Patients with CDHs account for about 4% to 5% of the general patient population but constitute a large percentage (80%) of patients who are seen in specialty clinics for headache (Dodick & Saper, 2003).
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Many patients with CDH (78%) also have chronic-transformed migraine (Dodick & Saper, 2003).
Diagnostic criteria for CDH include:
■ Headache occurs at least 15 days per month.
■ Headaches last for longer than 4 hours per day (Dodick & Saper, 2003).
What causes a CDH? The average CDH patient has a history of long-term episodic migraine, with headaches that gradually increase in frequency. There can be a family history of depression, anxiety, or alcoholism (Dodick & Saper, 2003).
Although the true cause of CDH is still being investigated, there are some common theories that are considered to be valid for determining the source of CDH pain. Pathophysiologic mechanisms that are considered to contribute to CDH include:
■ Medication overuse
■ Genetic alterations in the central brain and pain-modulating systems
■ Deficiencies or excesses in neurotransmitter systems
■ Stress or trauma
■ Brain stem changes related to free-radical damage and iron deposition (Dodick & Saper, 2003)
No matter what the cause of the CDH, the effect can be very disruptive to the patient. For patients who are overusing medications, trying to taper and stop the overuse medication can result in a withdrawal headache that will also cause pain. The vicious circle of medication use for headache and trying to manage the medication withdrawal can be quite challenging. Prophylactic treatment should start prior to the withdrawal of any medications. Medications that can be used during this period as preventative treatment include tricyclic antide-pressants, beta blockers, antiepileptic drugs, and ergot derivatives. Suggested measures to manage the withdrawal headache include:
■ Clonidine for opioid withdrawal
■ Temporary substitution of phenobarbital for butalbital to avoid seizures or other serious withdrawal symptoms
■ Intravenous dihydroergotamine for headache relief (Ward, 2004)
Tapering and replacement of medications can take as long as 1 to 3 months. Careful monitoring of headache symptoms and adverse effects is needed to ensure maximum pain control and symptom management.
Treatment options for CDH are varied, and the overuse aspect of the condition limits some of the available options. The use of medication to treat the pain of CDH should be to target pain relief and provide additional support for treating flare migraine headaches when they occur.
The goals of treatment for CDH include the following:
1. Design a treatment plan that combines a variety of approaches that
■ Minimize symptomatology
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Are Headaches Taking Your Life Hostage and Preventing You From Living to Your Fullest Potential? Are you tired of being given the run around by doctors who tell you that your headaches or migraines are psychological or that they have no cause that can be treated? Are you sick of calling in sick because you woke up with a headache so bad that you can barely think or see straight?