Chronic daily headache

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Chronic daily headache (CDH) is defined as any headache syndrome affecting more than half of the month, i.e. a headache on more than 15 days per month. It is also known as daily persistent headache.

Some sufferers of this condition have also had migraine for many years but it has upgraded to become a chronic daily headache affecting the majority of days of the month. Other sufferers have never had migraine before.

Many people awake every day with a headache. It is also possible to have exacerbations of this headache several times a months, which may have some of the features of migraine such as nausea or sensitivity to light or sound.

Chronic daily headache can be caused by:

A neck / head / spinal injury Nervous system disorders

Infections Overuse of analgesics and / or ergot preparations Sleep disorders Depression and / or anxiety

Inflammatory disorders Inadequate management of migraine

Diagnosis of chronic daily headache

There is no specific test to diagnose CDH and it’s largely based on an individual’s medical history and the ruling out of other possible causes. Frequency of headaches helps doctors distinguish chronic from episodic headache. The frequency of an episodic headache is, by definition, less than 15 days per month, whereas the frequency of chronic headache is at least 15 days per month. The duration of a headache is also important; paroxysmal headaches have a duration of less than 4 hours, as compared to CDH, which is a daily or near-daily headache that lasts at least 4 hours and occurs more than 15 days per month. Headaches of short duration include cluster headache, paroxysmal hemicrania, idiopathic stabbing headache, hypnic headache, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing.

The major longer-duration subtypes of CDH are chronic migraine (CM), hemicrania continua (HC), chronic tension-type headache (CTTH), and new daily persistent headache (NDPH). [1.].

CDH may be further split into primary or secondary types: primary headache types are the headaches themselves whilst secondary headaches are a result of

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Chronic migraine

CM is experienced on 15 or more days per month but also is accompanied by migrainous symptoms that commonly include sleep disturbances, depression, anxiety, and drug overuse, especially of acute headache medications. [2.]. There

may or may not be light sensitivity, noise sensitivity or nausea, but not vomiting.

Chronic tension-type headache

CTTH is similar to CM and is a headache that occurs at least 15 days per month for at least 3 months. Its duration may range from hours to continuous, but individuals always experience at least 2 (but not all) of the following characteristics: bilateral (both sides) location on the head, pressing / tightening (non-pulsating) feeling, mild or moderate intensity, mild light sensitivity, mild noise sensitivity or mild nausea. It may not be accompanied by moderate or severe nausea or vomiting, may not be aggravated by routine physical activity and may not be attributed to another disorder. [3.]. CTTH evolves from episodic tension-type headache, with daily or very

frequent occurrences. CTTH differs from CM in that CTTH includes low-grade daily or almost-daily chronic headache without migrainous features, whereas CM includes daily or almost-daily headache with migrainous features (i.e. nausea, light sensitivity or noise sensitivity). It is possible for both disorders to coexist and both may lead to medication overuse.

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New daily persistent headache

Unlike CM or CTTH, which generally evolve from episodic versions, a NDPH is a primary CDH that lasts more than 3 months and has a fast and unpleasant onset. [4.]. Some individuals can recall the exact day or time that their headache began.

The cause of NDPH is unclear, although there may be an association with the Epstein-Barr virus and NDPH may be complicated by medication overuse. [5.].

Features of this headache are similar to those of CTTH but because of its sudden onset, it is imperative to rule out secondary causes in this type of headache. [3.]. Some individuals with NDPH sometimes find that the condition resolves

spontaneously after several months, whereas others remain unresponsive even to aggressive treatments. [3.].

Hemicrania continua

Hemicrania continua is a rare headache disorder marked by continuous, unilateral (one-sided), fluctuating levels of moderate-to-severe pain that can (rarely) alternate sides of the head. This type of headache responds well to indomethacin. Individuals sometimes note tender spots in the neck and attacks are associated with light sensitivity, noise sensitivity, nausea and occasional other symptoms, such as tearing, drooping of the eye lids, dilation of the pupils and / or sweating. [3., 6., 7.].

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Chronic daily headache and medication overuse headache

Chronic daily headache can develop from medication overuse or occur without it, which leads to 2 sub-types: CDH without medication overuse (TM, CTTH, NDPH) and CDH with medication overuse (medication overuse headache [MOH]). 80% of individuals overuse medications. [8., 9., 10.].

As a general rule, increasing the dosage of medication results in increasing headache symptoms and increasing resistance to preventative treatments, whereas discontinuing medication results in fewer headaches overtime. Individuals with MOH develop dependence on acute medication to provide pain relief, which distinguishes them from individuals who are addicted to alcohol or other drugs.

MOH is present on at least 15 days per month, and there must be regular overuse of a medication for more than 3 months (the amount depends on the drug). CDH may continue despite the patient discontinuing overused medication if it is the result, not the cause, of the headache or if there is another health condition present; for example, individuals with depression may overuse painkillers to treat their mood swings.

