Chronic Daily Headache
Chronic Daily Headache
Successful management of CDH depends on:
- Identification of the cause of the CDH e.g. medication reliance, co-morbidities, injury.
- Commitment from patient and doctor. There is no simple answer so a thorough approach to the patient is highly recommended.
- Managing patients with chronic headache disorders, especially those not attributable to medication overuse often demands intensity beyond the scope of general primary care teams. Some patients with CDH also require interdisciplinary treatment from a variety of medical specialists and in extreme cases they may require hospitalisation.
Medication Overuse Headache
In cases where the patient is clearly overusing acute medications, then the medication must be stopped. This can be frightening to the patient because the medication is considered the lifeline to a normal life. Gradual tapering off the offending medication (e.g. 10% weekly reduction in the consumption of the medication) is usually easier than abrupt withdrawal and compliance is more likely.
To encourage compliance the patient needs to be made aware that it may take a few months of being off the offending medications before CDH will improve. The patient must also be told that the headaches are likely to worsen in the short term if an abrupt withdrawal is initiated. Using a diary will also provide key information in the management of CDH.
Prophylactic treatments such as Amitriptyline, Gabapentin or Topiramate can also be prescribed, but only after a detoxification programme is underway. Otherwise, the preventive drug is unlikely to be beneficial. Standard migraine preventative drugs can be used in the prophylaxis of Transformed Migraine
Acute treatment of breakthrough attacks
The patient will also require a suitable acute treatment (e.g. a Triptan) if the daily headaches are accompanied by breakthrough migraine attacks. If the patient has been overusing Triptans a prophylactic treatment plan is recommended instead. Generally, once a patient has overused a specific medication, future treatment programmes should avoid that particular therapeutic class.
Co-morbid conditions include stress, anxiety and depression and are important predisposing risk factors. If present, anxiety and depression should be treated separately
Physiotherapy, biofeedback or chiropractic may be useful to some patients, especially those whose headaches are related to a history of head/neck injury. Massage and stress management may also benefit patients. In some cases, counselling may be used. Botilinum Toxin has been suggested for CDH in recent years, but its effectiveness has not yet been ascertained.