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

 Enlarge     Print


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.


show all references

1. Aurora SK, Brin MF. Chronic migraine: an update on physiology, imaging, and the mechanism of action of two available pharmacologic therapies. Headache. 2017;57(1):109–125....

2. Lipton RB, Bigal ME. Migraine: epidemiology, impact, and risk factors for progression. Headache. 2005;45(suppl 1):S3–S13.

3. Mathew NT. Pathophysiology of chronic migraine and mode of action of preventive medications. Headache. 2011;51(suppl 2):84–92.

4. Voigt AW, Gould HJ III. Chronic daily headache: mechanisms and principles of management. Curr Pain Headache Rep. 2016;20(2):10.

5. Headache Classification Committee of the International Headache Society (IHS).. The International Classification of Headache Disorders, 3rd ed. Cephalalgia. 2018;38(1):1–211.

6. Midgette LA, Scher AI. The epidemiology of chronic daily headache. Curr Pain Headache Rep. 2009;13(1):59–63.

7. Scher AI, Stewart WF, Ricci JA, et al. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain. 2003;106(1–2):81–89.

8. Scher AI, Midgette LA, Lipton RB. Risk factors for headache chronification. Headache. 2008;48(1):16–25.

9. Messali A, Sanderson JC, Blumenfeld AM, et al. Direct and indirect costs of chronic and episodic migraine in the United States: a web-based survey. Headache. 2016;56(2):306–322.

10. Sheeler RD, Garza I, Vargas BB, et al. Chronic daily headache: ten steps for primary care providers to regain control. Headache. 2016;56(10):1675–1684.

11. Katsarava Z, Schneeweiss S, Kurth T, et al. Incidence and predictors for chronicity of headache in patients with episodic migraine. Neurology. 2004;62(5):788–790.

12. Krymchantowski AV, Moreira PF. Clinical presentation of transformed migraine: possible differences among male and female patients. Cephalalgia. 2001;21(5):558–566.

13. Ashina S, Lyngberg A, Jensen R. Headache characteristics and chronification of migraine and tension-type headache: a population-based study. Cephalalgia. 2010;30(8):943–952.

14. Ashina S, Buse DC, Bigal M, et al. Cutaneous allodynia—a predictor of migraine chronification: a longitudinal population-based study. Cephalalgia. 2009;29:58–59.

15. Scher AI, Stewart WF, Lipton RB. The comorbidity of headache with other pain syndromes. Headache. 2006;46(9):1416–1423.

16. Jette N, Patten S, Williams J, et al. Comorbidity of migraine and psychiatric disorders—a national population-based study. Headache. 2008;48(4):501–516.

17. Scher AI, Stewart WF, Buse D, et al. Major life changes before and after the onset of chronic daily headache: a population-based study. Cephalalgia. 2008;28(8):868–876.

18. Institute for Clinical Systems Improvement. Headache, diagnosis and treatment of. 11th ed. January 2013. Accessed July 30, 2019.

19. Bendtsen L, Birk S, Kasch H, et al. Reference programme: diagnosis and treatment of headache disorders and facial pain: Danish Headache Society, 2nd ed. J Headache Pain. 2012;13(suppl 1):S1–S29.

20. Becker WJ, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Can Fam Physician. 2015;61(8):670–679.

21. Mayans L. Headache: migraine. FP Essent. 2018;473:11–16.

22. Ebell MH. Diagnosis of migraine headache. Am Fam Physician. 2006; 74(12):2087–2088. Accessed November 10, 2019.

23. Detsky ME, McDonald DR, Baerlocher MO, et al. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006;296(10):1274–1283.

24. American Headache Society. Patient education: migraines and other headaches. Accessed February 2019.

25. Peng KP, Wang SJ. Migraine diagnosis: screening items, instruments, and scales. Acta Anaesthesiol Taiwan. 2012;50(2):69–73.

26. Tepper SJ, Dahlöf CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache. 2004;44(9):856–864.

27. Schreiber CP, Hutchinson S, Webster CJ, et al. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache. Arch Intern Med. 2004;164(16):1769–1772.

28. Lyngberg AC, Rasmussen BK, Jørgensen T, et al. Incidence of primary headache: a Danish epidemiologic follow-up study. Am J Epidemiol. 2005;161(11):1066–1073.

