1.  Dr David PB Watson  Aberdeen

2.  Background Information  Case Presentation  General Discussion with Qs and As

3.  8.2 [G44.41 or G44.83] Medication-overuse headache † †  A.Headache present on ≥15 days/month fulfilling criteria C and D  B.Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache  C.Headache has developed or markedly worsened during medication overuse  D.Headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication

4.  Simple Analgesics 15 days a month  Opiate e.g. codeine 10 days a month  Triptans 10 days a month

5.  Paracetamol 450 mg  Codeine 10 mg  Doxylamine  Caffeine

6.  Codeine  Ibuprofen  Caffeine (headache)

7.  Codeine 12.8 mg  Ibuprofen 200mg

8.  Codeine 8 mg  Paracetamol 500 mg  Buclizine (Pink)

9.  Migraine  Tension Headache  Cluster (only if migraine tendency)  Hemicrania Continua

10.  If taking pain killers for other pain and have migraine can get medication overuse headache  If no headache tendency taking pain killers won’t cause headache

11.  Typical scenarios are  More frequent headache e.g. in perimenopausal period, work stress, insomnia leading to increased painkiller use  New pain condition or worsening pain condition in patient with migraine requiring increased medication

12.  Normal acute and preventer treatments tend to be ineffective  Management relies on withdrawal of overused medication for 8 weeks. “Stopping the Juice!”  Withdrawal should be gradual for opiates and can be abrupt for other medications  Headache can get worse before it gets better

13.  42 year old executive with migraine  Business trip 4 months ago and came back with severe migraine and now getting headache every day  Using a triptan every second day, migraleve most days and paracetamol every day  Stopped all medication except paracetamol with no headache relief

14.  39 year old lady with migraine and severe back pain  Using tramadol every day for back pain and triptan and ibuprofen most days for headache  Stopped ibuprofen and triptan and headache a lot better

15.  Stop all the Juice  Treat the worst pain  In patients with complex pain conditions modifying treatment regimes can give benefit