I consistently see medication overuse headache(MOH) conflated and confused with medication overuse(MO); however we want to define MO(say, 11+ days of analgesic use per month, or…11+ days of butalbital/opioid/triptan use per month or….), that does NOT mean that the “overuse” is causing rebound or MOH. Epidemiologic studies to determine MOH are not valid; to say someone suffers from MOH, you need to:1.take a careful history of exactly what happened with the headaches after the drug was started; often this history is not available, and 2. see what happens after stopping the drug, which is never easy(often the analgesic, or triptan, is the only med giving the person any quality of life)….

SO, people are told ‘only take your pain med/triptan/Excedrin 2 days a week”, and the poor patient says “but I have 2 kids, I work, I have headaches 7 days per week, what do I do to survive the other 5 days?”……This “second half of the sentence”, as I like to say, is not answered; the neurologist says “I dunno”….or says nothing…..The problem is, with our “preventive” measures, including the best one, Botox, only about 52% of chronic headache patients achieve long-term relief; SO, what are the other 1/2 of the millions of chronic headache sufferers supposed to do???….


Another common mistake I encounter(3 or 4 times per week, anyway) is patients with depression reflexively given antidepressants, when they are clearly in the “mild end” of the bipolar spectrum; Take your typical scenario: 17y.o. boy, 4 years of anxiety and depression off and on; he is irritable, often quick to anger, mind races at times; + family history of severe depression, substance abuse, anger…..went on Prozac(or Zoloft, or Lexapro or….), and was “up all nite, mind wired, racy”

..This is clearly the mild end of the bipolar spectrum; adding antidepressants to his brain is often like putting gasoline on a fire; we “wire and overcharge” the neurons. We need mood stabilizers in his situation, not antidepressants……But often the main complaint is depression, and antidepressants are given…and often backfire…….

There are a # of reasons for under diagnosing the mild end of the bipolar spectrum; I have written extensively on this. The clinical stakes for missing the diagnosis are enormous……

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