Chronic daily headache: Associated syndromes, evaluation, and management

INTRODUCTION — Chronic daily headache (CDH) is a descriptive term that encompasses several different specific headache diagnoses characterized by frequent headaches.

Primary CDH subtypes of long duration (ie, four hours or more) are chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Medication overuse headache, a secondary headache disorder, frequently complicates management of multiple primary headache disorders.

Primary headache types of shorter duration that can be chronic and occur daily are chronic cluster headache, chronic paroxysmal hemicrania, hypnic headache, and primary stabbing headache.

This topic will provide an overview of the subtypes of CDH. These headache subtypes are discussed in greater detail individually in appropriate separate topic reviews.

DEFINITION — CDH is not a specific headache type, but a descriptive term that encompasses other primary and secondary headaches. The term "chronic" in CDH refers either to the frequency of headaches or to the duration of the disease, depending upon the specific headache type.

ASSOCIATED HEADACHE SYNDROMES — The subtypes of CDH are briefly reviewed in the following sections and are discussed in greater detail in individual topic reviews as noted for each subtype.

Common headache disorders — The classification of CDH as a form of headache is based upon criteria originally proposed in 1996 by Silberstein and Lipton (the SL criteria) [1]. However, the International Classification of Headache Disorders, 3^rd edition (ICHD-3) does not define CDH [2]. Rather, CDH is a descriptive term that most commonly encompasses five subtypes of frequent headaches defined by ICHD-3:

●Chronic migraine headache

●Chronic tension-type headache

●Medication overuse headache (MOH)

●Hemicrania continua

●New daily persistent headache

These headache types are characterized by prolonged headaches lasting four hours or longer [3]. The term CDH is applied when the headache frequency is 15 or more days a month for longer than three months in the absence of organic pathology.

Chronic migraine — Chronic migraine typically occurs in those with a history of episodic migraine headache. Through a process known as migraine transformation, some patients with an episodic migraine pattern transition to a chronic migraine pattern (≥15 headache days a month). Many patients with chronic migraine have daily or near-daily headaches of low to moderate severity. Superimposed on this baseline are exacerbations of pain with more prominent migrainous features. (See "Chronic migraine".)

Chronic tension-type headache — Tension-type headache is a bilateral, nonthrobbing "featureless" headache characterized by gradual onset and mild to moderate intensity with or without pericranial muscle tenderness. Chronic tension-type headache is diagnosed when the headache is present for 15 or more days a month. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis".)

Medication overuse headache — MOH, a secondary type of headache, was previously termed analgesic rebound headache, drug-induced headache, and medication-misuse headache. MOH is the classification used when a primary headache develops or markedly worsens during medication overuse. In practice, MOH is typically preceded by an episodic headache disorder, most often migraine or tension-type, that has been treated with frequent and excessive amounts of acute symptomatic medications. (See "Medication overuse headache: Etiology, clinical features, and diagnosis".)

Hemicrania continua — Hemicrania continua is a strictly unilateral, continuous headache with superimposed exacerbations of moderate to severe intensity accompanied by ipsilateral cranial autonomic features and sometimes by migrainous symptoms. It is responsive to indomethacin. Remitting and unremitting forms have been described. (See "Hemicrania continua".)

New daily persistent headache — The syndrome of new daily persistent headache is characterized by headache that begins rather abruptly and is daily and unremitting from onset or within 24 hours at most, typically in individuals without a prior headache history. Considerable variability is seen in the clinical features. The pain is often bilateral, pressing or tightening in quality, and of mild to moderate intensity. However, migrainous features such as unilateral headache, throbbing pain, and associated photophobia are common. (See "New daily persistent headache".)

