Treatment guidelines for chronic daily headache
Algorithm
CDH ManagementGoals of therapy
Relieve the pattern of chronic headaches and reduce the impact on the patient’s activities of daily living.
First-line treatments
- Patients with a history of head injury, and/or those with current neck stiffness or restricted neck movement usually benefit from physical therapy and exercises for the neck.
- Patients with medication overuse headache should have the overused medications withdrawn. Withdrawal symptoms may develop, but can be managed with a 6-day course of prednisolone 20 mg.
- Prophylaxis should be introduced to reduce the frequency of the headaches. Amitriptyline and sodium valproate have been shown to be effective as prophylaxis for chronic headaches and may be used in practice. ‘Fashionable’ alternatives include other serotoninergic agents (e.g. fluoxetine or paroxetine) or neuromodulator agents (e.g. topiramate, gabapentin or BOTOX).
- Acute medications should be used to treat breakthrough headache attacks and to manage the original episodic primary headache. A triptan is the logical medication for patients with chronic migraine. Use should be strictly limited to no more than 12 doses per month.
Follow up
When a successful response is achieved, prophylactic medications can be withdrawn gradually, relying solely on acute medications for relief of the original episodic headache. However, if one prophylactic medication fails, another may be tried.
When to refer
The GP who is experienced in headache management should be able to successfully manage most patients with chronic daily headaches. However, referral to specialist neurology or headache services may be necessary when:
- A sinister headache is suspected.
- The diagnosis does not clearly identify patients with chronic migraine, chronic tension-type headache or medication overuse headache.
- The patient is refractory to repeated acute and/or prophylactic medications.
- The frequency of the patient’s headaches increases, despite intervention.
The GP who is not so experienced in headache management may wish to refer all their patients who have chronic daily headaches.
Reference
Dowson AJ, Bradford S, Lipscombe S et al. Managing chronic headaches in the clinic. Int J Clin Pract 2004; in press.
GP_Special_Interest