In step 7 of the program, a clinician should examine a patient’s medication history to assess past preventive attempts.1 Since preventive therapy is the mainstay in the treatment of CDH, it is important to determine which therapies have not been successful in the past to ensure finding an option that is best for a patient. Unfortunately, there is no specific way to determine which medication will be most effective for a patient (with the exception of HC, which responds solely to indomethacin), therefore trials of various medications are often required.

Step 8 of the program involves the creation of an action plan that addresses preventive, acute, and lifestyle components of CDH therapy.1 Table 2 lists medications used in the treatment of CDH. Preventive therapy, which is the cornerstone of CDH treatment, is used to decrease HA frequency and/or intensity. Success of preventive therapy is considered at least a 50% reduction in HAs or a 50% decrease in HA intensity. Acute therapy typically includes a combination of over-the-counter medicines plus more targeted pharmacotherapy. Targeted pharmacotherapy is used more in patients who suffer from migraines that are responsive to the medications used. To prevent MOH, simple analgesics should be used <14 days per month and targeted pharmacotherapy should be used <10 days per month. An additional factor to consider when treating CDH is the route of administration of an agent. Intranasal, injectable, or oral acute medications provide a faster onset compared to other medications and can be utilized for patients who suffer from sudden exacerbations of HAs. Lifestyle changes should also be initiated in a patient diagnosed with CDH. These modifications include routine exercise, stress management, behavioral therapy and counseling, avoidance of triggers, optimizing sleep patterns, and maintaining balanced meals.

In step 9 of the program, education regarding treatment should be provided.1 Teaching patients about their condition and setting realistic goals is an important step within this program. Points that should be discussed with a patient are listed in Figure 1. It is also recommended that a patient begin a headache diary, which should be maintained on a daily basis with details about headache days, treatment use, and treatment response and reviewed at every visit with the provider. The final step of the program involves initiation of follow-up for continuous patient improvement. It is important for clinicians to work closely with their patients to ensure treatment success over time.

CDH is a condition that can lead to functional impairment and a decrease in quality of life. Since CDH can often be difficult to treat, Sheeler et al recently published a 10-step program to assist clinicians in diagnosing and managing CDH.

References

1.      Sheeler RD, Garza I, Vargas BB, O’Neil AE. Chronic Daily Headache: Ten Steps for Primary Care Providers to Regain Control. Headache. 2016 Aug 23; DOI: 10.1111/head.12881.