Other headache disorders — Additional headache subtypes with shorter individual headaches (ie, less than four hours) are considered in the spectrum of CDH when the duration of the condition itself persists without remission. These include:

●Chronic cluster headache (must persist for at least one year without remission or with remissions lasting less than three months)

●Chronic paroxysmal hemicrania (must persist for at least one year without remission or with remissions lasting less than three months)

●Hypnic headache

●Short-lasting unilateral, neuralgiform headache attacks

●Primary stabbing headache

Chronic cluster headache — Cluster headache is characterized by attacks of severe unilateral orbital, supraorbital, or temporal pain. Most patients have unilateral cranial autonomic symptoms during an attack that are ipsilateral to the pain and may include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. A sense of restlessness or agitation is common during cluster attacks. Attacks usually last 15 to 180 minutes.

In the episodic form of cluster headache, attacks occur once every other day to eight times a day for some weeks, followed by a period of remission. The chronic form of cluster headache lacks sustained remissions. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".)

Chronic paroxysmal hemicrania — Patients with paroxysmal hemicrania typically have unilateral, brief, severe attacks of pain associated with cranial autonomic features that recur several times per day. An individual headache attack usually lasts 2 to 30 minutes. The mean attack frequency is 11 to 14 daily, with at least five attacks per day required by ICHD-3 diagnostic criteria. About 80 percent of patients have the chronic form of paroxysmal hemicrania, in which attacks occur for more than one year without remission or with remission periods that last less than three months. By definition, paroxysmal hemicrania is prevented completely by indomethacin. (See "Paroxysmal hemicrania: Clinical features and diagnosis".)

Hypnic headache — Hypnic headache, also known as "alarm clock headache," occurs almost exclusively after the age of 50 and is characterized by episodes of dull head pain, often bilateral, that awaken the sufferer from sleep. (See "Hypnic headache".)

Short-lasting unilateral neuralgiform headache attacks — Short-lasting unilateral neuralgiform headache attacks are divided into two subtypes:

●Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)

●Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)

SUNCT and SUNA are characterized by sudden brief attacks of severe unilateral head pain in orbital, peri-orbital, or temporal regions, accompanied by ipsilateral cranial autonomic symptoms. In SUNCT, the ipsilateral autonomic symptoms consist of both conjunctival injection and lacrimation. In SUNA, the autonomic symptoms may include either conjunctival injection or lacrimation but not both. There can be other cranial autonomic symptoms (eg, nasal congestion and/or rhinorrhea, or eyelid edema) with both SUNCT and SUNA. (See "Short-lasting unilateral neuralgiform headache attacks: Clinical features and diagnosis".)

Primary stabbing headache — Primary stabbing headache is characterized by sudden brief attacks of sharp, jabbing head pain in orbital, peri-orbital, or temporal regions. The stabs last a few seconds and occur at irregular intervals from once to many times each day. (See "Primary stabbing headache".)

EPIDEMIOLOGY — The prevalence of CDH among adults worldwide is approximately 4 percent [4-6]. Females are affected two to three times more often than males. The vast majority of CDH patients suffer from either chronic tension-type headache, chronic migraine, or medication overuse headache.

CDH results in significant pain and suffering, reductions in quality of life, and enormous economic costs to society [7,8].

DIAGNOSIS — CDH is suspected on the basis of a compatible headache history. Other disorders causing secondary headache must be excluded. (See 'Red flags' below.)

CDH is not a diagnosis but is a term used to refer to several specific headache diagnoses. Associated common conditions and diagnostic criteria include:

●Chronic migraine (table 1)

●Chronic tension-type headache (table 2)

●Medication overuse headache (table 3)

●Hemicrania continua (table 4)

●New daily persistent headache (NDPH) (table 5).

The CDH term is also used when there is persistence of headache subtypes with shorter individual headaches (ie, chronic cluster headache, chronic paroxysmal hemicrania, hypnic headache, or primary stabbing headache) for at least one year without remission.

