GPAtlas🧭 When to suspect
Medication overuse headache (MOH) is a secondary headache that develops in someone with a pre-existing primary headache – usually migraine or tension-type headache (TTH) – who has been using acute or symptomatic headache medication too frequently.
Under the International Classification of Headache Disorders, 3rd edition (ICHD-3), MOH is a headache:
• present on ≥ 15 days per month
• that has developed or worsened during regular overuse of acute treatment for more than 3 months
• that characteristically improves once the overused drug is withdrawn.
The mechanism is a vicious cycle: the acute drug, taken too often, perpetuates and amplifies the very headache it was meant to relieve (“rebound”).
• MOH is the commonest cause of chronic daily headache seen in primary care.
• MOH is repeatedly missed – largely because patients do not volunteer the over-the-counter (OTC) and codeine-containing analgesics they rely on.
Recognise the pattern, take a detailed medication history, exclude a secondary cause (red flags), and treat by withdrawal – not by escalating analgesia. The overuse threshold differs by drug class.
| Acute medication class | Overuse threshold (for > 3 months) | Typical UK examples |
|---|---|---|
| Triptans, opioids, ergots, or combination analgesics | ≥ 10 days per month | • Sumatriptan • Codeine/co-codamol • Migraleve • Ergotamine |
| Paracetamol, aspirin, or an NSAID (alone or in any combination) | ≥ 15 days per month | • Paracetamol • Ibuprofen (Nurofen), naproxen • Aspirin |
Risk is higher with a background of frequent migraine or TTH, comorbid anxiety or depression, and high caffeine intake (including caffeine-containing analgesics). Suspect MOH in any patient reporting near-daily headache who is using acute treatment on more days than not.
Source: NICE CG150 · ICHD-3
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