Medication Over-use Headache


Medication over-use headache (MOH) is a headache caused by too high a daily use of painkillers (paracetamol/NSAID). Patients often use such painkillers for headaches that already exist.


MOH is due to the daily use of pain medication for headaches (paracetamol, ascal, diclofenac, naproxen, ibuprofen). However, the mechanism of the headache is unknown. For example, it is unclear why these painkillers taken for other reasons (such as rheumatoid arthritis) do not cause these symptoms. Genetic factors may play a role, but psychological factors are important. The painkillers are often used before the onset of a headache and are even taken out of habit. The danger is that more and more painkillers will be used.

A certain minimum amount is required, e.g., > 50 g of aspirin or an equivalent per month. It appears that MOH occurs earlier when 1 to 2 tablets are taken daily, or 6 tablets once a week. As well as the painkillers, caffeine also plays a role. Caffeine is found not only in coffee, but also in tea, iced-tea and chocolate.

Signs and symptoms

The headache occurs after the daily use of pain medication for more than three months. It is chronic, occurs more than 15 times a month, and usually lasts for the whole day. The pain resembles a tension headache, because in both cases, the headache is bilateral with the feeling of a tight band around the head.


Physical Examination

There is no specific test to diagnose MOH, and it has to be considered when a patient uses painkillers on more than four days a week.

The diagnosis is clear when the patient's headache is reduced after one month without the use of any painkillers. In some cases, such headache reduction can take three months.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment


  • Recognise!
  • Good explanation to the patient
  • Stopping all painkillers for at least three months
  • Headache diary

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • In exceptional cases amitriptyline as support medication


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