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 patients with chronic daily headache. The first step in the management of chronic daily headache, whether it concerns chronic tension-type headache or chronic migraine, is to identify the potential overuse of analgesic and/or vasoconstrictor medications. Once medication overuse, if present, HDAC inhibitor is dealt with, preventive treatment is initiated with medications and/or non-pharmacological

strategies. Chronic migraine patients who are refractory to or do not tolerate those treatments, however, may end up taking a triptan frequently, if not daily. This is illustrated by the following case history, BMN 673 clinical trial which in turn is followed by questions regarding the safety of daily or almost-daily triptan use in the context of medication-overuse headache and cardiovascular safety concerns. These issues will be addressed in this expert opinion article. Daily triptan use for chronic migraine is probably not all that rare. A retrospective audit was carried out in 9 general-medicine practices in the United Kingdom and

Ireland,[2] examining all patients 18 years and older who had a recorded diagnosis of migraine and had been prescribed a triptan during a 1-year period. A total of 77,715 patients were registered 上海皓元 with the 9 participating practices, of whom 3672 (4.7%) had a recorded diagnosis of migraine and 360 met the audit inclusion criteria. Of these 360 patients, 7.4% had received prescriptions for at least 150 tablets during the year of the audit, which, if 1 tablet is taken daily, means an average triptan use of every other day at a minimum. A French, population-based, observational study of a regional health care insurance database covering medication use of 5.3 million people, that is, 8% of the population, revealed that over a period of 18 months, 0.04% of the population or 2.4% of

all triptan users obtained 60 daily triptan doses per 3 months, averaging a daily triptan dose every 1 day.[3] If the British and French data presented above can be generalized, they suggest that roughly 5% of all triptan-using migraineurs take a triptan, on average, at least 15 days per month, this is, for abortive treatment of chronic migraine. This 50-year-old woman has a history of migraine without aura since her teens. The headaches gradually increased in frequency over time and have been daily or almost daily for the last 5 years. She tried multiple preventive medications, including topiramate, amitriptyline, propranolol, onabotulinumtoxinA, divalproex sodium, gabapentin, zonisamide, and memantine, either alone or in combination, without benefit or side effects.