What is chronic daily headache?

As its name suggests, chronic daily headache^[1] (CDH) is the name given to long-lasting, frequent headaches. By definition, chronic daily headache refers to a headache that occurs 15 days or more per month.Chronic daily headache is not a specific type of headache. There are many different types of headaches, from tension headaches to migraines, and CDH can be just about any type. Instead, chronic daily headache refers to the duration and frequency of these headaches. Chronic daily headache can be primary (without an identifiable cause) or secondary (caused by an underlying health problem or disorder). CDH can also be characterized as short-lasting or long-lasting, depending on whether headaches last for fewer or more than four hours. Because CDH features such constant symptoms, it can have a significant impact on an individual’s quality of life. Generally, both aggressive initial treatment and longer-term symptom management are required to help patients achieve relief. The goal of treatment is to reduce the severity and frequency of headaches.

How common is chronic daily headache?

Chronic daily headache is said to affect roughly 4%^[2] of the general population. The two most common types of primary CDH are chronic tension-type headache (CTTH, which affects between 0.9–2.2% of Americans^[3]) and chronic migraine (CM, which affects 0.67% of Americans^[4]). Medication overuse headache, another common form of CDH, affects between 1–2% of people worldwide^[5]. The prevalence of MOH in the population is 1.4% and higher in chronic migraine sufferers (0.9% of population; 2/3 of all MOH), versus CTTH (0.4%) and NDPH (0.1%). More than 12% of adults^[6] in the United States experience migraines, with women three times more likely than men to have migraines. This type of headache is the most common underlying cause of CDH pain that is severe enough to be disabling.

Types of chronic daily headache

As previously stated, chronic daily headache is not a specific type of headache, but the term given to headaches that occur frequently over a long period of time. There are multiple different types of headaches that can progress to CDH. Each type of headache can have different causes, symptoms, and diagnostic criteria.

Medication overuse headache

Also called rebound headache, this is one of the most common forms of chronic daily headache. As its name suggests, medication overuse headache^[7] (MOH) is caused by the consistent long-term use of medication used to treat headaches (particularly in those who experience migraines). Because of this, it is considered a secondary CDH. MOH headaches usually occur every day or almost every day. They often improve with pain medication but return once the medication begins to wear off. The signs and symptoms of medication overuse headache can vary depending on the initial type of headache that was being treated and the kind of medication that was used. Symptoms generally fade once you stop taking the pain medication that led to MOH.

Chronic tension-type headache

Chronic tension-type headache^[8], or CTTH, often causes mild-to-moderate bilateral pain (pain that affects both sides of the head). This pain usually feels pressing or tight (but not pulsating) and is not worsened by everyday physical activity. CTTH may also be accompanied by either photophobia (sensitivity to light) or mild nausea with or without vomiting. CTTH is a primary headache disorder and is usually diagnosed when another secondary cause—including medication overuse—has been ruled out.

New daily persistent headache

New daily persistent headache^[9] (NDPH) is a form of chronic headache that comes on suddenly. NDPH becomes constant within three days of the initial headache and persists for more than three months. Patients with NDPH usually have not had a history of chronic headaches, and they can often recall exactly when the headache began—sometimes to the exact date and time. Many of the characteristics of NDPH are the same as those of CTTH, and, as a result, the condition is treated similarly. New daily persistent headaches also cause mild-to-moderate (most commonly) bilateral pain. This pain is constant, and, in some cases, has features of chronic migraine (including unilateral pain, pulsating pain, pain that’s worsened by physical activity, photophobia, phonophobia, nausea, and/or vomiting).

Hemicrania continua

Hemicrania continua^[10] is a form of chronic daily headache characterized by continuous pain that fluctuates in severity. This pain is daily and constant (no pain-free periods) and remains at a moderate baseline for more than 3 months. Hemicrania continua is also unilateral and always affects the same side of the face or head (although a small percentage of patients experience bilateral symptoms). By definition, hemicrania continua responds completely to therapy with the non-steroidal anti-inflammatory drug (NSAID), indomethacin. In addition to constant baseline pain, hemicrania continua can cause occasional attacks of severe pain. The condition also presents with at least one additional debilitating symptom: drooping of the eyelid (ptosis) or contraction of the iris (miosis), teariness or redness of the eye on the affected side, nasal congestion, or rhinorrhea (runny nose). In some cases, hemicrania continua can become severe and cause migraine-like symptoms, such as throbbing pain, photophobia and/or phonophobia (sensitivity to sound), and nausea and/or vomiting. Some patients also report that symptoms worsen after alcohol consumption or physical exertion.

Cluster headaches

Cluster headaches^[11] are comparatively rarer than other types of chronic headaches. As their name suggests, cluster headaches occur in groups of attacks called clusters. Periods during which these attacks are frequent, known as cluster periods, can last for weeks to months. The pain that these clusters cause is severe and tends to be the same with each attack. It comes on suddenly, peaking after about 10–15 minutes. The pain is usually focused around or behind the eye and can be accompanied by restlessness, sweating on the forehead, red or watery eyes, nasal congestion, or ptosis/miosis. Cluster periods may range in frequency, occurring every other day to as frequently as several times each day. These periods are followed by remission (symptom-free periods) that can last for months or even years.