Medication overuse headache has also been termed “rebound headache,” “drug-induced headache,” and “medication-misuse headache.” The drugs most often implicated in MOH include opioids, ergotamine, butalbital and caffeine. Other drugs that may cause MOH include non-steroidal anti-inflammatory drugs (e.g. ibuprofen, indometacin) and nasal decongestants. Triptans have a lower probability of causing MOH, with dihydroergotamine being the most unlikely. [3., 11., 12.]. MOH as a result of ergotamine, triptans, opioids, and combination painkillers

requires at least 10 days per month of use. This is not necessarily 10 days in a row, as might be seen when a woman requires 10 days of medication during a menstrual migraine; rather, it is the individual who takes these medication 2 to 3 days a week every week. All other medication require at least 15 days per month of use for the headache to be considered MOH. [13.]. Bunching of treatment days

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There are 3 main treatments:

1. Physical measures, such as physiotherapy, osteopathy and chiropractic, to the neck. Many people with CDH have restricted neck movement, sometimes due to a previous neck injury, such as a whiplash injury.

There are also some exercises which you can try on your own at home in order to loosen your neck muscles. Do each of the following movements twice each day, morning and evening:

• Put your chin on your chest and then slowly move your head backwards so that you are looking at the ceiling; then bring it slowly back to normal positioning. • Slowly tilt your head to the side to put first your left ear, then your right ear on

to the respective shoulders.

• Slowly turn your head so that you are looking as far to the left as possible, then slowly turn it through 180 degrees so that you are looking as far right as possible.

You can also try hot or cold treatments on your neck muscles, such as a covered hot water bottle or ice pack both before and after the above exercises.

2. Preventative drugs can also be helpful in improving this condition and reducing the frequency of headaches. Amitriptyline has been shown to be effective; alternatives include anti-convulsants and neuromodulator agents (e.g. topiramate, gabapentin or BOTOX).

3. One main problem with this type of headache is the risk of some people becoming dependant on painkillers. As the painkillers wear off, there is a rebound headache, so the sufferer takes more tablets and the painkillers fuel the headache. It is important to try to break this cycle by reducing / stopping to take painkillers especially

those containing codeine and caffeine. Diet changes may also be beneficial by reducing / stopping caffeine intake in your food and drink. This can be very difficult and may cause severe withdrawal symptoms sometimes requiring hospital admission.

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Follow up

When a successful response is achieved, preventative medications can be withdrawn gradually, relying solely on acute medications for relief of the original episodic headache. However, if one preventative medication fails, others may be tried and tested as part of your tailor care plan.

When to seek a referral

Your GP may be experienced in headache management and may be able to successfully manage your chronic daily headaches. However, referral to specialist neurology or headache services may be necessary for inexperienced GPs and those who are struggling to help manage your condition.

For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling 0116 275 8317, emailing info@migraine.org.uk, or visiting the charity’s website at www.migraine.org.uk. All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit www.migraine.org.uk/donate to support one of our

projects or visit www.migraine.org.uk/join to become a member.

References

1. Silberstein S.D., Upton R.B., Dalessio D.J, eds. Wolff’s Headache and Other Head Pain. 7th edition. New York. New York: Oxford University Press: 2001.

2. Goadsby P.J., Silberstein S.D., Dodick D.W., ed. Chronic Daily Headache for Clinicians. Hamilton, Ontario: BC Decker Inc; 2005.

3. Silberstein S.D., Chronic Daily Headache. J Am Osteopath Association, 2005: 105:S23-S29. 4. Li D., Rozen T.D. The clinical characteristics of new daily persistent headache. Cephalalgia.

2002; 22:66-69.

5. Vanast W. New daily persistent headaches: definition of a benign syndrome. Headache. 1986; 26:317.

6. Bordini C., Antonad F., Stavner L., et al. “Hemicrania continua”: a clinical review. Headache. 1991; 31:20-26.

7. Peres M.F., Silberstein S.D., Nahmias S., et al. Hemicrania continua is not that rare. Neurology. 2001; 57:948-951.

8. Matthew M.T., Reuvent U., Perez F. Transformed or evolutive migraine. Headache. 1987; 27:102-106.

9. Saper J. Headache disorders: Current Concepts and Treatment Strategies. Boston, Mass: J. Wright Publishing, 1983.

10. Matthew M.T., Stubtis E., Nigam M.P. Transformation of episodic migraine into daily headache: analysis of factors. Headache. 1982; 22:66-68.

11. Limmroth V., Katsarova Z., Frittsche G., et al. Features of medication overuse headache following overuse of acute headache drugs. Neurology. 2002; 59:1011-1014.

12. Katsarova Z., Frittsche G., Muessig M., et al. Clinical features of withdrawal headache following overuse of triptans and other headache drugs. Neurology. 2001; 57:1694-1698.

13. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004; 24:9-160.

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Acknowledgements

Migraine Action would like to thanks Dr Andy Dowson, Director of Headache Services, Kings College, London and Dr Sue Lipscombe, Headache Specialist, Royal Sussex County Hospital, Brighton for providing information used in this booklet and for reviewing the content.

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Related subjects : CDH -- CHRONIC DAILY HEADACHE