Evaluation — The diagnostic process of a CDH does not differ from that of other headache types. The clinician must determine the level of suspicion for a secondary versus a primary headache disorder. This is based upon a careful medical and headache history and a comprehensive physical and neurologic examination. With all subtypes of CDH, it is important to evaluate for the possibility of medication overuse as a causal or contributing factor in the production of CDH. (See "Medication overuse headache: Etiology, clinical features, and diagnosis".)

Special attention should be directed to the carotid and temporal arteries, cervical paraspinal muscles, range of motion at the neck, temporomandibular joints, sinuses, and ocular fundi. (See "Evaluation of headache in adults" and "Evaluation of the adult with nontraumatic headache in the emergency department".)

In general, patients with a CDH have normal physical and neurologic examinations. However, some headache types may be associated with specific abnormalities:

●With tension-type headache, there may be pericranial muscle tenderness.

●Chronic migraine may have manifestations, such as hyperalgesia and allodynia, related to sensitization of primary nociceptors and central trigeminovascular neurons.

●With the trigeminal autonomic cephalalgias (eg, cluster headache, hemicrania continua, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks), there may be evidence of cranial autonomic activation.

Other abnormalities on examination should raise suspicion for a secondary headache disorder.

The findings of the clinical history and examination determine whether further diagnostic testing is necessary. Investigations are considered on an individual basis and may include blood tests, brain imaging, neurovascular imaging (cerebral arteries and/or venous sinuses), cervical spine imaging, lumbar puncture, and others as indicated.

Red flags — The presence of "red flags" (potentially worrisome features) in the history and abnormalities on examination increase the suspicion for a secondary headache disorder and thus decrease the threshold for ordering diagnostic tests.

Worrisome historical features include but are not limited to:

●Older age of onset of headache (>50 years of age)

●Acute onset (thunderclap) headache

●New onset of headaches

●Significant change in the characteristics of prior headaches

●Signs or symptoms of systemic illness (eg, fever, chills, weight loss)

●Neurologic symptoms (eg, diplopia, limb weakness, pulsatile tinnitus) that are distinct from typical aura symptoms

●Known systemic illnesses that predispose to secondary headaches (eg, cancer, HIV)

●Headaches associated with maneuvers that increase or decrease intracranial pressure (eg, orthostatic headaches, Valsalva-induced headaches)

The presence of one or more of these features should prompt evaluation with appropriate studies [3].

Differential diagnosis — Although a list of causes of secondary headaches would be exhaustive, it includes metabolic abnormalities, infections, mass lesions, intracranial hypotension, intracranial hypertension, cerebral venous sinus thrombosis, vasculitis, cervicogenic headache, post-traumatic headache, and many others.

TREATMENT — The management of a CDH depends on the specific headache type and the presence or absence of medication overuse.

●The treatment of chronic migraine should focus on prophylactic therapy while avoiding migraine triggers and limiting the use of acute headache medications to prevent medication overuse headache. Prophylactic interventions may include pharmacotherapy, behavioral therapy, or physical therapy. Management often requires the simultaneous use of these different modalities. (See "Chronic migraine", section on 'Management'.)

●For chronic tension-type headache, effective preventive treatment involves the use of daily prophylactic medications, behavioral therapies, and physical therapy. Like chronic migraine, the combined use of these interventions is often optimal. (See "Tension-type headache in adults: Preventive treatment" and "Tension-type headache in children", section on 'Treatment'.)

●For medication overuse headache, basic steps in the management are to educate the patient, discontinue the offending medication and provide symptomatic bridge therapy, and establish preventive therapy appropriate for the underlying headache disorder to reduce the frequency of taking symptomatic medications and prevent relapses. (See "Medication overuse headache: Treatment and prognosis".)

●Hemicrania continua is responsive to indomethacin. (See "Hemicrania continua", section on 'Treatment'.)

●New daily persistent headache may be resistant to treatment. Although evidence is lacking, one suggested approach is to first classify the phenotype of new daily persistent headache as most similar to either migraine or chronic tension-type headache and then treat with appropriate preventive headache therapy accordingly. (See "New daily persistent headache", section on 'Treatment'.)

