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NR 565 Week 4 Chapter 35: Chronic Migraine and Cluster Headache
Chronic daily headache headaches 15 or more days a month for longer than 3 months
• Chronic daily headaches (CDH) can be divided into five subtypes:
o chronic tension-type headache
o chronic migraine
o hemicrania continua (Not in the study guide = not covered in depth)
▪ rare disorder that responds completely to indomethacin and to
nothing else. Indomethacin (Indocin) 75 to 150 mg is given daily;
doses up to 200 mg daily may be needed. Referral to a neurologist is
recommended.
o medication-overuse headache
o new daily persistent headache.
• Use of drugs for acute headache treatment more than 9 days a month is
associated with increased risk of chronic daily headaches.
• Medication-overuse is addressed later
Pathophysiology: Patho of CDH is often unclear and of mixed origin.
• There is a clear difference between chronic migraine and hemicrania continua
(Not in the study guide = not covered).
• The boundary between chronic tension-type headache and chronic migraine is
less clear and may require a neurology referral for treatment.
The term chronic migraine refers to CDH that starts as episodic migraine (less than 15
days a month) that transforms into a chronic pattern of greater than 15 days a month of
migraine headache
• It was formerly called “transformed migraine.”
• The initial migraines have the pathogenesis of migraine discussed earlier.
Chronic migraine is not well understood but is thought to be related to a combination of
atypical pain processing, cortical hyperexcitability, neurologic inflammation, and central
sensitization.
• Risk factors for chronic migraine include female gender, history of head or neck
injury, life stress, psychiatric disorders, and comorbid pain disorders
Goals of Treatment
The first goal of treatment for CDH is to break the pattern of daily headache. The
patient is then stabilized on prophylactic or preventive therapy.
Rational Drug Selection
,2
Chronic Migraine
In most patients with chronic migraine, the daily headache cycle can be broken by
using repeated doses of IV DHE (dihydroergotamine mesylate).
,3
• Approximately 70% to 80% of patients respond to DHE.
o The patient is given a test dose of 0.33 mL of DHE (1 mg/mL solution) with
5 mg of metoclopramide or 10 mg of prochlorperazine (Compazine).
o Followed by 0.5 mL of DHE and one of the anti-nausea medications every 6
hours for 48 to 72 hours.
o This usually requires inpatient treatment.
o DHE is contraindicated in coronary and peripheral vascular disease.
Alternatives to DHE:
• Chlorpromazine (Thorazine)
• Prochlorperazine.
If the patient has medication-overuse headache due to misuse of analgesics, ergots, or
combination medications, the patient has to be detoxified (Discussed later)
Treatment of chronic migraine may require consultation with a neurologist.
Preventive pharmacotherapy can be started after the headache cycle is broken.
• The patient usually responds to migraine-preventive medications such as
propranolol, divalproex, or a tricyclic antidepressant.
• Amitriptyline is a good choice if the patient is also depressed.
• The seizure medications topiramate or valproic acid may be used.
• The patient is on preventive medication until the headache days are reduced by
50%, and then an additional 3 to 4 weeks, for a total of 6 to 12 weeks.
The patient should also receive alternative therapy to treat CDH. Behavioral counseling,
biofeedback therapy, relaxation therapy, physical exercise, and acupuncture are all valid
alternative therapies for treatment of CDH.
Monitoring
Monitoring of patients with CDH who are on preventive therapy requires the patient to
keep a diary of headache and medication use.
• Patients’ blood pressure should be monitored if they are on a beta blocker
• Liver function monitored if on divalproex, as per migraine therapy monitoring.
• Ongoing monitoring of headache is necessary because 31% may have recurrence
of headache in spite of preventive medication.
Outcome Evaluation
Patients with CDH are difficult to treat. Treatment success is determined by how
effective it has been in breaking the cycle of daily headaches and how effective the
preventive treatment is. The patient's headache diary is key in the evaluation of the
success of treatment.
