Treatment plans for patients with medication-overuse headache should include the following: Patient education. Patients need to understand that -acute medication overuse can increase headache frequency -when medication overuse is stopped, headache might worsen temporarily and other withdrawal symptoms might occur -many patients will experience a long-term reduction in headache frequency after medication overuse is stopped -prophylactic medications might become more effective A strategy for cessation of medication overuse -abrupt withdrawal should be advised for patients with suspected medication-overuse headache caused by simple analgesics (acetaminophen, NSAIDs) or triptans; however, gradual withdrawal is also an option -gradual withdrawal should be advised for patients with suspected medication-overuse headache caused by opioids and opioid-containing analgesics Provision of a prophylactic medication while medication overuse is stopped. While many prophylactic agents are used (tricyclics, β-blockers, etc), drugs with the best evidence for efficacy in chronic migraine with medication overuse are -onabotulinumtoxinA, 155 units to 195 units injected at intervals of 3 mo by clinicians experienced in its use for headache -topiramate with slow titration to a target dose of 100 mg/d A strategy for the treatment of remaining severe headache attacks with limitations on frequency of use (eg, a triptan for patients with analgesic overuse, dihydroergotamine for patients with triptan overuse, etc) Patient follow-up and support

NSAID—nonsteroidal anti-inflammatory drug.

Based on the Scottish Intercollegiate Guidelines Network guideline²⁹ and expert opinion of the Guideline Development Group.