Treatment of Medication-overuse Headache in Overuse of Opioids, Barbiturates, or Tranquilizers
Clinical Scenario
This protocol applies to patients with medication-overuse headache who present with complicating factors that place them beyond the reach of simple advice: overuse of opioids, barbiturates, or tranquilizers/benzodiazepines; major psychiatric comorbidity; or a previous relapse into medication overuse.
Note: Advice alone is not appropriate for this population. Patients who have overused opioids, tranquilizers, or barbiturates, or who have relapsed previously, require structured specialist-led management.
Treatment Approach
These patients need to be referred to a headache specialist or to dedicated specialized care. Alongside management of overuse, specific preventive treatment is indicated — the appropriate agent is selected based on individual patient factors including contraindications. The complete selection algorithm and eligibility criteria are in the full protocol.
Treatment goal: Reduction in monthly migraine days from baseline, reassessed at approximately 12 weeks.
References
DOI: 10.1111/ene.14268
- Advice alone is not appropriate for patients who overuse opioids, tranquilizers or barbiturates or who have experienced previous relapses into overuse or who failed to stop overuse following advice.
- In patients with long-lasting abuse of opioids, barbiturates or tranquilizers, slow tapering of these drugs is recommended.
- These patients need to be referred to a headache specialist or to specialized care.
- Topiramate, onabotulinum toxin A or a monoclonal antibody targeting CGRP or the CGRP receptor are effective in patients with chronic migraine and medication overuse.
- Topiramate should not be used in women of childbearing potential.
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