Chronic Daily Headache: Diagnosis and Management


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Am Fam Physician. 2014 Apr 15;89(8):642-648.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on headache, written by the authors of this article

  Related letter: Pharmacologic Options for the Treatment of Chronic Daily Headache

Author disclosure: No relevant financial affiliations.

Chronic daily headache is defined as the presence of a headache on 15 days or more per month for at least three months. The most common types of chronic daily headache are chronic migraines and chronic tension-type headaches. If a red flag for a secondary cause of headache is present, magnetic resonance imaging of the head should be performed. All patients should be asked about medication overuse, which can increase the frequency of headaches. Patients who overuse medications for abortive therapy for headache should be encouraged to stop the medications entirely and consider prophylactic treatment. Several prophylactic treatments for chronic daily headache can reduce headache frequency and severity, as well as improve overall quality of life. Nonpharmacologic treatments include relaxation techniques, cognitive behavior therapy, acupuncture, osteopathic manipulation, and cervical exercises. Pharmacologic therapies include amitriptyline, gabapentin, onabotulinumtoxinA, propranolol, tizanidine, topiramate, and valproate.

Chronic daily headache is defined as the presence of a headache on 15 days or more per month for at least three months.1  It is further divided into headaches of short or long duration (Table 1).2 Headaches of short duration are defined as lasting less than four hours, whereas headaches of long duration are defined as lasting more than four hours. This article follows a single illustrative case of a patient with chronic daily headache.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Biofeedback and relaxation techniques can decrease the frequency and severity of chronic daily headaches, and reduce medication use.

B

13

Cognitive behavior therapy in group or individualized settings has been shown to reduce headache frequency and severity, and to improve overall quality of life.

B

14, 15

Amitriptyline may reduce headache duration and severity compared with placebo for chronic tension-type headache.

B

17

Selective serotonin reuptake inhibitors have no proven benefit for headache prophylaxis over placebo or tricyclic antidepressants in patients with chronic daily headache.

A

18

Tizanidine (Zanaflex) has some benefit in reducing the frequency, severity, and duration of chronic migraine and chronic tension-type headache.

B

22

Gabapentin (Neurontin) increases the number of headache-free days in patients with chronic daily headache when compared with placebo.

B

19

Valproate (Depacon) and topiramate (Topamax) reduce the rate of migraine attacks by at least 50%.

A

23

Propranolol reduces the frequency of migraine headache, although its effectiveness for chronic migraine is unclear.

C

21

All patients with chronic daily headache should be counseled about medication overuse, which can complicate the course of the headache.

C

9, 24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Biofeedback and relaxation techniques can decrease the frequency and severity of chronic daily headaches, and reduce medication use.

B

13

Cognitive behavior therapy in group or individualized settings has been shown to reduce headache frequency and severity, and to improve overall quality of life.

B

14, 15

Amitriptyline may reduce headache duration and severity compared with placebo for chronic tension-type headache.

B

17

Selective serotonin reuptake inhibitors have no proven benefit for headache prophylaxis over placebo or tricyclic antidepressants in patients with chronic daily headache.

A

18

Tizanidine (Zanaflex) has some benefit in reducing the frequency, severity, and duration of chronic migraine and chronic tension-type headache.

B

22

Gabapentin (Neurontin) increases the number of headache-free days in patients with chronic daily headache when compared with placebo.

B

19

Valproate (Depacon) and topiramate (Topamax) reduce the rate of migraine attacks by at least 50%.

A

23

Propranolol reduces the frequency of migraine headache, although its effectiveness for chronic migraine is unclear.

C

21

All patients with chronic daily headache should be counseled about medication overuse, which can complicate the course of the headache.

C

9, 24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN NEUROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not do imaging for uncomplicated headache.

American College

The Authors

JOSEPH R. YANCEY, MAJ, MC, USA, is a staff physician in the National Capital Consortium Family Medicine Residency at Fort Belvoir (Va.) Community Hospital.

RICHARD SHERIDAN, CPT, MC, USA, is brigade surgeon for the 1/25 Stryker Brigade Combat Team in Fort Wainwright, Alaska. At the time the article was written, Dr. Sheridan was a staff physician in the National Capital Consortium Family Medicine Residency at Fort Belvoir Community Hospital.

KELLY G. KOREN, LT, MC, USN, is a staff physician in the National Capital Consortium Family Medicine Residency at Fort Belvoir Community Hospital.

The authors thank Stacey Gruber, LCDR, MC, USN, for her assistance with reviewing and editing the manuscript.

Address correspondence to Joseph R. Yancey, MAJ, MC, USA, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060 (e-mail: joseph.r.yancey.mil@health.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, U.S. Navy, Department of Defense, or the U.S. government.

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This article is one in a series from the Faculty Development Fellowship of the Department of Family Medicine at the University of North Carolina at Chapel Hill. Guest editor of the series is Anthony J. Viera, MD, MPH.



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