers:
   Medications such as codeine, tramadol, and morphine derivatives are the most dangerous group in terms of both addiction and medication overuse headache.
   These medications can cause rebound effect even if used only a few times per month.
4. Barbital-Containing Medications:
   Although widely used in the past, they are now prescribed very limitedly due to high addiction risk. This group of medications also carries serious risk in terms of medication overuse development.
5. Caffeine:
   When daily caffeine consumption (coffee, tea, cola, energy drinks) exceeds 200 mg and is then suddenly stopped, rebound headache can occur.
   Additionally, frequent use of caffeinated painkillers increases this risk.
6. Other Risk Factors:

• Female gender
• Migraine history
• Stress, depression, and anxiety
• Chronic pain diseases
• Low socioeconomic level

Especially chronic migraine patients are at high risk for this picture because they have to use medication frequently due to attack frequency.

What Are the Symptoms of Medication Overuse Headache?

Medication Overuse Headache (MOH) is a condition that progresses with symptoms unique to itself, different from other headache types.
These symptoms are generally easily noticed by patients, but are often masked by painkiller use.

1. Daily and Chronic Headache

The most obvious symptom of this disease is headache felt almost every day.
Pain generally starts upon waking in the morning and continues throughout the day.

• Headache is seen more than 15 days per month.
• Pain type is generally dull, pressing, or throbbing.
• Pain severity is moderate or severe.

Headache starting upon waking in the morning is a typical indicator of the rebound effect that occurs with the decrease in medication level in the body at night.
Patients often express it as “I start the day with pain, my first thing is to take a painkiller.”

2. Drug Tolerance and Dose Increase

Over time, the body develops tolerance to painkillers.
While one tablet was sufficient initially, higher doses are needed to achieve the same effect.
Patients often describe this situation as follows:

“One tablet used to be enough, now I have to take three.”

This situation shows that the brain’s pain regulation mechanism is disrupted and a process similar to addiction has begun.

3. Anxiety and Panic Feeling

When medication is unavailable or when they don’t have medication with them, patients feel intense worry and panic.
This situation is an indicator of psychological dependence.
The person constantly carries medication with the fear that pain will come, and the thought of “being without medication” creates stress.

4. Short-Term Relief and Return of Pain

After medication is taken, pain temporarily decreases, but restarts within a few hours.
This cycle repeats every day:

1. Pain starts
2. Medication is taken → temporary relief
3. When medication effect wears off, pain returns
   This vicious cycle leads to headache becoming chronic.

5. General and Psychological Symptoms

• Chronic fatigue
• Attention and concentration difficulty
• Irritability (restlessness)
• Depressive mood
• Sleep disorders
• Social withdrawal

These symptoms generally develop due to both the chronicity of pain and medication withdrawal.

6. Physical Side Effects

Excessive medication use, especially with painkillers like NSAIDs (ibuprofen, naproxen, diclofenac), can cause systemic side effects:

• Stomach problems: gastritis, ulcer
• Kidney function disorders
• Liver enzyme elevation

Long-term and uncontrolled medication use negatively affects not only headache but also general health.

7. Change in Headache Character

The characteristics of the headache the patient knows change:

• Migraine can now become bilateral.
• Light and sound sensitivity decreases.
• Nausea and vomiting progress more mildly.
• Headache is now not “in attacks” but continuous.

This change shows that pain has now transformed into a chronic form due to medication overuse.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria – 8.2 Medication-Overuse Headache (MOH)

1. Having headache 15 days or more per month.
2. Having a primary headache disorder (migraine, tension-type, etc.) defined according to ICHD-3 previously.
3. Overuse of one or more acute/symptomatic headache medications:

• Medication use above the limits specified below for at least 3 months.

1. Headache cannot be better explained by another ICHD-3 diagnosis.

Overuse Limits by Medications:

How is Medication Overuse Headache Diagnosed?

Medication Overuse Headache (MOH) diagnosis is made by detailed patient history, evaluation of medication use frequency, and clinical examination.
This process requires careful neurological evaluation because symptoms can often be confused with migraine or chronic tension-type headache.

1. Detailed Patient History (Anamnesis)

The most important step in diagnosis is the patient’s medication use history.
The doctor focuses on the following questions:

• How long has the headache been present?
• How many days per month are painkillers used?
• Which medications, at what dose, and how frequently are taken?
• How has the pain type and frequency changed over time?

