Prophylaxis should be considered in patients who report two or more of the following conditions:
High frequency (4 or more M days/month; very frequent or chronic TTH)
Unsatisfactory response to symptomatic treatment of M or of TTH
Increasing use of symptomatic drugs with the risk of MO
Significant impact on well-being and functioning in work and nonwork activities, for M or TTH
Duration of treatment: Each drug should be used for at least 2–3 months
Drugs with a proven evidence:
Propranolol: Daily doses 40–240, the most commonly effective – and well-tolerated – being 80–120 mg daily
Divalproex/sodium valproate: Daily doses 500–1500 mg
Topiramate: Should be initiated at 25 mg per day, with gradual titration up to 100 mg, and up to 200 if necessary
Amitriptyline: Daily doses 15–50 mg
Flunarizine: Suggested daily dose 5 mg
22.2.5.2 Treatment of Chronic M [11–14]
Prophylaxis
All the drugs recommended in episodic M can also be commonly used in chronic M. Specific evidence exists for the following drugs.
Topiramate: Starting dose of 25 mg/day; final doses 100–200 mg/day
OnabotulinumtoxinA: Administered with a standard injection paradigm; toxin injected bilaterally in suggested sites of the head and neck; total dose 155–195 U; intervals of administration of 12 weeks
Nonpharmacological Interventions
Education about the possible trigger factors and information about the risks of MO are essential components in the therapy of chronic M, as well as specific approaches: biofeedback training, cognitive behavioral therapy, physical exercise programs, and relaxation training.
Withdrawal of Overused Medications
This is the initial step for those who present with MO. It can be performed as an outpatient or as an inpatient (in patients with overuse of multiple drugs, drug dependence, or psychiatric comorbidities) protocol.
Key Steps in Inpatient Withdrawal Programs
Intravenous infusion of fluids and/or antiemetics and anxiolytics.
Abrupt stop of the overused drugs (general suggestion).
Slow tapering down of drugs containing opioids or butalbital – or the prescription of clonidine patch to prevent opioid withdrawal symptoms, and of phenobarbital to prevent butalbital withdrawal seizures.
22.2.5.3 Risk Factors for Chronification and Long-Term Prognosis [4, 6, 12–17]
The course of M may be very different in different subjects. Episodic M forms generally tend to improve after 50 years of age and/or after menopause in women. M with aura tends to have a more evident progressive reduction in frequency of attacks, which can disappear after the age of 50, or can be limited to a short aura without headache.
However, in a minority of cases, a progressive worsening leads to the development of chronic M. As discussed in previous paragraphs, several clinical and population studies are concordant in identifying various factors potentially involved in the poor outcome of M. Among these risk factors for progression from episodic to chronic M, the potentially modifiable factors are the presence of psychiatric or somatic comorbidities (such as obesity, depression, anxiety, chronic pain syndromes, hypertension, sleep disorders, etc.), the presence of MO, and a high headache frequency [4, 15]. Baseline M frequency appeared as the strongest predictor in the few available population-based, prospective, long-term studies. In a European study in which 64 subjects with episodic M from a sample of 740 subjects were examined in 1989, and then reexamined in 2001, M remission was found in 42 %; low M frequency in 38 %; progression to chronic M in 20 %; and this poor outcome was associated with high frequency at baseline, together with age at onset <20 years [14].
Data from a US survey with a 1-year follow-up suggest that around 10 % of migraineurs experience a complete remission of 3 % a partial remission, and that 3 % progress to chronic M [4].
Thus, an appropriate management of episodic M is likely to reduce the rates of chronification. Prescription of specific treatments (prophylaxis drugs, nonpharmacological interventions), strategies to prevent MO, together with the optimal control of the earlier-listed comorbidities, must be encouraged.
Several literature reports suggest that the global impact of M can be contrasted by appropriate therapy. Controlled studies found evidence of improvement in daily functioning and in HRQoL after treatment, particularly after topiramate administration (both in patients with episodic and chronic M), and after onabotulinumtoxinA in chronic M [12, 13].
In those patients who have already progressed to chronic M, education and nonpharmacological interventions – particularly behavioral approaches – are crucial, together with the introduction of a (new) pharmacological prophylaxis.
All patients with MO should be encouraged to discontinue their overuse and to seek medical consultation. In fact, though published data about the long-term prognosis after withdrawal programs are different across studies, overall, success of treatment is likely in most cases. The relapse rate of MO may be around 30 % after 1 year (range, 14–41 % according to published studies) [12]. Higher rates of improvement are likely to occur in chronic M patients followed in headache centers: the percentage of chronic M patients reverting to episodic M over 1 year in a specialty clinic follow-up was 70 %, while it was 26 % in a population survey over 2 years [6, 17]. A significant improvement on headache days per month, symptomatic medication consumption, and disability was observed in a sample of chronic M patients followed during a 3-year inpatient withdrawal program [14].
22.3 Tension-Type Headache
22.3.1 Terminology and Definitions [2]
Terms used in the past: “Muscle contraction” or “muscle tension” headache, “psychogenic headache,” etc. Tension-type headache (TTH) is now recognized as a distinct primary headache form.
Episodic TTH: The most common subtype, characterized by headache occurring on less than 15 days/month, in attacks separated by symptom-free periods.
