What is the treatment for chronic headaches?

Treatment for Chronic Headaches

For chronic headaches, particularly chronic migraine, the first-line preventive medication should be topiramate, followed by onabotulinumtoxinA or CGRP monoclonal antibodies if topiramate fails. 1

Diagnosis and Classification

Before initiating treatment, it's essential to properly classify the chronic headache:

• Chronic headache: Headache occurring on ≥15 days per month for at least 3 months
• Chronic migraine: Headache on ≥15 days per month with migraine features on ≥8 days per month
• Medication overuse headache (MOH): Chronic headache resulting from regular overuse of acute headache medications

Treatment Algorithm for Chronic Headaches

Step 1: Rule Out Medication Overuse Headache

• If medication overuse is present:
  • Withdraw the overused medication (abrupt withdrawal preferred, except for opioids) 1
  • Patient education about withdrawal symptoms and expected temporary worsening
  • Consider preventive therapy during withdrawal period

Step 2: Preventive Treatment

For chronic migraine, evidence-based options include:

1. First-line: Topiramate (most cost-effective option) 1

   • Dosage: Start low, titrate up to effective dose
   • Monitor for side effects: cognitive issues, paresthesia, weight loss

2. Second-line: OnabotulinumtoxinA (FDA-approved specifically for chronic migraine) 1

   • Only after failure of topiramate
   • Should be administered by neurologist or headache specialist
   • Reduces headache days, severity, and improves quality of life

3. Third-line: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1

   • For patients who have failed at least two preventive medications
   • Effective but more costly than topiramate

Step 3: Acute Treatment

• Limit use of acute medications to prevent medication overuse headache:
  • Simple analgesics: <15 days/month 1
  • Triptans: <10 days/month 1

Step 4: Address Comorbidities and Modifiable Risk Factors

• Identify and manage comorbidities that may affect treatment choice: 1

  • Depression/anxiety: Consider amitriptyline
  • Obesity: Consider topiramate (associated with weight loss)
  • Sleep disorders: Evaluate for sleep apnea, insomnia
  • Stress: Behavioral interventions

• Address modifiable risk factors: 1

  • Obesity
  • Caffeine use
  • Stress
  • Sleep disorders

Step 5: Non-pharmacological Approaches

• Lifestyle modifications: 2

  • Regular sleep schedule
  • Regular meals
  • Regular exercise
  • Stress management techniques

• Consider complementary approaches: 3, 4

  • Relaxation techniques
  • Cognitive behavioral therapy
  • Acupuncture
  • Certain supplements (magnesium, feverfew, riboflavin)

Monitoring and Follow-up

• Maintain headache diary to track frequency, severity, and medication use 1
• Use validated assessment tools to monitor progress
• Adjust treatment based on response and side effects
• Consider referral to specialist care for patients with:
  • Refractory chronic migraine
  • Complex comorbidities
  • Medication overuse that cannot be managed in primary care

Important Caveats

• Beta-blockers, candesartan, and amitriptyline lack robust evidence from randomized controlled trials for chronic migraine, though they are commonly used in practice 1
• Medication overuse can transform episodic migraine to chronic migraine and complicate treatment 1
• Chronic migraine is often underdiagnosed and undertreated in primary care 1
• Treatment should be continued for at least 6 months after achieving good control before considering tapering 1

By following this algorithm and selecting appropriate preventive and acute treatments while addressing comorbidities and lifestyle factors, most patients with chronic headaches can achieve significant improvement in headache frequency, severity, and overall quality of life.