From the Guidelines
Chronic daily headaches should be treated with preventive medications, such as beta blockers, topiramate, or candesartan, as first-line options, as recommended by the most recent guidelines 1. When managing chronic daily headaches, it's essential to consider the frequency and impact of headaches on the patient's quality of life.
- The treatment approach should prioritize preventive strategies to reduce the frequency and severity of headaches.
- First-line medications, including beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan, should be considered for patients who experience headaches on ≥2 days per month despite optimized acute treatment 1.
- Lifestyle modifications, such as maintaining regular sleep patterns, staying hydrated, avoiding known triggers, and practicing stress management techniques, can also help alleviate headache symptoms.
- In cases where first-line medications are ineffective, second-line options like flunarizine, amitriptyline, or sodium valproate (in men) can be considered, followed by third-line options like CGRP monoclonal antibodies if necessary 1.
- Additionally, adjunctive therapies such as neuromodulatory devices, biobehavioural therapy, and acupuncture may be useful in conjunction with medication or as stand-alone preventive treatment when medication is contraindicated 1.
From the Research
Definition and Diagnosis of Chronic Daily Headaches
- Chronic daily headache is defined as the presence of a headache on 15 days or more per month for at least three months 2, 3, 4, 5.
- The most common types of chronic daily headache are chronic migraines and chronic tension-type headaches 2, 3, 4.
- To diagnose chronic daily headaches, it is essential to rule out secondary causes of headache, and if a red flag is present, magnetic resonance imaging of the head should be performed 2, 3, 4, 5.
Treatment of Chronic Daily Headaches
- Several prophylactic treatments for chronic daily headache can reduce headache frequency and severity, as well as improve overall quality of life 2, 6.
- Nonpharmacologic treatments include relaxation techniques, cognitive behavior therapy, acupuncture, osteopathic manipulation, and cervical exercises 2.
- Pharmacologic therapies include amitriptyline, gabapentin, onabotulinumtoxinA, propranolol, tizanidine, topiramate, and valproate 2, 6.
- Patients who overuse medications for abortive therapy for headache should be encouraged to stop the medications entirely and consider prophylactic treatment 2, 3, 5.
Management and Prevention
- A 10-step process can help primary care providers evaluate and treat chronic daily headache patients, including excluding secondary headache disorders, classifying the primary underlying headache disorder, and identifying exacerbating factors and comorbid conditions 5.
- Keeping a headache diary can help initiate a cycle of continuous improvement in a patient's response to acute and preventive therapeutic approaches 5.
- A systematic approach and partnership with patients can often make it possible to convert chronic daily headaches to episodic headaches that are responsive to both acute and preventive therapies 5.