Chronic TTH: Headache is present with daily or nearly daily course.
Medication overuse (MO): The excessive (10 or 15 days/month, or more) consumption of symptomatic drugs for headache.
22.3.2 Demographics
Overall, TTH appears as the most frequent primary headache
Episodic forms are most prevalent than chronic forms
One-year prevalence is estimated around 60 % for all forms, around 2–5 % for chronic TTH
TTH shows a slight female preponderance (female:male ratio around 5:4)
22.3.3 Clinical Features and Diagnosis [2, 18]
The different TTH subtypes are characterized mainly on the basis of frequency.
Episodic TTH: It includes infrequent episodic TTH, with attacks on <1 day/month (<12 days/year), and frequent episodic TTH, with attacks on 1–14 days/month (<180 days/year).
Chronic TTH: Headache may be unremitting for weeks to months, or even daily; diagnosis requires headaches on ≥15 days/month on average for >3 months (≥180 days/year).
Headache characteristics required for diagnosis are similar for all TTH subtypes: pain duration from 30 min to 7 days; presence of at least two of the following: bilateral location of pain; pressing or tightening (nonpulsating) quality; mild to moderate intensity; no aggravation by routine physical activity. The diagnostic requirements are somewhat different for associated symptoms: difficulty in concentration, limitation of neck movement or stiffness of pericranial muscles may be present in all forms; only one of photophobia or phonophobia is accepted for the diagnosis of the episodic forms; no more than one among photophobia, phonophobia, or mild nausea for chronic TTH.
Chronic TTH is the most severe form, and evolves from episodic TTH.
22.3.4 Prognosis
22.3.4.1 Disability [18–20]
The impact of TTH on sufferers and on society has not been so extensively studied as in M. Infrequent episodic TTH has usually no or minimal functional consequences, while frequent episodic and chronic forms may impair social activities in around 50–60 % of subjects, causing decreased work effectiveness, with one-fifth of patients missing work.
22.3.5 Treatment
22.3.5.1 Nonpharmacological Interventions
Acupuncture, physiotherapy, massage, TENS, and trigger point injection, are relatively common, though evidence for their effectiveness is not definitive. Behavioral treatments, relaxation training, biofeedback, and cognitive therapy were found to lead to significant reductions in TTH, with a response rate ranging from 30 to 60 %.
22.3.5.2 Symptomatic (or Acute) Treatment [18, 20]
NSAIDs and Analgesics
Drugs of first choice, mainly in chronic TTH, with percentages around 15–40 % of pain-free response after hours.
The most effective compounds are: ibuprofen, ketoprofen, diclofenac, naproxen, acetylsalicylic acid, paracetamol (acetaminophen)
22.3.5.3 Prophylaxis [18, 20]
Only a few drugs have been tested in placebo-controlled studies in TTH prophylaxis, and their efficacy in clinical practice is often modest.
Amitriptyline: The drug of first choice; started at low dosages (10 mg/day) and slowly titrated to a maintenance dose of 30–75 mg/day, 1–2 h before bedtime
Mirtazapine: Second choice drug; usual daily dose 30 mg, 1–2 h before bedtime; side effects: drowsiness, weight gain
The general principles of prophylaxis in TTH are reported in Table 22.1
22.3.5.4 Risk Factors for Chronification and Long-Term Prognosis [15, 18]
Episodic TTH generally has a favorable prognosis, though in some subjects a poor outcome is possible. Chronification of TTH may be related to several risk factors. As discussed for chronic M, a significant association with chronification is generally found for female sex, obesity, high baseline headache frequency, as well as low education level and divorce [4]. In a population study, 146 subjects with frequent episodic TTH and 15 with chronic TTH were examined in 1989, and then in 2001. Among them, 45 % experienced headache remission or infrequent episodic TTH or remission, 39 % had frequent episodic TTH, and 16 % presented with a chronic TTH. When the possible variables for poor outcome were analyzed, baseline chronic TTH, coexisting M, not being married, and sleep disorders were the most common predictors for poor outcome [15].
It is therefore likely that an appropriate management of episodic TTH may prevent headache chronification. The available nonpharmacological interventions (particularly among the behavioral approaches) can be very useful, together with pharmacological prophylaxis, when indicated. The most used drugs for TTH prophylaxis (amitriptyline and mirtazapine) may in fact be effective also in reducing some of the above-mentioned conditions.
Avoidance of frequent use of symptomatic drugs, particularly in those with chronic TTH, must be suggested: MO (as in chronic M patients) is likely to enhance disability and to further promote headache chronification. In patients with MO, specific withdrawal programs are warranted to discontinue overuse (see Sect. 22.2.5.2).
22.4 Cluster Headache and Other Trigeminal Autonomic Cephalgias
22.4.1 Terminology and Definitions [2]
Trigeminal autonomic cephalgias (TACs): Group of primary headaches which share a strictly lateralized, orbitotemporal, short-lasting attacks of severe pain and a series of typical ipsilateral autonomic features
Cluster headache (CH): The most common of TACs; the term derives from the prominent feature, which is the recurrence of attacks typically presenting durin.g periods of weeks or months followed by remission phasesRelated posts:
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