What are the treatment options for chronic headaches?

Treatment Options for Chronic Headache

For chronic headache, the most effective treatment approach includes both prophylactic medications to reduce headache frequency and as-needed treatments for acute episodes, with topiramate and OnabotulinumtoxinA being first-line prophylactic options based on the strongest evidence. 1, 2

Diagnosis and Assessment

• Chronic headache is defined as headache occurring on 15 or more days per month for at least 3 months 2
• Rule out secondary causes of headache through careful history taking and physical examination 1
• Encourage patients to maintain a headache diary to track frequency, severity, triggers, and medication use 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

Prophylactic Treatment Options

First-Line Options

• Topiramate: The only prophylactic medication with strong evidence from randomized, placebo-controlled trials specifically for chronic migraine 1, 2

  • Common side effects: cognitive inefficiency, paresthesia, fatigue, weight loss 1
  • Serious adverse effects: acute angle closure glaucoma, metabolic acidosis 1

• OnabotulinumtoxinA (Botox): The only FDA-approved therapy specifically for prophylaxis of headache in adults with chronic migraine 1, 2

  • Administered by neurologists or headache specialists using the PREEMPT protocol 1
  • Shown to reduce headache days, episodes, and severity while improving quality of life 1

Second-Line Options

• Amitriptyline: Second-choice drug for migraine prophylaxis 1

  • Side effects: dry mouth, sedation, weight gain, constipation 1
  • Serious adverse effects: cardiac dysrhythmias 1

• Beta-blockers (propranolol, metoprolol, timolol): Effective for episodic migraine but limited evidence for chronic migraine 1, 3

  • Side effects: lethargy, depression, dizziness, exercise intolerance 1
  • Avoid in patients with asthma, diabetes, bradycardia, or heart failure 1

• Valproate: Limited evidence from small trials in chronic daily headache 1

  • Side effects: weight gain, tremor, nausea, alopecia 1
  • Serious adverse effects: pancreatitis, liver failure, thrombocytopenia 1

• Other options: Gabapentin, tizanidine, fluoxetine, venlafaxine 1

Acute Treatment Options

• NSAIDs: First-line for mild to moderate headache episodes 4, 5

  • Limit use to fewer than 15 days/month to prevent medication overuse headache 2

• Triptans: For moderate to severe episodes 4

  • Limit use to fewer than 10 days/month to prevent medication overuse headache 2
  • Contraindicated in patients with cardiovascular disease 4

• Antiemetics: Add metoclopramide or prochlorperazine for associated nausea or vomiting 6, 7

Non-Pharmacological Approaches

• Behavioral interventions: Shown to provide relief for chronic headache patients 1, 2

  • Cognitive behavioral therapy (CBT) 1, 2, 8
  • Relaxation training and meditative therapy (abdominal breathing exercises) 1, 2
  • Progressive muscle relaxation and visualization/guided imagery 1
  • Biofeedback 1, 2, 8

• Exercise: 40 minutes three times weekly has shown efficacy comparable to relaxation therapy or topiramate 1, 2

• Trigger identification and management: Use headache diary to identify and avoid personal triggers 2, 4

  • Common triggers include stress, sleep disturbances, caffeine, and alcohol 4, 7

Managing Medication Overuse Headache

• Medication overuse is present in up to 73% of patients with chronic migraine 1
• Limit acute medications to prevent medication overuse headache 2, 9:
  • Simple analgesics: fewer than 15 days/month 2
  • Triptans: fewer than 10 days/month 2
• Consider withdrawing overused medications and initiating prophylactic treatment 2, 9

Addressing Comorbidities

• Screen for and manage common comorbidities 2, 7:

  • Psychiatric disorders (depression, anxiety) 2, 9
  • Sleep disorders (insomnia, obstructive sleep apnea) 2, 7
  • Obesity 2

• Select prophylactic medications that may benefit comorbid conditions 2:

  • Beta-blockers for patients with hypertension or tachycardia 1
  • Topiramate for patients with obesity 6
  • Amitriptyline for patients with depression or insomnia 7

Follow-up and Monitoring

• Schedule regular follow-up visits to assess treatment response and adjust therapy as needed 2
• Use disability assessment tools to monitor progress 2
• Set realistic expectations - chronic headache often requires long-term management 1, 2
• Consider referral to headache specialists when diagnosis is uncertain, treatment is ineffective, or complex comorbidities are present 2

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache 2, 9
• Not addressing comorbid conditions that may exacerbate headaches 2
• Setting unrealistic expectations for complete headache resolution 1
• Using opioids or butalbital-containing medications, which increase risk of medication overuse headache and dependency 6, 9