Chronic Daily Headaches

• Chronic migraine
• Chronic tension-type headache
• New daily persistent headache
• Hemicrania continua

Chronic migraine

These headaches evolve from episodic migraine without aura. To be diagnosed with chronic migraine, you must have headaches — migraine, tension-type or both — 15 days or more a month, for at least three months. In addition, on eight or more days a month for at least three months, you must experience the following symptoms.

Your headaches have at least two of the following characteristics:

• Affect only one side of your head
• Cause a pulsating pain
• Cause moderate to severe pain
• Are aggravated by routine physical activity

And they cause at least one of the following:

• Nausea, vomiting or both
• Sensitivity to light and sound

Alternatively, if your headaches respond to triptan medications or ergot medications taken in anticipation of these symptoms — on eight or more days a month for at least three months — they're also considered chronic migraines.

Chronic tension-type headache

These headaches evolve from episodic tension-type headaches. They may last hours or be constant.

Chronic tension-type headaches have at least two of the following characteristics:

• Hurt on both sides of your head
• Cause mild to moderate pain
• Cause pain that feels pressing or tightening, but not pulsating
• Aren't aggravated by routine physical activity

In addition, they cause no more than one of the following:

• Sensitivity to light or sound
• Nausea (mild only)

New daily persistent headache

These headaches become constant within a few days of the moment you have your first headache.

New daily persistent headaches have at least two of the following characteristics:

• Hurt on both sides of your head
• Cause pain that feels like pressing or tightening, but not pulsating
• Cause mild to moderate pain
• Aren't aggravated by routine physical activity

In addition, they cause no more than one of the following:

• Sensitivity to light or sound
• Nausea (mild only)

Hemicrania continua

These headaches cause pain on only one side of your head that doesn't shift sides. They also:

• Are daily and continuous with no pain-free periods
• Cause moderate pain but with spikes of severe pain
• Respond to the prescription pain reliever indomethacin (Indocin)
• May sometimes become severe with development of migraine- like symptoms

In addition, hemicrania continua headaches cause at least one of the following:

• Tearing or redness of the eye on the affected side
• Nasal congestion or runny nose
• Drooping of the eyelid or constriction of the pupil

Causes

The causes of many chronic daily headaches aren't well understood. True (primary) chronic daily headaches don't have an identifiable underlying cause. They may occur if:

• You develop a heightened response to pain signals
• The part of your brain that suppresses pain signals isn't working properly

Other frequent headaches may be caused by various underlying diseases or conditions, including:

• Inflammation or other problems with the blood vessels in and around the brain, including stroke
• Infections, such as meningitis
• Intracranial pressure that's either too high or too low
• Brain tumor
• Traumatic brain injury

Many people who have frequent headaches are actually experiencing a rebound effect from taking pain medication too often. If you're taking pain medications — even over-the-counter analgesics — more than three days a week, you're at risk of developing rebound headaches.

Risk factors

Various factors may increase the risk of developing frequent headaches, including:

• Anxiety
• Depression
• Sleep disturbances
• Obesity
• Snoring
• Overuse of caffeine
• Overuse of pain medication
• Regular use of physical postures that put a strain on your head or neck

Complications

If you have chronic daily headaches, you're also more likely to experience depression, anxiety, sleep disturbances, and other psychological and physical problems.

Diagnosis

Your doctor will probably do a physical exam to check for signs of illness, infection or neurological problems. If the cause of your headaches remains uncertain, you may need blood or urine tests to identify any underlying medical conditions. Sometimes imaging studies — such as an X-ray, CT scan or MRI scan — are recommended.

Treatments and drugs

Treatment for any underlying diseases or conditions often stops frequent headaches. When no underlying diseases or conditions are present, treatment focuses on preventing the pain before it starts.

Specific prevention strategies vary, depending on which type of headache you have and whether medication overuse is contributing to these headaches. If you're taking pain relievers more than two days a week, the first step in treatment may be to stop using these drugs. When you're ready to begin preventive therapy, your doctor may recommend:

• Antidepressants. Tricyclic antidepressants can be used to treat chronic headaches. These medications can also help treat the depression, anxiety and sleep disturbances that often accompany chronic daily headaches. Other antidepressants, such as the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), may be helpful, for treatment of depression and anxiety, too.
• Beta blockers. These drugs, commonly used to treat high blood pressure, are also a mainstay for preventing episodic migraines. Some beta blockers include atenolol (Tenormin), metoprolol and propranolol (Inderal). Sometimes beta blockers are prescribed in combination with antidepressants, and this combination is sometimes more effective than either medication on its own.
• Anti-seizure medications. Some anti-seizure drugs seem to prevent migraines. These medications may be used to prevent chronic daily headaches as well. Options may include gabapentin (Neurontin) and topiramate (Topamax).
• NSAIDs. Nonsteroidal anti-inflammatory drugs — such as naproxen may be helpful, especially if you're going through withdrawal from other pain relievers. They may also be used periodically when the headache is more severe.
• Others. Injections of a local anesthetic around a nerve or injections of a numbing agent and corticosteroid at the point of pain (trigger point injections) are sometimes recommended for chronic daily headaches. Although their role needs to be better defined, botulinum toxin type A (Botox) injections provide relief for some people as well.

