CDH -- CHRONIC DAILY HEADACHE

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Is chronic daily headache a useful diagnosis?

Is chronic daily headache a useful diagnosis?

academic approach to the difficult headache patient in the clinic, although it may be time demanding at first glance. Headache patients deserve as careful a scientific and sys- tematic approach as other neurological patients and until a precise diagnostic or genetic test has been developed, we have to rely on patient history and develop further instru- ments to characterize headache patients on a clinical basis. The effort usually proves to be cost effective as patients are withdrawn from the frequent medication overuse, receive a more specific therapy and demonstrate a better treatment outcome. In pathophysiological research as well as in clinical trials, specific diagnostic groupings have been used for more than a decade and it is time that clini- cians follow the general rules and avoid the term CDH, chronic daily headache.
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The term chronic daily headache (CDH)

The term chronic daily headache (CDH)

Silberstein and Lipton 14 developed criteria in which the diagnosis of one dis- order took precedence over the diagnosis of another. They suggest that a putative diagnosis of CTTH has not met criteria for hemicrania continua, NDPH, or chronic migraine. This diagnosis would handle the difficulty of a small group of patients who fulfill the IHS diagnostic criteria for both chronic migraine and CTTH. This solution would be possible when two (and only two) of the four pain characteristics are present and headaches are associated with mild nausea. These cases are most likely chronic migraine and have been shown to be associated with elevated calcitonin gene-related pep- Table 2
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Chronic daily headache

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.
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Chronic Daily Headache and Chronic Migraine

Chronic Daily Headache and Chronic Migraine

For example, a patient who presents with CDH and features suggestive of intracranial hypertension should have MRV to rule out CVST. A patient who presents with unilateral CDH, particularly frontal/temporal/or periorbital, which may have began abruptly and now continues should have MRA to rule out carotid dissection - parenthetically, I just had a case like this last week - a 22 year old with 22 years of CDH wherein the diagnosis of carotid dissection due to fibromuscular dysplasia was missed - only a carotid bruit and a small pupil on the same side of the headache gave it away)
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Is there a brainstem generator of chronic daily headache?

Is there a brainstem generator of chronic daily headache?

There was no alteration of R2 in any of our subject groups, providing important structural evidence of no change in tissue water content. The decreases in R2' and R2* of RN and SN in the CDH patient group are explained best by flow activation and hyperoxia of these structures associated with head pain. This is supported by unchanged R2' and R2* in episodic migraine patients without headache. A study of CDH patients when headache-free is needed to evaluate if there is increased tissue iron in RN and SN. As noted in the Introduction, activation of these brainstem structures has been observed using fMRI-BOLD [6, 7]. The Fig. 2 a Spin-echo T2-weighted image (TE/TR = 98/2500 ms) of the midbrain showing the red nucleus (RN) and sub- stantia nigra (SN). Eleven images, one from each echo of the GESFIDE pulse sequence were used in the computer cluster analysis (ISODATA) to segment brain tissue. b, c Results of ISODATA segmentation (b) and the segmented zones superimposed on the T2 image (enlarged view) (c). Each color of the ISODATA segmented image is repre- sentative of a different cluster with unique properties in feature space.
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Clinical neurophysiology of chronic daily headache

Clinical neurophysiology of chronic daily headache

Exteroceptive suppression (ES) of muscular activity in the temporalis muscle is an inhibitory brain stem reflex that was applied for the first time by Schoenen in primary headaches [5]. After electrical stimulation of the mental nerve, early (ES1) and late (ES2) exteroceptive silent periods can be recorded over the temples during voluntary jaw occlusion. The second silent period was described to be decreased or abolished in up to 85% of CTTH sufferers [5], but ES2 abnormalities were unable to distinguish patients with chronic daily headache with drug misuse from those with CTTH, ETTH and migraine. This reflects the heterogeneous pathophysiology of CDH patients that evolves from tension- type headache, migraine, or a combination of both. Moreover, various pharmacological agents are able to mod- ulate ES2 duration [6].
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Chronic daily headache: how to manage it?

Chronic daily headache: how to manage it?

of their own lives, more than as an external accident against which there are no defences and the use of a drug is the only response. In this way, patients feel as guilty as addicts, and this anxiety increases the fear of the pain enhancing the cen- tral sensitization, and facilitating the relapse in CDH and drug overuse. In fact, some reports suggested a compulsive mode of assumption of antimigraine analgesics by chronic sufferers, i.e. time-scheduled assumption, preventive assumption of analgesic because of a forecast of headache linked to a partic- ular life event (trip, job, dinner meeting, etc.). This fact could suggest the role of the drug significance in abuse or addictive behavior present in chronic headache patients.
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Diagnosis and Management of Chronic Daily Headache

