Issues and solutions in the management of chronic headaches

In the management of chronic headaches many problems are encountered and the solutions are only partial. The problem the solution of which would lead to the greatest benefits is the prevention of these conditions. To implement prevention it is recommended that patients with severe and frequent headaches receive, in addition to the diagnosis: 1. an effective treatment of the attack; 2. early initiation of prophylactic therapy that is appropriate for dosing and length and duration, the identification and treatment of comorbidities and modifiable risk factors for progression. However, it is not easy to put in place these recommendations. For the acute treatment medications non-specific analgesic- anti-inflammatory drugs and triptans are available. One must remember that NSAIDs have a ceiling of action and explain to the patient that increasing the dose over the recommended does not increase the analgesic action but only the side effects. It is still necessary to restrict their use in patients with heart disease and hypertension because of their cardiovascular toxicity and today we know that this effect concerns all COX inhibitors. These medications are a good choice for perimenstrual attacks as the system of PGs seems specifically involved in the pathogenesis of menstrual migraine. It has been also suggested that COX inhibitors are protective against the development of medication-overuse headache in patients with low (<10d/mo) frequency of headache. Many migraine patients respond poorly to oral NSAIDs but the parenteral route, that avoids the problems of absorption in case of nausea or vomiting, is not always viable outside the hospital. Also the absorption of oral triptans is reduced during the migraine attack and so the result is not predictable. Several patients woke up in the last hours of the night with severe migraine attacks, with nausea and vomiting, probably already in allodynic phase where oral triptans are ineffective. All triptans give better results when used early, before allodynia develops. Only the injectable sumatriptan is effective in these conditions. The early initiation of prophylactic therapy is regarded as the decisive intervention to prevent chronification. Prophylactic drug have limited efficacy. Approximately 50% of patients can expect a reduction of 50% of attacks. Moreover, prophylactic treatments do not significantly change the severity and length of the attacks, which is just what the patient needs. In addition, the choice among the drugs recommended is empirical, in that there are no factors predictive of response.