Management of Chronic Headache
For chronic headache management, a comprehensive approach including prophylactic medications (with topiramate as first-line therapy), lifestyle modifications, and non-pharmacological interventions is recommended to reduce headache frequency and improve quality of life. 1
Diagnosis and Initial Assessment
- Chronic headache is defined as headache occurring on 15 or more days per month for at least 3 months 1
- Rule out secondary causes of headache through careful history taking and examination before establishing a diagnosis of primary chronic headache 1
- Encourage patients to maintain a headache diary to accurately track frequency, severity, triggers, and medication use 1, 2
- Ask patients specifically: "Do you feel like you have a headache of some type on 15 or more days per month?" as patients often underreport milder headaches 1
Pharmacological Management
Prophylactic Treatment
- Initiate prophylactic treatment in all patients with chronic headache to reduce frequency and severity 1
- First-line prophylactic medication: Topiramate - the only agent with strong evidence from randomized, placebo-controlled trials specifically for chronic migraine 1
- Alternative prophylactic options with varying levels of evidence:
- OnabotulinumtoxinA (Botox) - FDA-approved specifically for chronic migraine prophylaxis, administered by specialists 1
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - effective for patients who have failed at least two other preventive medications 1
- Valproate - limited evidence from small trials in chronic daily headache 1
- Gabapentin - limited evidence from one double-blind trial 1
- Amitriptyline - commonly used but limited evidence from small open-label trials 1
- Beta-blockers (propranolol) - FDA-approved for migraine prophylaxis but no specific evidence for chronic migraine 3, 1
Acute Treatment
- Limit use of acute medications to prevent medication overuse headache:
- NSAIDs can be used as first-line treatment for acute attacks 2, 4
- Triptans are effective for moderate to severe attacks but should be avoided in patients with seizure history 2, 4
- Avoid opioids and butalbital-containing medications due to risk of medication overuse headache and dependency 2, 4
Non-Pharmacological Management
- Identify and manage modifiable risk factors and triggers, including:
- Implement behavioral interventions:
- Regular exercise (40 minutes three times weekly) has shown efficacy comparable to relaxation therapy or topiramate 1, 2
- Maintain consistent sleep patterns and meal schedules 2, 5
Management of Medication Overuse Headache
- Medication overuse is present in up to 73% of patients with chronic migraine 1
- Withdraw overused medications - abrupt withdrawal is preferred except for opioids 1
- Educate patients about the risk of medication overuse headache with frequent use of acute medications 1
- Consider prophylactic treatment during medication withdrawal 1, 6
Addressing Comorbidities
- Screen for and manage common comorbidities:
- Select prophylactic medications that may benefit comorbid conditions:
Follow-up and Monitoring
- Regular follow-up to assess treatment response and adjust therapy as needed 1, 2
- Use disability assessment tools to monitor progress 1, 2
- Set realistic expectations - chronic headache often requires long-term management with periods of relapse and remission 1, 6
- Refer to headache specialists when:
Common Pitfalls and Caveats
- Failure to recognize medication overuse as a contributor to chronic headache 1
- Inadequate prophylactic treatment - benefits may take several weeks to become apparent 2, 6
- Overreliance on acute medications without addressing underlying factors 1
- Not considering sleep disorders as potential contributors to chronic headache 5, 6
- Unrealistic expectations for complete headache resolution - focus on reducing frequency and improving quality of life 1, 6