Chronic Daily Headache:
Same Old, Same Old

Gary Cordingley, MD, PhD
Daily and near-daily headaches are common and disabling. Correct
diagnosis of headaches can lead to effective treatment, decreased
suffering and improved quality of life.
“Chronic daily headache” (CDH) refers to the unhappy situation in which headaches are present at least
fifteen days per month. Headaches can even occur every day or almost every day. CDH is more of a
category than a final diagnosis, and different, recognizable patterns of headache are included in this
category. It is important to distinguish among the different patterns because, once recognized, they can
indicate the underlying cause and dictate appropriate treatment.

CDH can occur in the form of either “primary headaches” or “secondary headaches.” Secondary
headache means that the headache is a symptom of some other disease or process. In this case, the best
treatment is one that addresses the underlying cause. Primary headache means that the headache
disorder itself is the disease, and is not a symptom of something else.

The most common primary headache condition is “tension-type headaches.” Generally affecting the left
and right sides equally, tension-type headaches often involve the back of the head and neck, but can also
include the front of the head. These headaches are usually mild to moderate in intensity and have
pressing or tightening qualities. Nausea, photosensitivity and sound sensitivity are not prominent in this
headache disorder and tension-type headaches do not usually worsen with exertion.

Migraine is another common primary headache disorder which, when present more days than not, is also
categorized as CDH. Migraine attacks typically last 4-72 hours when untreated. They are of moderate to
severe intensity and often have a pulsating quality. They show increased tendency to affect just one side
of the head and to include the associated symptoms of nausea, light sensitivity and sound sensitivity.
They usually worsen with exertion.

While some people have frequent, individual, migraine attacks that span more than 15 days per months
and are therefore categorized as CDH, another form of migraine involves a blending together of attacks
into a more continuous, never-ending pattern. This usually occurs in people who previously had the more
recognizable pattern of distinct, individual, migraine attacks. Just what happens in these cases--or even
what to call it when it does happen--is a source of great debate among headache experts. One camp of
experts calls it “chronic migraine” and another camp calls it “transformed migraine.”

To make matters even more interesting, a person can have more than one type of headache, for example,
a mixture of migraine and tension-type headaches. When this occurs, the mixture can be difficult to
distinguish from the previously mentioned chronic (or transformed) migraine.

Two other kinds of primary headache are rarer than migraine and tension-type headaches, and show
quite different characteristics. These are “hemicrania continua” and “chronic cluster.” Hemicrania continua
(“hemicrania” means half-headed and “continua” means continuous) is a strictly one-sided headache
which can wax and wane in intensity without resolving. It does not include migraine’s usual associated
symptoms of nausea, light sensitivity, sound sensitivity and exertional aggravation. Chronic cluster, like its
less-frequent “episodic” form, involves intense, recurring pain in or around just one eye that lasts for only
15-180 minutes per attack, but which can occur more than once per day. Unlike its episodic cousin,
chronic cluster does not go into remission without treatment.

Secondary headaches taking the form of CDH can be due to numerous causes. Among them are head
injury, arthritis of the neck bones, arthritis of the jaw joints (TMJs), sinus disease, breathing problems
during sleep, tumors or other conditions causing increased pressure within the braincase, and leakages of
the cerebrospinal fluid that surrounds the brain and spinal cord.

Two secondary forms of CDH deserve special mention--giant cell arteritis and medication overuse
headaches. Giant cell arteritis (previously called temporal arteritis) occurs in people who are at least 50
years old and becomes more common in subsequent decades of life. It involves inflammation of larger-
diameter arteries supplying blood to the brain and the rest of the head and, untreated, can lead to stroke
or blindness. So it is important to recognize and treat this source of headaches before these complications
occur. Classically, people with giant cell arteritis show a swollen, stiff, tender artery just beneath the skin of
one or both temples. When this occurs, it facilitates diagnosis, but giant cell arteritis can still be present in
the absence of this tell-tale sign. As a rule of thumb, giant cell arteritis should be considered as a possible
diagnosis in every new headache disorder starting at the age of 50 or older.

Medication overuse headaches (also known as rebound headaches) occur when a primary headache
disorder becomes transformed into an even worse secondary headache disorder via too many doses of
as-needed medication. Typically, the primary headache disorders involved are either migraine or tension-
type headaches, and the transformation occurs when the headache-sufferer takes need-driven
medication for them at least two to three days each week. When the as-needed medication is a painkiller
this syndrome is called “analgesic rebound” and when a triptan drug is used, it is called “triptan rebound.”
Triptans are newer drugs, which include sumatriptan (Imitrex) and rizatriptan (Maxalt), that interact with
specific chemical receptors and halt the generation of migraine attacks. The bottom line with medication
overuse headaches is that they don’t get better until the drug that caused them is withdrawn and, even
then, can take up to two months to wash out.

The group of disorders known as chronic daily headache afflicts 3-5% of the worldwide population and is a
source of major disability in the form of lost or decreased functioning at home and at work. While many
people with CDH treat them on their own, medical management can reduce suffering and improve quality
of life.

(C) 2005 by Gary Cordingley