29. Peres MF, Gonçalves AL, Krymchantowski A. Migraine, tension-type headache, and transformed migraine. Curr Pain Headache Rep. 2007;11(6):449–453.

30. Mitsikostas DD, Ashina M, Craven A, et al.; EHF committee. European Headache Federation consensus on technical investigation for primary headache disorders. J Headache Pain. 2015;17:5.

31. Sandrini G, Friberg L, Coppola G, et al.; European Federation of Neurological Sciences. Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Eur J Neurol. 2011;18(3):373–381.

32. Douglas AC, Wippold FJ II, Broderick DF, et al. ACR appropriateness criteria: headache. J Am Coll Radiol. 2014;11(7):657–667.

33. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–144.

34. Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155–1160.

35. Munksgaard SB, Madsen SK, Wienecke T. Treatment of medication overuse headache–a review. Acta Neurol Scand. 2019;139(5):405–414.

36. Tepper SJ. Medication-overuse headache. Continuum (Minneap Minn). 2012;18(4):807–822.

37. Limmroth V, Katsarava Z, Fritsche G, et al. Features of medication overuse headache following overuse of different acute headache drugs. Neurology. 2002;59(7):1011–1014.

38. Radat F, Creac'h C, Swendsen JD, et al. Psychiatric comorbidity in the evolution from migraine to medication overuse headache. Cephalalgia. 2005;25(7):519–522.

39. Dousset V, Maud M, Legoff M, et al. Probable medications overuse headaches: validation of a brief easy-to-use screening tool in a headache centre. J Headache Pain. 2013;14:81.

40. Grande RB, Aaseth K, Benth JŠ, et al. Reduction in medication-overuse headache after short information. The Akershus study of chronic headache. Eur J Neurol. 2011;18(1):129–137.

41. Evers S, Jensen R; European Federation of Neurological Societies. Treatment of medication overuse headache—guideline of the EFNS headache panel. Eur J Neurol. 2011;18(9):1115–1121.

42. de Goffau MJ, Klaver AR, Willemsen MG, et al. The effectiveness of treatments for patients with medication overuse headache: a systematic review and meta-analysis. J Pain. 2017;18(6):615–627.

43. Chiang CC, Schwedt TJ, Wang SJ, et al. Treatment of medication-overuse headache: a systematic review. Cephalalgia. 2016;36(4):371–386.

44. Scottish Intercollegiate Guidelines Network (SIGN). Pharmacological management of migraine. February 2018. Accessed February 2019.

45. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3–20.

46. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society [published correction appears in Neurology. 2013;80(9):871]. Neurology. 2012;78(17):1337–1345.

47. Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache – report of an EFNS task force. Eur J Neurol. 2010;17(11):1318–1325.

48. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology. 2010;75(5):463–473.

49. Evers S, Goadsby P, Jensen R, et al. Treatment of miscellaneous idiopathic headache disorders (group 4 of the IHS classification) – report of an EFNS task force. Eur J Neurol. 2011;18(6):803–812.

50. Mayans L, Walling A. Acute migraine headache: treatment strategies. Am Fam Physician. 2018;97(4):243–251. Accessed July 30, 2019.

51. Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016;86(19):1818–1826.

52. Bendtsen L, Sacco S, Ashina M, et al. Guideline on the use of onabotulinumtoxinA in chronic migraine: a consensus statement from the European Headache Federation. J Headache Pain. 2018;19(1):91.

53. Ha H, Gonzalez A. Migraine headache prophylaxis. Am Fam Physician. 2019;99(1):17–24. Accessed January 22, 2020.

54. Matsuzawa Y, Lee YS, Fraser F, et al. Barriers to behavioral treatment adherence for headache: an examination of attitudes, beliefs, and psychiatric factors. Headache. 2019;59(1):19–31.

55. Probyn K, Bowers H, Mistry D, et al.; CHESS team. Non-pharmacological self-management for people living with migraine or tension-type headache: a systematic review including analysis of intervention components. BMJ Open. 2017;7(8):e016670.

56. Probyn K, Bowers H, Caldwell F, et al.; CHESS Team. Prognostic factors for chronic headache: a systematic review. Neurology. 2017;89(3):291–301.



Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

More in AFP

Editor's Collections

Related Content

More in Pubmed


Nov 2021

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article