ConditionBrain & nerves
Medication Overuse Headache (Rebound Headache)
Medication overuse headache (MOH), also called rebound headache, is a daily or near-daily headache caused by taking headache pain relievers too often. It develops in people who already have migraine or tension-type headaches and use acute medicines on 10 to 15 or more days a month for over 3 months. The headaches become more frequent, and the medicines work less well. Treatment means cutting back or stopping the overused medicine, usually with a preventive treatment. Most people improve within weeks to months.
Also called: Rebound headache, analgesic overuse headache, drug-induced headache, medication-misuse headache
At a glance
- What it is
- Headache on 15 or more days a month caused by overusing acute headache medicines.
- Who gets it
- People with migraine or tension-type headache. More common in women.
- Overuse thresholds
- 10 or more days a month for triptans, opioids, combination pain relievers and ergots. 15 or more days for simple pain relievers.
- Symptoms
- Daily or near-daily headache, often on waking, that eases briefly with medicine then returns.
- Treatment
- Stop or reduce the overused medicine, start prevention, manage withdrawal.
When to get help
Call 911 or go to the ER
- A sudden, severe "worst ever" headache, or headache with confusion, weakness, slurred speech, fever and stiff neck, or after a head injury: call 911 or your local emergency number
See a doctor within a day or two
- Withdrawal from opioid, butalbital or benzodiazepine-containing medicines: do not stop suddenly without medical supervision, as withdrawal can cause seizures
- Severe vomiting and inability to keep fluids down during medication withdrawal
- A new headache pattern after age 50, or headache that wakes you from sleep with vomiting
Book a routine appointment
- Headache on 15 or more days a month
- Taking headache medicines on more than 2 or 3 days a week
- Pain relievers that work less well or for a shorter time
- Low mood, anxiety or poor sleep with frequent headaches
Usually safe to manage at home
- Occasional headaches treated on fewer than 2 to 3 days a week, with a headache diary to track use
How medication overuse headache develops
Frequent use of acute headache medicines appears to change pain pathways in the brain, lowering the threshold for headaches. Each dose brings short-term relief, but as it wears off the headache returns, prompting another dose. Over time, headache days increase and the medicine works less well, creating a cycle.
MOH only develops in people with an underlying headache disorder, mainly migraine or tension-type headache. People taking regular pain relievers for arthritis or back pain do not usually develop it unless they also have a headache disorder.
Medicines that can cause it
| Medicine type | Examples | Overuse threshold |
|---|---|---|
| Simple pain relievers | Acetaminophen (paracetamol), ibuprofen, naproxen, aspirin | 15 or more days a month |
| Triptans | Sumatriptan, rizatriptan, others | 10 or more days a month |
| Combination pain relievers | Acetaminophen, aspirin and caffeine combinations | 10 or more days a month |
| Opioids | Codeine, hydrocodone, tramadol, oxycodone | 10 or more days a month |
| Butalbital-containing products | Butalbital with acetaminophen or aspirin and caffeine | 10 or more days a month |
| Ergotamines | Ergotamine | 10 or more days a month |
Opioids and butalbital are particularly likely to cause MOH and are generally not recommended for migraine. Newer acute migraine medicines called gepants (such as ubrogepant and rimegepant) do not appear to cause MOH and may be options for people at risk.
Symptoms
- Headache on 15 or more days per month
- Headache often present on waking
- Headache that improves briefly with medicine and then returns as it wears off
- A change in headache character, sometimes alternating between migraine-like and tension-type features
- Nausea, restlessness, irritability, difficulty concentrating, poor sleep
- Low mood and anxiety, which are common alongside MOH
Diagnosis
Diagnosis is based on the history. The International Classification of Headache Disorders (ICHD-3) criteria are:
- headache on 15 or more days a month in someone with a pre-existing headache disorder
- regular overuse of one or more acute headache medicines for more than 3 months
- not better explained by another diagnosis
A headache diary recording headache days and every dose taken is the most useful tool. Brain imaging is not needed unless there are red-flag features. MOH overlaps with chronic migraine and chronic daily headache, and many people have both.
Treatment
Stop or reduce the overused medicine
- Simple pain relievers and triptans: usually stopped abruptly or reduced to no more than 2 days a week.
- Opioids, butalbital and benzodiazepines: must be tapered gradually under medical supervision because of withdrawal risks.
Headaches often get worse for the first 2 to 10 days after stopping (withdrawal headache), with nausea, restlessness and poor sleep. This usually settles within 2 weeks. Doctors may prescribe a short "bridging" treatment, such as a short course of steroids, an anti-nausea medicine, or a long-acting NSAID, to ease this phase. Severe cases, especially with opioid overuse, may need inpatient care.
Start preventive treatment
Preventive medicines reduce headache frequency and the need for acute medicines. Options include topiramate, amitriptyline, beta blockers such as propranolol, candesartan, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab), and onabotulinumtoxinA injections for chronic migraine. Some of these can be started at the same time as withdrawal.
Plan acute treatment
Limit acute medicines to no more than 2 to 3 days a week. Use the most effective option early in an attack. Your doctor may suggest gepants for people at high risk of overuse.
Lifestyle and behavioral measures
- Regular sleep, meals and hydration
- Regular exercise
- Limiting caffeine
- Stress management, relaxation training, biofeedback and cognitive behavioral therapy
- Treating depression, anxiety and sleep problems
Outlook
Most people improve after stopping overuse, often with a substantial drop in headache days within 2 months. Relapse is common in the first year, so follow-up, a headache diary and good preventive treatment are important.
Frequently asked questions
What is a rebound headache?
A rebound headache, or medication overuse headache, is a frequent or daily headache caused by taking headache medicines too often. Each dose gives temporary relief, but the headache returns as the medicine wears off, leading to more doses and more headache days.
How many days a month can I take pain relievers for headaches?
To avoid medication overuse headache, limit simple pain relievers such as acetaminophen or ibuprofen to fewer than 15 days a month, and triptans, combination pain relievers and opioids to fewer than 10 days a month. A practical rule is no more than 2 to 3 days a week.
How do you stop rebound headaches?
The overused medicine must be stopped or reduced, usually with help from a doctor, who may also start a preventive treatment. Headaches often worsen for a week or two before improving. Opioids and butalbital need to be tapered gradually, not stopped suddenly.
How long does medication overuse headache last after stopping?
Withdrawal headache usually peaks in the first few days and settles within 2 weeks. Overall improvement in headache frequency often appears within 1 to 2 months. Some people take longer, especially if they have chronic migraine.
Sources
This guide was written from current patient and clinical guidance, including:
- International Headache Society: International Classification of Headache Disorders, 3rd edition (ICHD-3)
- American Headache Society: Consensus statement on the acute treatment of migraine
- American Migraine Foundation: Medication overuse headache
- NICE: Headaches in over 12s, diagnosis and management (CG150)
- NHS: Medication overuse headache