In the era of monoclonal antibodies targeting the calcitonin gene-related peptide pathway, is it still necessary to stop taking excessive pain medication - Medication overuse headache (MOH) debate point of view

Sep 29, 2026

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Medication-overuse headache (MOH), first described with ergotamine overuse, remains a complex management challenge despite decades of study on risk factors, pathophysiology, prevention, and treatment. The debate frames MOH care in the era of monoclonal antibodies targeting the CGRP pathway, emphasizing that different patient subgroups may benefit from different individualized strategies. Approaches include immediate or delayed prophylaxis, optional bridging therapy, and recommending either immediate cessation or gradual reduction of medication overuse, aiming for sustained improvement.

LanguageEnglish

CategoryHealthcare

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Pages2

Reading Time5 min

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Medication-overuse headache and individualized management

MOH background, risk factors, and ongoing challenge

Treatment individualization in the era of anti-CGRP monoclonal antibodies

Bridging, stopping vs gradual reduction, and long-term outcomes

Article published online: 2025-07-28 Point of View 1 In the era of monoclonal antibodies targeting the calcitonin gene-related peptide pathway, is it still necessary to stop taking excessive pain medication? Renata Gomes Londero 1 1 Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Clínica de Cefaleia, Porto Alegre RS, Brazil. Arq. Neuro-Psiquiatr. 2025;83(9):s00451809333 . Address for correspondence Renata Gomes Londero (email: [rlondero@hcpa.edu.br](rlondero@hcpa.edu.br)) Abstract Keywords ► Headache Disorders, Secondary ► Antibodies, Monoclonal ► Eptinezumab ► Galcanezumab ► Fremanezumab Medication-overuse headache (MOH) was ﬁrst described in 1951 with ergotamine overuse. Since then, much has been studied about its risk factors, pathophysiology, prevention, and treatment. Despite this, many people still suffer from this condition. Even for those who reach medical care, the path to maintaining signiﬁcant improvement is neither short nor easy. Here, we propose the ubiquitous individualization of headache treatment. The more we study the condition, the more it becomes evident that different groups of patients beneﬁt from different approaches: starting prophylactic medication immediately or postponing it, providing a bridge treatment or not, and advising patients to either stop medication overuse immediately or reduce it gradually. Medication overuse headache (MOH) was ﬁrst described by Peters and Horton in 1951, with ergotamine-overuse.1 Since then, much has been described about risk factors, pathophysiology, prevention, and treatment. Described in the International Classiﬁcation of Headache Disorders-3 (ICHD-3), MOH continues to be a challenge in terms of management, even in the era ofmonoclonal antibodies targeting the calcitonin generelated peptide (anti-CGRP mAbs). In the present study, we propose the ubiquitous individualization of headache treatment. Why is it that the more we study the condition, the more we observe that different groups of patients beneﬁt from different approaches? As in This article is part of a debate series on Headache and Pain (CGRPMonoclonal Antibodies for Migraine), featuring different perspectives. Check out the other points of view: [https://doi.org/10.1055/](https://doi.org/10.1055/)[ ](https://doi.org/10.1055/)s-0045-1809332 and [https://doi.org/10.1055/s-0045-1809658](https://doi.org/10.1055/s-0045-1809658). received February 11, 2025 received in its ﬁnal form February 28, 2025 accepted March 7, 2025 DOI [https://doi.org/](https://doi.org/)[ ](https://doi.org/)10.1055/s-0045-1809333 . ISSN 0004-282X. Editor-in-Chief: Hélio A. G. Teive. Associate Editor: Carlos Henrique Ferreira Carmago. Guest Editor: Pedro Augusto Sampaio Rocha Filho. many areas, it is possible to individualize procedures and offer each patient a greater chance of success. Recent studies show us immediate success rates of15to40% 2,3 in reducing days with headache and use of rescue medication in patients with chronic migraine and MOH between the different forms of management proposed. For many of those patients (20–40%)4,5 MOH recurs after12 months, in studies that look for those data. Studies of anti-CGRP MAbs raised the possibility of improving patients who were unable to stop MOH on their own. A real-world analysis showed that 60.6% of patients with chronic migraine and MOH had their symptoms resolved after treatment with CGRP antibodies. However, 40% of them did not improve, which can have many explanations. It has already been observed that the motivation to take pills to treat headache vary in different patients, including relief for pain, fear of having a ﬂare-up after being exposed to conditions known to trigger pain, fear of having a crisis at an © 2025 . The Author(s) . This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as t

FAQs

What is medication-overuse headache (MOH) and why does it remain difficult to manage?

MOH is described as a condition linked to excessive use of pain medication. It remains challenging because management requires sustained improvement, and many patients experience persistent or recurrent symptoms even after medical care.

How does the CGRP monoclonal antibody era change MOH treatment considerations?

Studies of anti-CGRP monoclonal antibodies suggest potential improvement for patients who cannot stop medication overuse on their own. However, not all patients improve, indicating that response varies.

What individualized strategies are proposed for MOH management?

The discussion proposes tailoring headache treatment by starting prophylactic medication immediately or postponing it, considering or not considering bridging therapy, and advising patients to stop medication overuse immediately or reduce it gradually.

Sep 29, 2026

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