Medication-overuse headache is a prevalent type of headache affecting up to 7% of the population. It occurs when pain medications are overused to treat frequent headaches. Diagnosis involves meeting criteria for overuse of certain medication classes. Management requires abrupt withdrawal of overused medications combined with rescue therapies and preventive treatments. Prognosis is good, with over 70% improving after 6 months, though relapse is common without behavioral therapies to prevent returning to old medication overuse patterns.

1. Medication-
Overuse
Headache
ADE WIJAYA, MD
September, 2017

2. Outline:
 Introduction
 Epidemiology
 Etiology and Risk Factors
 Pathophysiology
 Diagnostic Criteria
 Management
 Prognosis
 Conclusion

3. Introduction
First reported by Peters and Horton in 1951
In 1988, the first International Classification of Headache Disorders (ICHD) criteria called this
disorder “headache induced by chronic substance use or exposure”
2004 (ICHD2)  Medication-overuse headache (MOH)
Poor Quality of Life
Westergaard ML, Hansen EH, Glumer C, Olesen J, Jensen RH. Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review. Cephalalgia. Nov 29 2013.
Evers S, Marziniak M. Clinical features, pathophysiology, and treatment of medication-overuse headache. Lancet Neurol. 2010;9 (4):391–401.
Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8(Suppl 7):1–96

4. Epidemiology
Prevalence varied up to 7,2 % in population
30-50 % of all headache
Female > male
40-50 years of age
Cheung, V., Amoozegar, F., & Dilli, E. (2015). Medication overuse headache.Current neurology and neuroscience reports, 15(1), 509.

5. Etiology & Risk Factors
• smoking
• sedentary lifestyle
• chronic musculoskeletal complaints
• gastrointestinal complaints
• hospital anxiety
•depression
• obsessive-compulsive disorder
• low socioeconomic status
• use of tranquilizers
• barbiturates
Cheung, V., Amoozegar, F., & Dilli, E. (2015). Medication overuse headache.Current neurology and neuroscience reports, 15(1), 509.

6. Pathophysiology
Unknown
Genetics role
serotonin and dopamine transporter polymorphisms
Biobehavioral disorder
dysfunctions in the mesocorticolimbic dopamine circuit, specifically in the ventromedial
prefrontal cortex and the substantia nigra/ventral tegmental area
The ventral tegmental area plays a role in the brain reward circuit and likely in drug dependence
changes in serotonin receptors and transporters in the periaqueductal grey and locus ceruleus
Low cannabinoid level
Cheung, V., Amoozegar, F., & Dilli, E. (2015). Medication overuse headache.Current neurology and neuroscience reports, 15(1), 509.

7. Pathophysiology
hypometabolism in structures that process pain, including the bilateral thalamus, anterior
cingulate gyrus, insula/ventral striatum, right inferior parietal lobe and orbitofrontal cortex
reversed with drugs withdrawal
neurons are excitable in the somatosensory and visual cortices. (cortical spreading depression)
Trigeminovascular system
Serotonin deplete state:
- susceptible to CSD
-  CGRP and c-fos expression (trigeminovascular system)
- up-regulating pro-nociceptive 5- HT2A receptors
Cheung, V., Amoozegar, F., & Dilli, E. (2015). Medication overuse headache.Current neurology and neuroscience reports, 15(1), 509.

8. Diagnostic Criteria (ICHD2)

9. Drug Class and Duration of Intake
The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.

10. Management

11. Prognosis
Patient motivation is key in the MOH treatment strategy
72,4 % successful at 1 to 6 months
Relapse rate: 41 % at 4 years
Behavioral therapy can reduce relapse rate  12,5 %
Relapse risk factors:
- high baseline medication used
- no improvement 2 months after withdrawal
- smoking, alcohol use
- migraine is less relapse than tension-type headache / mixed-type headache
Cheung, V., Amoozegar, F., & Dilli, E. (2015). Medication overuse headache.Current neurology and neuroscience reports, 15(1), 509.

12. Conclusion
1. Medication-overused headache are quite prevalent and decrese Quality of Life
2. Diagnosis using ICHD2 diagnostic criteria
3. Management including drug withdrawals, rescue, and preventive therapies
4. Prognosis is better when treatment combined with behavioral therapy

13. THANK YOU