Chronic daily headache (CDH) is a challenging condition to treat. CDH is often accompanied by significant comorbidities, such as chronic fatigue, depression, anxiety, and insomnia, which further complicate treatment. Unrealistic expectations of treatment goals can lead to patient frustration, and, as a result, decrease treatment adherence. Patients often desire headache-free status, but this outcome is not realistic for many patients with CDH. By contrast, an effective treatment goal starts with establishing the correct diagnosis and creating a multimodal treatment plan to improve function and well-being. With proper comprehensive treatment, the condition improves in most patients.
Key points
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The term chronic daily headache (CDH) is used when patients present with 15 or more headache attacks per month for 3 or more months.
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The International Headache Society Criteria should be used to diagnose specific CDH disorder. CDH is a symptom diagnosis that does not reflect the underlying cause of the headache.
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Secondary causes need to be ruled out before CDH is diagnosed as a primary headache syndrome.
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Medication overuse, comorbid psychiatric disease, physical deconditioning, and obesity complicate CDH.
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Effective treatment involves multimodal therapy, including education; pharmacologic intervention; nonpharmacologic, appropriate procedural intervention; and lifestyle changes.
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Treatments need to focus on improving function and well-being.
Introduction
In 1672, physician Thomas Willis described CDHs of the philosopher Viscountess Anne Conway. Dr Harvey recommended mercury treatments, whereas Dr Willis recorded a long list of attempted treatments, attesting to the patient’s determination to try every possible medical cure. Dr Willis suggested treatment of refractory headaches with trepanation and poultices of millipedes and wood lice. Despite her willingness to engage in multiple treatments, she continued to suffer from severe headaches until her death. Two hundred years later, Dr Liveing noted valerian as a possible treatment of frequent headaches, and Doctor Gowers described bromide and India hemp as headache treatments. However, the perfect cure for CDHs has not yet been found.
The International Headache Society defines CDH as a headache disorder whereby patients suffer 15 or more headache attacks per month for 3 or more months. Patients who have more than 4 headache days per month, have some associated disability, or report significant suffering might be at risk of progressing to CDH and may need preventive treatment.
Introduction
In 1672, physician Thomas Willis described CDHs of the philosopher Viscountess Anne Conway. Dr Harvey recommended mercury treatments, whereas Dr Willis recorded a long list of attempted treatments, attesting to the patient’s determination to try every possible medical cure. Dr Willis suggested treatment of refractory headaches with trepanation and poultices of millipedes and wood lice. Despite her willingness to engage in multiple treatments, she continued to suffer from severe headaches until her death. Two hundred years later, Dr Liveing noted valerian as a possible treatment of frequent headaches, and Doctor Gowers described bromide and India hemp as headache treatments. However, the perfect cure for CDHs has not yet been found.
The International Headache Society defines CDH as a headache disorder whereby patients suffer 15 or more headache attacks per month for 3 or more months. Patients who have more than 4 headache days per month, have some associated disability, or report significant suffering might be at risk of progressing to CDH and may need preventive treatment.
Patient evaluation overview
The specific diagnosis of CDH is key for properly managing patients. When counseling patients, it is helpful to explain that headache can be caused by either a structural problem or medication overuse (called secondary headache), by a change in the functioning of the brain (called primary headache), or by a combination of both. Asking the right questions can establish a specific diagnosis without further tests, so it is important to learn to use precise questions ( Table 1 ).
| History of Headaches | Possible Answers and Their Implications |
|---|---|
| Do you have more than 15 headache days per month? | Diagnosis of CDH with >15 d of headaches per month If answer is no: diagnosis of episodic headaches |
| Are your headaches nonstop? | If yes, further workup needs to rule out a secondary headache diagnosis |
| Is the headache duration longer than 4 h? | 4 h/d: likely chronic migraine or chronic tension-type headache <4 h: Trigeminal autonomic cephalalgia, such as cluster or hemicrania |
| Do you use abortive medications more than 10 d/mo? | Consider medication overuse headaches |
| What are the associated symptoms? | Nausea, light and sound sensitivity go along with chronic migraine phenotype Autonomic symptoms are often associated with trigeminal autonomic cephalalgia |
After establishing that CDH is primary, not secondary, the primary CDH is further subdivided into primary headache subtypes of short duration, which is less than 4 hours, and long duration, which is 4 hours or greater. The 2 most common long-duration subtypes are chronic migraine (CM) and chronic tension-type headache. The short-duration headache disorders include hemicrania continua, new daily persistent headache, and chronic cluster headache. Most patients with CDH who present to specialists have either chronic tension-type headache or CM.
