Chronic Daily Headache

Chronic daily headache is a descriptive term for headache present on 15 or more days per month for more than 3 months, lasting 4 hours or more per day in most. It affects 3 to 5 percent of adults, is more common in women, and is a major cause of disability. It is not a single diagnosis, so the aim is to identify the subtype, the contributing factors and any secondary cause.

• Primary subtypes with long duration (4 hours or more): chronic migraine (headache on 15 or more days per month, with migraine features on at least 8 of those days), chronic tension type headache, new daily persistent headache (abrupt onset in a person with no headache history, becoming continuous within 3 days), and hemicrania continua (strictly unilateral, continuous, indomethacin responsive).
• Medication overuse headache is the most common secondary driver: simple analgesics on 15 or more days per month, or triptans, opioids, ergots and combination analgesics on 10 or more days per month, for more than 3 months.
• Secondary causes of daily headache: cervicogenic headache, temporomandibular disorders, raised intracranial pressure (idiopathic intracranial hypertension, mass lesion), low cerebrospinal fluid pressure, chronic sinus disease, sleep apnoea, hypertension, giant cell arteritis (age over 50), cerebral venous thrombosis, chronic subdural haematoma, after head injury, medicines (nitrates, calcium channel blockers, caffeine), and carbon monoxide.
• Risk factors for progression: frequent attacks, obesity, depression and anxiety, sleep disorders, high caffeine intake, medicine overuse, snoring, and stressful life events.

• Headache pattern (location, quality, severity, duration, frequency, triggers) and associated features: photophobia, phonophobia, nausea, aura, unilateral location, throbbing, worsening with activity (migraine); bilateral pressing tightness of mild to moderate intensity (tension type); continuous side locked pain with autonomic signs (hemicrania continua).
• Medicine history: all analgesics, triptans, opioids, caffeine, over-the-counter combinations, quantity and days per month.
• Mood, anxiety, sleep, snoring, neck pain, jaw symptoms, diet, caffeine, alcohol.
• Red flags: new headache after age 50, thunderclap onset, progressive pattern, change from usual headache, neurological deficit, papilloedema, seizures, fever and neck stiffness, jaw claudication, scalp tenderness, visual loss, headache with exertion or coughing, postural headache (worse upright or lying), pregnancy or postpartum, cancer, immunosuppression, HIV, and recent head injury.
• Examination: blood pressure, temporal arteries, fundi, cranial nerves, neck, jaw and pericranial tenderness, gait, and visual fields.

• Clinical diagnosis from history, a headache diary for 4 to 8 weeks (days, severity, treatment, medicine use, triggers, menstrual relation), and examination.
• Blood tests in at risk groups: full blood count, C-reactive protein, erythrocyte sedimentation rate (age over 50), thyroid function, glucose, urea and electrolytes, ferritin, vitamin D if indicated.
• Neuroimaging (magnetic resonance imaging of the brain, with venography when venous thrombosis is suspected) for red flags, abnormal examination, new onset after 50, or headache not fitting a primary pattern; contrast enhanced if infection or mass.
• Lumbar puncture with opening pressure when raised pressure, infection or subarachnoid haemorrhage is suspected after imaging.
• Temporal artery ultrasound or biopsy for suspected giant cell arteritis (give prednisolone 40 to 60 mg daily immediately while arranging).
• Sleep study for snoring, obesity and morning headache.
• Medication overuse headache is diagnosed by the history of overuse and often improves 2 months after withdrawal.
• Differentials: cervicogenic headache, temporomandibular disorder, raised or low intracranial pressure, giant cell arteritis, venous thrombosis, chronic sinus disease, sleep apnoea related headache, trigeminal autonomic cephalalgias (cluster headache), idiopathic intracranial hypertension, spontaneous intracranial hypotension, cervicogenic headache.

Education and self management

• Explain that headache is real and treatable, and that medicine overuse, sleep, caffeine, regular meals, hydration, regular exercise (30 minutes of aerobic activity, 3 to 5 days a week), weight loss, and stress management reduce attacks.
• Limit caffeine to under 200 mg daily (two cups of coffee), avoid alcohol triggers, keep a regular sleep schedule, and use relaxation, biofeedback or cognitive behavioural therapy.
• Treat depression, anxiety and sleep disorders; consider continuous positive airway pressure for sleep apnoea.

