Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178
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DOI: 10.48208/HeadacheMed.2021.16
Headache Medicine
© Copyright 2021
Editorial
International Classication of Headache Disorders - ICHD-4. Will
medication-overuse headache survive?
Mario Fernando Prieto Peres
1
, Thaiza Agostini Córdoba de Lima
1
, Marcelo Moraes Valença
2,3
1
Instituto de Psiquiatria, HCFMUSP, São Paulo, Brasil
2
Unidade de Neurologia e Neurocirurgia, Universidade Federal de Pernambuco, Recife, Brasil
3
Unimed Recife, Recife, Brasil
The fourth edition of the International Classication of Headache Disorders (ICHD-4) initiatives has
been already started. A new Classication Committee leadership with Dr Peter Goadsby (chair)
and Dr Stefan Evers (secretary) took over Professor Jes Olesen, who has made an incredible effort
leading the rst three editions.
1-4
The current leaders published a letter asking for comments, suggestion for changes or improvements
on the ICHD-3.
5
It has already been suggested two interim modications; rst, in
Denition of Terms
,
episodic migraine was included, dening it as a headache frequency of fewer than 15 days a
month over the last 3 months, which on some days is migraine. The second, premonitory symptoms
denition was corrected.
Although the extensive work and advances in the eld were achieved with the rst three editions, its
current status is still far from ideal.
Some issues are more urgent than others. The main weakness, in our opinion, is the criteria for
medication-overuse headache (MOH) (Figure 1). The current description states that MOH develops
as a consequence” of regular overuse of acute medication; however, the criteria do not require
any aspect of the causal relationship with acute medication use and the development of a chronic
headache disorder.
Medication-overuse headache criteria do not include the denition of overuse; this is a signicant
drawback, by the current criteria; acute medication use, misuse, overuse, or abuse may be inade-
quately included, although each has a completely different meaning.
It is unsustainable for such a diagnosis without an operational denition of its main aspect: the word
overuse”. The criteria in item B on 8.2.1 to 8.2.8 describes regular intakefor 15 days/month for
>3 months” in 8.2.3 and 10 for all the others. Therefore, what the current MOH diagnostic criteria
is diagnosing is nothing but frequent analgesic use”. Not only the lack of operational denition
of overuse causes MOH to be ill-dened; even more confusion is brought when reading the third
paragraph of the Comment section:
The behaviour of some patients with 8.2 Medication-overuse headache is similar to that seen
with other drug addictions, and the Severity of Dependence Scale (SDS) score is a signicant
predictor of medication overuse among headache patients.
Mario Fernando Prieto Peres
mariop3r3s@gmail.com
Received: August 28, 2021
Accepted: September 23, 2021
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Peres MFP, Lima TAC, Valença MM
International Classification of Headache Disorders - ICHD-4. Will medication-overuse headache survive?
Figure 1. ICHD-3 Diagnostic criteria for 8.2 Medication-Overuse Headache.
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Peres MFP, Lima TAC, Valença MM
International Classification of Headache Disorders - ICHD-4. Will medication-overuse headache survive?
This paragraph is misleading in directing the physician in
understanding overuse as abuse, addiction, or dependence.
If MOH is then abuse, or addiction, or dependence, the
specic criteria should be included. The trend in psychiatric
diagnosis for substance abuse disorder in the DSM-V is to
merge dependence and abuse into one set of criteria with
11 aspects6, which are not fully applicable in the reality
of headache disorders and acute medication relief. The
Severity of Dependence Scale suggested by the comments’
paragraph also has limited applicability.
The next paragraph in the comments states that the number
of days of medication use