Chronic headache is not a single disease entity but an umbrella term that encompasses all the chronic headaches. The International Headache Society defines chronic daily headaches (CDH) as "15 or more headache episodes per month for at least 3 months." Chronic headaches are not included as an official class in the International Classification of Headache Disorders (ICHD).
A chronic daily headache can be divided into primary and secondary headache disorders depending upon its etiology. Primary chronic headache disorders do not have secondary organic etiology. Within the primary headache categories, a headache duration of fewer than 4 hours is labeled as a 'short headache,' and more than 4 hours is known as a 'long headache.' Long headache is more commonly include chronic migraine and chronic tension headaches. Secondary headaches can occur due to secondary causes such as medication overuse, intracranial tumors, central nervous system (CNS) infections, raised intracranial pressure, metabolic abnormalities, post-traumatic, vascular, and structural pathologies. It is important to realize that chronic headaches are often caused by a multifactorial combination of the above-mentioned causes and can occur along a continuum.
The International Classification of Headache Disorders (ICHD) recognizes over 200 headache disorders and divides them into three groups, which are primary, secondary, and painful cranial neuropathies. The ICHD system is hierarchical with multiple subtypes within each main headache type.
All chronic headaches meet the criteria of occurring at least 15 times a month for at least 3 months, but both primary and secondary chronic headaches have unique characteristics.
Primary headaches lasting greater than four hours include chronic migraines, tension headaches, new daily persistent headaches, and hemicrania continua.
Primary headaches lasting less than four hours include chronic cluster headache, neuralgiform headache attacks, and primary stabbing headache.
Secondary chronic daily headaches include medication overuse, CNS infection, CNS hematomas, intracranial tumor, raised intracranial pressure, low-pressure headache, vasculitis, aneurysms, and cerebrospinal fluid (CSF) leak.
Headache disorders have a large global burden. Both acute and chronic headaches are most prevalent between the teenage years and the fifth decade.
Chronic headaches occur in 1% to 4% of the entire population. Approximately 39 million people in the United States and 1 billion people worldwide are affected. Of patients seen in a headache clinic, 40% are diagnosed with chronic headaches. Prevalence rates in women are 3 to 5 times higher than in men.
Chronic migraines are associated with significant comorbidities, including obesity, obstructive sleep apnea, depression, chronic pain disorders, and cardiovascular disease.
Chronic migraine headaches also have a prevalence of 7% to 17% in children and adolescents. The prevalence is equal between boys and girls until age 12 when females predominate.
Hemicrania continua is less common than chronic migraine or tension headache. It has a 2 to 1 female to male incidence with the peak diagnosis occurring in the third decade.
Chronic cluster headache occurs more often in men but is also experienced by women. Women often have nausea and vomiting associated with chronic cluster headaches and may be initially diagnosed with migraine headaches.
Although the pathophysiology of each type of chronic headache varies, shared features include sensitization of the trigeminal system, alterations in brain structure and function, and environmental factors. Most chronic headaches result form the transformation of an episodic headache disorder.
Modifiable risk factors, including sleep disorders, obesity, and high caffeine consumption, increase the chance of headache transformation from episodic to chronic headache.
Serotonin, which has vasoconstrictive and anti-inflammatory effects, is a therapeutic target of triptans in migraines.
Calcitonin gene-related peptide (CGRP), which affects pain transmission and vasodilation, is another molecule implicated in the pathogenesis of chronic headaches, including migraine and cluster headaches.
Medication overuse headaches share much of the pathophysiology of migraine and tension headaches as both functional and structural changes in the central nervous system. Changes in the serotonergic neuromodulatory system and upregulation of vasoactive and proinflammatory mediators also contribute.
Trigeminal autonomic cephalalgias, cluster headache, SUNCT, SUNA, and hemicrania continua, have complex pathogenesis. Severe pain and autonomic symptoms are attributed to the trigeminal autonomic reflex, via pain-producing innervation, and cranial parasympathetic activation.