Medication overuse headache (when present)

• Withdraw the overused medicine, abruptly for simple analgesics, triptans and ergots (and gradually for opioids, barbiturates and benzodiazepines), for at least 2 months. Expect a temporary worsening for 2 to 10 days. Start a preventive drug at the same time and give a short bridge: naproxen 500 mg orally twice daily for 2 weeks, or prednisolone 40 to 60 mg daily tapered over 5 to 10 days (specialist advice), with antiemetics (metoclopramide 10 mg or domperidone 10 mg) as needed.
• After withdrawal, limit acute treatment to simple analgesics on fewer than 14 days per month and triptans, opioids and combinations on fewer than 10 days per month (preferably fewer than 8 triptan days).

Preventive treatment (headache on 15 or more days per month; give each drug for 8 to 12 weeks at an adequate dose before judging it)

• Amitriptyline 10 mg orally at night, increased by 10 mg weekly to 50 to 75 mg (sedation, dry mouth, constipation; avoid in arrhythmia, glaucoma, urinary retention, and in older adults at high dose).
• Topiramate 25 mg orally at night, increased by 25 mg weekly to 50 mg twice daily (maximum 100 mg twice daily); side effects: paraesthesia, cognitive slowing, weight loss, kidney stones, glaucoma; teratogenic and reduces the efficacy of hormonal contraceptives at doses above 200 mg, so effective contraception is essential in women of childbearing age.
• Propranolol 40 mg orally twice daily (or 80 mg modified release daily), up to 160 to 240 mg daily; avoid in asthma, heart block, bradycardia. Alternatively candesartan 8 mg daily increasing to 16 mg, in those with hypertension.
• Venlafaxine modified release 75 mg daily, up to 150 mg, in coexisting depression or anxiety; sodium valproate is avoided in women of childbearing age.
• Onabotulinumtoxin A 155 units, injected at 31 sites across the head and neck every 12 weeks, for chronic migraine in specialist centres, after at least 2 or 3 failed preventives; stop if there is less than a 30 percent response after 2 to 3 cycles.
• Calcitonin gene related peptide antibodies by specialist: erenumab 70 mg or 140 mg subcutaneously monthly; fremanezumab 225 mg monthly or 675 mg every 3 months; galcanezumab 240 mg loading dose then 120 mg monthly; eptinezumab 100 mg or 300 mg intravenously every 12 weeks. Avoid in pregnancy, severe constipation (erenumab) and uncontrolled hypertension (erenumab).
• Neuromodulation devices, nerve blocks (greater occipital nerve injection with lidocaine 1 to 2 percent plus methylprednisolone 40 mg) and acupuncture are options.

Acute treatment of attacks

• Aspirin 900 mg, ibuprofen 400 to 600 mg or naproxen 500 to 750 mg with metoclopramide 10 mg, and a triptan for migraine (sumatriptan 50 to 100 mg, rizatriptan 10 mg, eletriptan 40 mg, or zolmitriptan 2.5 mg), repeated once after 2 hours if needed; avoid triptans in coronary disease, uncontrolled hypertension, hemiplegic or brainstem aura, and avoid opioids.

Other subtypes

• Hemicrania continua: indomethacin 25 mg orally three times daily with food, increased by 25 mg every 3 days to 50 mg three times daily (maximum 225 mg daily) with a proton pump inhibitor; once control is achieved, reduce to the lowest dose.
• Chronic tension type headache: amitriptyline 10 mg at night increased to 50 mg; physiotherapy, relaxation and cognitive behavioural therapy; avoid regular simple analgesics.
• New daily persistent headache: reassure; use the preventive and acute treatments that match the migraine or tension type features; refractory cases need specialist referral.

Special groups

• Pregnancy: paracetamol 1 g up to four times daily for acute attacks, avoid topiramate, valproate, candesartan and CGRP antibodies; propranolol and amitriptyline are used with specialist advice; folic acid 5 mg daily is advised if topiramate is considered in women at risk of pregnancy.
• Older adults: exclude giant cell arteritis, subdural haematoma, mass lesion and medicine causes first; use lower doses of amitriptyline and propranolol.
• Children and adolescents: review sleep, caffeine, school stress and screen time; amitriptyline 10 mg at night or propranolol are options with paediatric advice; refer when daily headache persists.

Follow up

• Review at 4 to 8 weeks with the diary, again at 3 months, and every 6 months after improvement; stop preventives after 6 to 12 months of good control and taper slowly. Refer for diagnostic uncertainty, red flags, failure of two preventives, medicine overuse that does not resolve, or progressive disability.