How do you manage patients with chronic migraine as well as medication overuse headaches?

I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting clonidine and sleeping meds.

The most important treatment is careful education about what they are doing and why they need to change. If they do not agree, there is no point in continuing. Although we...

Updates to this answer 4/3/2026: anti-CGRP medications are an excellent way to avoid rebound headaches and should be used as early as possible. The challenge in doing this is that some insurances still require trying triptans first, but this is changing over the past year, where great strides have been made with some insurances to offer anti-CGRP as first line, but prior authorization is still needed.

Original Answer 2022:

Chronic migraine is treated with a combination of transitional, abortive, ...

The worst to control in these scenarios are the patients who are on chronic opioids for chronic intractable other pain, not headaches. I usually go through the standard first-line meds and at times, CGRP antagonists alone with no luck. I have a few on combination therapy of Botox, topiramate, and a CGRP antagonist before getting any improvement. These patients have to have their heavy-duty analgesics for whatever their problems are and are always followed by pain specialists who send them to us ...

I'm in pain management and work with our headache specialists. I spend a lot of my time having conversations with patients about opioid wean and the most important thing is to get patients on board. A process of trust, as they have to understand things may feel "worse" (when they initially get off opioids) before it gets better or more normal again. I do my best but I'm not always able to convince every patient about this path. I agree with Dr. @Dr. First Last that if a patient is not on the sam...

Just to add to all traditional treatments.

Most of the time, neck abnormality is a trigger so include instructions for better neck posture, neck stretching, and release technique for a more successful treatment.

I educate patients about the pitfalls of medication overuse headaches and try my best to transition them to a CGRP inhibitor. However, challenges arise when patients require opiates for concurrent arthritis and face difficulties tapering off these medications with their pain specialists. If MOH stems from ibuprofen, I typically initiate a migraine cocktail of Depakote, magnesium oxide, and Benadryl for a five-day duration. Simultaneously, I explore other migraine preventive medications.

Treatmen...