Primary prevention

MOH is, in principle, preventable. However, high-quality studies on different preventative strategies are lacking; hence, recommendations are based on expert experience.[27]

  • One of the most important preventative strategies is to increase awareness among both health professionals and the wider population about the relationship between frequent use of medications to treat acute headache episodes and the risk of an increase in frequency of headache days, with a transition from episodic to chronic headache.[27][30]​ This can help to reduce the risk of MOH associated with over-prescribing of medications such as triptans, barbiturates, and opioids for pre-existing headache disorders.[10]

It is important to develop a comprehensive plan for the underlying primary headache disorder that promotes early and optimal use of preventative and rescue medications, in combination with non-pharmacological therapies and lifestyle modifications. This can reduce the need for acute medications and thereby lower the likelihood of individuals progressing from lower to higher headache frequency.[10][30]

  • Regular re-assessment of the effectiveness and tolerability of the preventative strategy is important so that adjustments can be made as necessary to achieve optimal management of the primary headache.[10]

In particular, if a primary or secondary headache disorder is not adequately addressed, the headache may persist and perpetuate the overuse behaviour. Among patients with migraine (which is the most common underlying headache disorder in MOH), the American Headache Society recommends the following to reduce the risk of MOH:[31]

  • Instruct individuals to limit use of acute medication to an average of two headache days per week. Offer preventative treatment to any patient who exceeds this limit.

  • If a patient continues to exceed this limit while taking preventative treatment, consider: increasing the dose of preventative medication; changing the acute or preventative therapy; or adding a second preventative treatment.

  • Consider recommending use of an approved neuromodulatory device as this may reduce the use of acute medication.

  • Be aware that repeated use of oral calcitonin gene-related peptide (CGRP) antagonists (also known as gepants) does not appear to be associated with development of MOH.

Secondary prevention

There is a relatively high relapse rate after initially successful treatment for MOH, particularly in the first year.[27]​ In the absence of sufficient evidence to make strong recommendations, the European Academy of Neurology MOH guideline includes a good practice statement that regular follow-up is important and risk factors for relapse should be identified.[27]

For individuals identified as being at risk of relapse:[27]

  • Use of a headache diary to monitor drug intake is probably effective in reducing relapse rates

  • Short-term psychodynamic psychotherapy and/or mindfulness-based training can be considered and might possibly reduce early and late relapse rates

  • Ongoing treatment with preventative medication may be effective in preventing relapse.

Predictive factors that increase the risk of relapse of MOH include:[10]

  • The presence of both migraine and tension-type headache as underlying headache disorders

  • Longer duration of regular acute medication intake

  • A higher number of acute treatments

  • Overuse of opioids

  • Lack of improvement after 2 months of withdrawal

  • Smoking and/or alcohol consumption

  • Poor sleep

  • High levels of bodily pain.

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