Chronic Daily Headaches

Chronic daily headaches is not a specific diagnosis. It simply refers to patients who are experiencing some form of headache, 15 days or more per month, on a chronic (greater than three month) basis. Surprisingly, as much as 5% of the world's population experiences a headache daily or near daily. The problem affects mainly adults including those greater than 65 years of age. Causes and categories of chronic daily headache can be subdivided into the common and uncommon causes, as outlined below.

Common Chronic Daily Headaches

Chronic Migraine

Patients with chronic migraine experience headaches more than 15 days per month that fit the criteria of migraine. This means they will commonly experience nausea, possibly vomiting; sensitivity to light, sound, or smells, with the pain itself often being experienced as throbbing in nature and often on one side of the head. Mild activity or simply bending forward can exacerbate the pain.

Chronic migraine includes the diagnosis of transformed migraine. Those with transformed migraine often start out with migraine headaches that occur occasionally. Gradually, over months or years, the headaches begin to last longer and/or occur closer and closer in time until eventually the headaches are daily or almost daily. Very often the headaches themselves lose their severity so that nausea and/or vomiting won't occur as often and the sensitivity to light and sound may not be as prominent. Indeed, the headaches may be harder to clearly identify as migraine headaches and can have many features of tension headaches (see below for a description of tension headaches).

While migraine may indeed transform to being daily on its own, doctors are always on the look out for the possibility that the headaches are due to medication overuse. A patient may initially experience an occasional migraine and appropriately treat it with a short-acting pain medication. Over months or years, the headaches may become more frequent and so a patient may treat them more frequently with these pain medications. Unfortunately, the body will often become tolerant of the pain medications so that (1) each dose of the medication is less effective and (2) withdrawal from the drug will trigger another headache. Now the patient is stuck with near daily headaches and a dependence on whatever drug is being used to treat them. For more on this topic, see Rebound Headaches which explains this special form of chronic daily headaches.

Chronic Tension-Type Headaches

Patients with chronic tension-type headaches have tension-type headaches more than 15 days per month. Tension-type headaches are usually non-throbbing, experienced more as a tight band around the head or a sense of tension or pressure in the head. They are not typically as severe as migraine and they do not usually have associated symptoms such as nausea or sensitivity to light, sound, or smell. The pain is usually throughout the head and may also include the neck and shoulders.

Chronic tension-type headaches can also be due to rebound (medication overuse) headaches. Please review Rebound Headaches to learn about this special cause of chronic daily headaches.

For treatment of chronic tension-type headaches please review the treatment options under Tension-Type headaches.
In addition, if you feel you have tension-type headaches that are daily, but you also know that you have a history of migraine headaches, it is worth reviewing chronic migraine headaches (above), since 'low-intensity' migraines may be affecting you, which are not accompanied by prominent nausea or sensitivity to light and sound.

Uncommon Chronic Daily Headaches

Worrisome Causes of Daily Headache

If you don't have a long history of daily headaches, or if your daily headaches appear to be getting progressively worse over time, you should review the page regarding Worrisome Headache Symptoms, as these are important to exclude (as causes of chronic daily headaches) before you attempt to treat your headaches.

Hemicrania Continua

This is a rare headache disorder which occurs most commonly in women. The headache is characterized by pain that occurs only on one side of the head. The pain waxes and wanes in intensity, but never really goes away. As with all chronic daily headaches, it is generally not diagnosed unless present for at least three months. During severe episodes of worsening, patients may experience 'autonomic features'; these are symptoms such as eyelid drooping on the side of the headache, eye tearing, or the pupil on that side becoming smaller (miotic). Occasionally patients experience sudden 'jabs' of pain and occasionally mild sensitivity to light, sound, and mild nausea.

Hemicrania continual is particularly sensitive to the anti-inflammatory drug indomethacin (Indocin).
Because structural problems in the brain can lead to similar symptoms, it is important to undergo an evaluation by a physician, preferably a headache specialist, if this diagnosis is being considered. This physician will likely order brain imaging to exclude other causes of chronic daily headaches.