Chronic migraine

Migraine^[12] is a primary headache disorder (meaning it has no underlying cause) characterized by moderate to severe recurrent headaches. Migraine headaches typically affect one half of the head and feature throbbing or pounding pain that lasts between a few hours and a few days. Severe migraines can cause nausea and/or vomiting and sensitivity to light, noise, and/or smells. Up to 25%^[13] of people with migraines experience an aura^[14]—a temporary sensory disturbance with symptoms lasting for less than one hour—right before the headache pain begins. Migraine aura can present with visual perceptions (blind spots [called scotomas], shimmers, flashes of lights, and floating zig-zags) and physical symptoms (pins and needles, numbness, weakness, speech difficulty). Some patients even experience auras without having a headache. Chronic migraine^[15] is defined as having at least 15 headache days each month, eight or more of which fulfill the criteria for migraine, for longer than three months. Chronic migraine usually occurs^[16] in patients who have a history of episodic (periodic) migraines.

Transformed migraine

Some people who have migraines begin to experience transformed migraine^[17]. This is a migraine that becomes increasingly frequent over time, eventually becoming a constant, 24-hour-a-day background headache with occasional attacks of more severe migraine symptoms. Transformed migraine is very difficult to treat. Because of this, preventive care is crucial to managing migraine and preventing it from becoming more severe.

Chronic daily headache causes

It’s not fully understood what causes^[18] most headaches. What researchers do_ know is that the skull and brain tissue are not involved—they don’t contain nerve endings, and, as a result, can’t register pain sensations. Instead, the blood vessels in the neck and head, the tissues surrounding the brain, and several major nerves originating in the brain can all signal the pain experienced in a headache. Other structures, including the scalp, teeth, and muscles and joints in the neck, can also cause head pain. Different types of headaches may originate in different areas. Pressure in the sinuses, for example, can lead to a sinus headache, while stress^[19] is reported to be the most common trigger of tension headaches. By definition, primary chronic daily headaches (such as chronic migraine and chronic tension-type headache) have no discernible cause. Secondary chronic daily headaches, however, are caused by an underlying health problem or disorder. Some conditions that may lead to secondary chronic daily headache include:

• Problems with the blood vessels in and surrounding the brain (often inflammation), including stroke
• Infection, such as meningitis (acute inflammation of the meninges—the protective membranes covering the spinal cord and brain)
• Traumatic brain injury (TBI)
• Increased intracranial pressure
• Seizures
• Brain tumor

Medication overuse headache (MOH), one particularly common type of CDH, is directly caused by the use of pain medication to treat chronic headaches (usually for chronic migraine or tension-type headache). Other factors that can cause headaches include:

• Sleep disturbances
• Snoring^[20]
• Changes in weather
• Stress
• Hunger and/or dehydration
• Teeth grinding (bruxism) at night
• Caffeine consumption

Risk factors for chronic daily headache

There are a number of factors that can increase the risk of headaches progressing into chronic daily headache. These factors can be either modifiable (changeable), like caffeine use, or non-modifiable (inherent or unchangeable), like biological sex. Some common risk factors^[21] for the progression of headache to CDH include:

• Obesity
• Caffeine consumption
• Overuse of pain medication that contains caffeine (generally, more than two days per week for months on end)
• Stress and/or traumatic life events (especially when an individual has untreated anxiety and/or depression)
• Biological sex (women are more likely than men to experience CDH)
• Having other chronic pain conditions, such as fibromyalgia

Chronic daily headache symptoms

Different types of chronic daily headache can present with different symptoms. Generally, what varies between different headaches are the duration, type, and severity of pain experienced. Chronic daily headaches are also sub-classified^[22] according to the length of individual episodes. Chronic cluster headache, for example, is a short-duration CDH (lasting fewer than four hours), while long-duration CDH (longer than four hours) includes medication overuse headache, chronic tension-type headache, new daily persistent headache, hemicrania continua, and chronic migraine.

Medication overuse headache symptoms

Generally, MOH occurs every day (or almost every day). Patients with MOH are often awoken by their symptoms early in the morning. The signs and symptoms of medication overuse headache (MOH) can vary depending on the type of headache originally being treated, as well as the medication used to treat it. Some common signs and symptoms^[23] of medication overuse headache include:

• Irritability
• Weakness or lack of energy
• Nausea
• Difficulties with memory and/or concentration

The signs and symptoms of medication overuse headache usually improve or subside once you stop taking the original pain medication.

