Chronic Daily Headache

Management of Transformed Migraine

When daily migraine headache is the dominant symptom of the CDH, the patient is said to have transformed migraine. In general, patients with CDH should be treated primarily with preventive medications. For transformed migraine-type headaches, many of the agents used for migraine prophylaxis (anticonvulsants, antidepressants) are also used in this type of CDH. Antidepressants are a reasonable choice, particularly in patients with comorbid depression and anxiety, and TCAs are the most widely used. Beta blockers are also used, and the anticonvulsant divalproex sodium is an effective preventive agent for CDH, particularly for patients who have failed other preventive therapies.

For patients with transformed migraine and medication overuse, it should be explained that it may take weeks to months after cessation of daily medications before the daily headache pattern reverts to an episodic pattern; once the headaches are episodic, they can be managed with specific migraine medications.⁸⁸ To treat medication-rebound headaches and control other headaches that may arise during the medication-withdrawal period, IV dihyrdroergotamine is an option.⁸⁹