Treatment Options
There are very little treatment data, Dr. Markley pointed out. “There’s only experience, and it’s very difficult.” The benign form goes away by itself, so it doesn’t need therapy. The refractory form can be totally intractable even to the most aggressive treatment. Some evidence, however, suggests that some of these patients may respond to topiramate or gabapentin. “But the gabapentin does need to be quite high, almost 3 grams a day, and again there are anecdotal reports only,” he noted. In Dr. Markley’s practice, “we have an algorithm when we see patients like this, even teenagers. We start with riboflavin 200 mg bid for a minimum of six weeks, we have them keep a headache diary, and then they come back in six weeks and we see what the pattern looks like. Then we add topiramate, [increasing the dose] by 15 mg per week, up to as high as 200 mg/day, with a minimum of eight weeks at Dmax.”
Next Dr. Markley suggests adding gabapentin 400 to 800 mg weekly, up to 3 g/day. Split doses, he noted, improve absorption. “If we find we’re dealing with the most severe form of the disorder we go on to botulinum toxin, three rounds of treatment, 100 units each. And at the end, at least adult patients are getting occipital nerve stimulators.” Anecdotal reports, he said, indicate that occipital nerve stimulation may be dramatically effective for this type of headache. If headaches substantially improve or stop, Dr. Markley recommends maintaining the last level of treatment for at least six months and then taper.
No Magic Bullet
Treatment of new daily persistent headache is difficult. Pharmacotherapy can include antidepressants and anticonvulsants. Nondrug treatment can include biofeedback, relaxation, and cognitive therapy. These patients should be seen in a headache clinic or specialized care center, and inpatient treatment is sometimes indicated. Multiple therapies, and multidisciplinary care, are required.
—Glenn S. Williams