- Polypharmacy: Combinations of two of the first or second line preventives are often very effective. Tricyclics may be combined with NSAIDs or b-blockers; NSAIDs may also be combined with b-blockers or verapamil. Valproate (Depakote) may be combined with tricyclics, b-blockers, or verapamil. The various preventive medications possess different mechanisms of action.
- Long-acting Opioids
- Repetitive IV DHE:
Four to nine injections of 1 mg. DHE are utilized over 2 to 4 days, either in the hospital or, preferably, as an outpatient. More effective for migraine, but daily headache often responds to DHE. DHE is useful in helping to withdraw patients off of analgesics. This is a safe but expensive therapy.
Occasionally effective for daily headache, but habit forming. Benzodiazepines or phenobarbital are the primary sedatives used for daily headache. Doses need to be minimized and patients must be carefully monitored.
Helpful for some patients as an "end of the line therapy." Methylphenidate (Ritalin) or Dextroamphetamine (Dexedrine) have been used. Tolerance may be a problem.
- MAO inhibitors: (phenelzine)
Phenelzine (Nardil) is a powerful medication for migraine and daily headache. Use is limited because of the dietary restrictions, weight gain, and insomnia. Phenelzine is also effective for depression and anxiety. Combining phenelzine with tricyclics, b-blockers, verapamil, or NSAIDs often enhances the efficacy.
- The long-acting daily triptans (such as Amerge (naratriptan)) in low doses can be useful for prevention of daily headache. However, long-term side effects are not known.