Unfortunately, some chronic daily headaches remain resistant to all medications.

Alternative medicine

For many people, complementary or alternative therapies offer welcome relief from headache pain. It's important to be cautious, however. Not all complementary or alternative therapies have been studied as headache treatments, and others need further research.

• Acupuncture. This ancient technique uses hair-thin needles inserted into several areas of your skin at defined points. Studies have shown that acupuncture helps reduce the frequency and intensity of chronic headaches.
• Biofeedback. In biofeedback, you can learn to control headaches by becoming more aware of and then changing certain bodily responses such as muscle tension, heart rate and skin temperature.
• Meditation. Practicing meditation can help you relax physically and remain calm mentally. The practice creates a deeply restful state in which your breathing slows and your muscles relax — which can help you manage pain and reduce stress.
• Massage. Massage can reduce stress, relieve pain and promote relaxation. Although its value as a headache treatment hasn't been determined, massage may be particularly helpful if you have tight, tender muscles in the back of your head, neck and shoulders.
• Herbs, vitamins and minerals. Some evidence exists that the herbs feverfew and butterbur may prevent migraines or reduce their severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in brain cells. Coenzyme Q10 supplements may be helpful in some individuals. And oral magnesium sulfate supplements may reduce the frequency of headaches in some people, although studies don't all agree. Magnesium taken intravenously seems to help some people during an acute headache, particularly people with magnesium deficiencies. Ask your doctor if these treatments are right for you. Don't use feverfew or butterbur if you're pregnant.
• Chiropractic care. Spinal manipulation can effectively treat some types of pain, though it's not been proved to be effective for headaches.
• Electrical stimulation of the occipital nerve. A small battery-powered electrode is surgically implanted near the occipital nerve, which is at the base of your neck. The electrode sends continuous energy pulses to the nerve to ease pain. This approach is investigational and has shown some good results but is not a standard therapy.

If you'd like to try a complementary or alternative therapy, discuss the risks and benefits with your doctor.

Coping and support

Chronic daily headaches can interfere with your job, your relationships and your quality of life. But you can cope with the challenges.

• Take control. Commit yourself to living a full, satisfying life. Work with your doctor to develop a treatment plan that works for you. Take good care of yourself. Do things that lift your spirits. Set aside time for your loved ones — and yourself — every day.
• Seek understanding. Don't expect friends and loved ones to instinctively know what's best for you. Ask for what you need, whether it's time alone or less attention focused on your headaches.
• Check out support groups. You may find it useful to talk to other people who experience painful headaches. Try finding a support group in your area to learn how other people cope with their headache pain and discomfort.
• Consider counseling. A counselor or therapist offers much needed support and can help you manage stress. Your therapist can also help you understand the psychological effects of your headache pain.

Prevention

Taking good care of yourself can help prevent chronic daily headaches.

• Avoid headache triggers. If you're not sure what triggers your headaches, keep a headache diary. Include details about every headache. When did it start? What were you doing at the time? What did you eat that day? How did you sleep the night before? What was your stress level? How long did the headache last? What, if anything, provided relief? Eventually, you may begin to see a pattern — and be able to take steps to prevent future headaches.
• Avoid medication overuse. Taking headache medications, including over-the-counter medications, more than twice a week can actually increase the severity and frequency of your headaches. If you are taking medication too often, it is important to consult your doctor about how best to wean yourself off the medication because there can be serious side effects if done improperly.
• Get enough sleep. The average adult needs six to eight hours of sleep a night. It's best to go to bed and wake up at regular times, as well.
• Don't skip meals. Start your day with a healthy breakfast. Eat lunch and dinner at about the same time every day. Avoid any food or drinks, such as those containing caffeine, that seem to trigger headaches.
• Exercise regularly. Regular physical activity can improve your physical and mental well-being. Exercise also helps reduce stress. With your doctor's OK, choose activities you enjoy — such as walking, swimming or cycling. To avoid injury, start slowly.
• Reduce stress. Stress is the most common trigger of chronic headaches. Get organized. Simplify your schedule. Plan ahead. Stay positive. Most headaches caused by stress end when the period of stress is over.
• Relax. Try yoga, meditation or relaxation exercises. Set aside time to slow down. Listen to music, read a book or take a hot bath.
• Reduce caffeine. While some headache medications include caffeine because it can be beneficial in reducing headache pain, it can also aggravate headaches. Try to minimize, or better yet, eliminate caffeine from your diet.

References:

http://www.neurology.org/content/76/7_Supplement_2/S37.full

http://www.l-t-b.org/assets/13/B2813DE1-CB7E-6298-D5DEB5FC0734EF28_document/What_is_Chronic_Daily_Headache.pdf

https://www.migrainetrust.org/about-migraine/types-of-migraine/chronic-migraine/

http://www.americanheadachesociety.org/assets/1/7/NAP_for_Web_-_CDH___Chronic_Migraine.pdf