When painkillers become the problem
Headaches are among the most common health complaints of all. Many people reach for an over-the-counter analgesic at the first signs – often without realising that this very reflex can, in the long run, cause new problems. The so-called medication overuse headache (MOH) is a distinct clinical condition caused by the overly frequent use of acute medication.
Estimates suggest that around one to two per cent of the European population are affected. People with migraine or tension-type headache are at particular risk of falling into this vicious cycle.
What is a medication overuse headache?
Medication overuse headache is a chronic headache that develops in people with a pre-existing headache disorder when painkillers or migraine medication are taken regularly and too frequently over a longer period of time.
The International Headache Society (IHS) defines it by two criteria:
- Headaches on 15 or more days per month for at least three months.
- Regular intake of one or more acute medications during this period.
How often is "too often"?
The following thresholds are considered critical:
- Simple analgesics (e.g. paracetamol, ibuprofen, acetylsalicylic acid): on 15 or more days per month.
- Triptans, opioids, ergot alkaloids or combination preparations: already on 10 or more days per month.
What matters is not the amount taken per day, but the frequency of intake days.
Why can painkillers themselves cause headaches?
The precise mechanisms are not yet fully understood. Several factors are being discussed:
- Altered pain processing in the brain: continuous medication intake can lower the central pain threshold.
- Receptor changes: serotonin and other receptors may adapt to the constant effect of the medication.
- Rebound phenomenon: when the effect wears off, the headache often returns more strongly – which encourages repeated intake.
- Psychological conditioning: the expectation of not being able to function without a tablet reinforces the behaviour.
This creates a cycle of headache, medication intake, brief improvement and the recurrence of the headache.
Typical signs: how to recognise MOH
Medication overuse headache does not have a uniform clinical picture. Those affected often report:
- Dull, pressing headaches that occur almost every day.
- Pain that is particularly strong in the morning after waking up.
- Declining effectiveness of the usual medication.
- Accompanying tiredness, difficulty concentrating, irritability or sleep problems.
- Worsening of a pre-existing migraine or tension-type headache.
Those affected often fail to notice how frequently they are already taking painkillers – a headache diary can provide valuable clues here.
Risk factors
Not everyone who regularly takes painkillers develops MOH. Contributing factors include:
- Pre-existing migraine or chronic tension-type headache.
- Female sex (women are affected around three times more frequently).
- Ongoing psychological stress, anxiety disorders or depression.
- Use of combination preparations containing caffeine or codeine.
- Lack of prophylactic (preventive) treatment of the underlying condition.
Diagnosis: the path to clarity
The diagnosis is usually made clinically, based on the patient's history. Particularly helpful are:
- A headache diary over at least four weeks: documenting frequency, duration, intensity and medication intake.
- A detailed medical history interview with the doctor.
- A neurological examination to rule out other causes.
- Where necessary, imaging procedures (e.g. MRI) to exclude organic causes.
Treatment: finding a way out of the vicious cycle
The most important measure in medication overuse headache is analgesic withdrawal, i.e. the controlled discontinuation or pausing of the medication that triggers it. Medical supervision is strongly recommended.
Forms of withdrawal
- Abrupt withdrawal: the triggering medications are stopped at once. This variant is often used for simple analgesics and triptans.
- Gradual withdrawal: especially with opioids or sedatives, slow tapering can be advisable.
- Outpatient or inpatient withdrawal: depending on severity, comorbidities and the patient's social situation, withdrawal can take place at home, in a day clinic or as an inpatient.
What happens during withdrawal?
In the first few days to two weeks, a temporary worsening of the headaches often occurs, sometimes accompanied by nausea, sleep disturbances, restlessness or low blood pressure. This phase is challenging but usually limited in time. After two to four weeks, many of those affected experience significant improvement.
Supportive measures may include:
- Adequate fluid intake and rest.
- Antiemetics for nausea.
- Short-term use of certain medications to relieve withdrawal symptoms – following medical advice.
- Relaxation techniques such as progressive muscle relaxation, breathing exercises or biofeedback.
Prophylactic treatment of the underlying condition
Alongside withdrawal, preventive treatment of the underlying headache disorder – usually migraine or tension-type headache – is essential. Depending on the findings, options include:
- Pharmacological prophylaxis (e.g. with beta blockers, certain antidepressants or specific migraine medications).
- Botulinum toxin type A in chronic migraine, following appropriate indication.
- Non-pharmacological approaches such as endurance exercise, behavioural therapy or acupuncture.
Prevention: how MOH can be avoided
The best strategy is to prevent medication overuse headache from developing in the first place. The following recommendations can help:
- Observe the 10-20 rule: take acute medication on no more than 10 days per month (for triptans and combination preparations) or on fewer than 15 days per month (for simple analgesics).
- Keep a headache diary to maintain an overview.
- If headaches are frequent, seek medical advice early and consider prophylactic treatment.
- Pay attention to lifestyle factors: regular sleep, a balanced diet, stress management and moderate exercise can help prevent headaches.
- Avoid using combination preparations containing caffeine or codeine as long-term medication.
Conclusion
Medication overuse headache is an underestimated but very treatable condition. Anyone who notices that the number of headache days and the frequency of reaching for a tablet are steadily increasing should take this seriously and seek medical support. A structured analgesic withdrawal, combined with targeted prophylaxis of the underlying condition, can help many of those affected to achieve significantly greater quality of life.
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This article does not replace medical advice.