, 4
Patient Education
NR 565 Week 4 Chapter 35: Chronic Migraine and Cluster Headache
Chronic daily headache headaches 15 or more days a month for longer than 3 months
• Chronic daily headaches (CDH) can be divided into five subtypes:
o chronic tension-type headache
o chronic migraine
o hemicrania continua (Not in the study guide = not covered in depth)
▪ rare disorder that responds completely to indomethacin and to
nothing else. Indomethacin (Indocin) 75 to 150 mg is given daily;
doses up to 200 mg daily may be needed. Referral to a neurologist is
recommended.
o medication-overuse headache
o new daily persistent headache.
• Use of drugs for acute headache treatment more than 9 days a month is
associated with increased risk of chronic daily headaches.
• Medication-overuse is addressed later
Pathophysiology: Patho of CDH is often unclear and of mixed origin.
• There is a clear difference between chronic migraine and hemicrania continua
(Not in the study guide = not covered).
• The boundary between chronic tension-type headache and chronic migraine is
less clear and may require a neurology referral for treatment.
The term chronic migraine refers to CDH that starts as episodic migraine (less than 15
days a month) that transforms into a chronic pattern of greater than 15 days a month of
migraine headache
• It was formerly called “transformed migraine.”
• The initial migraines have the pathogenesis of migraine discussed earlier.
Chronic migraine is not well understood but is thought to be related to a combination of
atypical pain processing, cortical hyperexcitability, neurologic inflammation, and central
sensitization.
• Risk factors for chronic migraine include female gender, history of head or neck
injury, life stress, psychiatric disorders, and comorbid pain disorders
Goals of Treatment
The first goal of treatment for CDH is to break the pattern of daily headache. The
patient is then stabilized on prophylactic or preventive therapy.
Rational Drug Selection
,2
Chronic Migraine
In most patients with chronic migraine, the daily headache cycle can be broken by
using repeated doses of IV DHE (dihydroergotamine mesylate).
,3
• Approximately 70% to 80% of patients respond to DHE.
o The patient is given a test dose of 0.33 mL of DHE (1 mg/mL solution) with
5 mg of metoclopramide or 10 mg of prochlorperazine (Compazine).
o Followed by 0.5 mL of DHE and one of the anti-nausea medications every 6
hours for 48 to 72 hours.
o This usually requires inpatient treatment.
o DHE is contraindicated in coronary and peripheral vascular disease.
Alternatives to DHE:
• Chlorpromazine (Thorazine)
• Prochlorperazine.
If the patient has medication-overuse headache due to misuse of analgesics, ergots, or
combination medications, the patient has to be detoxified (Discussed later)
Treatment of chronic migraine may require consultation with a neurologist.
Preventive pharmacotherapy can be started after the headache cycle is broken.
• The patient usually responds to migraine-preventive medications such as
propranolol, divalproex, or a tricyclic antidepressant.
• Amitriptyline is a good choice if the patient is also depressed.
• The seizure medications topiramate or valproic acid may be used.
• The patient is on preventive medication until the headache days are reduced by
50%, and then an additional 3 to 4 weeks, for a total of 6 to 12 weeks.
The patient should also receive alternative therapy to treat CDH. Behavioral counseling,
biofeedback therapy, relaxation therapy, physical exercise, and acupuncture are all valid
alternative therapies for treatment of CDH.
Monitoring
Monitoring of patients with CDH who are on preventive therapy requires the patient to
keep a diary of headache and medication use.
• Patients’ blood pressure should be monitored if they are on a beta blocker
• Liver function monitored if on divalproex, as per migraine therapy monitoring.
• Ongoing monitoring of headache is necessary because 31% may have recurrence
of headache in spite of preventive medication.
Outcome Evaluation
Patients with CDH are difficult to treat. Treatment success is determined by how
effective it has been in breaking the cycle of daily headaches and how effective the
preventive treatment is. The patient's headache diary is key in the evaluation of the
success of treatment.
, 4
Patient Education