Diagnosis and Management of Chronic Daily Headache

Chronic daily headache (CDH) is a descriptive term that encompasses multiple headache diagnoses and affects 4% of the general adult population. Chronic daily headache results in significant pain and suffering with substantial impact on quality of life, and enormous economic costs to society. Although most patients with primary CDH suffer from chronic migraine or chronic tension-type headache, other primary and secondary headache disorders can also manifest as a CDH syndrome. For CDH manage- ment to succeed, secondary headaches need to be ruled out with proper investigations when judged necessary. If the diagnosis of primary CDH is established, diagnosis of the specific CDH subtype is imperative to institute appropriate treatment. The diagnosis and manage- ment of distinct CDH entities, chronic migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua, are the primary forms of CDH and the emphasis of this review. Although, strictly speaking, medication overuse headache is a secondary form of CDH, it is also highlighted in this review given its frequent association with primary CDH.
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Many patients present to their physicians with frequent. Chronic Daily Headache: Classification, Diagnosis, and Management CHRONIC DAILY HEADACHE

Many patients present to their physicians with frequent. Chronic Daily Headache: Classification, Diagnosis, and Management CHRONIC DAILY HEADACHE

• Objective: To review the classification, diagnosis, and management of chronic daily headache (CDH). • Methods: Qualititative assessment of the literature. • Results: Many patients present to their physicians with frequent or even daily head pain. Careful evalu- ation of these patients is essential to rule out a num- ber of possible secondary causes of persistent headache, such as trauma, vascular causes, altered intracranial pressure, and neoplastic and infectious processes. Proposed subdivisions of primary CDH include chronic migraine, chronic tension-type head- ache, new daily persistent headache, and hemicra- nia continua. All of these may be exacerbated by frequent use of analgesics (analgesic rebound), and all imply a duration of more than 4 hours and a fre- quency of greater than 15 days per month. A num- ber of medications are available for use in the treat- ment of CDH, but no controlled double-blind studies have examined pharmacotherapy for CDH.
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Chronic Daily Headache in a Patient With Nasopharyngeal Carcinoma

Chronic Daily Headache in a Patient With Nasopharyngeal Carcinoma

Although imaging studies are recommended to identify skull-base invasion, intracranial metastasis or skull-base osteora- dionecrosis, a headache diary is also a practical approach. A 42-year-old woman had been bothered with CDH since she was diagnosed with T3N1M0 stage III NPC 2 years earlier. Although the imaging studies did not show any abnormality, the attending doctor informed her that there remained the possibility of an intracranial or skull-base lesion. She was reg- ularly taking painkillers. Eventually, when her headache diary was examined, the diagnosis of chronic migraine superim- posed on medication overuse headache was made according to the ICHD-IIR. The CDH abated after 1 week of outpatient detoxification. The following half year was uneventful. In reporting this case, we suggest that it would be of interest to a number of disciplines including otorhinolaryngologists, oncologists and radio-oncologists. By avoiding medication overuse in similar patients, we hope to improve the quality of life of these individuals. [J Chin Med Assoc 2010;
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Chronic daily headache: biochemical and neurotransmitter abnormalities

Chronic daily headache: biochemical and neurotransmitter abnormalities

excitability at different levels of the central nervous system (CNS), due to a prolonged nociceptive input from vascular or pericranial myofascial tissues, is believed to play a role in CDH, both in episodic migraine and that evolving from a previous episodic tension-type headache. Recent data sug- gest an alteration in central nociceptive circuits in patients with chronic headache. Fusco et al. [27] investigated the two painful sensations induced by appropriate nociceptive stim- uli, the “first pain”, i.e. the initial pain sensation depending on the applied stimulus and the “second pain” that is char- acterized by a deeper painful sensation, more difficult to localize and with variable duration. Second pain was char- acterized by the phenomenon of temporal summation, i.e. the increase in its intensity due to repeated painful stimuli. This phenomenon is considered to be the physiological cor- relate of the activation of central excitatory circuits. The entity and characteristics of second pain were investigated by the authors in patients affected by transformed migraine, patients with chronic headache ab initio and in patients with chronic tension-type headache. They showed that second pain was significantly amplified and particularly accentuat- ed in all chronic headache patient groups, whereas temporal summation of second pain was altered in patients affected by transformed migraine and chronic headache ab initio (both groups suffered from CDH with superimposed migraine attacks) but not by CTTH. Ergotamine withdrawal in chronic migraine patients who abused this drug induced a decrease of second pain.
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Headache ISSN A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache

Headache ISSN A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache

Our findings corroborate those of a recent clinical trial in which a 3-month course of acupuncture treat- ments improved health status and headache scores compared to no acupuncture. 17 Both studies included patients who experienced frequent headaches, but ours included only patients who met criteria for CDH and who received headache-specialty medical care. In- terestingly, in both studies acupuncture was associated with significant improvements in the SF-36 health do- mains of vitality and role limitations due to physi- cal problems long after the acupuncture treatments had been discontinued, whereas neither study demon- strated between-group changes in the bodily pain domain.
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Phantom headache: pain-memory-emotion hypothesis for chronic daily headache?

