From the Guidelines
The management of intractable headache should prioritize a multifaceted approach, including accurate diagnosis, lifestyle modifications, and a stepped-care pharmacological approach, with first-line medications such as beta blockers, topiramate, or candesartan, as recommended by the most recent guidelines 1. The approach to managing intractable headache involves several key components, including:
- Accurate diagnosis and classification of the headache type
- Lifestyle modifications, such as regular sleep patterns, stress management, trigger avoidance, and proper hydration
- A stepped-care pharmacological approach, with first-line medications such as beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan, as recommended by the most recent guidelines 1
- Second-line medications, such as flunarizine, amitriptyline, or sodium valproate, for patients who do not respond to first-line treatments
- Consideration of CGRP monoclonal antibodies as third-line medications for patients with chronic migraine 1
- Adjunctive therapies, such as neuromodulatory devices, biobehavioural therapy, and acupuncture, for patients who do not respond to pharmacological treatments or who have contraindications to medication 1
- Education on chronic migraine, including its biological basis, environmental and psychological triggers, and the importance of a multimodal and multidisciplinary approach to therapy 1
- Encouragement of patient empowerment through education, non-pharmacologic treatments, and establishment of realistic expectations 1
- Consideration of referral to specialist care for patients with chronic migraine who do not respond to initial treatments 1
From the FDA Drug Label
to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day.
The management of intractable headache may include the use of onabotulinumtoxinA (BOTOX) to prevent headaches in adults with chronic migraine. However, the specific term "intractable headache" is not directly addressed in the label. Based on the information provided, onabotulinumtoxinA (BOTOX) is used to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day 2.
From the Research
Management of Intractable Headache
The management of intractable headache, particularly chronic migraine, involves various treatment options, including:
- Pharmacological treatments, such as acute and preventive measures 3
- Non-pharmacological treatments, including behavioral interventions like cognitive behavioral therapy, biofeedback, and relaxation techniques 3
- Neurostimulation procedures, such as occipital stimulation, supraorbital transcutaneous stimulation, non-invasive vagal nerve stimulation, and transcranial direct current stimulation 3
Botulinum Toxin in Chronic Migraine Management
Botulinum toxin, specifically onabotulinumtoxinA (Botox®), has been shown to be effective in reducing headache frequency and severity in patients with chronic migraine 4, 5, 6, 7
- The treatment protocol typically involves 31-39 pericranial injection sites, with a total dose of 155-195 units, administered every three months 5
- Studies have demonstrated that onabotulinumtoxinA treatment can improve quality of life, reduce healthcare resource utilization, and decrease work impairment in patients with chronic migraine 5, 7
Efficacy of Botulinum Toxin in Intractable Chronic Migraine
Research has shown that botulinum toxin type-A (Botox®) can be efficacious in intractable chronic migraine patients with no pain-free time, including those with new onset daily persistent headache 7
- A retrospective report found that 21% of patients exhibited a sustained reduction in Headache Impact Test (HIT)-6 scores below 60 after receiving Botox® therapy 7
- The study suggests that Botox® treatment can improve disability in patients with intractable chronic migraine, even if the number of headache days and pain-free time do not change 7