What is the appropriate management for a patient with a persistent headache lasting 6 months?

Management of Persistent Headache for 6 Months

A patient with persistent headache for 6 months requires systematic evaluation to distinguish between chronic migraine (≥15 headache days/month for >3 months) and other primary headache disorders, followed by initiation of preventive therapy if diagnostic criteria are met. 1

Initial Diagnostic Assessment

Rule Out Secondary Causes First

• Ask the patient directly: "Do you feel like you have a headache of some type on 15 or more days per month?" This simple question helps establish chronicity when patients cannot accurately recall headache frequency without a diary. 1

• Evaluate for red flags requiring neuroimaging: rapidly increasing headache frequency, focal neurologic signs, headache awakening patient from sleep, abrupt onset of severe headache, marked change in pattern, or persistent headache following head trauma. 1

• Neuroimaging is NOT indicated if the patient has a typical headache pattern with normal neurologic examination and no red flags. 1

Classify the Primary Headache Type

For Chronic Migraine diagnosis, confirm: 1

• Headache on ≥15 days/month for >3 months
• On ≥8 days/month, headaches meet migraine criteria (unilateral, pulsating, moderate-to-severe intensity, aggravated by activity) OR have associated symptoms (nausea/vomiting, photophobia/phonophobia) OR respond to triptan/ergot treatment
• History of at least 5 prior attacks meeting full migraine criteria

Critical pitfall: Patients often under-report milder headache days, focusing only on severe attacks. Explicitly ask about both severe and mild headache days. 1

Assess for Medication-Overuse Headache

• This is a common perpetuating factor that must be identified and addressed. 1
• Criteria: Headache ≥15 days/month with regular overuse for >3 months of acute medications (non-opioid analgesics ≥15 days/month OR triptans/ergots/combination analgesics ≥10 days/month) 1
• If present, medication withdrawal is essential before preventive therapy can be fully effective. 2

Treatment Strategy

Acute Treatment Optimization

Even with chronic headache, optimize acute treatment for breakthrough attacks: 2

• First-line for mild-to-moderate attacks: NSAIDs (ibuprofen, naproxen sodium, aspirin) 2
• First-line for moderate-to-severe attacks: Triptans (sumatriptan, rizatriptan, zolmitriptan) 2, 3
• Limit acute medication use to ≤2 days per week to prevent medication-overuse headache. 2

Preventive Therapy Initiation

Preventive therapy is indicated for any patient with chronic migraine (≥15 headache days/month) or when quality of life remains impaired despite optimized acute therapy. 1

First-line preventive medications: 1

• Beta-blockers: propranolol, metoprolol, atenolol, or bisoprolol
• Topiramate: 50-100 mg daily (note: only preventive medication with proven efficacy specifically in chronic migraine from randomized controlled trials) 1
• Candesartan

Second-line options if first-line fails or contraindicated: 1

• Amitriptyline: 10-100 mg at night
• Flunarizine: 5-10 mg daily
• Sodium valproate: absolutely contraindicated in women of childbearing potential 1

Third-line options after failure of multiple first/second-line agents: 1

• OnabotulinumtoxinA: 155-195 units to 31-39 sites every 12 weeks
• CGRP monoclonal antibodies: erenumab (70-140 mg monthly), fremanezumab (225 mg monthly or 675 mg quarterly), eptinezumab (100-300 mg IV quarterly), or galcanezumab

Timeline for Efficacy Assessment

Critical to set appropriate expectations: 1

• Oral preventive medications: assess efficacy after 2-3 months at therapeutic dose
• CGRP monoclonal antibodies: assess after 3-6 months
• OnabotulinumtoxinA: assess after 6-9 months
• Discourage patients from abandoning treatment prematurely due to apparent early inefficacy. 1

Non-Pharmacological Adjuncts

• Biobehavioral therapy, non-invasive neuromodulatory devices, and acupuncture have supporting evidence as adjuncts. 1
• Maintain headache diary to track frequency, severity, and medication use—essential for monitoring treatment response. 1

Follow-Up Strategy

• Evaluate treatment response within 2-3 months after initiation or change in preventive therapy. 1
• Measure outcomes: attack frequency (headache days per month), severity, and migraine-related disability. 1
• If successful for 6-12 months, consider pausing preventive therapy to determine if continued treatment is necessary. 1
• If preventive treatment fails, review adherence and dosing before concluding true failure. Simplified once-daily dosing improves adherence. 1