Phantom headache: pain-memory-emotion hypothesis for chronic daily headache?

Abstract The neurobiology of chronic pain, including chronic daily headache (CDH) is not completely under- stood. ‘‘Pain memory’’ hypothesis is one of the mechanisms for phantom limb pain. We reviewed the literature to delineate a relation of ‘‘pain memory’’ for the development of CDH. There is a direct relation of pain to memory. Patients with poor memory have less chance to develop ‘‘pain memory’’, hence less possibility to develop chronic pain. Progressive memory impairment may lead to decline in headache prevalence. A similar relation of pain is also noted with emotional or psychiatric symptoms. Literature review suggests that there is marked overlap in the neural network of pain to that of memory and emotions. We speculate that pain, memory, and emotions are interrelated in triangular pattern, and each of these three is related to other two in bidirectional pattern, i.e., stimulation of one of these will stimulate other symptoms/networks and vice versa (triangular theory for chronic pain). Longstanding or recurrent noxious stimuli will strengthen this interrelation, and this may be responsible for chronicity of pain. Reduc- tion of both chronic pain and psychological symptoms by cognitive behavioral therapy or psychological interventions further suggests a bidirectional interrelation between pain and emotion. Longitudinal studies are warranted on the prevalence of headache and other painful conditions in patients with progressive memory impairment to delineate
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What is chronic daily headache? Information for patients Neurology

What is chronic daily headache? Information for patients Neurology

CDH is common in neurology clinics and a period of assessment often lasting weeks or several months is required while a number of diagnoses are being considered. The term CDH can therefore be used during this time without committing to a specific diagnosis but still acknowledging that a person is suffering from chronic and frequent headaches.

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Chronic daily headache: old problems, new vistas

Chronic daily headache: old problems, new vistas

The development of CDH from a pre-existing form of migraine deserves further consideration. Migraine is a chronic illness interspersed with acute signs and symptoms, and although it is currently defined in terms of attacks according to IHS criteria, it displays a considerable variabil- ity in the way it manifests itself in the single individual and especially in different individuals. Whether migraine is con- sidered from the point of view of the attacks (e.g. presence or absence of aura, degree of pain severity) or as a disease (e.g. pattern of onset, recurrence, association with other dis- eases, evolution, outcome), this heterogeneity is a feature that consistently underpins it. For these reasons, migraine can be currently viewed as a “complex disease” [11]. In most cases, migraine has a multifactorial, inherited charac- ter: such level of complexity, however, is further increased by the effect of modifying genes (i.e. those encoding dopamine receptors), by comorbidity, and by the fact that the expression of comorbidity varies over time. The importance of this phenomenon, which may be referred to as “pheno- typical heterochronia”, emerges upon simple observation of the natural history of migraine in the lifetime of different individuals. The phenotypical manifestations remain unchanged over the years in some patients, while in others the clinical picture becomes more complicated, and may include arterial hypertension (per se a risk factor for cere- brovascular accidents), anxiety and mood disturbances. On the other hand, it is well known that the presence of hyper- tension and psychiatric disorders often facilitates changes in the migraine pattern, resulting in forms of CDH [7, 11].
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Chronic daily headache in developmental ages: diagnostic issues

Chronic daily headache in developmental ages: diagnostic issues

The aim of our study was to analyze the clinical features of CDH with childhood or adolescence onset on the basis of the current status of knowledge. The symptoms of CDH in children and adolescents present age-related features [24] and do not overlap with adult characteristics. De- velopmental factors, onset age, comorbidities and several other factors influence the clinical phenomenology, the time trend and the outcome of CDH, even if little is known about them. Two points seem to differentiate the child or adoles- cent clinical expression of CDH compared to the adult form. On one hand, in the developmental age, frequent and severe migraine attacks overlap daily crises of tension-type headache. The onset clinical features are similar to the sub- sequent (chronic) trend. On the other hand, in adults, the tendency of migraine to change over time is more typical, taking tension features with almost daily crises. About 30% of adult CDH sufferers are “unclassifiable” according to IHS criteria [11, 25]. Either the symptomatological features of the crises are incompatible with IHS criteria for chronic tension-type headache, because specific migraine symptoms occur, or the length of the attacks exceeds 72 hours (over the border term accepted for migraine).
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Chronic migraine and chronic daily headache in the Asia-Pacific region: A systematic review

Chronic migraine and chronic daily headache in the Asia-Pacific region: A systematic review

