Approach to Chronic Headache with Normal MRI Brain

Initial Clinical Assessment

The American College of Neurology recommends confirming chronic headache criteria: Headache occurring ≥15 days per month for at least 3 months 1
Assess for medication overuse headache (MOH): Present in up to 73% of chronic migraine patients, with simple analgesics/NSAIDs used ≥15 days per month or triptans used ≥10 days per month indicating overuse 1
Patients should maintain a headache diary to track frequency, severity, triggers, and medication use, with specific questioning to avoid underreporting of headache frequency 1

The American Academy of Neurology recommends topiramate as the first-line prophylactic medication for chronic migraine, supported by strong evidence from randomized, placebo-controlled trials 1
Prophylactic treatment should be started in all patients with chronic headache to reduce frequency and severity, and maintained for at least 3-6 months before considering discontinuation 1
Consider discontinuing prophylactic therapy after 3-6 months of stability to determine if it is still needed, with a strength of evidence level of moderate 2
Alternative prophylactic options include CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, with varying evidence levels 1

The American Headache Society recommends a stratified-care approach for acute episodes, assigning treatment based on severity of migraine-related disability, with a strength of evidence level of high 3, 4
For mild-moderate attacks, NSAIDs or acetaminophen are recommended, while for moderate-severe attacks with disability, a combination of triptan + NSAID is most effective based on recent evidence 5

The American Academy of Neurology recommends withdrawing overused medications, with abrupt withdrawal preferred except for opioids, and educating patients about the risk of MOH with frequent acute medication use 1
Initiate prophylactic therapy concurrently with medication withdrawal, with a strength of evidence level of moderate 1

The American Headache Society recommends implementing behavioral interventions alongside pharmacologic treatment, including evidence-based behavioral therapies such as cognitive behavioral therapy (CBT) and relaxation training 3, 1
Regular exercise, such as 40 minutes three times weekly, has efficacy comparable to relaxation therapy or topiramate, with a strength of evidence level of moderate 1, 2

The American College of Neurology recommends screening for and managing common comorbidities, including anxiety and depression, sleep disorders, obesity, caffeine overuse, and stress 1, 4

The American Academy of Neurology recommends establishing regular follow-up to assess treatment response, using disability assessment tools such as the Headache Impact Test (HIT-6) to monitor progress, with a strength of evidence level of moderate 1, 2
Set realistic expectations, as chronic headache requires long-term management with periods of relapse and remission, and adjust therapy based on response and tolerability 1, 2