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Therapeutic Guidelines: Neurology, version 4, 2011 Headache attributed to a substance or its Copyright 2011 Therapeutic Guidelines Limited Ground Floor, 473 Victoria Street West Melbourne 3003 age Preventive medication should be continued for a minimum of 3 to 6 months and then tapered and ceased.
Vasodilators such as dihydropyridine calcium channel blockers, nitrates, The effective dose of amitriptyline varies widely between individuals, phosphodiesterase type 5 inhibitors (eg sildenafil) and dipyridamole but is typically in the range of 50 to 75 mg daily. Its efficacy in relief frequently cause headache. The combined oral contraceptive pill is a of headache is independent of its antidepressant action. Other tricyclic well-known cause of migrainous headache, and in some individuals this antidepressants may be effective, but data are lacking. If amitriptyline can occur even after years of symptom-free use. Hormone replacement produces unacceptable adverse effects, nortriptyline or dothiepin can be therapy can also cause headaches. Idiopathic (benign) intracranial used. Selective serotonin reuptake inhibitors may not be as effective as hypertension is an uncommon adverse effect of tetracyclines, but their wide use for the treatment of acne has resulted in an increasing number For patients with tension headache and sleep disturbance, depression of cases. Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly should be considered. Counselling in conjunction with appropriate indomethacin, may be associated with paradoxical headache.
antidepressant therapy may be helpful.
Any drug with a possible temporal relationship to persistent or recurring For patients with tension headache and symptoms of anxiety, counselling headache should be suspected if no other cause is obvious. The drug should be ceased in order to determine its possible causal role.
Antiepileptic drugs (eg sodium valproate, gabapentin), acupuncture and botulinum toxin type A have been advocated for treatment of frequent tension headache, but evidence supporting their use is limited.
Medication-overuse (rebound) headache can insidiously develop with prolonged frequent use of the medications used for treatment of acute headache. It is usually indistinguishable from the primary headache. The syndrome is not present in every individual who frequently uses acute medications. It has not been reported in some types of headache True cluster headache is rare and mainly seen in males; however, the (eg cluster headache) or in other types of pain where there is frequent term ‘cluster headache’ is often incorrectly used to refer to migraines where the attacks occur in cycles. Attacks of cluster headache are much Medication-overuse headache occurs after the effect of each dose wears shorter in duration than (untreated) attacks of migraine, and unlike off, and the resultant headache is suppressed by a further dose. This migraine the headache does not swap sides between attacks. In cluster leads to escalating drug use in a futile attempt to control the headache.
headache, the pain is centred around the orbit and is usually accompanied by unilateral rhinorrhoea, lacrimation or conjunctival congestion. The list of acute medications implicated is long and includes Attacks typically last from 15 minutes to 3 hours, recurring in separate dihydroergotamine, triptans, opioids, most analgesics and caffeine. bouts, often nocturnally, with 1 to 8 attacks per day for several weeks or Combination analgesics containing codeine or other opioids are the months. Cluster headache can sometimes be difficult to distinguish commonest cause of medication-overuse headache. Frequent use from paroxysmal hemicrania (see p.9).
of any of these drugs may lead imperceptibly over time to a state of treatment is to prevent further attacks Prevention of further attacks Patients may be at risk of medication-overuse headache if they (see ‘Preventive treatment’, p.7), and is the main focus of cluster persistently use acute medication on more than 2 to 3 days per week. A gradual escalation in medication use may be a clinical clue that (see ‘Bridging treatment’ [p.8] and ‘Acute treatment’ [p.8]).
medication-overuse headache is developing. Patients with headache requiring more frequent use of medications should be counselled about their use of acute medications and have a preventive drug added. The pain-modifying action of preventive drugs can take several weeks

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