Management of daily headache unresponsive to preventive treatment: daily triptans versus daily opioids

Daily headache affects an estimated 3% to 6% of the general population and affects women 2 to 3 times more frequently than men. The vast majority of daily headache is nonparoxysmal, or chronic daily headache. In the general population, the distribution of chronic tension-type headache and chronic migraine is fairly equal, but in medical practice chronic migraine accounts for the vast majority of nonparoxysmal daily headache. The first step in the management of chronic daily headache is to identify potential overuse of analgesic and vasoconstrictor medications. Preventive treatment is then initiated with a tricyclic antidepressant, beta-blocker, calcium-entry blocker, and/or anticonvulsant. Chronic migraine patients who are refractory to specific headache treatment may take a triptan frequently, if not daily, or a (long-acting) opioid. Both management strategies of refractory daily headache are controversial but appear safe and effective, although daily opioid treatment should be reserved for a relatively small, selected subpopulation. Through a practice survey, we looked at potential differences between daily (long-acting) opioid and daily triptan treatment in 53 patients. We found patient satisfaction with either treatment to be relatively favorable, although there was an implication that triptans outperform opioids in providing headache relief. However, it was also evident that in both treatment groups, despite the relatively positive patient satisfaction results, chronic migraine patients clearly continued to experience a negative impact from their headaches.