Asking the right questions
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What is the goal of your visit today?
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Do you have questions regarding your diagnosis?
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Is your main goal of visit pain relief?
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Are you seeking further testing?
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What are you worried about?
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What is the number of headache days per month that you are having? If your headaches last multiple days, count each day.
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Do you have any headache-free days?
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What is the duration of each individual headache?
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What medications do you use? (Ask specifically about the frequency of use of medications that can be associated with overuse, such as acetaminophen, ibuprofen, opioids, and triptans.)
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Do your headaches have any associated symptoms?
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Do you have any trouble with sleep?
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How much caffeine do you consume?
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Did you have recent changes in your weight?
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Do you also have anxiety and/or depression?
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Have you recently perceived increased stress in your life?
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What is your understating of the reason behind your headaches?
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What is your understanding of the medications that were prescribed to you?
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Are you okay with taking daily preventive medications?
Risk factors for migraine progression
A combination of many different factors can cause headaches in susceptible individuals, and chronic medication administration can cause long-term unexpected consequences ( Table 2 ). The most significant risk factors for headache progression are cumulative and include medication overuse, increased caffeine use, stress, anxiety, depression, high attack frequency, and obesity. Other factors include lower education level and lower socioeconomic status, trauma to the head or neck, and problems with insomnia and sleep apnea.
| Not-Readily-Modifiable Risk Factors | Modifiable Risk Factors |
|---|---|
| Age | Baseline high headache attack frequency with more than 3 headache days per month |
| Low education | Obesity |
| Socioeconomic status | Medication overuse |
| Head injury | Ongoing life stress |
| Female gender | High caffeine use |
| Snoring |
Modifiable Risk Factors
Several modifiable risk factors have been identified :
Frequency of headache attacks at baseline
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Three or more headaches per month elevates risk for developing CDH.
Obesity
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Obesity is associated with worsening pain intensity.
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Patients with obesity are often more difficult to treat and unresponsive to usual treatment.
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CDH is 3 times more likely with body mass index (BMI) 25 to 29 (overweight).
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CDH is 5 times more with BMI greater than or equal to 30 (obese).
Medication overuse
“Overuse of abortive medication can contribute to the transformation of episodic into transformed migraine.” High doses of certain medications can change the function of the pain control mechanism in genetically predisposed patients. The mechanism is not fully understood, but it is thought that this phenomenon includes combination of many different mechanisms such as increased central sensitization via N -methyl-d-aspartate receptors and decreased antinociceptive mechanisms. Chronic opioid use can further increase pain perception via rostral ventromedial medulla activation. Inhibitory γ-aminobutyric acid interneurons that modulate pain perception can be damaged by opioid-induced neurotoxicity.
Highlights of medication overuse
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About 80% of patients with CM seen by headache specialists exhibit medication overuse.
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Medication overuse decreases the effectiveness of short-term and preventive treatment.
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Abortive medication use is more likely to cause CDH in patients who have a biologic predisposition to headaches.
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Medications used for other conditions, such as other chronic pain conditions, may induce CDH in genetically susceptible individuals.
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Even after medication overuse stops, CDH may continue.
Caffeine
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Caffeine withdrawal can manifest as headache.
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Consumption of as little as 1 cup of coffee per day can worsen headaches in some patients.
Snoring/sleep apnea
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Sleep-disordered breathing is associated with cluster headache.
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Sleep apnea can present as daily headaches in the morning.
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Insomnia and CDH are often comorbid.
Depression and stressful life events
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Major depression was present in 58.7% of patients with CM. The prevalence of “some depression” was 85.8% in patients with CM, whereas it was only 28.1% in patients with episodic migraine.
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Stressful life event is also a risk factor for CDH.
Subtypes of chronic daily headaches
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Chronic tension-type headache is defined as headaches occurring more than 15 days a month with no specific significant associated feature.
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CM is defined as having more than half of headache days with migraine features, such as unilateral pain, nausea, and light and sound sensitivity.