Critical threshold for diagnosis:
Having a history of painkiller use more than 10-15 days per month.
This threshold is included in the International Classification of Headache Disorders (ICHD-3) criteria.

2. Keeping a Headache Calendar

Patients are generally asked to keep a headache diary for at least one month.
This diary should include the following information:

• On which days there was headache
• Severity of pain (e.g., between 0-10)
• Whether medication was used that day

These records provide objective data both for diagnosis and monitoring treatment response.

3. Neurological Examination and Physical Assessment

Physical examination is generally normal, but is important for excluding secondary headache causes.
For example:

• If there is neck stiffness, neurological deficit, or vision disorder, brain MRI is performed.
• Findings specific to migraine or cluster headache are also considered in differential diagnosis.

4. Laboratory Tests

The following tests may be performed to evaluate medication side effects and systemic effects:

• Liver function tests (AST, ALT)
• Kidney function tests (urea, creatinine)
• Complete blood count
  These tests are especially important in long-term NSAID (ibuprofen, diclofenac, naproxen) or paracetamol use.

5. Differential Diagnosis

Medication Overuse Headache can be confused with:

• Chronic migraine,
• Chronic tension-type headache,
• Cluster headache,
• Secondary headaches.

The most obvious difference in differential diagnosis is the relationship between medication use frequency and pain increase.
Therefore, medication use habit is the most determinant factor in diagnosis.

6. Psychological Assessment

The following conditions frequently accompany patients with medication overuse headache:

• Anxiety disorder
• Depression
• Addiction tendency or substance use history

Psychological assessment helps personalize the treatment plan and reduces relapse risk.

How is Medication Overuse Headache Treated?

Treatment of Medication Overuse Headache (MOH) is complex but quite successful with the right strategy. Treatment requires strong cooperation based on trust between patient and physician and is generally conducted with a multidisciplinary approach (neurology, psychiatry, psychology, and physical therapy support).

1. Withdrawal of Overused Medications (Detoxification)

The basic step of treatment is discontinuing the painkiller medications causing headache.
This procedure can be done in two ways:

• Abrupt cessation (“cold turkey”) method: Provides faster effect, but headache may intensify in the first days (rebound phenomenon).
• Gradual reduction: More tolerable, but duration is longer.

The first 7-10 days often pass with difficulty. During this period, nausea, vomiting, sleep disorder, irritability, and increased pain may be seen. In severe cases, performing detoxification in hospital is recommended.

2. Supportive Treatments

During the detoxification period, antiemetics (metoclopramide) and steroids (e.g., prednisolone) can be used temporarily.
These medications both facilitate symptom control and help with pain control during the transition period.
The goal is to manage this period without returning to the previously overused medication group.

3. Preventive (Prophylactic) Treatment

Should be started simultaneously with detoxification.
Classic preventive medications include:

• Amitriptyline
• Topiramate
• Valproic acid

These medications reduce headache frequency, prevent re-medication overuse, and are generally used for 6-12 months.

4. Advanced and Mechanism-Based Treatments

In medication overuse developing on chronic migraine background, the following modern treatments can be effective:

• Nerve blocks: Especially occipital or trigeminal nerve blocks can rapidly alleviate pain during withdrawal period.
• Botulinum toxin (Botox): In patients with chronic migraine, when applied according to PREEMPT protocol, significantly reduces headache day count and acute medication need.
• Monoclonal antibodies (anti-CGRP or CGRP receptor antibodies): Medications such as fremanezumab, galcanezumab, eptinezumab, and erenumab reduce both migraine frequency and medication overuse risk.
• Gepants: Oral CGRP antagonists such as rimegepant and atogepant are among acute and preventive treatment options and provide advantage in this patient group due to very low rebound risk.

5. Education and Psychological Support

Patients should be informed about medication overuse mechanism, correct medication use, avoiding triggers, and lifestyle changes.
Cognitive behavioral therapy, stress management, relaxation techniques, and antidepressant treatment can be added if necessary.
Psychiatry consultation is important in patients with addiction tendency.

6. Lifestyle Modifications

Basic habits that increase treatment success:

• Regular and adequate sleep
• Stress avoidance and relaxation exercises
• At least 3 days per week light exercise (e.g., walking, yoga)
• Balanced nutrition and caffeine restriction
• Termination of smoking and alcohol consumption

7. Follow-up and Long-Term Monitoring

Frequent check-ups in the first 3 months, then follow-up every 3-6 months is recommended.
Since relapse risk is high, long-term monitoring is critical for treatment success.

