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Efficacy of Preventive Medications for
Chronic Daily Headache
Lawrence Robbins, M.D., Joseph Maides, Jr., M.S
Posted July/Nov 1999

The objective of this retrospective study was to evaluate preventive medications in a large number of chronic daily headache (CDH) patients. Preventive medications in 540 CDH patients were evaluated. The patients, 18 to 67 years of age, had moderate or severe CDH without analgesic rebound. Each had utilized two or more classes of preventive medications, comprising four classes including tricyclic antidepressants, selective serotonin reuptake inhibitors, sodium valproate, and beta-blockers. Rebound and noncompliant patients were excluded. Forty-six percent of patients obtained long-term relief (defined as 50% improvement over at least 6 months), while 54% had discontinued the preventives due to lack of efficacy and/or adverse effects. Selective serotinin reuptake inhibitors and sodium valproate yeilded the most impressive results -- 35%. Most patients who discontinued the medications did so due to lack of efficacy.

Approximately 20% of patients in each medication group reported that significant adverse effects contributed to their decision to discontinue the respective medications. The authors conclude that, while some CDH sufferers responded to preventive therapy, 54% of the patients in this study failed to obtain adequate long-term relief.

Selective serotonin reuptake inhibitors and sodium valproate were slightly preferred over tricyclics, and beta-blockers were least effective.

To retrospectively evaluate preventive medications in a large number of chronic daily headache patients.

Chronic daily headache is a common problem that often leads to analgesic overuse. For those patients with moderate or severe chronic daily headache, preventive medications are often utilized in an effort to limit analgesics. To warrant use as a preventive, a medication should significantly decrease the frequency and/or the severity of the chronic daily headache.

Five hundred forty moderate or severe chronic daily headache patients, ages 18 to 67, were evaluated. Inclusion criteria included: at least 18 years of age, diagnosis of chronic daily headache (or transformed migraine) based on International Headache Society revisions proposed by Silberstein et al, moderate or severe intensity of the chronic daily headache, exclusion of analgesic rebound headache (or resolved), and current or past use of at least two classes of daily preventive medications for at least six months. Exclusion criteria for the study included: continuous analgesic rebound headache that had not been resolved, or non-compliance with the daily preventive medications.

The treating neurologist conducted chart review and patient interviews. Relief was defined as at least a 50% improvement in frequency and/or severity of the daily headache. Four main classes of preventive medications were evaluated: selective serotonin re-uptake inhibitors, sodium valproate, tricyclic antidepressants, and B-blockers. Patient choice of continuation/discontinuation was significantly related to the class of preventive medication utilized. Of the 540 patients, 249 (46%) stated that at least one of the four categories of daily preventive medications provided long-term relief without signficant side effects. However, 54% (291 patients) had discontinued the daily preventive medications due to lack of efficacy and/or side effects.

Selective serotonin reuptake inhibitors and sodium valproate had the highest success rate. For each of these categories, 35% of patients who had utilized them stated that they were effective and wished to continue on them long-term. Thirty two percent of the patients who had utilized tricyclics continued on these long-term, while only 23% of patients on B-blockers did so.

Most patients who discontinued the medications did so due to a lack of efficacy. Approximately 1/5 of patients in each class noted that significant side effects contributed to their discontinuation of the medication.

For almost half of moderate or severe chronic daily headache sufferers, at least one of the four classes of preventive medication can provide long-term relief without significant side effects. However, there remains a significant portion of chronic daily headache patients where preventive medications have not been effective. Sodium valproate and selective serotonin re-uptake inhibitors were the most successful medications in this study.

Chronic daily headache, headache preventive medication, transformed migraine, analgesic rebound headache.

CDH Chronic daily headache, TM transformed migraine, SSRI selective serotonin reuptake inhibitor, NSAID nonsteroidal anti-inflammatory drug, MAOI monoamine oxidase inhibitor, IV DHE intravenous dihydroergotamine.