What is the recommended treatment for chronic symptoms present for one year?

Treatment of Chronic Symptoms Present for One Year

For chronic symptoms lasting one year, treatment must be tailored to the specific symptom type and underlying pathophysiology, with chronic pain requiring multimodal therapy combining behavioral interventions (cognitive-behavioral therapy and mindfulness-based treatments as first-line), targeted pharmacotherapy based on pain mechanism, and avoidance of long-term opioids. 1

Initial Assessment Requirements

Comprehensive Symptom Characterization

• Document the specific symptom pattern: pain location and quality, fatigue severity, functional limitations, and temporal patterns (constant vs. intermittent, triggers, relieving factors) 1, 2
• Use validated assessment tools: Brief Pain Inventory (BPI) or the ultra-brief 3-item PEG scale (assessing Pain intensity, interference with Enjoyment of life, and General activity) for pain symptoms 1
• Quantify disability using condition-specific measures: Headache Impact Test-6 (HIT-6) for chronic migraine, ESSDAI for systemic symptoms in autoimmune conditions 1, 3
• Screen for psychiatric comorbidities: depression, anxiety, and catastrophizing are present in the majority of chronic symptom patients and directly worsen outcomes 1, 4

Diagnostic Clarification

• Determine if symptoms represent ongoing tissue injury, central sensitization (upregulation of nociceptive signaling without active injury), or denervation-related dysfunction 1
• Distinguish between neuropathic pain (burning, shooting, electric quality with sensory changes) and non-neuropathic musculoskeletal pain, as treatment differs substantially 1
• Rule out new pathology: any change in chronic symptom pattern requires re-evaluation for new opportunistic infections, medication adverse effects, or comorbid conditions 1
• For chronic migraine specifically: confirm ≥15 headache days per month for ≥3 months with migraine features on ≥8 days, and rule out medication overuse headache before initiating preventive therapy 5, 3

Treatment Algorithm by Symptom Type

Chronic Pain (Non-Inflammatory, Non-Neuropathic)

Step 1: Behavioral Interventions (First-Line)

• Initiate cognitive-behavioral therapy (CBT) immediately - this has equivalent efficacy to pharmacological treatments and should not be delayed 1
• Add mindfulness-based therapies concurrently - both have strong evidence for chronic multisymptom illness, fibromyalgia, and irritable bowel syndrome 1
• Prescribe structured aerobic exercise: 40 minutes three times weekly, which is as effective as topiramate or relaxation therapy for pain reduction 3
• Establish consistent activity-rest-sleep patterns before attempting graded activity increases 6

Step 2: Pharmacotherapy Based on Pain Mechanism

• For neuropathic pain: gabapentin 300 mg at bedtime, titrating up to 2400 mg daily in three divided doses, or pregabalin 75-300 mg every 12 hours 1
• For fibromyalgia-pattern pain: serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line pharmacotherapy, or pregabalin 1
• For chronic daily non-inflammatory pain: avoid repeated NSAIDs or corticosteroids; consider antidepressants (amitriptyline, sertraline) or anticonvulsants 1
• Strongly avoid long-term opioids - there is no evidence of benefit for chronic non-cancer pain and substantial risk of harm 1

Step 3: Topical Therapies for Localized Pain

• Lidocaine 5% patches applied to affected areas, delivering medication gradually over hours - more effective than lidocaine gel or cream 1
• Compounded amitriptyline 1-2% with ketamine 0.5% (can increase ketamine to 5% if ineffective) applied up to three times daily 1

Chronic Migraine (≥15 Headache Days/Month)

Acute Treatment Limitations

• Restrict acute medication use to no more than twice weekly to prevent medication overuse headache 3
• First-line acute treatment: NSAIDs (aspirin, ibuprofen, or diclofenac) plus prokinetic antiemetics (metoclopramide) when nausea present 3
• Avoid ergot alkaloids, opioids, and barbiturates due to dependency risk and medication overuse headache 3

Preventive Medication Algorithm

• First-line: Topiramate, titrating gradually to 100 mg/day due to proven efficacy and lower cost 3
• Second-line: OnabotulinumtoxinA (Botox) 155-195 units to 31-39 sites every 12 weeks per PREEMPT protocol, reserved for patients who have failed topiramate and at least one other preventive medication 5, 3
• Botox reduces headache days by 1.9-3.1 days per month compared to placebo and improves quality of life 5
• Third-line: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) only after failure of 2-3 other preventive medications due to cost 3

Chronic Multisymptom Illness (CMI)

Core Treatment Approach

• Cognitive-behavioral therapy and mindfulness-based treatments are the only interventions with strong evidence 1
• Consider emotion-focused therapy for patients with fibromyalgia or irritable bowel syndrome symptoms 1
• Avoid mifepristone - guidelines recommend against its use 1
• Treat all comorbid conditions definitively (depression, anxiety, PTSD, diabetes, sleep disorders) as their management directly improves symptom outcomes 1

Chronic Non-Inflammatory Musculoskeletal Pain (e.g., Sjögren's Syndrome)

For Daily Non-Inflammatory Pain

• Emphasize non-pharmacological management: physical activity and aerobic exercise reduce pain severity and improve function 1
• Avoid repeated NSAIDs or corticosteroids for chronic daily pain 1
• Consider gabapentin, pregabalin, or amitriptyline for chronic neuropathic pain (monitor for exacerbation of dryness symptoms) 1
• Never use opioids - recent epidemiological data confirm they must not be used 1

For Episodic Articular Pain

• Hydroxychloroquine may be considered for frequent episodes of joint pain in appropriate conditions 1
• Biological agents (rituximab, anakinra) have not shown significant benefit for pain/fatigue and are not warranted for musculoskeletal pain alone 1

Interdisciplinary Team Approach

• Develop interdisciplinary teams for complex chronic pain, especially with co-occurring substance use or psychiatric disorders 1
• Include physical therapy, occupational therapy, behavioral therapy, and patient education on pain neurophysiology 1
• Refer to pain specialists for: failure of multiple treatments, consideration of interventional procedures, or diagnostic uncertainty 1, 3
• For chronic migraine, specialist referral is usually necessary for optimal management 3

Monitoring and Reassessment

• Conduct reassessments at regular intervals after adequate time for each treatment change to take effect 1
• Use headache diaries and validated tools (HIT-6, MSQ) to track treatment response objectively 3
• Focus on functional goals, decreasing symptom severity, improving quality of life, and identifying treatment-related adverse events 1
• For chronic migraine on Botox: administer at least 2-3 treatment cycles before classifying as non-responder 5

Critical Pitfalls to Avoid

• Do not assume existing chronic treatment is sufficient for new symptoms - new pain requires complete re-evaluation for new pathology, end-of-dose failure, or tolerance development 1
• Do not initiate preventive therapy for chronic migraine without first ruling out medication overuse headache - MOH prevents response to preventive medications 3
• Do not allow unlimited acute medication use - strict limitation prevents progression and medication overuse headache 3
• Do not prescribe opioids for chronic non-cancer pain - no evidence of benefit and substantial harm 1
• Do not delay behavioral interventions - CBT and mindfulness have proven efficacy and should be first-line, not rescue therapy 1