How do I count medication days to spot medication-overuse headache?

Count the days in each month on which you took any medicine for a headache attack, and keep the total for each type of drug separately. ICHD-3 and NICE set the thresholds in days per month, not in doses: 10 or more days for triptans, opioids, ergots and combination analgesics, and 15 or more for paracetamol, aspirin or NSAIDs, for more than 3 months. Only a doctor can diagnose medication-overuse headache.

Facts checked on · Written by Alfonso Matos, the developer of MyGrain.

The thresholds, by type of drug

ICHD-3 defines medication-overuse headache as headache on 15 or more days a month in a person with a pre-existing headache disorder, together with regular overuse for more than 3 months of one or more drugs taken for acute or symptomatic treatment of headache. The number of days of use that counts as overuse depends on the type of drug:

  • Ergotamine and triptans: 10 or more days a month (ICHD-3 8.2.1 and 8.2.2).
  • Non-opioid analgesics (paracetamol, aspirin, other NSAIDs; ICHD-3 treats them as one class, so use on different days adds up): 15 or more days a month (8.2.3).
  • Opioids and combination analgesics: 10 or more days a month (8.2.4 and 8.2.5).
  • Several drug classes, none overused on its own: 10 or more days a month in total (8.2.6).

NICE lists the same thresholds. ICHD-3 states that these numbers of days are based on expert opinion rather than on formal evidence.

How to count

The criteria are written in days of use per month, so what you need from your diary is, for each calendar month, the number of days on which you took each drug or drug class. A practical way to do it is to note on each day what you took and a total at the end of the month. Keep three things apart: days with headache, days with acute medication, and the type of medication on each of those days, because the threshold depends on the type. The time frame matters as well: both ICHD-3 and NICE refer to use over 3 months or more, so one month over the threshold is not the same as a pattern.

Why the diary matters here

ICHD-3 notes that people who clearly use several drugs but cannot give an adequate account of their names and quantities are coded as unspecified or unverified overuse, and that in almost all of these cases this requires diary follow-up. It also notes that more than half of the people with headache on 15 or more days a month have medication-overuse headache. The WHO describes it as the most common secondary headache disorder, and says it occurs on more days than not. NICE advises being alert to it in people whose headache developed or worsened while taking these drugs for 3 months or more, and explaining the risk to people who use acute treatments.

What to do with the count

A count over a threshold is not a diagnosis: bring it to your doctor. In MyGrain you log the treatment taken in each episode, see it on the calendar, and can take that record to your appointment. MyGrain does not diagnose and does not replace your doctor: only a doctor can diagnose medication-overuse headache.

Frequently asked questions

Do I count doses or days?

Days. The ICHD-3 criteria for medication-overuse headache are written as days of medication use per month, for example 10 or more days a month for triptans and 15 or more for non-opioid analgesics.

How many months does it have to go on?

More than 3 months, according to ICHD-3. NICE also refers to use for 3 months or more.

Does paracetamol count towards the same total as ibuprofen?

In ICHD-3, all non-opioid analgesics are regarded as a single class, so using paracetamol and an NSAID on different days adds up toward the 15-day threshold.

Is medication-overuse headache common?

The WHO says it may affect up to 5% of some populations, women more than men, and that it is the most common secondary headache disorder.

Sources

Classification criteria, NICE guideline and the WHO, re-read on .

Medical disclaimer. MyGrain is a self-tracking diary, not a medical device. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your doctor or another qualified health professional with any question about a medical condition.
Download on theApp Store Get it onGoogle Play

More guides