Frequent Headaches: Evaluation and Management


Most frequent headaches are typically migraine or tension-type headaches and are often exacerbated by medication overuse. Repeated headaches can induce central sensitization and transformation to chronic headaches that are intractable, are difficult to treat, and cause significant morbidity and costs. A complete history is essential to identify the most likely headache type, indications of serious secondary headaches, and significant comorbidities. A headache diary can document headache frequency, symptoms, initiating and exacerbating conditions, and treatment response over time. Neurologic assessment and physical examination focused on the head and neck are indicated in all patients. Although rare, serious underlying conditions must be excluded by the patient history, screening tools such as SNNOOP10, neurologic and physical examinations, and targeted imaging and other assessments. Medication overuse headache should be suspected in patients with frequent headaches. Medication history should include nonprescription analgesics and substances, including opiates, that may be obtained from others. Patients who overuse opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment to prevent acute withdrawal. Patients who overuse other agents can usually withdraw more quickly. Evidence is mixed on the role of medications such as topiramate for patients with medication overuse headache. For the underlying headache, an individualized evidence-based management plan incorporating pharmacologic and nonpharmacologic strategies is necessary. Patients with frequent migraine, tension-type, and cluster headaches should be offered prophylactic therapy. A complete management plan includes addressing risk factors, headache triggers, and common comorbid conditions such as depression, anxiety, substance abuse, and chronic musculoskeletal pain syndromes that can impair treatment effectiveness. Regular scheduled follow-up is important to monitor progress.

Patients with increasingly frequent headaches can develop disabling symptoms. Biochemical, metabolic, and other changes induced by frequent headaches and/or medication are thought to cause central sensitization and neuronal dysfunction that results in inappropriate response to innocuous stimuli, lowered thresholds to trigger pain response, exaggerated response to stimuli, and persistence of pain after removal of inciting factors.14 Together, these changes result in increasingly frequent—and often daily—headache and related symptoms. Each year, 3% to 4% of patients with episodic migraine or tension-type headaches (TTH) escalate to chronic forms.5,6

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Clinical recommendationEvidence ratingComment

Physicians should conduct a complete assessment in patients with frequent or increasing headaches—even in those with long-standing headaches—because a new headache type may have developed or the current diagnosis may be inaccurate.1821,26,27


Expert consensus and several diagnostic studies showing high rates of misdiagnosis of headache, especially migraine and sinus headaches

Neuroimaging is indicated in patients with headaches with new features or neurologic deficits, trigeminal autonomic cephalalgias, or suspected intracranial abnormality.1821,3032


Expert consensus based on concerns that intracranial conditions can mimic unilateral autonomic symptoms of trigeminal autonomic cephalalgias

All patients with frequent or increasing headaches should be assessed for medication overuse.1821,34


Expert consensus based on multiple observational studies showing that at least 30% to 50% of patients with chronic headache have medication overuse headache

Prophylactic and acute therapy should be offered to patients with frequent migraine, tension-type, cluster, or other primary headache.1821,4452


Expert consensus based on studies and meta-analyses supporting the effectiveness of prophylactic and acute therapy in reducing the number and severity of headache episodes

Nonpharmacologic therapies such as relaxation with or without biofeedback, cognitive behavior therapy, acupuncture, and physical therapy should be incorporated in management strategies for frequent headaches.1820,47,53


Expert consensus supporting biofeedback in the treatment of tension-type headache (meta-analysis) and few studies supporting benefits of other modalities

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


Clinical recommendationEvidence ratingComment

Physicians should conduct a complete assessment in patients with frequent or increasing headaches

The Author

ANNE WALLING, MB, ChB, is professor emerita in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita.

Address correspondence to Anne Walling, MB, ChB, University of Kansas School of Medicine–Wichita, 1010 N. Kansas St., Wichita, KS 67214 (email: Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.


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