●Treatment for chronic cluster headache includes preventive therapy to reduce the frequency of attacks and acute therapy to reduce the duration of attacks. (See "Cluster headache: Treatment and prognosis", section on 'Preventive interventions'.)

●For chronic paroxysmal hemicrania, indomethacin is the treatment of choice. (See "Paroxysmal hemicrania: Treatment and prognosis".)

●For hypnic headache, limited evidence suggests that several treatments are effective, including caffeine at bedtime, indomethacin, and lithium carbonate. (See "Hypnic headache", section on 'Management'.)

●Short-lasting unilateral neuralgiform headache attacks tend to be more refractory to treatment than other primary headaches. Preventive treatments with at least limited evidence for benefit include anticonvulsants (lamotrigine, topiramate, gabapentin, carbamazepine, valproic acid), lithium, and glucocorticoids. (See "Short-lasting unilateral neuralgiform headache attacks: Treatment and prognosis".)

●Primary stabbing headache may respond to melatonin or indomethacin. (See "Primary stabbing headache", section on 'Treatment'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Headaches in adults (The Basics)")

●Beyond the Basics topic (see "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition and epidemiology – Chronic daily headache (CDH) is not a specific headache type but a descriptive term that encompasses other headaches. The term "chronic" refers either to the frequency of headaches or to the duration of the disease, depending upon the specific headache type. The worldwide prevalence of CDH among adults is approximately 4 percent. Most patients with CDH have either chronic tension-type headache or chronic migraine. (See 'Definition' above and 'Epidemiology' above.)

●Common headache disorders – CDH commonly occurs in disorders characterized by headaches lasting four or more hours when the headache frequency is 15 or more days a month for longer than three months in the absence of organic pathology. These include:

•Chronic migraine (see 'Chronic migraine' above)

•Chronic tension-type headache (see 'Chronic tension-type headache' above)

•Medication overuse headache (see 'Medication overuse headache' above)

•Hemicrania continua (see 'Hemicrania continua' above)

•New daily persistent headache (see 'New daily persistent headache' above)

●Other headache disorders – CDH may also occur in headache disorders typically of shorter duration (ie, less than four hours) when the condition itself occurs as a prolonged duration without remission. The headache disorders include:

•Chronic cluster headache (see 'Chronic cluster headache' above)

•Chronic paroxysmal hemicrania (see 'Chronic paroxysmal hemicrania' above)

•Hypnic headache (see 'Hypnic headache' above)

•Short-lasting unilateral neuralgiform headache attacks (see 'Short-lasting unilateral neuralgiform headache attacks' above)

•Primary stabbing headache (see 'Primary stabbing headache' above)

●Diagnosis – The diagnosis of CDH is suspected on the basis of a compatible headache history. Other disorders causing secondary headache must be excluded. (See 'Diagnosis' above.)

●Evaluation – The findings of the clinical history and examination determine whether further diagnostic testing is necessary. Worrisome historical features include but are not limited to:

•Older age of onset of headache (>50 years of age)

•Acute onset (thunderclap) headache

•New onset of headaches

•Significant change in the characteristics of prior headaches

•Signs or symptoms of systemic illness (eg, fever, chills, weight loss)

•Neurologic symptoms (eg, diplopia, limb weakness, pulsatile tinnitus) that are distinct from typical aura symptoms

•Known systemic illnesses that predispose to secondary headaches (eg, cancer, HIV)

•Headaches associated with maneuvers that increase or decrease intracranial pressure (eg, orthostatic headaches, Valsalva-induced headaches)

Investigations are considered on an individual basis and may include blood tests, brain imaging, neurovascular imaging (cerebral arteries and/or venous sinuses), cervical spine imaging, lumbar puncture, and others as indicated. (See 'Evaluation' above.)

●Treatment – The management of CDH depends on the specific headache type and the presence or absence of medication overuse. (See 'Treatment' above.)