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Hemicrania continua is a unilateral headache associated with autonomic features.
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Chronic cluster headache is an excruciating unilateral headache associated with autonomic features (eg, tearing in the ipsilateral eye, runny nose, droopy eye, miosis, ptosis, restlessness).
Chronic Migraine
About 35 million people in the United States experience migraines annually. CM is estimated to be present in about 2% of the adult population (about 6 million Americans), with only 20% of these individuals having received formal diagnosis. The International Classification of Headache Disorders 3 (beta) 2013 defines CM as “Headache occurring on 15 or more days per month for more than three months, with features of migraine on at least eight days per month.” CM is considered a complication of episodic migraine; each year, in approximately 2.5% of patients, episodic migraine transforms to CM. This transformation may occur with or without medication overuse. Patients meeting criteria for both CM and medication-overuse headache should be given both diagnoses.
Approach to patients presenting with chronic headaches
- 1.
Exclude secondary headache disorders.
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Make a diagnosis of the specific primary headache disorder type (CM, chronic tension-type headache, hemicrania continua, or new daily persistent headache) using International Headache Society Criteria.
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Identify comorbid medical and psychiatric conditions and address as necessary.
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Exclude medication overuse.
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Limit all abortive medication use to less than 4 to 6 days per month in most patients with CDH (with the exception of long-acting nonsteroidal anti-inflammatory medications, which can be used for up to 10 days per month).
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Start administration of preventive medication with the goal of decreasing use of abortive medications. Preventive medications are not fully therapeutic until overuse of abortive medications is addressed, and it can take months for them to be significantly effective.
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Consider termination of headache cycle with dihydroergotamine (DHE) therapy.
Indications for neuroimaging
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Acute worsening in frequency and intensity of headaches
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New or changed headaches present after age 50 years
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History of sudden headache onset in someone who has never experienced headaches
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New neurologic symptoms (eg, vision loss)
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Focal or lateralizing neurologic signs
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Papilledema
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Headaches that worsen or improve with postural change (eg, upright vs supine)
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Headaches provoked by a Valsalva maneuver (eg, a cough or sneeze)
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Systemic symptoms (eg, fever)
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Immunosuppression
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History of cancer or other neoplastic disease
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History of human immunodeficiency virus infection
Pharmacologic treatment options
Short-term Pharmacotherapy
The choice of short-term pharmacotherapy depends on the specific headache diagnosis. Patients with CM who are not overusing short-term drugs can treat headache exacerbations with migraine-specific drugs such as triptans, DHE-45, or long-acting nonsteroidal anti-inflammatory drugs (NSAIDs) ( Tables 3 and 4 ). The use of these drugs must be limited to prevent medication overuse headache (MOH), which complicates treatment.
| Generic Name | Trade Name | Forms | Dose (mg) | MR in HR | Max Dose in 24 h (mg) | Year FDA Approved |
|---|---|---|---|---|---|---|
| Sumatriptan | Imitrex | Inj | 4; 6 | 1 | 12 | 1992 |
| Sumatriptan | Imitrex | Tab | 50, 100 | 2 | 200 | 1995 |
| Sumatriptan | Imitrex | NS | 20 | 2 | 40 | 1997 |
| Sumatriptan | Zecuity | TD | 6.5 over 4 h | 2013 | ||
| Naratriptan | Amerge | Tab | 2.5 | 4 | 5 | 1998 |
| Rizatriptan | Maxalt | Tab | 5; 10 | 2 | 20 | 1998 |
| Rizatriptan | Maxalt-MLT | ODT | 5; 10 | 2 | 20 | 1998 |
| Zolmitriptan | Zomig | Tab | 2.5; 5 | 2 | 10 | 2003 |
| Zolmitriptan | Zomig-ZMT | ODT | 2.5; 5 | 2 | 10 | 2003 |
| Almotriptan | Axert | Tab | 12.5 | 2 | 25 | 2001 |
| Frovatriptan | Frova | Tab | 2.5 | 2 | 5 | 2001 |
| Eletriptan | Relpax | Tab | 40 | 2 | 80 | 2002 |
| Zolmitriptan | Zomig-NS | NS | 5 | 2 | 10 | 2003 |
| Sumatriptan Naproxen | Treximet | Tab | 85 500 | 2 | 170 1000 | 2008 |
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