What is the best approach to manage a patient with combination headache?

Management of Combination Headache

For patients with combination headache (mixed migraine and tension-type features), initiate amitriptyline 30-150 mg/day as first-line prophylactic therapy, as it is the only agent specifically recommended for this mixed presentation. 1, 2

Initial Assessment and Diagnosis

Rule out medication overuse headache first, as it is present in up to 73% of chronic headache patients and will sabotage all other treatments. 1, 3 Ask specifically about:

• Simple analgesics (aspirin, acetaminophen, NSAIDs) - if used ≥15 days/month, this is medication overuse 1, 3
• Triptans - if used ≥10 days/month, this is medication overuse 1, 3
• Opioids or butalbital compounds - these are the worst offenders and should be withdrawn immediately 2, 4

Have the patient maintain a headache diary documenting frequency, severity, triggers, and all medication use - this is fundamental for both diagnosis and monitoring treatment response. 1, 3, 5

Medication Withdrawal Protocol (If Overuse Present)

Withdraw overused medications abruptly for all agents except opioids, barbiturates, and benzodiazepines, which require slow tapering to prevent acute withdrawal. 2, 4

• Patients overusing opioids or barbiturates may require inpatient treatment 4
• Start prophylactic therapy immediately during withdrawal - do not wait for withdrawal to complete 2

Prophylactic Pharmacotherapy

Amitriptyline 30-150 mg/day is the preferred first-line agent for combination headache because it addresses both migraine and tension-type components. 1, 2

Alternative first-line options if amitriptyline is contraindicated or not tolerated:

• Topiramate - the only agent with randomized controlled trial evidence specifically for chronic migraine, also beneficial if obesity is present 1, 3, 5
• Propranolol 80-240 mg/day or timolol 20-30 mg/day - avoid in patients with asthma, diabetes, or bradycardia 1, 5
• Divalproex sodium 500-1500 mg/day or sodium valproate 800-1500 mg/day 1

For chronic migraine specifically (≥15 headache days/month with ≥8 migrainous days), onabotulinumtoxinA (Botox) is the only FDA-approved therapy and should be administered by a specialist using the PREEMPT protocol. 1, 3, 5

Acute Treatment Strategy

Limit acute medication use strictly to prevent recurrence of medication overuse:

• Simple analgesics: <15 days/month 1, 3
• Triptans: <10 days/month 1, 3
• Never prescribe opioids or butalbital compounds as first-line therapy - they promote medication overuse and reduce quality of life 2

For moderate-to-severe attacks, triptans are appropriate if cardiovascular disease has been excluded. 2, 6

Non-Pharmacological Interventions

Regular aerobic exercise (40 minutes, 3 times weekly) has efficacy comparable to topiramate or relaxation therapy and should be prescribed to all patients. 3, 5

Behavioral interventions are essential components:

• Cognitive behavioral therapy (CBT) - especially beneficial for patients with psychiatric comorbidities 3, 5
• Relaxation training (progressive muscle relaxation, guided visualization, biofeedback) 3, 5

Identify and Manage Modifiable Risk Factors

Systematically address all modifiable factors that perpetuate chronic headache:

• Obesity - consider topiramate for dual benefit 3, 5
• Obstructive sleep apnea - evaluate and treat 3, 5
• Psychiatric comorbidities (depression, anxiety) - screen and treat, as they impair treatment effectiveness 3, 4
• Excessive caffeine use - taper gradually 1, 3
• Stress - behavioral interventions are critical 1, 3

Follow-Up and Monitoring

Schedule regular follow-up visits to assess treatment response using objective tools like the Migraine Disability Assessment Score. 1, 3, 5

Set realistic expectations - chronic headache requires long-term management with periods of relapse and remission, not immediate cure. 3, 2

Refer to a neurologist or headache specialist when:

• Diagnosis remains uncertain 3, 5
• Treatment fails after adequate trials of multiple prophylactics 3, 5
• Complex comorbidities complicate management 3, 5
• OnabotulinumtoxinA therapy is being considered 1, 5

Critical Pitfalls to Avoid

Do not prescribe opioids or butalbital-containing compounds except as rare rescue medication - they are the most likely to cause medication overuse headache and worsen outcomes. 2, 4

Do not use β-blockers with intrinsic sympathomimetic activity (pindolol, acebutolol) - they are ineffective for migraine prevention. 2

Do not delay prophylactic therapy while attempting medication withdrawal - start both simultaneously. 2