CDH
meduploader - 05-14-09 13:46

Chronic daily headache" (CDH) includes a variety of headache types, of which chronic migraine is the most common.
Medication overuse, or drug rebound headache, is the most treatable cause of refractory daily headache.
A pathologic underlying cause should be considered in patients with recent-onset daily headache, a change from a previous headache pattern, or associated neurologic or systemic symptoms.
Most patients with CDH have chronic (transformed) migraine.
There is a hx of episodic migraine that has evolved (transformed) over time into a pattern of almost daily headaches.
These daily headaches may be mild, but migraine flares may continue to be superimposed on the daily headache symptoms.
The most common causes of migraine transformation à a) frequent headaches at baseline and b) obesity.
Other modifiable risk factors for transformation include medication overuse, snoring, and stressful life events.
Drug rebound & Medication overuse
Patients who do not stop analgesic overuse fail to improve despite use of preventive therapy à patients who stop taking analgesics on a daily basis have a marked reduction in frequency of headache
Drug rebound headache is a common treatable cause of transformed migraine.
Patients who have drug rebound headache are refractory to usual acute and prophylactic interventions à CLUE : The patient who repeatedly presents to the emergency department requesting narcotics for headache relief most commonly has drug rebound headache.
The sustained use of these medications more than three days per week is sufficient to develop drug rebound headache.
All headache medications, including triptans,have the potential to cause drug rebound headache.
Most common agents that cause drug rebound headache are narcotics, butalbital products, and combination products containing caffeine.
Be alert to recognize signs of secondary headache in patients who are self-medicating frequently à Only after a careful evaluation for secondary headache should drug rebound headache be suspected in patients with medication overuse.
Rx:
Treat medication overuse, if present
Select pharmacologic therapies
Treat potential underlying pathology à Myofascial pain, Physical therapy, Temporomandibular treatment, Psychiatric comorbidity (antidepressants, anxiolytics) and Sinus evaluation and treatment etc
Limit symptomatic medication use to two days per week (after withdrawal ["detoxification"] is completed).
Recommend use of nonsteroidal anti-inflammatory drugs.
Recommend use of triptans for migraine flares.
Avoid use of medications prone to drug rebound, especially combination analgesics, caffeine-containing compounds, butalbital products, and narcotics.
Consider behavior therapy
Encourage lifestyle management, Regular exercise, Regular meals; no caffeine; migraine diet
Sleep hygiene
Stress reduction
Biofeedback
Cognitive-behavior therapy
Monitor progress (using headache calendar).
Rx of medication overuse headaches
1. Withdrawal of symptomatic medications, including caffeine.
A. Gradually taper medications in patients where physiolgic withdrawal is a concern (i.e., narcotics, butalbital).
B. Use abrupt withdrawal or taper medications in all other patients.
2. Preventive therapy
Any preventive therapy, or combination medicine for headache
3. Transition therapy
Daily migraine-specific therapy
Dihydroergotamine (DHE), intranasal, intramuscular, or intravenous
Long-acting triptan: naratriptan (Amerge) or frovatriptan (Frova)
A. Anti-inflammatory agents
Short course of corticosteroids
Long-acting nonsteroidal anti-inflammatory drugs
4. Rescue therapy, as needed
A. Non-narcotic analgesics: parenteral ketorolac (Toradol)
B. Antiemetics
C. Sedating antihistamines: diphenhydramine (Benadryl) or hydroxyzine (Atarax)