What are the treatment options for chronic headache management?

Comprehensive Management of Chronic Headaches

For chronic headache management, a multimodal approach combining prophylactic medications, acute treatments, lifestyle modifications, and non-pharmacological interventions is essential to reduce headache frequency, severity, and improve quality of life. 1

Diagnosis and Assessment

• Define chronic headache as headaches occurring ≥15 days/month for >3 months 2, 3
• Use a headache diary to track:
  • Frequency and duration
  • Pain intensity and characteristics
  • Associated symptoms
  • Triggers
  • Medication use and response 1
• Screen for medication overuse: NSAIDs >15 days/month or triptans >10 days/month 1

Prophylactic Treatment Options

First-Line Medications

• Topiramate (100 mg/day): Only agent with proven efficacy in randomized controlled trials specifically for chronic migraine 2
• Propranolol (80-240 mg/day): FDA-approved for migraine prophylaxis 1, 4
• OnabotulinumtoxinA (Botox): Only FDA-approved therapy specifically for chronic migraine prophylaxis 2

Other Effective Options

• Amitriptyline (30-150 mg/day)
• Divalproex sodium/Valproate (500-1500 mg/day)
• Timolol (20-30 mg/day)
• Gabapentin
• Tizanidine 2, 1, 3

Newer Options

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Consider for patients with inadequate response to traditional preventives 1
• CGRP antagonists (gepants): Emerging options for prevention 1

Acute Treatment Strategies

• NSAIDs: Ibuprofen, naproxen for less severe episodes
• Triptans: Sumatriptan, rizatriptan, eletriptan for moderate-severe attacks
• Combination therapy: Triptan + NSAID (e.g., sumatriptan + naproxen) for enhanced efficacy 1
• CGRP antagonists: Rimegepant, ubrogepant, zavegepant for acute treatment 1, 5
• Antiemetics: Add when nausea is prominent 1

CAUTION: Limit acute medication use to prevent medication overuse headache: NSAIDs ≤15 days/month and triptans ≤10 days/month 1

Non-Pharmacological Approaches

Evidence-Based Options

• Behavioral therapies:
  • Relaxation training
  • Cognitive behavioral therapy
  • Biofeedback
  • Progressive muscle relaxation 2, 1
• Physical interventions:
  • Regular exercise (40 minutes, 3 times/week) - as effective as topiramate in some studies 2
  • Cervical exercises 3
• Complementary approaches:
  • Magnesium (400-600mg daily)
  • Riboflavin (400mg daily)
  • Coenzyme Q10
  • Feverfew 1, 6

Managing Triggers and Comorbidities

• Identify and address modifiable risk factors:
  • Obesity
  • Medication overuse
  • Caffeine use
  • Obstructive sleep apnea (may cause morning headaches) 2, 7
  • Psychiatric comorbidities (depression, anxiety) 8
  • Stress 2
• Implement lifestyle modifications:
  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Stress management techniques 1
• Consider food diary to identify potential dietary triggers:
  • Phenylethylamine
  • Tyramine
  • Aspartame
  • Monosodium glutamate
  • Nitrates/nitrites
  • Alcohol
  • Caffeine 6

Treatment Algorithm

1. Start prophylactic treatment with topiramate or propranolol (based on comorbidities and contraindications)
2. Add acute treatment plan with appropriate limits to prevent medication overuse
3. Implement non-pharmacological approaches simultaneously
4. Assess response after 6-8 weeks at therapeutic dose
5. If inadequate response (less than 50% reduction in headache frequency):
   • Switch to alternative first-line agent OR
   • Consider onabotulinumtoxinA OR
   • Add CGRP monoclonal antibody
6. For refractory cases: Refer to headache specialist for multimodal approach

Special Considerations

• Pregnancy: Acetaminophen is safest acute option 1
• Cardiovascular risk: Avoid triptans 5
• Women of childbearing age: Avoid valproate derivatives due to teratogenic potential 1
• Patients with sleep disorders: Screen for and treat obstructive sleep apnea 7

The goal of treatment is to reduce headache frequency by at least 50%, decrease severity, and improve quality of life between attacks 1. Patient education about realistic expectations is essential, as chronic headache often follows a pattern of relapses and remissions 8.