BASH Guideline

At 8 weeks following medication withdrawal 45% of patients report improvement in headaches while in 48 % the headaches remain unchanged (Zeeberg et al., 2006b) (though it must be noted that this data is from a single trial).

A randomised controlled trial looking at basic intervention (talking about risk of medication overuse headaches and advice to reduce headache medication) compared to standard care showed at 6 months post intervention chronic headaches resolved in 63% in the intervention group vs 11%for standard care (Kristoffersen et al., 2016).

Older studies prior to CGRP blocking therapies show that between 22 – 45% patients relapse back into MOH within 1 year, and 40 – 60% within 4 years of withdrawing from their overused medications (Fritsche & Diener, 2002; Katsarava et al., 2005). This is likely to be lower with modern advanced migraine preventive therapies such as CGRP blocking drugs.

The relapse rate is lower for patients with migraine and for individuals overusing triptans rather than analgesics (21% vs 71%) (Katsarava et al., 2005). Other predictors of relapse were more than 8 headache days per month before withdrawal, a longer duration of drug overuse and greater number of previous preventive treatments in the past (Rossi et al., 2008).

Comorbid anxiety and depression can be associated with difficulty in medication withdrawal and a high risk of relapse following withdrawal of medication (Radat & Lanteri-Minet, 2010).

Consensus Practical Tips

Patients should be supported during the withdrawal phase with regular review, reassurance, and education. The multidisciplinary team can help support the patient e.g. Primary care Psychologists, social prescribers, and in secondary care headache, clinical nurse specialists. Supporting the patient ensures adherence is optimised, withdrawal symptoms are managed and relapse risk is reduced.

Caffeine overuse and withdrawal (which can manifest as nocturnal or early morning exacerbations of headaches) can compound headache and stopping caffeine may contribute to improved outcome (Silverman et al., 1992; van Dusseldorp & Martijn, 1990).

An effective communication and patient education strategy in MOH is crucial. Clinicians need to be empathetic and offer a non-blaming explanation of MOH in simple terms.

Use shared decision-making and motivational interviewing to build engagement and tailor a realistic withdrawal plan. Support this with headache diaries and education materials (such as leaflets) to improve awareness and track medication use. Agree a clear withdrawal plan with expected timelines and preparation for short-term rebound symptoms, and arrange structured follow-up for safety-netting, relapse prevention, reinforcement of limits, and timely adjustment of preventive therapy.