Treatment Outcomes

With properly conducted treatment, significant and permanent improvement is achieved in 60-80% of patients.
Permanent success is possible with acquiring correct medication use habits, compliance with prophylactic treatment, and maintenance of lifestyle modifications.

Frequently Asked Questions About Medication Overuse Headache

1. Which Medications Cause Medication Overuse Headache? How Much Use is Risky?

Medication Overuse Headache (MOH) most commonly occurs as a result of excessive and uncontrolled use of painkillers.
Risky medications and use thresholds are as follows:

• Simple painkillers (paracetamol, aspirin, ibuprofen): Using more than 15 days per month is risky.
• Caffeine-containing combination medications (paracetamol + caffeine, aspirin + caffeine): Carry higher risk; caffeine can cause addiction.
• Triptans (sumatriptan, rizatriptan, eletriptan, etc.): MOH can develop with use exceeding 10 days per month.
• Opioid-containing medications (codeine, tramadol, morphine derivatives): Can cause rebound pain even if taken only a few times per month.
• Ergot derivatives: Carry almost certain risk with use exceeding 10 days per month.
• Caffeine: Daily consumption over 200 mg (approximately 2-3 cups of coffee) can also trigger headache.

Remember: Using any painkiller exceeding 10-15 days per month without doctor’s recommendation is dangerous.

2. How Can I Get Rid of Medication Overuse Headache? How Does the Detox Process Work?

It is possible to get rid of MOH, but this process should be conducted under doctor guidance and planned.
The basis of treatment is discontinuing the overused medications (detoxification).

• Abrupt cessation (“cold turkey”): Gives faster results but pain may intensify in the first 3-7 days.
• Gradual reduction: More tolerable, but prolongs the process.

Supportive treatments:

• Anti-nausea medications
• Temporary steroid treatments
• Preventive headache medications

The first 1-2 weeks is the most difficult period because rebound phenomenon may be experienced. However, when continued with patience, significant improvement generally starts within 7-14 days.
Psychological support (e.g., cognitive behavioral therapy, stress management) increases success rate.
With treatment, 70-80% of patients completely recover and their quality of life significantly increases.

3. What Will I Experience When I Stop Medications? How Long Does This Process Last?

When medication is stopped, the body gives a short-term withdrawal reaction.
Stages are generally as follows:

• First 24-48 hours: Pain increases (rebound pain).
• Days 3-7: Most difficult period; nausea, sleep disorder, irritability, and restlessness may occur.
• Days 7-14: Pains begin to decrease, sleep and energy level improve.
• Weeks 2-8: Permanent improvement is achieved and headache disappears.

During this period, the desire to take medication may increase; therefore, doctor control and supportive treatment are very important.
Most patients say “I wish I had started earlier” at the end of the process because headache frequency and medication need significantly decrease.

4. Can Medication Overuse Headache Be Treated? Does It Recur?

Yes, MOH is a treatable condition.
After detoxification, most patients return to their original headache type (e.g., migraine). Daily headache disappears, medication use decreases.

• With treatment, 70-80% of patients completely improve.
• However, there is a 30-40% relapse (recurrence) risk.

To prevent recurrence:

• Using painkillers limitedly
• Continuing preventive treatments (e.g., botox, monoclonal antibodies, gepants)
• Going to regular doctor check-ups is necessary.

Long-term monitoring provides permanent improvement.

5. When Should I Go to the Doctor? Which Symptoms Are Alarming?

In the following situations, medication overuse headache should be considered and treatment should be started by consulting a neurology specialist:

• Headache more than 15 days per month
• Painkiller use more than 10-15 days per month
• Headache upon waking in the morning
• Noticing that medication effect is decreasing
• Anxiety or panic feeling when medication is not with you

Situations requiring urgent consultation:

• Suddenly starting very severe headache
• Fever, neck stiffness, or clouded consciousness
• Vision loss, seizure, weakness in arm or leg

Warning: Do not suddenly stop medications on your own. Especially patients using opioid or high-dose medication should undergo detox process in hospital conditions.

With early diagnosis and treatment, both pains decrease and medication dependence risk is eliminated.