Patients with chronic daily headache may view the headache situation in black and white terms. They will come back for a return visit and state, “Well, I still have a headache everyday.” They need to accept that if we have gone from moderate-to-severe headaches (7 on a scale of 1-10) to mild-to-moderate (4 on a scale of 1-10), then the situation is improved, and we should not change all the medication. If the patients keep a headache chart or calendar, this may help. Patients need to be willing to accept 50% to 90% improvement in frequency and/or severity of headaches.

While most patients are honest about analgesic use, some are embarrassed to tell us how much they are utilizing. Between over-the-counter analgesics and herbal preparations, many patients are consuming larger quantities of medications than we realize.

Weight gain is a major issue. Even though a drug may be more effective, choosing one that avoids weight gain (in those prone to it) is more likely to lead to long term success. Fatigue is another major reason for patients abandoning a preventive medication. Headache patients commonly complain of fatigue. Many of our preventives (amitriptyline, beta blockers, valproate, etc.) may add to weight gain and/or fatigue.     First published on July 1, 2006, edited and re-written 2012   By Lawrence Robbins, MD

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