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The Prophylactic Treatment of Chronic Daily Headache
Chronic daily headache (CDH), a heterogeneous group of headache disorders
occurring on at least 15 days per month, affects up to 4% to 5% of the general population.
CDH disorders include transformed (or chronic) migraine, chronic tension-type headache, new
daily persistent headache, and hemicrania continua. Patients with CDH have greater disability
and lower quality of life than episodic migraine patients and often overuse headache pain
medications. To date, only topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline,
and botulinum toxin type A (BoNTA) have been evaluated as prophylactic treatment of CDH in
randomized, double-blind placebo-controlled, or active comparator-controlled trials. The
evidence supporting the use of BoNTA as prophylaxis of CDH is composed of larger and longer
trials, as over 1000 patients were evaluated for up to 11 months duration. Compared with
placebo BoNTA has significantly reduced the frequency of headache episodes, a recommended
efficacy measure for headache trials and has been demonstrated to be safe and very well
tolerated with few discontinuations due to adverse events. Side effects are generally
transient, mild to moderate, and nonsystemic. The results of clinical trials using
traditional oral pharmacotherapy, while supportive of their use as prophylactic treatment of
CDH, are limited by several factors, including small numbers of patients, the choice of
efficacy measures, and short treatment periods. The use of oral agents was associated with
systemic side effects, which may limit their effectiveness as prophylactic treatment of CDH.
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