Common Prophylactic Practices for Chronic Daily Headache*

A variety of medications and treatment interventions, including antiepileptic drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors, combined serotonin and norepinephrine reuptake inhibitors, β blockers, calcium channel antagonists, α2-adrenergic agonists, nonsteroidal anti-inflammatory drugs, muscle relaxants, occipital nerve blocks, and botulinum toxin type A injections, have been utilized in the prophylactic treatment of chronic daily headache (CDH). None of these currently possesses a strong scientific basis for such use, and none are approved by the US Food and Drug Administration for management of CDH. This article addresses the clinical management of the patient with CDH, and in particular, the patient with medication overuse headache, and describes findings from recent investigations of the more commonly prescribed prophylactic therapies, such as divalproex, topiramate, opioids, and botulinum toxin type A. (Adv Stud Med. 2006;6(4D):S331-S335) A n impressive arsenal of medications and procedures commonly are used for chronic daily headache (CDH) therapy by primary care providers and neurologists (Table). These include: tricyclic antidepressants (eg, amitriptyline and nortriptyline), selective serotonin reuptake inhibitors (SSRI), serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine), β blockers, calcium channel antagonists (eg, verapamil), α2-adrenergic agonists (eg, tizanidine), antiepileptic drugs (AED; eg, divalproex sodium, topiramate, gabapentin, and zonisamide), nonsteroidal antiinflammatory drugs, muscle relaxants (eg, metaxalone and methocarbamol), occipital nerve blocks, and botulinum toxin type A injections. Even so, none are of proven value for CDH or, more specifically, for socalled transformed migraine (TM), and none are approved by the US Food and Drug Administration (FDA) for treatment of CDH—a condition that affects over 4% of the US population. Although clinicians consequently must base treatment largely on their own experience and that of other clinicians, there are now studies—in progress, just completed, or about to commence—that have looked prospectively at various therapies for this condition. As a result, healthcare practitioners eventually should have data sufficient to determine whether the therapies under investigation are of benefit to at least a portion of our most afflicted patients with migraine—those with CDH.