What is the approach to managing chronic bilateral headaches in a middle-aged person?

Approach to Chronic Bilateral Headache in Middle-Aged Patients

First, rule out secondary causes through careful history and examination for red flags, then if chronic migraine is suspected (≥15 headache days/month with ≥8 migraine days), initiate topiramate as first-line preventive therapy while addressing medication overuse headache if present. 1

Initial Assessment: Rule Out Secondary Causes

Critical red flags requiring immediate neuroimaging:

• New headache onset after age 50 (12 times more likely to have serious underlying causes) 2, 3, 4
• Sudden "thunderclap" onset 2, 3
• Progressive worsening pattern 2, 3
• Headache awakening patient from sleep 2, 3
• Worsening with Valsalva maneuver 2
• Scalp tenderness, jaw claudication (suspect giant cell arteritis) 2
• Systemic symptoms: fever, weight loss, malaise 3

Essential initial workup:

• Complete neurological examination focusing on mental status, cranial nerves, motor/sensory function, and fundoscopy for papilledema 2
• Blood pressure measurement 2
• ESR and CRP to rule out giant cell arteritis in patients over 50 2, 3
• MRI with and without contrast is preferred imaging modality 2

Diagnosis of Chronic Migraine

Diagnostic criteria (simplified):

• ≥15 headache days per month for ≥3 months 1
• ≥8 days per month meeting migraine criteria or responding to migraine-specific treatment 1
• Each headache lasting ≥4 hours 1

Practical diagnostic approach:

• Ask: "Do you feel like you have a headache of some type on 15 or more days per month?" 1
• Patients often underreport milder headache days, focusing only on severe episodes 1
• Implement headache diary for accurate tracking 1

Differential diagnosis to consider:

• Chronic tension-type headache 1
• New daily persistent headache 1
• Hemicrania continua 1
• Medication overuse headache 1

Critical Step: Assess for Medication Overuse Headache (MOH)

MOH is present in up to 73% of chronic migraine patients seeking treatment: 1

• NSAIDs used ≥15 days per month 5
• Triptans or combination analgesics used ≥10 days per month 1
• Any acute medication used ≥2 days per week increases risk 1, 5

Management of MOH:

• Explain the mechanism and necessity of withdrawal 1
• Abrupt withdrawal is preferred (except for opioids) 1
• Initiate preventive therapy concurrently 1

Evidence-Based Preventive Treatment

First-line therapy: Topiramate

• Only medication with proven efficacy in randomized, placebo-controlled trials specifically for chronic migraine 1
• Preferred due to much lower cost compared to alternatives 1
• Additional benefit in patients with obesity (associated with weight loss) 1
• Start at low doses and titrate slowly in middle-aged patients 2, 5

Second-line options when topiramate fails or is contraindicated:

• OnabotulinumtoxinA: FDA-approved for chronic migraine prophylaxis, proven effective in large Phase III trials 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): proven beneficial after ≥2 other preventives have failed 1
• Regulatory restrictions typically limit these to patients who have failed 2-3 other preventives 1

Commonly used but lacking robust evidence in chronic migraine:

• Beta-blockers (propranolol, metoprolol, atenolol) 1, 2, 5
• Amitriptyline 1
• Candesartan 1
• Note: These agents have evidence for episodic migraine but not specifically for chronic migraine 1

Consider comorbidities when selecting preventive:

• Depression or sleep disturbances: amitriptyline preferred 1
• Obesity: topiramate preferred 1
• Hypertension or tachycardia: beta-blockers may address both conditions 1

Acute Treatment Strategy

Limit acute medication use to prevent MOH:

• No more than 2 days per week 1, 5
• NSAIDs (ibuprofen 400mg, naproxen 500-825mg) as first-line 2, 5
• Monitor for cardiovascular and gastrointestinal risks in middle-aged patients 5

Address Modifiable Risk Factors

Key factors to identify and manage:

• Obesity (risk factor for transformation to chronic migraine) 1
• Medication overuse 1
• Caffeine overuse 1
• Obstructive sleep apnea 1
• Psychiatric comorbidities (anxiety, depression) 1
• Stress 1

Lifestyle modifications:

• Patient education on modifiable risk factors 1
• Behavioral interventions to modify stress response 1

Non-Pharmacologic Treatments

Evidence-based options to offer all patients:

• Cognitive-behavioral therapy 1
• Biofeedback 1
• Relaxation training 1, 6
• Progressive muscle relaxation 1
• Acupuncture 6
• Exercise: 40 minutes three times weekly (as effective as topiramate in one trial) 1

Referral to Specialist Care

Indications for neurology/headache specialist referral:

• Patients with chronic migraine should be referred to specialist care 1
• While awaiting specialist appointment, primary care can initiate topiramate 1
• Specialist can administer onabotulinumtoxinA using Phase III protocol 1
• Return to primary care once sustained efficacy achieved for 6 months without substantial adverse effects 1

Long-Term Management and Follow-Up

Primary care responsibilities:

• Maintain stability of adequate outcomes 1
• Monitor treatment response within 2-3 months 2
• Use headache calendars to track frequency, severity, and medication use 2
• Avoid routine regular contact unless necessary for repeat prescriptions 1
• Emphasize patient education and self-efficacy 1
• React appropriately to changes requiring review 1

Common Pitfalls to Avoid

Critical errors in management:

• Assuming migraine without thorough investigation in middle-aged patients with new-onset headache 3
• Missing medication overuse headache (present in majority of chronic migraine patients) 1
• Failing to initiate preventive therapy (every chronic migraine treatment plan should include prophylaxis) 1
• Using acute medications >2 days per week (perpetuates medication overuse cycle) 1, 5
• Not addressing comorbidities that affect treatment choice and outcomes 1
• Setting unrealistic expectations (chronic migraine requires multimodal approach and improvement takes time) 1