Management of Chronic Headache

Diagnosis and Assessment

Chronic headache is defined as headache occurring on 15 or more days per month for at least 3 months, according to the Mayo Clinic Proceedings 3
The American Academy of Neurology recommends ruling out secondary causes of headache through careful history taking and examination before establishing a diagnosis of primary chronic headache 3
Patients should maintain a headache diary to accurately track frequency, severity, triggers, and medication use, as suggested by the Mayo Clinic Proceedings 2, 4
The Mayo Clinic Proceedings suggests asking patients specifically: "Do you feel like you have a headache of some type on 15 or more days per month?" as patients often underreport milder headaches 2

The American Headache Society recommends initiating prophylactic treatment in all patients with chronic headache to reduce frequency and severity 2
Topiramate is the first-line prophylactic medication, with strong evidence from randomized, placebo-controlled trials specifically for chronic migraine, according to the American Academy of Neurology 1, 2
Alternative prophylactic options with varying levels of evidence include OnabotulinumtoxinA (Botox), CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab), valproate, gabapentin, and amitriptyline, as suggested by the Mayo Clinic Proceedings 1, 2, 5, 6
The American Academy of Neurology recommends limiting use of acute medications to prevent medication overuse headache, with simple analgesics limited to fewer than 15 days/month and triptans limited to fewer than 10 days/month 6

The American Headache Society suggests identifying and managing modifiable risk factors and triggers, including obesity, medication overuse, caffeine use, obstructive sleep apnea, psychiatric comorbidities, and stress 2, 5
Behavioral interventions such as cognitive behavioral therapy (CBT), relaxation training, meditative therapy, progressive muscle relaxation, visualization/guided imagery, and biofeedback may be beneficial, according to the Mayo Clinic Proceedings 7, 8
Regular exercise (40 minutes three times weekly) has shown efficacy comparable to relaxation therapy or topiramate, as suggested by the Mayo Clinic Proceedings 7, 4

Medication overuse is present in up to 73% of patients with chronic migraine, according to the Mayo Clinic Proceedings 6
The American Academy of Neurology recommends withdrawing overused medications, with abrupt withdrawal preferred except for opioids, and educating patients about the risk of medication overuse headache with frequent use of acute medications 1, 6

The American Headache Society suggests screening for and managing common comorbidities, including anxiety and depression, sleep disorders, and obesity, and selecting prophylactic medications that may benefit comorbid conditions, such as topiramate for patients with obesity 1, 5
The Mayo Clinic Proceedings recommends avoiding beta-blockers in patients with asthma, diabetes, or bradycardia 5, 6

The American Academy of Neurology recommends regular follow-up to assess treatment response and adjust therapy as needed, using disability assessment tools to monitor progress, and setting realistic expectations - chronic headache often requires long-term management with periods of relapse and remission 1, 2, 4, 8
Referral to headache specialists is recommended when diagnosis is uncertain, treatment is ineffective, or complex comorbidities are present, according to the Mayo Clinic Proceedings 1, 3