Clinical Review

Chronic headache: Stop the pain before it starts

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Treating other headache syndromes

Chronic tension-type headache. Treatment of CTTH applies similar principles to those of CM, and amitriptyline and venlafaxine—as well as mirtazapine, a sedating SNRI—have evidence to support their use for this type of headache.29 Overall, however, CTTH therapies have not been studied as extensively as those for migraine. There is conflicting evidence of the value of anticonvulsants for prophylaxis of CTTH, and botulinum toxin A has been shown to be no better than placebo.30

Medication overuse headache. Prophylactic medications are not effective in patients who are overusing acute headache medications, and patients with MOH should be instructed to stop the offending drugs. Withdrawal of triptans, simple analgesics, and ergots—either cold turkey or with a slow wean over 4 to 6 weeks—is fairly safe and can be done in an outpatient setting. Concomitant use of prednisone, long-acting NSAIDs, or botulinum toxin A can be used as “bridge therapy” to relieve acute pain. Start the patient on a prophylactic medication based on the best estimate of his or her baseline headache and comorbidities.31,32 For patients who have been overusing opiates or barbiturates, most experts recommend inpatient treatment to manage withdrawal symptoms and prevent complications.10

Most patients with MOH will improve with drug withdrawal, but some will be left with the same disabling headaches that caused them to overuse medication in the first place. For such patients, weekly office visits during the withdrawal period may be helpful. After completion of the bridge therapy, they will likely require abortive headache treatment, but its use must be limited to no more than twice a week. Referral to a specialty headache clinic may be appropriate for such patients.

Hemicrania continua. The treatment for HC is indomethacin. A 2- to 5-day course typically results in complete recovery.

New daily persistent headache. For patients with NDPH, the first step is ruling out secondary causes. Once that has been done, most experts recommend trying to characterize the headache as having features of either migraine or tension and treating accordingly with preventive therapy. If acute headache medication is still needed, limit the quantity you prescribe and stress the importance of taking it no more than twice a week.

CASE Mr. K receives a diagnosis of MOH and probable CM. You explain the way MOH develops and how his medication use has contributed to the escalation of his headaches, and ask him to stop all the headache medications he has been using and to keep a headache journal. You prescribe meloxicam as a short-term bridge therapy and low-dose venlafaxine, which is increased to 150 mg/d over the next 4 weeks; recommend riboflavin 400 mg/d; and refer Mr. K to a neurologist for botulinum toxin A.

You ask him to return in 4 weeks and explain that because he has successfully stopped the overuse of acute headache medications, he can begin taking them again—provided he limits their use to no more than twice a week.

Nonpharmacologic measures can help, too
Lifestyle modification can play an important role in the treatment of chronic daily headache. Advise patients of the importance of proper sleep hygiene, regular exercise, stress reduction, and a healthy diet, as well as avoiding known triggers and minimizing intake of caffeine. Tell patients that biofeedback, cognitive behavioral therapy, and physical therapy may play a role in conjunction with pharmacotherapy, especially for CTTH,26,29,33 but that hypnosis, acupuncture, chiropractic manipulation, transcutaneous electrical nerve stimulation, and hyperbaric oxygen have too little evidence to recommend for or against their use.26,34

In discussing treatment for chronic headache and the goals of therapy with a patient with chronic headache, it is important to be frank. Explain that while a complete cure is not always possible, a decrease in both the frequency and severity of headaches and an improvement in the quality of life and the patient’s ability to function are realistic goals.

CASE At the 3-month follow-up, Mr. K reports that his headaches are down to less than twice a week, and that he is undergoing cognitive behavioral therapy for depression. For acute headache pain, he takes sumatriptan 100 mg with ibuprofen 800 mg, and is careful not to do so more than twice a week.


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