What is the best course of treatment for new daily persistent headache with associated symptoms, including intense pressure, balance issues, and tinnitus, unresponsive to gabapentin (neurontin)?

Treatment of New Daily Persistent Headache Unresponsive to Gabapentin

Discontinue Gabapentin and Transition to Evidence-Based Preventive Therapy

You should discontinue gabapentin, as the 2024 VA/DoD guidelines explicitly recommend against its use for migraine prevention, and transition to a proven first-line preventive medication while simultaneously optimizing acute treatment strategies. 1

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Critical Diagnostic Considerations Before Treatment

Rule Out Medication Overuse Headache

• Your symptom pattern of constant 24/7 pressure for two years raises concern for medication overuse headache (MOH), which occurs when acute medications are used more than twice weekly 1
• MOH creates a vicious cycle where increasing medication use paradoxically worsens headache frequency, potentially leading to daily headaches 1
• Any acute medication use (including over-the-counter analgesics) must be limited to no more than 2 days per week to prevent or break this cycle 1

Address Pulsatile Tinnitus Specifically

• Your pulsatile tinnitus in the right ear requires specific evaluation, as the 2014 AAO-HNS guidelines recommend imaging for pulsatile tinnitus to exclude vascular abnormalities 1
• For the bilateral regular tinnitus, guidelines recommend against gabapentin, Ginkgo biloba, melatonin, or zinc, as systematic reviews show no benefit 1, 2, 3
• Cognitive-behavioral therapy (CBT) is the only treatment with a strong recommendation for persistent, bothersome tinnitus 1
• If hearing loss accompanies your tinnitus, hearing aid evaluation is recommended as first-line intervention 1

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First-Line Preventive Therapy Options

Strongest Evidence: CGRP Monoclonal Antibodies

The 2024 VA/DoD guidelines provide a strong recommendation for erenumab, fremanezumab, or galcanezumab for prevention of episodic or chronic migraine 1

• These represent the highest level of evidence for preventive therapy
• Efficacy should be assessed after 3-6 months of treatment 1
• These agents are particularly appropriate given your failed trial of gabapentin

Alternative First-Line Options

If CGRP antibodies are not accessible, consider these evidence-based alternatives:

Angiotensin receptor blockers:

• Candesartan or telmisartan have strong recommendations for episodic migraine prevention 1

Topiramate:

• Suggested for both episodic and chronic migraine prevention 1
• Requires 2-3 months to assess efficacy 1

Propranolol:

• Suggested for migraine prevention with consistent evidence 1
• Dose range: 80-240 mg/day 1

Valproate:

• Suggested for episodic migraine prevention 1
• Strictly contraindicated if you are of childbearing potential due to teratogenic risk 1

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Optimize Acute Treatment Strategy

For Moderate to Severe Attacks

The strongest recommendation is combination therapy: triptan + NSAID 1, 4

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides superior efficacy compared to either agent alone 4
• This combination results in 130 more patients per 1000 achieving sustained pain relief at 48 hours 4
• Take medication early in the attack while pain is still mild for maximum effectiveness 1, 4

For Mild to Moderate Attacks

• NSAIDs alone (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) as first-line 1, 4
• Aspirin-acetaminophen-caffeine combination has strong recommendation 1

Critical Frequency Limitation

Strictly limit all acute medications to no more than 2 days per week to prevent medication overuse headache 1, 4

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Address Associated Vestibular Symptoms

Your balance issues, dizziness with head movement, and motion sensitivity suggest vestibular migraine features:

• These symptoms are consistent with migraine-associated vestibular dysfunction 1
• The same preventive medications used for migraine (CGRP antibodies, propranolol, topiramate) can address both headache and vestibular symptoms 1
• Vestibular rehabilitation therapy may provide additional benefit for the balance and motion sensitivity components

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Address Cervicogenic Component

Your description of neck muscle tightness that partially relieves pressure suggests a cervicogenic contribution:

• Greater occipital nerve block is suggested for short-term treatment of migraine 1
• Physical therapy targeting cervical musculature may provide adjunctive benefit
• However, this should not delay initiation of systemic preventive therapy

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Treatment Algorithm

1. Immediately discontinue gabapentin (no evidence for efficacy in your condition) 1
2. Initiate first-line preventive therapy with CGRP monoclonal antibody (erenumab, fremanezumab, or galcanezumab) 1
3. Optimize acute treatment with triptan + NSAID combination, limited to ≤2 days/week 1, 4
4. Refer for CBT specifically for tinnitus management 1
5. Obtain audiologic evaluation if not already completed, given persistent tinnitus 1
6. Assess preventive therapy efficacy after 3-6 months; if inadequate response, trial alternative first-line preventive (topiramate, propranolol, or ARB) 1

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Critical Pitfalls to Avoid

• Do not continue gabapentin - it has a weak recommendation against use for migraine prevention and no evidence for new daily persistent headache 1, 5
• Do not allow acute medication use to exceed 2 days per week - this perpetuates the cycle of chronic daily headache 1
• Do not use opioids or butalbital-containing compounds - these lead to dependency, rebound headaches, and loss of efficacy in chronic daily headache 1
• Do not pursue dietary supplements (Ginkgo biloba, melatonin, zinc) for tinnitus - guidelines recommend against these due to lack of efficacy 1
• Do not delay preventive therapy - with 24/7 symptoms for two years, you require preventive treatment immediately 1