A thorough history and physical exam are indispensable in the diagnosis of chronic daily headaches. As noted above, a chronic headache should have 15 or more episodes per month for at least 3 months. One should determine the frequency, intensity, characteristics of the pain, as well as the aggravating and alleviating factors. Many headache types involve ipsilateral autonomic symptoms such as lacrimation, conjunctival injection, conjunctival edema, ptosis, miosis, nasal congestion, rhinorrhea, etc.
A thorough medication reconciliation, including over-the-counter analgesics, is essential. Patients with medication-overuse headaches often have a primary headache disorder, and they frequently use pain medications. Medication classes may include non-steroidal anti-inflammatory drugs (NSAIDs), triptans, ergotamines, opioids, or a combination of multiple analgesics. Key historical features include morning headaches, the onset of headaches when medication is delayed, and relief when medication is taken.
Comorbidities, sleep history, and family history of headaches should also be noted. A secondary headache disorder should be excluded from the history and examination.
Recognition of headache "red flags" is a critical piece in identifying secondary headaches and ordering additional diagnostic testing. Those "red flags" include:
Physical exam findings concerning secondary headache causes include focal neurological deficits, papilledema, bitemporal hemianopia, homonymous hemianopia, decrease visual acuity or increased pain with the Valsalva method.
Primary chronic headaches often lack physical findings but may have autonomic activation or muscle tenderness in the occipital or cervical regions.
In a straight-forward chronic primary headache disorder, further evaluation may not be warranted, but many clinicians will advise for baseline laboratory testing and brain imaging to exclude the secondary treatable causes.
Laboratory workup includes a complete blood count to look for infection. Erythrocyte sedimentation rate (ESR) is increased in giant cell arteritis and other vasculitides. A metabolic panel to look for metabolic causes of headache, and endocrine testings to look for pituitary gland abnormalities.
Magnetic resonance imaging (MRI) of the brain is the imaging modality of choice. A contrast study is often recommended to increase the sensitivity and specificity to detect structural abnormalities. A need for vascular imaging is based on the differential diagnosis. Further studies may be warranted depending upon the underlying cause. These may include positron emission tomography (PET) scan, magnetic resonance spectroscopy (MRS), and/or biopsy. A lumbar puncture may be required if there is suspicion of a CNS infection or idiopathic intracranial hypertension.
Treatment and management of chronic headache disorders depend upon the underlying etiology and may require an interprofessional approach.
A patient should maintain a headache journal that will document their headache episodes and any accompanying triggers. If found, stressors should be avoided or minimized.
Chronic Tension Headache
Medication Overuse Headache
Chronic Autonomic Cephalgia
The prognosis of chronic headaches is variable. Anxiety and mood disorders, elevated levels of stress, insufficient sleep, poor headache management, and low socioeconomic status are the primary prognostic characteristics. Patients with higher expectations for treatment display a better prognosis for decreased headache intensity and frequency. No specific age group has an improved response to treatment. Incidence at an older age generally correlates to less severe symptoms. Employed patients responded better to treatment than those patients on medical leave. Exercise, prophylactic medication regimen compliance, and cessation of overused medications tend to lead to a favorable prognosis.
Patients should be educated to become more aware of their headache symptoms and triggers. Interventions should be clearly explained to patients.
The role of over-the-counter analgesics in medication overuse headache must be explained to patients. Patients with all types of primary headaches have the potential to overuse analgesics and should be counseled on the potential for frequent use of these medications to worsen the intensity and frequency of headaches.
A primary care physician manages the majority of chronic headaches. Non-responsive cases are usually referred to neurologists or headache specialists. These patients also need the services of a team that also include psychologist, nurse, pharmacist, and physical therapist. This interprofessional team approach helps to maximize treatment potential, foster a clear message about chronic headache treatment, improves patient education.
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