Chronic Paroxysmal Hemicrania

This is a rare disorder, similar to hemicrania continua. In the case of chronic paroxysmal hemicrania, the pain is only on one side of the head, but it is severe, short-lasting, and tends to occur multiple times per day. An individual attack may last between 2 to 30 minutes, with complete resolution of pain afterwards. Associated with the attack may be other symptoms such as eye redness on the side of the pain, nasal congestion, facial sweating, eye tearing, and some migraine features such as sensitivity to light or mild nausea. The attacks can occur once per day, or as many as 40 times per day. Episodic paroxysmal hemicrania occurs generally for a few weeks, but can last as long as 5 months. Chronic paroxysmal hemicrania involves recurrent attacks for at least a year, with only brief (less than a month) periods of freedom from headaches.

Just as with hemicrania continua, paroxysmal hemicrania often responds well to the anti-inflammatory drug indomethacin (Indocin).
Because structural problems in the brain can lead to similar symptoms, it is important to undergo an evaluation by a physician, preferably a headache specialist, if this diagnosis is being considered, and brain imaging may be necessary to exclude other causes of chronic daily headaches.

Chronic Cluster Headaches

Cluster headaches that occur at least daily for three months are classified as chronic cluster headaches. Cluster headaches, and preventative treatment, are further discussed on their own page here.

Hypnic Headaches

Hypnic headaches characteristically awaken patients from sleep, usually between 1:00 and 3:00 am or (rarely) during a daytime nap. The pain typically affects the whole head, is throbbing , and lasts from 15 minutes to 2 hours. In as many as 30% of cases, the pain is only on one side of the head. Patients may experience a recurrence of the headache after falling back to sleep. These headaches start most commonly late in life, after age 60 years. They can occur every day, or at least most days. In some cases, eye tearing, facial sweating, nasal congestion, nausea, photophobia, and phonophobia may occur, though they are not prominent.

Treatment has standardly been with lithium, a drug also used to treat bipolar disorder. Doses are titrated up to 600mg at bedtime while kidney and thyroid function are monitored. Because of the significant side effects associated with lithium, alternative therapies can also be tried including caffeine at bedtime, melatonin, or flunarizine (a calcium channel blocker, not available in the U.S.). Verapamil (another calcium channel blocker) has been found effective as has methylsergide (not available in the U.S.). Some report that a bedtime dose of indomethacin (an anti-inflammatory medication) is effective, but typically only for headaches that only affect one side of the head.

New Daily Persistent Headache

This disorder seems more like a description than a diagnosis, but it is really both. New daily persistent headache usually starts rapidly, reaching its daily character within three days or less of initial onset. The headaches are like tension-type headaches, involving the whole head, with feelings of pressure throughout. The headache is constant and does not tend to be aggravated by mild physical activity. It is usually not associated with significant sensitivity to light, sound, or significant nausea; but mild symptoms of this type often occur. Headaches may last only part of the day or the whole day. It is most easily thought of as the sudden development of daily tension-type headaches.

Patients are not suspected of this disorder if they have a long history of frequent migraine or tension-type headaches. It can affect persons of any age, with one study finding an age range of 12 to 78 years.

Clearly in cases of suspected new daily persistent headache, it is important to exclude other diseases which could lead to this pattern of headache. For this reason, persons who think they may have this diagnosis should review Worrisome Headache Symptoms.
A treating physician will need to order brain imaging as well as other testing prior to making this diagnosis, so that structural causes of chronic daily headaches are excluded. Other causes of sudden but persistent daily headaches include spontaneous cerebrospinal fluid leaks (CSF hypovolemia) or venous sinus thrombosis.
The cause of new daily persistent headache is theorized to be due to a viral illness that modifies the brain in such a way as to stimulate recurrent headaches. Indeed, in about 30% of cases, an infection or flu-like illness is associated with the onset of headaches.

New daily persistent headache is an unfortunate diagnosis, since it is very difficult to treat. Patients may go from months and even years with a persistent headache despite aggressive treatment. There no general recommendations for treatment except those that are used for tension-type and migraine headaches. A headache specialist should be sought for the diagnosis and treatment of new daily persistent headache.

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