Update on Chronic Daily Headache

Abstract

Chronic daily headache (CDH), defined as a primary headache occurring at least 15 days per month, is a problem of worldwide scope, which is seen in 3% to 5% of the population. Though it has been recognized since ancient times, only recently have there been attempts to define and classify it. CDH usually consists of a mixture of migraine and tension-type headaches (TTH), with the more severe headaches having migraine features and the less severe headaches fitting the definition of TTH. Some patients have pure chronic TTH and no migrainous features, and others have only migraine, but most have a mixed migraine-TTH pattern. New daily persistent headache, a CDH pattern that comes on over a few days, constitutes 9% to 10% of this group and is otherwise indistinguishable from CDH. Hemicrania continua (1% of CDH) appears to be unique in being absolutely responsive to indomethacin. Accurate diagnosis of CDH is critical to management, as all organic etiologies of chronic headache must be ruled out. Problems often associated with CDH and complicating the diagnosis are head injury or medication overuse (rebound-withdrawal headache). These accompanying issues must be recognized and treated appropriately in the management plan. Finally, psychiatric problems (unipolar depression, bipolar disease, generalized anxiety disorder, and obsessive/compulsive disorder) often accompany CDH, as they are comorbid with migraine. These conditions must be recognized and treated along with the headache itself for treatment to succeed fully. Treatment of CDH is multimodal. The cornerstone of therapy is the use of prophylactic antimigraine medications to prevent or modulate the next headache. Amitriptyline, topiramate, valproic acid, and gabapentin have all had class I studies showing effectiveness in reducing headache occurrence. Recent studies with botulinum toxin have also shown effectiveness in reducing the headache burden. Recognition and treatment of medication overuse headache (MOH) must be carried out as part of the initial approach. Use of acute symptomatic treatments such as triptans or NSAIDs must be undertaken with care, as frequent use of these agents can lead to MOH. Educating the patient about the condition and reasonable expectations for therapy is essential to success. Recognition and appropriate treatment of psychiatric disorders is likewise essential. Adjunctive nondrug therapies and lifestyle changes round out the requirements for a management plan. The chances for long-term remission or significant improvement are up to 65%. The patient and physician must understand that CDH is a long-term process with relapses and remissions. A strong and trusting relationship between patient and physician is a major asset in managing this condition.

Combination of acupuncture and spinal manipulative therapy: management of a 32-year-old patient with chronic tension-type headache and migraine

“…10,15 Observational and population-based studies describe progressive migraine headaches that become CDHs, a condition that affects 3% to 5% of the population with episodic headaches. [16][17][18][19][20][21] Chronic daily headaches are defined as primary headaches that occur at least 15 days per month, 22-26 although they are not described in the International Classification of Headache Disorders (ICHD)-2 criteria.…”

“…22,27 When CTTHs are accompanied by less than 8 migraines per month, the ICHD-2 classifies these patients as having CTTH with migraine. 21,27 The term chronic migraine has been suggested as being more appropriate to describe migraine attacks superimposed on a background of daily TTH. 22,23 The ICHD-2 criteria use the term chronic migraine specifically when patients experience more than 8 migraines per month for more than 3 consecutive months.…”

“…26 Most notably, the headache worsens during the period of medication overuse. 18,19,21,23 What differentiates the quality of MOHs from CTTHs most clearly is that MOHs worsen significantly with mental or physical exertion, whereas CTTHs do not. Medication overuse headaches occur in approximately 1% of the population 28 and can be a major contributing factor in the transformation of episodic headaches to CDHs.…”

“…27 Thirty percent of all CDH patients are estimated to have MOH. 20 The term transformed migraines is used to describe a progressive evolution from episodic migraine headaches to chronic migraine headaches, formerly called mixed headaches, 19 80% of the time against a background of MOH, [20][21][22][23][24][25] although this evolution can also occur without medication overuse. 25,26,[30][31][32] Some authors state that 14% of patients will transform from episodic to chronic migraine headaches.…”

“…25,26,[30][31][32] Some authors state that 14% of patients will transform from episodic to chronic migraine headaches. 21 Transformed migraines are not addressed in the ICHD-2. 19,[21][22][23] Migraines can be chronic, more than 8 migraines per month for 3 months according to ICHD-2 criteria, 27,30 without being transformed.…”