Medication overuse headache in Australia: a call for multidisciplinary efforts at prevention and treatment

Medication overuse headache (MOH)1 is prevalent, under-recognised and potentially treatable or avoidable using a multidisciplinary approach.

Worldwide, about 4% of the population misuse pain relief medication,2 4% suffer chronic daily headache and 1–2% suffer from MOH (more than 15 headache days per month with the use of opioids or triptans over 10 days, or with the use of simple analgesics over 15 days per month). In Australia, perhaps as a legacy of the availability of over-the-counter (OTC) codeine-containing medications, opioids are the most troublesome culprit.

In October 2015, the Therapeutic Goods Administration published an interim decision to up-schedule codeine as a prescription-only medication.3 In many countries — such as the United States, most of Europe, Hong Kong, India and Japan — codeine is not available OTC. The subsequent controversy over this decision focused attention on codeine-associated adverse events, but little emphasis was placed on MOH.

Patients at risk of developing MOH usually have frequent episodic migraine (8–15 headache days per month) or chronic migraine (more than 15 headache days per month). It is therefore vital that general practitioners recognise these conditions, screen for medication overuse and have a strategy for dealing with frequent primary headache disorders to minimise the risk of medication overuse. This strategy may, for example:

• introduce appropriate migraine prophylaxis;4

• use a staged approach to acute headache treatments;

• use non-steroidal anti-inflammatory drugs or simple analgesics for mild headaches;

• use triptans for more severe headaches (but not exceeding 10 days per month); and

• avoid codeine-containing medications.

Patients may be unaware of the link between medication overuse and headache and may not consult their GP about headache. Pharmacists, as the initial contacts for patients who self-medicate, have a role in direct patient education about MOH, and in encouraging patients who may be overusing pain-relief medication (or be on the verge of doing so) to discuss other treatment options with their GP.

Once established, MOH is difficult to treat, particularly if caused by opioids. Withdrawal of the offending agent can be achieved, but only after empathetic and time-consuming discussion and the establishment of an effective treatment plan.

We believe that there is an urgent need for increased awareness of this preventable condition among patients and health care professionals.