Diagnosing and treating chronic daily headaches

Diagnose and treat chronic daily headaches with confidence. Learn to identify the key clinical characteristics here.
Last update28th Feb 2021

Chronic daily headaches are defined as headaches which occur at least 15 days or more per month for at least three months, regardless of the underlying headache etiology.

Chronic daily headaches can have migraine features, tension headache features, or even a mixture of the two. However, in order to be considered a chronic daily headache there must not be any characteristics of hemicrania continua (HC) or new daily persistent headache (NDPH).

Figure 1. Chronic daily headaches occur at least 15 days per month for at least three months and can have features of migraine, tension headache or both.

Prevalence of chronic daily headaches

Chronic daily headache is most common among middle-aged adults between 30 and 50 years of age. The female to male ratio is around 3:1. The prevalence of chronic headache is 4–5%, with an incidence of 3% per year. The incidence of new-onset chronic migraine in patients with episodic migraine is around 2.5% per year.

Accurately diagnosing chronic daily headaches can be difficult

It may be difficult to identify the primary headache type. Given the overlap in symptoms, it may be almost impossible to differentiate chronic migraine without aura from chronic tension headaches. For example, sometimes migraine without aura evolves slowly, leading to misdiagnosis as chronic tension headache.

The defining moment of when a headache becomes chronic may also be difficult to pinpoint. While cluster headaches also are a type of headache that occurs repeatedly over a number of days, cluster headaches only become chronic when they are characterized by a lack of periodic remission normally seen in the cluster syndrome.

The diagnosis can easily become even more muddled when complicated by responses to headache medications such as triptans.

Secondary factors can further complicate the diagnosis of chronic daily headaches

Diagnosis of chronic daily headaches can be further complicated by secondary factors, such as medication overuse, post traumatic headache, cervicogenic headache, and other more serious causes such as arterial dissection, tumor, and intracranial hypotension from a cerebrospinal fluid leak or pseudotumor cerebri.

Figure 2. Chronic daily headaches can be further complicated by secondary factors, such as medication overuse, post traumatic headache, cervicogenic headache, and other more serious causes such as arterial dissection, tumor, and intracranial hypotension.

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Risk factors for chronic daily headaches

Socioeconomic status

Chronic daily headache is more common in individuals of lower income and / or less education.

Obesity

Obesity is a risk factor for chronic daily headache, for unknown reasons.

Other neurological conditions: depression and pain

A history of migraine and depression is frequently found in those who suffer from chronic daily headaches. And, sufferers tend to report a higher incidence of other pain associated conditions, particularly musculoskeletal pain.

Stress

Those that suffer from chronic daily headaches also tend to report associated stressful life events including death in the family or illness, moves, job changes, marital status changes, and child-related issues.

Sleep disturbances

Sleep disturbances, particularly snoring, are more common in patients with chronic daily headaches. And studies show this to be independent of obstructive sleep apnea. Interestingly, chronic daily headache patients tend to sleep either too much or not enough.

High medication use

Individuals with chronic daily headaches tend to have high medication use, as documented by many authors. In fact, it is estimated that approximately one third of chronic daily headache patients overuse medicines.

Treating chronic daily headaches

Due to all these complicating factors, frequent or daily to near-daily headaches are challenging to treat and will often lead to referral to a tertiary center.

Still, by accurately categorizing these headaches treatments can be successful. First, potential causes of secondary headaches must be excluded. Treatment approaches will then vary based on the type of primary headache which has become chronic. For example, a chronic migraine versus chronic tension headache versus new daily persistent headache may all have individual and differing treatment strategies.

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Recommended reading

  • Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
  • Fernández-de-las-Peñas, C, Arendt-Nielsen, L, and Gerwin, R. 2010. Tension-Type and Cervicogenic Headache—Pathophysiology, Diagnosis and Management. Sudbury: Jones and Bartlett Publishers.
  • Goadsby, PJ and Silberstein, SD. 1997. Headache. Vol 17 of Blue books of practical neurology. Boston: Butterworth-Heinemann.
  • Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
  • Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition.  London: Martin Dunitz.
  • Ward, TN. 2012. Migraine diagnosis and pathophysiology. Continuum (Minneap Minn). 18: 753–763. PMID: 22868539

About the author

Robert Coni, DO EdS
Neurohospitalist, Medical Director and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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