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Pain Management

Chronic Daily Headaches

chronic daily headaches - treatingpain.com

Headaches are a common source of pain affecting 50% of the adult population at any given time. Worldwide, 66% of the population has experienced a headache at some time in their life.

“Chronic daily headache” is an umbrella term for several types of headaches. The term “chronic” describes the persistent nature of these headaches that may last for years on end. The term “daily” indicates that these headaches may start on a daily basis.

You may have a chronic daily headache and find that it interferes with your work, disturbs your sleep, and decreases the quality of your life. A pain specialist can help you find the right treatment for your headache. You can also reduce the frequency of your headaches by avoiding your headache triggers. 

The chronic daily headache

You have this disorder if you experienced headaches for more than 15 days a month, over the last three months.

A primary chronic daily headache is not linked to an underlying illness. It can start after stress, a change in blood pressure, a dilation or narrowing of your blood vessels. An example of this type of headache is a migraine, although there are multiple different subgroups of chronic daily headaches.

A primary chronic headache may be further divided into:

  • Short-duration headaches that last under four hours.
  • Long-duration headaches that last over four hours.

Short-duration headaches

There are several different types of headaches where a single pain episode lasts under 4 hours.

Some examples:

Hypnic headaches

  • Start during sleep
  • Last more than 15 minutes after you wake up
  • Usually, start after 50 years of age

Headaches related to coughing

  • Triggered by a cough or a strain (a Valsalva maneuver)
  • Last anywhere from 1 second to 30 minutes
  • Your doctor must rule out more serious (secondary) causes when you have this type of headache

Exertional headaches

  • Brought on by physical strain
  • Pain may feel like it is “pulsating”
  • Can last anywhere from 5 minutes to 2 days
  • Must rule out secondary causes

Stabbing headache

  • Short-lasting stabs of pain over your eye, temple and on the sides of your head
  • There are no other symptoms such as nausea or light sensitivity

Cluster headache

  • Deep stabbing pain behind the eye
  • Starts suddenly
  • Lasts 15 minutes to 3 hours
  • May start once every other day or may start 8 times a day
  • Headache episodes occur up to a year with an occasional one-month remission (stop in pain)
  • Symptoms in the eye or nose, on the same side as the headache. For example:
  1. Eye turns red or eyelid swells
  2. Nose is stuffed up or watery
  3. Forehead or face starts sweating
  4. Pupil changes size

Chronic paroxysmal hemicrania (CPH)

  • A severe headache on one side of the face, usually around the eye or temple
  • Starts suddenly
  • Up to 5 short episodes a day
  • Episodes last 2 to 30 minutes (less than a cluster headache)
  • Has some of the same “one-sided” symptoms as a cluster headache (watery eye, red eye, changes in pupil size)
  • More common in women
  • No neurological symptoms (vision changes or sensitivity to light)

Long-duration headaches

Long-duration headaches are primary headaches that last over four hours.

Here are some examples:

Hemicrania continua

  • Non-stop pain on one side of the face
  • Pain is of moderate severity
  • There may be:
  • Eye redness or tearing
  • Nose congestion or a runny nose
  • A droopy eyelid or a change in pupil size

Migraine

  • Usually, the pain is on one side of the head
  • Lasts 4 to 72 hours
  • There is often nausea/vomiting and a sensitivity to light and sound
  • The appearance of an “aura” – lights flashing or other vision changes
  • Activity and stress make it worse
  • Rest helps

New daily persistent headache

  • Is felt daily for more than 3 months;
  • Usually, pain is on both sides of the head
  • Has a pressing/tightening “vice-like” quality
  • Activity does not make it worse
  • No other symptoms in the eye or nose

Tension-type headache

  • The pain episodes start to increase in frequency until it becomes a chronic headache
  • Increase in frequency from episodic to a chronic headache
  • Usually felt on both sides of the head
  • Has a pressing/tightening quality
  • Activity does not make it worse
  • No other symptoms in the eye or nose

Secondary Headaches

Sometimes a headache is a red flag that something else is wrong. They are called secondary headaches because there is a second cause for the pain.

A secondary chronic daily headache results from an underlying illness, infection, a deformity in your vessels, or even from taking too much medication. The underlying problem needs to be treated in order for a headache to go away.

