Medication-overuse headache
ICD-10 G44.4 · ICD-11 8A84.Y

Medication-overuse headache with opioid, barbiturate or tranquilizer overuse after specialist preventive care did not achieve reduction in monthly migraine days

This protocol is for patients with medication-overuse headache who overuse opioids, barbiturates, or tranquilizers/benzodiazepines — including those with major psychiatric comorbidity or a history of previous relapse into medication overuse — in whom an earlier course of specialist-directed preventive treatment did not reach its target at the 12-week reassessment.

Clinical scenario: Advice alone is not appropriate for patients overusing opioids, tranquilizers or barbiturates, those with major psychiatric comorbidity, or those with a previous relapse into overuse. These patients require a supervised, structured approach that goes beyond outpatient guidance.
Previous line did not reach its goal: Referral to a headache specialist or to specialised care, with preventive treatment — topiramate, onabotulinum toxin A, or a monoclonal antibody targeting CGRP or its receptor (erenumab or fremanezumab) — did not achieve a reduction in monthly migraine days from baseline, as reassessed at approximately 12 weeks. This protocol represents the next step after that failure.
Next-line approach (partial overview): The protocol is centred on supervised inpatient drug withdrawal with a slow, controlled tapering of the overused substance. The complete regimen — including transition management, monitoring parameters, and sequencing — is specified in the full protocol.

Treatment goals: Cessation of medication overuse and restoration of an episodic pattern of headache.

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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.

However for opioids, barbiturates and benzodiazepines, a tapered inhospital withdrawal is prudent to prevent withdrawal symptoms.

Patients overusing opiates, barbiturates and tranquilizers may require long-acting opioids, phenobarbital and clonidine as a transition during detoxification.

Withdrawal from overused acute medications is effective in ceasing overuse and restoring an episodic pattern of headache for prolonged periods in a high percentage of subjects.

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