What criteria should I use to diagnose medication overuse headache (MOH) in my patients?

Criteria to diagnose medication overuse headache (MOH) in patients:

• Headache that has developed or worsened during the use of acute headache medication for 3 months or more.
• Use of triptans, opioids, ergots, or combination analgesic medications on 10 or more days per month.
• Use of simple analgesics such as paracetamol, aspirin, or NSAIDs (alone or in combination) on 15 or more days per month.
• The headache is typically a worsening or new pattern of headache occurring in the context of this medication overuse.
• Exclude secondary causes or red flags that may suggest other serious pathology.

Diagnosis is supported by a detailed headache history, including medication use frequency and duration, ideally recorded in a headache diary.

Consider MOH especially if the headache frequency increases in parallel with frequent use of acute medications as above.

Withdrawal of the overused medication for at least 1 month is both diagnostic and therapeutic, with headache improvement expected after withdrawal.

Review and reassess the diagnosis 4 to 8 weeks after starting withdrawal of overused medication.

Referral to specialist care is advised if there are red flags, serious secondary causes suspected, use of strong opioids, comorbidities, or unsuccessful withdrawal attempts.

References: ¹,²,³