101), together with limited data for other drugs (102–105). This systematic review highlights both the limited population-based prevalence data on CM and CDH in the Asia-Pacific region and the positive steps being taken to remedy this situation, with studies incorporat- ing CDH completed or ongoing in China, India and Pakistan. The available data suggest that the regional prevalence of CDH may be lower than the global aver- age, with the exception of Singapore and Taiwan. The CM prevalence in Taiwan was consistent with inter- national estimates. Given the population of Asia, even conservative prevalence estimates for CM imply that tens of millions of individuals are affected by this disabling condition. The total annual cost of CDH in China was estimated to be USD 9.3 billion (21), while the economic and societal burden of CM in Asia remains to be established. Internationally, economic studies have documented high costs associated with CM and MOH, indicating a need to improve headache management and prevent migraine progression (106,107).
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Psychiatric morbidity and cognitive representations of illness in chronic daily headache

Psychiatric morbidity and cognitive representations of illness in chronic daily headache

We had speculated that HADS-positive patients would be less likely to attribute their headaches to psychological factors, but this was not confirmed by this study. The HADS-positive group was actually more likely to cite psychological factors as causal in their illness than the HADS-negative group was; this was despite the HADS- positive group having more somatic symptoms. This suggests that the HADS-positive group acknowledges the presence of psychiatric symptoms and is able to link these to their headaches. The dexternal attributionsT factor consisted of items that are generally perceived to be beyond the control of the individual, such as daccident or injuryT or dpoor medical care in my pastT. The HADS-positive group was also more likely to endorse these attributions, although this did not reach significance. Overall, CDH patients appear to accept that psychological stressors play a role in their headaches, which may be useful when planning treatment for these patients, in general, and the HADS- positive subset, in particular. We would hypothesise that HADS-positive CDH patients would accept and benefit from treatment that included anxiety management techni- ques, problem solving or other cognitive–behavioural strategies in their treatment.
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The patients’ perceptions of migraine and chronic daily headache: a qualitative study

The patients’ perceptions of migraine and chronic daily headache: a qualitative study

A purposive sample of adult patients, who had suffered from migraine according to International Headache Society (IHS) cri- teria [15], were recruited in Surrey (UK) by theoretical sampling [16]. Participants were recruited through personal contacts (MP and MM), posters in 2 local supermarkets and letters to 20 mem- bers of the Migraine Action Association. Thirty-nine participants had been in contact with the researcher to obtain a final sample of 15 participants. Due to the high frequency of their headaches (>15 days per month), 5 participants were classed as suffering from CDH. Dissimilar cases were recruited to reflect a range of personal characteristics based on gender, socio-demographics, age, headache-related disability and consultation status. The pur- pose of recruiting dissimilar cases was to ensure that the findings were applicable to the wider population of headache sufferers, and not necessarily for generalisation to the wider population. Headache-related disability was assessed by the Migraine Disability Assessment (MIDAS) questionnaire [17]. MIDAS scores of 0–5 signify ‘minimal or infrequent disability’, scores of 6–10 ‘mild or infrequent disability’, scores of 11–20 ‘moder- ate disability’ and 21 and above ‘severe disability’. Consultation status was determined according to Lipton and Stewart [9]. Patients who had never consulted a physician about migraine were classed as ‘never consulter’. Patients who had consulted within the last year were classed as ‘current consulter’ and those who had not consulted for more than one year were classed as ‘lapsed consulter’ [9]. The participants’ characteristics are described in Table 1.
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The effect of sodium valproate on chronic daily headache and its subgroups

The effect of sodium valproate on chronic daily headache and its subgroups

VPA, have mechanisms of action that may be effective for the prevention of chronic headaches and migraine attacks. In our study VPA has significantly positive effect on PF and MaxVAS level in patients with CDH. As there was no statistically significant difference between the VPA and placebo groups by means of decrement in GnVAS values in first and third months after the treatment, decrement in MaxVAS level and PF parameters occurred in the same period was significant. This means that there was a statis- tically significant decrease in MaxVAS levels and pain frequencies in VPA given group. Freitag et al. [3] in a ret- rospective study, reported that divalproex sodium can be used for a prolonged period as a sole agent for the successful treatment of CDH. In their report, nearly 75% of the patients had at least a 50% reduction in PF. Mathew and Ali [21] conducted an open-label trial of 30 patients using doses of divalproex sodium between 1,000 mg and 2,000 mg per day. Based on weekly headache index, headache-free days, dysfunctional days, patients’ general well-being rating and physicians’ global assessment were improved significantly in two-thirds of the patients. In another study, Rothrock et al. [22] consecutively recruited 75 patients with intractable headache syndromes, divided them into three groups as frequent migraine, transformed migraine, and tension type headache based on their headache symptoms and treated all the 75 patients with 500 mg divalproex sodium twice daily. Thirty-six patients (48%) reported a 50% or greater reduc- tion in headache frequency. Contrarily, Vijayan and Spillane [23] reported that VPA was not significantly effective in the treatment of CDH in 16 patients.
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