Chronic Non-Progressive Headache

Aka: Chronic Non-Progressive Headache, Chronic Daily Headache

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II. Definitions

  1. Chronic Daily Headache
    1. Headache on at least 15 days/month AND for at least 3 months

III. Epidemiology

  1. Incidence
    1. Chronic Daily Headache accounts for 3-5% of acute Headache presentations in U.S.
  2. Race
    1. More common in white patients by a factor of 1.3
  3. Gender
    1. More common in women (5-9% Prevalence) than men (1-3% Prevalence)
  4. Prevalence
    1. Headaches >15 days/month: 5% of U.S. population
    2. Migraine Headaches: 25% of the U.S. population
  5. References
    1. Castillo (1999) Headache 39:190-6 [PubMed]

IV. Differential Diagnosis: Short Duration Chronic Daily Headache

  1. Brief Headache syndrome
    1. Hypnic Headache
      1. Headache onset with sleep
    2. Primary Cough Headache
    3. Primary Exertional Headache
    4. Primary Stabbing Headache
  2. Trigeminal autonomic Cephalgia (cluster-like, shorter duration)
    1. Chronic Cluster Headache
    2. Paroxysmal Hemicrania
    3. SUNA/SUNCT

V. Differential Diagnosis: Long Duration Chronic Daily Headache

  1. Common Primary Headaches
    1. Tension Headache
    2. Migraine Tension-Type Headache complex
      1. Features of both Tension Headache and Migraine Headache may may characterization and medication selection difficult
      2. Often evolves from Migraine Headache
    3. Migraine Headache (<3 days duration)
      1. Under-recognized (may account for 95% of acute Headache presentations to ED)
      2. Transformed Migraine
        1. Responsible for many Migraine Headache patients presenting with Chronic Daily Headache
        2. Represents Chronic Daily Headache with periodic Migraine Headache flares of worsening
  2. Less common Headaches
    1. Hemicrania Continua
      1. Trigeminal autonomic Cephalgia (cluster-like, longer duration)
    2. New Daily Persistent Headache
      1. Features similar to Migraine or Tension Headache, but becomes constant and unremitting in the first 3 days

VI. Differential Diagnosis: Secondary Headaches

  1. See Headache Red Flags
  2. See Chronic Progressive Headaches (Organic Headache)
  3. Analgesic or Ergotamine Rebound Headache
    1. Almost two thirds of Chronic Daily Headache patients have used Analgesics on 14 or more days per month
    2. Wiendels (2006) Cephalalgia 26(12): 1434-42 [PubMed]
  4. Myofacial pain
    1. Cervical Spine disorder
    2. Temperomandibular joint dysfunction
  5. Obstructive Sleep Apnea

VII. History

  1. See Headache History

VIII. Exam

  1. See Headache Examination

IX. Imaging

  1. Indications
    1. See Headache Red Flags
  2. Cases in which diagnostic testing can be avoided
    1. No Headache Red Flags suggesting Organic Headache
    2. Stable Headache pattern for >6 months
    3. No associated neurologic changes
  3. Imaging modality options
    1. CT Head
    2. MRI Head

X. Management: Non-pharmacologic

  1. General measures (minimal evidence)
    1. Sleep Hygiene
    2. Avoid Caffeine
    3. Avoid Tobacco
    4. Maintain hydration and nutritional intake
  2. Physical rehabilitation interventions
    1. Cervical neck Exercises (low load)
    2. Osteopathic cervical manipulation
      1. Jull (2002) Spine 27(17): 1835-43 [PubMed]
    3. Acupuncture (for Tension Headaches)
      1. Linde (2009) Cochrane Database Syst Rev (1): CD001218 [PubMed]
    4. Occipital region Peripheral Nerve stimulation
      1. Silberstein (2012) Cephalalgia 32(16): 1165-79 [PubMed]
  3. Psychological interventions
    1. Internet-based Biofeedback
      1. Devineni (2005) Behav Res Ther 43(3): 277-92 [PubMed]
    2. Cognitive Behavioral Therapy
      1. Nash (2004) Pain Med 5(2): 178-86 [PubMed]
      2. Thorn (2007) J Pain 8(12): 938-49 [PubMed]

XI. Management: Pharmacologic

  1. Reduce or eliminate Headache abortive Analgesics
    1. See Analgesic Rebound Headache
    2. Analgesic overuse is a common contributing factor to Chronic Daily Headache
    3. Limit Analgesics to less than one third the days of the month
      1. Some Headache experts recommend complete Analgesic withdrawal in Chronic Daily Headache
      2. Some studies suggest partial Analgesic withdrawal on Headache prophylaxis is effective
      3. Hagen (2011) Acta Neurol Scand Suppl (191): 38-43 [PubMed]
  2. Headache prophylaxis agents for Chronic Daily Headache from Tension Headache or Migraine Headache
    1. Tricyclic Antidepressants (e.g. Amitriptyline, Nortriptyline)
      1. Effective for Migraine Headache and Tension Headache prevention
      2. Couch (2011) Headache 51(1): 33-51 [PubMed]
    2. Tizanidine (Zanaflex)
      1. Saper (2002) Headache 42(6): 470-82
    3. Gabapentin (Neurontin)
      1. Spira (2003) Neurology 61(12): 1753-9 [PubMed]
  3. Headache prophylaxis for chronic Migraine Headache
    1. See Migraine Prophylaxis
    2. See agents listed above (TCA, Tizanidine, Gabapentin)
    3. Propranolol
    4. Valproate
    5. Topiramate (Topamax)
    6. Onabotulinumtoxin A local injection
  4. Avoid ineffective agents for Headache prophylaxis
    1. Selective Serotonin Reuptake Inhibitors (SSRI) such as Fluoxetine (Prozac)
      1. Not found to be effective in Headache prophylaxis
      2. Moja (2005) Cochrane Database Syst Rev (3): CD02919 [PubMed]

XII. References

  1. Dodick (2006) N Engl J Med 354(2): 158-65 [PubMed]
  2. Haiker (2011) Neurology 76(7 suppl 2): S37-43 [PubMed]
  3. Yancey (2014) Am Fam Physician 89(8): 642-8 [PubMed]

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