  • Intracerebral hemorrhage is a sudden rush of blood into your brain after a trauma or a blood vessel rupture. A headache starts suddenly, along with confusion and an inability to move a part of your body.
  • Brain tumors may present with a new headache, that starts after 50 years of age.
  • Giant cell arteritis is an inflammation of the lining of the arteries in your head. In addition to headaches, there are general body symptoms: weight loss, fevers, muscle aches.
  • Encephalitis and meningitis are inflammations in the brain or in the lining of the brain, due to a viral infection. A headache may be felt alongside confused thinking, seizures, or problems with senses or movement.
  • Postpartum preeclampsia results in a headache after a recent pregnancy. It is the result of high blood pressure in women that normally don’t suffer from this problem.

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When to see a doctor

Occasional headaches are common and usually do not require medical attention.

However, you may need to see a doctor if:

  • You have more than 2 headaches each week
  • You take an over-the-counter pain reliever for your headaches on most days
  • Your over-the-counter pain medicine does not improve your headaches
  • Headaches become more frequent or more intense
  • The headaches interfere with your concentration or sleep

Diagnosis

Your primary care doctor, a neurologist, or a pain specialist can help you to control your headaches. The doctor will start by asking detailed questions about the quality (sharp, dull) of your pain. He/she will perform a neurologic exam that evaluates your eyes, strength, and balance. Imaging tests are done if needed.

The following may be ordered:

  • Magnetic resonance imaging (MRI) is the most useful test for finding secondary causes for your headache. It is more sensitive (more likely to find the problem) than computed tomography (CT). An MRI with contrast media (a substance that is injected in your vein), will detect a brain tumor. An MRI will appear normal if the cause for your pain is a primary headache.
  • Computed tomography is a better test if a headache is suspected due to an intracranial bleeding or a pressure from a mass.

Treatment with medications

Medications for chronic daily headaches serve two purposes: to control headaches once they start and to prevent headaches. An overuse of pain medications may actually lead to rebound headaches. Rebound headaches start as your body withdraws from the effects of medication that may have initially helped treat your headache.

Therefore, medication overuse may be a secondary cause for your headaches. In this situation, your doctor may stop the medications you are using for acute (sudden-onset) headaches and eventually replace them with prophylactic medications (medications that prevent headaches). This can determine if medication overuse is increasing your headaches.

Medications that control headaches

  • Acetaminophen (Tylenol) is an over the counter pain reliever.
  • Nonsteroidal anti-inflammatory drugs (Aspirin, Motrin) – medications that stop pain resulting from inflammation.
  • Triptans are a family of tryptamine-based drugs used to stop migraines and cluster headaches.

Medications that prevent headaches

There are multiple medications that reduce the frequency of chronic daily headaches. Consult your pain specialist for a personalized regimen to prevent headaches.

  • Amitriptyline (Elavil) is an antidepressant that reduces the duration of headaches as well as the severity. It is used for chronic tension-type headaches.
  • Tizanidine (Zanaflex) is an alpha2-adrenergic agonist that is effective for chronic migraine and chronic tension-type headache. It reduces headache severity, frequency, and duration.
  • Gabapentin (Neurontin), a gamma-aminobutyric acid analogue, increases the number of headache-free days compared with placebo in patients who have chronic daily headaches.
  • Valproate (Depacon) and topiramate (Topamax) are anticonvulsants that can reduce the frequency of chronic migraine by 50%.
  • Propranolol is a beta blocker (a medication that is often used to control high heart rates) that also reduces the frequency of migraines. Its effectiveness for chronic migraine treatment is unclear.
  • OnabotulinumtoxinA (Botox) is an injectable substance that reduces the frequency of chronic migraines.

Prevention Tips

You can also reduce the frequency of your headaches by taking precautions to avoid habits that can cause headaches.

For example:

  1. Avoid headache triggers. For example, migraines can start when you’re tired or after you eat a certain food, such chocolate. A diary can help you keep track of what you were doing before your headache started. Include details such as the time of day the headache started and how long it lasted.
  2. Get enough sleep. Try to rest for seven to eight hours a night. Try to go to bed and wake up at the same time every day.
  3. Limit caffeine intake. Excessive caffeine use can lead to rebound headaches.
  4. Avoid medication overuse. Taking headache medications more than twice a week can increase the severity and frequency of your headaches. Your doctor can prescribe some medications that prevent headaches.
  5. Relaxation techniques can decrease the frequency and severity of chronic daily headaches, and reduce medication use.
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