Medication overuse headache (MOH) has incited passionate debate among headache clinicians and researchers in recent years. The existence of MOH as a diagnostic category1 and as a potentially modifiable risk factor for headache chronification is well-recognized by most headache specialists.2 However, the greatest controversies seem to exist over whether medication overuse should be regarded as cause or consequence; and over the treatment strategies, including advice about withdrawal of frequently used symptomatic (acute pain relieving) medication and whether prophylactic treatment should be initiated during withdrawal or after detoxification.3,4 This ongoing debate is undoubtedly a symptom of a lack of high-quality evidence, as Scher et al.5 state in this issue of Neurology®. Other contributing factors include the difficulty of disentangling retrospectively the underlying primary headache type predating medication overuse and cultural differences regarding types of overused symptomatic medication. Most notably, the advice to patients to stop symptomatic medication that may provide transient benefits seems to counter the mission of headache practitioners to minimize pain.

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