Chronic tension-type headache symptoms

The pain associated with chronic tension-type headache (CTTH) is bilateral (meaning it affects both sides of the head). Common signs and symptoms^[24] of CTTH include:

• Mild-to-moderate pain that feels dull or aching (but not throbbing/pulsating)
• Feeling of pressure or tightness across the forehead or on the sides and back of the head
• Tenderness on the scalp, shoulder, and neck muscles
• Rarely, sensitivity to light (photophobia) or sound (phonophobia)

Because their signs and symptoms can overlap, it can be difficult to differentiate between migraine and tension headaches. Unlike migraines, however, tension headaches usually aren’t accompanied by aura, nausea, or vomiting.

New daily persistent headache symptoms

The most notable feature of new daily persistent headache (NDPH) is its abrupt onset. Like CTTH, most patients with NDPH experience bilateral head pain. This pain may vary in severity from mild to severe, and is often worsened by stress or physical activity. The signs and symptoms^[25] of NDPH include:

• “Out-of-the-blue” headache—patients often can remember the exact date (and, in some cases, time) of onset
• Pain that has occurred on a daily basis since onset
• Mild-to-moderate pain that feels pressing or tight
• In some cases, migraine-like features, including photophobia, phonophobia, and/or nausea

Hemicrania continua symptoms

The signs and symptoms^[26] of hemicrania continua include:

• Constant mild-to-moderate pain, always on the same one side of the head (unilateral)
• Occasional attacks of severe pain (exacerbations) on top of baseline pain, which can last from 20 minutes to several days
• Red, watery eyes on the affected side
• Nasal congestion or rhinorrhea (runny nose) on the affected side
• Drooping of the eyelid (ptosis) on the affected side
• In some patients, photophobia, nausea, and/or vomiting

The symptoms of hemicrania continua are relieved completely by the medication indomethacin (generic Indocin, Tivorbex).

Cluster headache symptoms

Cluster headaches occur in groups of attacks (clusters) that last for 15 minutes to 2 hours when untreated. Cluster periods may range in frequency, in some cases occurring as often as several times each day. Periods of frequent clusters are followed by symptom-free periods (known as remission) that can last for months to years. Common signs and symptoms^[27] of cluster headaches include:

• Sudden onset of pain, usually located around or behind the eye
• Pain builds to a peak within 10–15 minutes
• Red or watery eyes
• Restlessness
• Nasal congestion or rhinorrhea (runny nose)
• Sweating on the forehead
• Drooping of the eyelid (ptosis)
• Contraction of the iris (miosis)

Because the signs and symptoms of cluster headache can mimic those of other conditions, it’s important that you see your healthcare provider as soon as you begin to experience them.

Chronic migraine symptoms

Migraines^[28] can progress through four different stages: prodrome, aura, attack, and post-drome. Not everyone who gets migraines experiences all four of these stages, as migraines can present in two ways: with aura (“classic migraine”) and without aura. Prodrome: Subtle signs that a migraine is impending that may appear one or two days before the attack. These may include:

• Changes in mood, sometimes as severe as going between depression and euphoria
• Food cravings
• Increased thirst and frequent urination
• Neck stiffness
• Constipation
• Frequent yawning

Aura: In some patients, disturbances (usually visual) that occur prior to or during migraines. Individual symptoms usually build gradually over the course of several minutes and last for 20 minutes to an hour. Common signs and symptoms of migraine aura^[29] include:

• Visual disturbances/phenomena: bright spots, flashes of light, blind spots (scotoma), or shapes floating across your vision
• Vision changes or vision loss
• Auditory disturbances: hearing noises or music
• Sensation of pins and needles in an arm or leg
• Numbness or muscle weakness in the face or on one side of the body
• Speech difficulty
• Uncontrollable movements

While the phenomena associated with aura can be disturbing if you’ve never experienced them before, they are temporary. You should, however, see your healthcare provider immediately if you experience any of the signs or symptoms of migraine with aura, as they can be similar to those of other serious conditions, including retinal tear and stroke. Attack: An attack refers to the period during which the migraine itself is occurring. When untreated, migraines usually last between four hours and three days. While the pain associated with migraines can vary in intensity, chronic migraines in particular usually cause moderate to severe pain. During a migraine attack, you may experience:

• Throbbing, pulsing pain, usually on one side of the head (unilateral), but often on both sides (bilateral). May be concentrated on one particular spot, such as behind the eye.
• Sensitivity to light (photophobia) and/or sound (phonophobia)
• In some cases, sensitivity to smell and/or touch
• Nausea, vomiting, or both

Post-drome: The period following a migraine attack. During this time, you may feel:

• Fatigued or exhausted
• Confused
• Elated/euphoric (in some patients)

Complications from chronic daily headache

CDH can significantly impact quality of life. For this reason, patients with CDH are more likely to have^[30]:

• Depression
• Anxiety
• Sleep disturbances
• Other psychological and/or physical problems

It’s important that you seek immediate care if your headache:

• Begins abruptly and is severe
• Comes on after a head injury
• Is accompanied with a stiff neck, fever, confusion, double vision (diplopia), muscle weakness, numbness, or speech difficulties
• Worsens, despite getting adequate rest and taking pain medication