Three percent to 4% of patients in North American and Europe have chronic daily headaches, which, by definition, are headaches lasting four or more hours per day at least 15 days a month for four to six months or longer. About half of patients with chronic daily headaches have rebound or medication overuse headache. About two-thirds of patients with chronic daily headache evolve from episodic to chronic migraine. Limiting acute analgesic therapy to nine days per month or less can limit the development of rebound headaches.
Most patients with mild-to-moderate migraine will respond to OTC analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) aspirin, acetaminophen, and combinations containing caffeine. Caffeine-containing combinations may be somewhat more effective but also have a higher risk of bringing on rebound headaches. Aspirin may be a particularly good choice, if tolerated, as it is cardioprotective rather than increasing cardiovascular risks, as most NSAIDs do. Significant risks of NSAIDs include GI ulceration and bleeding, renal damage, provocation of aspirin-sensitive asthma (particularly in patients with nasal polyps), and increased risk of heart attack and stroke in susceptible patients.
Patients who have more than one day of headache per week, who miss work because of their headaches, or have associated complex symptoms can benefit from migraine-preventive treatment rather than just treatment of each acute headache attack. Preventive therapy often takes 8 to 12 weeks to become effective. Particularly good OTC/supplement treatments to prevent migraine include Petadolex® brand butterbur, magnesium supplements, and coenzyme Q10. Petadolex is effective in both adults and children and is very well-tolerated. A brand such as this, which has been purified of potentially toxic alkaloids, is an important consideration when using butterbur. Magnesium is especially beneficial for patients with aura, and when given at bedtime can also help sleep and sleep quality. Coenzyme Q10 has also been effective but can be more expensive than other choices. Coenzyme Q10 also lowers blood pressure slightly which is of value for some patients.
Patients with migraine with aura are at increased risk of heart attack and stroke, particularly occipital stroke. Therapy with estrogen hormones, particularly at doses in oral contraceptives, can exacerbate this risk. Opinions differ on whether this is a relative or an absolute contraindication to their use. At a minimum, having and documenting a discussion of risks/benefits and alternatives is of value in this circumstance.
Management of stress- and lifestyle-related factors can have a major impact in improving headache frequency and intensity. Aggressive hydration, sleeping more than six hours per night for adults or more than nine hours per night for children and teens, and avoiding any triggers that set off attacks, especially alcohol and nitrates, can be of value. Similarly, treating neck pain and tension with physical therapy, massage and other modalities can decrease headaches as well since afferent input from C2 to C7 feeds into centers in the brainstem that trigger migraine.