What is medication overuse headache?
Taking headache or migraine medicines on a great many days over several months can itself make headaches more frequent. Doctors call this medication overuse headache (MOH), also known as rebound headache. It builds on an existing headache disorder, usually migraine or tension-type headache. Headache days go up, the medicines work less well, and it becomes tempting to take them even more often.
The good news: for most people this type of headache improves once the overuse stops and the underlying headache disorder is treated well. What that looks like for you is something to decide with your doctor.
The limits: 10 and 15 days a month
The International Classification of Headache Disorders (ICHD-3) of the International Headache Society describes medication overuse headache like this: headache on 15 or more days a month in someone with an existing headache disorder, plus regular use of acute medicines above a limit for more than three months. The limit depends on the type of medicine and is measured in days, not in tablets.
Headache specialists also use the 10/20 rule as a simple rule of thumb: acute medicines on no more than 10 days a month, and none on at least 20 days. For simple painkillers it is deliberately stricter than the ICHD-3 limit and easy to remember in everyday life.
| Acute medicine | Days of use per month (for more than 3 months) |
|---|---|
| Simple painkiller paracetamol/acetaminophen, ibuprofen, aspirin, naproxen, diclofenac (NSAIDs) |
15 days or more |
| Triptan e.g. sumatriptan, rizatriptan, zolmitriptan |
10 days or more |
| Combination painkiller several ingredients in one tablet, e.g. aspirin + paracetamol + caffeine |
10 days or more |
| Opioid e.g. codeine, tramadol, oxycodone |
10 days or more |
| Ergotamine ergot alkaloids, rarely used today |
10 days or more |
| Several groups | Several groups, none above its own limit: 10 days or more combined |
| 10/20 rule (rule of thumb) | Acute medicines on no more than 10 days a month, none on at least 20 days |
Why counting beats guessing
At the appointment the question is often: “On how many days did you take something last month?” From memory you think of the bad attacks. The single ibuprofen before a long meeting or the tablet for back pain is easily forgotten – and those are exactly the days that push the total over a limit.
The counter does three things that get lost when you guess. It counts each day only once, even if you took two medicines. It counts each group separately, because triptans have a different limit from ibuprofen. And it adds the groups together: taking ibuprofen on 6 days and a triptan on 5 other days stays below each single limit, but adds up to 11 days.
Besides the calendar month, the counter shows the last 30 days, so you can see where you stand in the middle of a month too. The traffic light is a guide: green means below all limits, amber means close to or above the 10-day mark or a very high number of headache days, red means an ICHD-3 limit has been reached.
How to use the counter
Each evening, tap today and choose whether you had a headache and which acute medicines you took. Log painkillers you take for other complaints too; your doctor will judge whether they matter for your headache. Days without an entry count as days without headache and without medicine. You can fill in past days by going back a month.
Before your appointment, print the monthly overview or save it as a PDF. It lists every day of the month with headache and medicine group, plus the totals. Three months in a row tell your doctor the most.
What to do if the light turns amber or red
Stay calm and make an appointment. A red light is a good reason to see your GP, a neurologist or a headache clinic, not a diagnosis. They can work out which type of headache you have, whether preventive treatment makes sense and, if needed, how a break from medication could work.
Do not stop medicines you have been prescribed on your own – opioids in particular. And do not go without treatment you need out of worry about the limit; raise the problem openly instead. The days you have counted are the best basis for that conversation.
Get medical help immediately
Call your emergency number or get seen straight away if you have a sudden, extremely severe headache, a headache with fever and a stiff neck, weakness or paralysis, problems speaking or seeing, confusion, or a headache after a head injury.
Frequently asked questions
How many days of painkillers can cause medication overuse headache?
ICHD-3 counts days of use per month for more than three months: 15 days or more for simple painkillers such as paracetamol, ibuprofen or aspirin, and 10 days or more for triptans, ergotamines, opioids and combination painkillers, or when several groups are combined. Headache on 15 or more days a month is also part of the definition.
What is the 10/20 rule?
It is a rule of thumb used by headache specialists: take painkillers or migraine medicines on no more than 10 days a month and on at least 20 days take none. It is stricter than the ICHD-3 limit for simple painkillers and is meant to prevent overuse.
Do two tablets on the same day count twice?
No. What counts is the day. If you take two different medicines on one day, that day counts for each group but only once in the total.
Does ibuprofen for back pain count?
Log it either way. Whether it matters for your headache is for your doctor to judge, looking at everything you take.
Where is my data stored?
Only in your browser's storage on this device. There is no account and nothing is sent to a server. If you clear your browser data or tap “Delete all data”, the marks are gone.
Does the counter replace a doctor's visit?
No. It does not diagnose and does not tell you how much you may take. It gives you the numbers that help your doctor assess the situation.
Read more
Sources
- International Headache Society (IHS): ICHD-3: 8.2 Medication-overuse headache (MOH)
- American Migraine Foundation: Medication Overuse Headache
- IQWiG / informedhealth.org: Medication overuse headaches
- Schmerzklinik Kiel: Die 10-20-Regel in der Migräne- und Kopfschmerztherapie
More than ticks in a calendar: in the PainTrack app you add your acute medicines as as-needed medicines and log every dose with the time, with an optional follow-up on how well it worked – for free. PainTrack Pro adds monthly reports and a PDF doctor report with your medication list and intake log.
The counter helps you count and put the numbers in context. It does not diagnose and gives no dosing advice. If you get a sudden, very severe or unusual headache, get medical help immediately – in an emergency call your local emergency number (999 in the UK, 911 in the US, 112 in the EU).