Treatment of chronic daily headache

Patients with chronic daily headache (CDH) are difficult to treat. A combination of general measures and specific pharmacological treatments is necessary. When possible, pharmacological management should be planned on an outpatient basis. The general protocol should include abrupt discontinuation of the offending symptomatic medications, specific treatment for detoxification, daily nonsteroidal anti-inflammatory drugs (NSAIDs) for about 1 month, triptans only for moderate-severe headache, and prophylactic treatment. Either amitriptyline plus propranolol or valproic acid have been classically recommended for transformed migraine prophylaxis. Refractory patients can respond to a combination of a beta-blocker and valproic acid, possibly due to their complementary mechanisms of action. Recently, the new antiepileptic topiramate has been shown to be especially useful in this indication. At least one-third of patients, however, do not improve. Therefore, the best treatment of this incapacitating entity continues to be its prevention. Preventive measures should include: (1) public information concerning the risk of frequent self-treatment for headaches; (2) inform headache patients of the risk of analgesic overuse/rebound headache; (3) recommend NSAIDs and triptans as symptomatic medications; and (4) active use of preventive medications when headaches begin to increase in frequency.