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`Blackwell Science, Ltd
`
`Oxford, UKCHA
`Cephalalgia
`
`0333-1024Blackwell Science, 2004
`256460465
`
`Brief Report
`The International Classification of Headache Disorders, 2nd edn SD Silberstein et al.
`
`BRIEF REPORT
`
`The International Classification of Headache Disorders, 2nd Edition
`Medication-overuse headache
`(ICHD-II)—revision of criteria for 8.2
`
`SD Silberstein, J Olesen, M-G Bousser, H-C Diener, D Dodick, M First, PJ Goadsby, H Göbel, MJA Lainez,
`JW Lance, RB Lipton, G Nappi, F Sakai, J Schoenen & TJ Steiner on behalf of the International Headache
`Society
`
`Silberstein SD, Olesen J, Bousser M-G, Diener H-C, Dodick D, First M, Goadsby
`PJ, Göbel H, Lainez MJA, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J &
`Steiner TJ on behalf of the International Headache Society. The International
`Classification of Headache Disorders, 2nd Edition (ICHD-II)—revision of criteria
`Medication-overuse headache
`. Cephalalgia 2005; 25:460–465. London. ISSN
`for 8.2
`0333-1024
`
`䊐
`
`Classification, headache disorders, medication-overuse headache
`
`Stephen D Silberstein MD, Professor of Neurology, Thomas Jefferson University,
`Philadelphia, PA, USA. Received 30 June 2004, accepted 29 July 2004
`
`Introduction
`
`Medication-overuse head-
`The ICHD-II criteria for 8.2
`ache
` have been revised based on constructive criti-
`cism at
`the
`International Headache Research
`Seminar in Copenhagen in March 2004. The major
`changes are: (i) elimination of the headache charac-
`Medication-
`teristics; and (ii) a new subform (8.2.6
`overuse headache attributed to combination of acute
`medications
`) that takes into account patients overus-
`ing medications of different classes but not any sin-
`gle class.
`The revised section is below.
`
`General comment
`Definite or probable?
`In the particular case of 8.2
`Medication-overuse headache
`, a period of 2 months
`after cessation of overuse is stipulated in which
`improvement (resolution of headache, or reversion
`to its previous pattern) must occur if the diagnosis
`is to be definite. Prior to cessation, or pending
`improvement within 2 months after cessation, the
`Probable medication-overuse headache
`diagnosis 8.2.8
`should be applied. If such improvement does not
`then occur within 2 months, this diagnosis must be
`discarded.
`
`8.2 Medication-overuse headache (MOH)
`
`8. Headache attributed to a substance or
`its withdrawal
`
`Previously used terms
`
`8.2 Medication-overuse headache (MOH)
`8.2.1 Ergotamine-overuse headache
`8.2.2 Triptan-overuse headache
`8.2.3 Analgesic-overuse headache
`8.2.4 Opioid-overuse headache
`8.2.5 Combination analgesic-overuse headache
`8.2.6 Medication-overuse headache attributed
`to combination of acute medications
`8.2.7 Headache attributed to other medication
`overuse
`8.2.8 Probable medication-overuse headache
`
`Rebound headache, drug-induced headache, medi-
`cation-misuse headache.
`
`Diagnostic criteria
`
`1
` present on
`A Headache
`criteria C and D.
`
`≥
`
`15 days/month fulfilling
`
`1
`
`The headache associated with medication overuse is variable
`and often has a peculiar pattern with characteristics shifting,
`even within the same day, from migraine-like to those of
`tension-type headache.
`
`460
`
`© Blackwell Publishing Ltd
`
`Cephalalgia,
`
`2005,
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`25
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`, 460–465
`
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`The International Classification of Headache Disorders, 2nd edn
`
`461
`
`2
`3 months of one or more
` for
`B Regular overuse
`>
`drugs that can be taken for acute and/or symp-
`3
`tomatic treatment of headache.
`C Headache has developed or markedly worsened
`during medication overuse.
`D Headache resolves or reverts to its previous pat-
`tern within 2 months after discontinuation of
`overused medication.
`
`Comments
`MOH is an interaction between a therapeutic agent
`used excessively and a susceptible patient. The best
`example is overuse of symptomatic headache drugs
`causing headache in the headache-prone patient. By
`far the most common cause of migraine-like head-
`ache occurring on
`15 days per month and of a
`≥
`mixed picture of migraine-like and tension-type-like
`headaches on
`15 days per month is overuse of
`≥
`symptomatic antimigraine drugs and/or analgesics.
`Chronic tension-type headache is less often associ-
`ated with medication overuse but, especially
`amongst patients seen in headache centres, episodic
`tension-type headache has commonly become a
`chronic headache through overuse of analgesics.
`Patients with a pre-existing primary headache
`who develop a new type of headache or whose
`migraine or tension-type headache is made mark-
`edly worse during medication overuse should be
`given both the diagnosis of the pre-existing head-
`Medication-overuse
`ache and the diagnosis of 8.2
`headache
`.
`The diagnosis of MOH is clinically extremely
`important because patients rarely respond
`to
`preventative medications whilst overusing acute
`medications.
`
`8.2.1 Ergotamine-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`10 days/month on a reg-
`B Ergotamine intake on
`≥
`3 months.
`ular basis for
`>
`
`2
`
`Overuse is defined in terms of duration and treatment days
`per week. What is crucial is that treatment occurs both fre-
`quently and regularly, i.e. on 2 or more days each week.
