Past, present, and future prospects of medication-overuse headache classification

The 1988 classification by the International Headache Society (IHS) first defined drug-induced headache as a specific disorder, belonging to secondary headaches, subtype 8.2 (headache induced by chronic substance use or exposure). In 2004 ICHD-II, this definition was replaced by medication-overuse headache (MOH). It was established that a definite diagnosis of MOH required the improvement of the disorder after cessation of medication overuse. The specific characteristics of the various subforms were also indicated. Later revisions have first eliminated these headache characteristics and then the diagnosis of probable MOH. The diagnosis of MOH has therefore become more useful to clinical aims. However, the last revision has eliminated the need to prove that the disorder is caused by drugs, that is, the headache improves after cessation of medication overuse. The classification of MOH as a secondary headache has therefore been modified, too. Clinical trials can consequently include in the same group patients with primary headache and drug overuse and patients with MOH. We therefore propose to continue to use the diagnosis of probable MOH to research aims. We also propose to modify the classification of MOH subforms according to the presence or absence of a dependence-producing property of overused drugs. This will allow to better analyze the role of the various medications in inducing chronic headache and the outcomes of treatments.