Medication-Overuse Headache & Migraine

Part 9: When Treatment Becomes Part of the Problem

When someone has a headache, taking something for the pain seems perfectly logical.

The headache returns, so they take it again.

And again.

Eventually, what began as a few migraine attacks each month may become fifteen, twenty, or even thirty headache days a month.

At that point, an uncomfortable question needs to be asked:

Could the medication being used to treat the headache now be contributing to the headache itself?

This phenomenon is called medication-overuse headache (MOH)—previously referred to as rebound headache—and it's an important condition for every acupuncturist treating migraine to recognize.

How Common Is Medication-Overuse Headache?

More common than many clinicians realize.

Medication-overuse headache is estimated to affect approximately 1–2% of the general population, but among people with chronic headache, estimates can reach 50%.

And the medications involved aren't necessarily unusual or dangerous drugs.

They include medications patients may keep in their purse, desk drawer, bathroom cabinet, or car:

ibuprofen, acetaminophen, Excedrin, triptans, opioids and other acute headache medications.

That's one reason MOH can be so easy to miss.

Patients may carefully report their prescription medications while barely mentioning the ibuprofen they've been taking almost every day.

How Much Is Too Much?

The answer depends on the medication.

Under current ICHD-3 criteria, medication-overuse headache occurs in someone with a pre-existing headache disorder who develops headache on 15 or more days per month, in association with regular overuse of acute headache medication for more than three months.

The medication thresholds are surprisingly easy to reach:

NSAIDs such as ibuprofen:≥15 days/month
Acetaminophen:≥15 days/month
Triptans:≥10 days/month
Opioids:≥10 days/month
Combination analgesics, such as some acetaminophen/aspirin/caffeine products:≥10 days/month
Multiple acute medication classes:≥10 days/month

Importantly, these are days of use, not number of pills.

A patient doesn't necessarily need to be taking enormous doses.

Frequency matters.

Why Would a Pain Medication Cause More Pain?

This is where MOH becomes particularly interesting.

The exact biology isn't completely understood.

Neuroimaging studies have identified changes in brain regions involved in pain processing, reward, salience, and behavioral control in people with medication-overuse headache. Researchers have also described altered descending pain modulation and increased sensitization. But the 2024 review emphasizes that we still don't have a single mechanism that completely explains MOH.

A useful way to think about it is that repeated reliance on acute medication may contribute to a nervous system becoming more, rather than less, susceptible to headache.

And that brings us back to a concept we've discussed throughout this series:

migraine threshold.

Medication overuse doesn't appear to affect everyone equally. In fact, the 2024 review cites an intriguing study of rheumatology patients regularly taking analgesics: medication-overuse headache developed specifically in those with a previous history of migraine.

The medication may therefore be only one piece of the equation.

The nervous system taking the medication matters too.

Clinical Pearl: Ask About Days, Not Doses

This may be one of the simplest changes you can make to your migraine intake.

Don't just ask:

“What medications do you take for your headaches?”

Ask:

“How many days each month do you take something for your headache?”

Then specifically ask about over-the-counter medications.

Ibuprofen.

Aleve.

Tylenol.

Excedrin.

Patients don't always think of these as important medications worth reporting.

I learned this lesson from a patient in her thirties whom I was treating after a traumatic brain injury. Many of her symptoms had improved and she had returned to work, but her daily headaches persisted.

I repeatedly asked about ibuprofen use, and for months she downplayed how frequently she was taking it.

Eventually, after I explained medication-overuse headache and told her that using ibuprofen on 15 or more days per month could be relevant, she admitted she was taking it practically every day.

She discussed discontinuing it and stopped taking it.

When I saw her approximately a month later, she told me her daily headaches were gone. Over the following months, she experienced only a handful of headaches.

Not every patient will have such a dramatic response.

But you'll never identify medication overuse if you don't ask the right question.

The Goal Isn't to Demonize Medication

This point is particularly important coming immediately after our discussion of CGRP.

Medication is not the enemy.

Effective acute migraine treatment can be enormously important, and newer migraine-specific therapies have changed the landscape considerably. CGRP-targeting preventive treatments can benefit patients who also have medication overuse, and newer acute treatments such as gepants appear less likely to produce the same MOH problem seen with traditional acute medications.

The lesson is not:

“Migraine medications are bad.”

It's:

“Acute medications need to be understood in the context of frequency, medication class, and the individual patient's underlying headache disorder.”

And when medication overuse is suspected, withdrawal or medication changes should be coordinated with the patient's prescribing clinician—particularly when opioids, barbiturates, or other medications requiring supervised withdrawal are involved.

Why This Matters for Acupuncturists

Acupuncturists may actually be in an excellent position to recognize medication-overuse headache.

We often see patients frequently enough to notice that the headache that once occurred occasionally has gradually become a daily or near-daily problem.

And because acupuncture can be incorporated as a nonpharmacologic preventive strategy, we may also be able to help patients reduce their reliance on acute medications as part of a coordinated treatment plan.

But the first step is recognizing what's happening.

Sometimes the most important question you ask a patient with chronic migraine isn't:

“Where does your head hurt?”

It's:

“How many days this month did you take something for it?”

Continue Rethinking Migraine

Previous Article → Part 8: Light Sensitivity – A Brain (Not Eye) Problem

Next Article → Part 10: Migraine or Tension Headache? Why the Difference Matters

Explore Migraine Course 1A Clinical Guide for Acupuncturists Explore Migraine Course 2Hormones, Histamine & Nutrition

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