`Bunching of treatment days with long periods without med-
`ication intake, practised by some patients, is much less likely
`to cause medication-overuse headache and does not fulfil cri-
`terion B.
`3
`MOH can occur in headache-prone patients when acute
`headache medications are taken for other indications.
`
`© Blackwell Publishing Ltd
`
`Cephalalgia,
`
`2005,
`
`25
`
`, 460–465
`
`Comment
`Bioavailability of ergots is so variable that a mini-
`mum dose cannot be defined.
`
`8.2.2 Triptan-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`B Triptan intake (any formulation) on
`10 days/
`≥
`3 months.
`month on a regular basis for
`>
`
`Comment
`Triptan overuse may increase migraine frequency to
`that of chronic migraine. Evidence suggests that this
`occurs sooner with triptan overuse than with ergot-
`amine overuse.
`
`8.2.3 Analgesic-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`4
`15 days/month
`B Intake of simple analgesics on
`≥
`on a regular basis for
`3 months.
`>
`
`8.2.4 Opioid-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
` 10 days/month on a regular
`B Opioid intake on
`≥
`basis for
`3 months.
`>
`
`Comment
`Prospective studies indicate that patients overusing
`opioids have the highest relapse rate after with-
`drawal treatment.
`
`8.2.5 Combination analgesic-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`5
`B Intake of combination analgesic medications
`10 days/month on a
`regular basis
`≥
`3 months.
`
` on
`for
`
`>
`
`4
`
`Expert opinion rather than formal evidence suggests that use
`on
`15 days/month rather than
`10 days/month is needed
`≥
`≥
`to induce analgesic-overuse headache.
`5
`Combinations typically implicated are those containing sim-
`ple analgesics combined with opioids, butalbital and/or
`caffeine.
`
`

`

`462
`
`SD Silberstein et al.
`
`8.2.6 Medication-overuse headache attributed to
`combination of acute medications
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`B Intake of any combination of ergotamine, trip-
`tans, analgesics and/or opioids on
`10 days/
`≥
`month on a regular basis for
`3 months without
`>
`6
`overuse of any single class alone.
`
`8.2.7 Headache attributed to other medication overuse
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A, C and D for 8.2
`Medication-overuse headache
`.
`7
` for
`3 months of a medication
`B Regular overuse
`>
`other than those described above.
`
`8.2.8 Probable medication-overuse headache
`
`Diagnostic criteria
`
`A Headache fulfilling criteria A and C for 8.2
`Medication-overuse headache
`.
`B Medication overuse fulfilling criterion B for any
`one of the subforms 8.2.1–8.2.7.
`C One or other of the following:
`
`1
`
`2
`
`Overused medication has not yet been with-
`drawn.
`Medication overuse has ceased within the last
`2 months but headache has not so far resolved
`or reverted to its previous pattern.
`
`Comments
`Probable medication-overuse
`Codable subforms of 8.2.8
`headache
`Probable ergotamine-overuse head-
` are 8.2.8.1
`ache
`Probable triptan-overuse headache
`, 8.2.8.2
`, 8.2.8.3
`Probable analgesic-overuse headache
`Probable
`, 8.2.8.4
`opioid-overuse headache
`Probable combination
`, 8.2.8.5
`analgesic-overuse headache
`Headache probably
`, 8.2.8.6
`attributed to overuse of acute medication combinations
`Headache probably attributed to other medi-
`and 8.2.8.7
`cation overuse
`.
`Prob-
`Many patients fulfilling the criteria for 8.2.8
`able medication-overuse headache
` also fulfil criteria for
`Probable chronic migraine
`Probable
`either 1.6.5
` or 2.4.3
`
`6
`
`The specific subform(s) 8.2.1–8.2.5 should be diagnosed if
`criterion B is fulfilled in respect of any one or more single
`class(es) of these medications.
`7
`The definition of overuse in terms of treatment days per week
`is likely to vary with the nature of the medication.
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`chronic tension-type headache
`. They should be coded
`for both until causation is established after with-
`drawal of the overused medication. Patients with
`Probable chronic migraine
`1.6.5
` should additionally be
`coded for the antecedent migraine subtype (usually
`Migraine without aura
`1.1
`).
`
`Copyright
`
`2003/4.
`Society
`©International Headache
`Applications for copyright permissions should be
`submitted to Blackwell Publishing, 9600 Garsington
`Road, Oxford OX4 2DQ, UK (Tel.: + 44 1865 776868;
`fax: + 44 1865 714591, website: http://www.
`blackwellpublishing.com).
`Any part of The International Classification of
`Headache Disorders, 2nd Edition, may be repro-
`duced freely for scientific or clinical uses by institu-
`tions, societies or individuals. Otherwise, copyright
`belongs exclusively to the International Headache
`Society. Reproduction in any manner for commercial
`uses requires the Society’s permission which will be
`granted on payment of a fee. Please contact the pub-
`lisher at the address above.
`Permission for translations must be applied for,
`and will be granted to National Headache Societies
`or Linguistic Groups of the International Headache
`Society. In the absence of a National Headache Soci-
`ety or Linguistic Group, a headache expert may be
`approved on behalf of the International Headache
`Society by the Chairman of the Headache Classifica-
`tion Subcommittee to be responsible for translation
`into a specific language. Sponsorships may be listed
`and advertisements accepted in translations.
`
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