Medical Chronicle November/December 2013 | Page 32

PAIN
CHRONIC TENSION-TYPE
HEADACHE
These headaches evolve from episodic
tension-type headaches. They may last
hours or be constant.
Chronic tension-type headaches have
at least two of the following characteristics:
• Pain on both sides of the head
• Mild to moderate pain
• Feels pressing or tightening, but not
pulsating
• Not aggravated by routine physical
activity.

In addition, they cause no more than one
of the following:
• Sensitivity to light or sound
• Nausea (mild only).

NEW DAILY PERSISTENT
HEADACHE AND HEMICRANIA CONTINUA
These headaches are much less common and although important, will not be
discussed in detail.
New daily persistent headaches become constant within a few days, from
the moment of the first headache. This
is a bilateral pressing or tightening pain,

but is not pulsating and cause mild to
moderate pain not aggravated by routine
physical activity.
Hemicrania continua headaches cause
pain on only one side of the head. These
headaches are daily and continuous with
no pain-free periods and cause moderate
pain but with spikes of severe pain. The
most striking element of this headache
is that it responds to the indomethacin.

TREATMENT
Chronic tension-type
headache
Chronic tension-type headache (CTTH)

is the most common of the primary
headache disorders. Different therapeutic strategies (pharmacological and
non-pharmacological) are generally
used for the management of these
patients. CTTH is generally treated
with non-steroidal anti-inflammatory
drugs (NSAIDs), tricyclic antidepressants and physical therapy, although
the therapeutic efficacy of these approaches is controversial.
Amitriptyline, a tricyclic antidepressant, is considered the treatment of
choice for different types of chronic
pain, including chronic myofascial pain.
Its antinociceptive property is independent of its antidepressant effect.
Although its analgesic mechanism is
not precisely known, it is believed that
the serotonin reuptake inhibition in the
central nervous system plays a fundamental role in pain control.
This, in combination with physical
therapy, is still the most frequently
used treatment in this condition.

Migraine
In acute migraines, treatment is usually divided into acute or abortive and
prophylactic therapy. Acute therapy
consists mainly of triptans with addition of NSAIDs and antiemetic drugs
if needed. Prophylaxis is a complex
issue and depends on various factors,
antihypertensive drugs (beta blockers,
alpha blockers, angiotension-converting
enzyme inhibitors, angiotensin receptor
blockers, and calcium channel blockers)
and antiepileptic medications (topiramate and valproic acid) are most commonly prescribed.
For the prophylaxis of chronic
migraine, only topiramate and onabotulinumtoxinA have been shown
to be effective in placebo-controlled,
randomised trials. OnabotulinumtoxinA
in the PREEMPT studies demonstrate
that prophylactic treatment compared
with placebo led to sustained, significant
improvements from baseline across
multiple headache symptom measures.
OnabotulinumtoxinA and topiramate
demonstrated similar efficacy in the
prophylactic treatment of CM. Patients
receiving onabotulinumtoxinA had fewer
side effects and discontinuations.

Conclusion
Chronic headache disorders are
a diverse group of conditions
affecting a significant portion
of the population and leading to
significant disability. Some recent,
large studies on prophylaxis of
chronic migraine gave new insight
in the pathophysiology of these
conditions, but more importantly,
offers hope to many patients. Understanding of the different clinical
presentations and treatment
options significantly improves the
outcome of headache therapy.
References available on request.
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32 MEDICAL CHRONICLE NOVEMBER/DECEMBER 2013

2013/11/06 9:49 AM