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The Term Chronic Daily Headache(CDH)

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The Term Chronic Daily Headache(CDH) attacks with conjunctival injection and tearing (SUNCT). When headache duration is greater than 4 hours, the major primary disor- ders for which there are operational diagnostic criteria as defined by the second edition of the International Clas- Chronic Daily Headache sification of Headache Disorders (ICHD- 2 Stephen D. Silberstein, MD 2) are chronic migraine, hemicrania continua, chronic tension-type headache (CTTH), and new daily persistent headache (NDPH).1 Chronic migraine is used by the ICHD-2 in place of trans- formed migraine (defined by the Silber- stein and Lipton criteria). Chronic ten- sion-type headache was included in the first International Headache Society (IHS) classification and inappropriately equated to CDH.3 Chronic migraine, Chronic daily headache represents a range of disorders characterized by the NDPH, and hemicrania continua are new occurrence of long-duration headache 15 or more days per month. The classi- to the ICHD-2.2,4 fication of these disorders continues to undergo revision to make them more Long-duration CDH is a significant clinically relevant, such as that which has been most controversial, the clas- public health concern. Approximately sification of chronic migraine. The role of medication overuse in what has com- 3% to 5% of the population worldwide monly been known as rebound headache can have a significant influence on have daily or near-daily headaches.5-9 these disorders. The diagnosis of the chronic daily headaches, including Patients with long-duration primary chronic migraine and chronic tension-type headache, truly cannot be made if CDH, most of which is transformed patients are having medication-overuse headache. This article reviews the migraine, account for the majority of criteria for medication-overuse headache and the subset of headaches making headache subspecialty practice consul- up chronic daily headache, as well as the epidemiologic and therapeutic tations in the United States.2,3,10 The dis- aspects of these disorders. ability associated with this disorder is substantial, as patients have a signifi- cantly diminished quality of life and he term chronic daily headache (CDH) gorized into primary and secondary mental health, as well as impaired phys- Trefers to a group of disorders char- varieties.1 Secondary CDH has an iden- ical, social, and occupational func- acterized by very frequent headaches tifiable underlying cause such as acute tioning.4,11,12 (у15 days a month), including those headache medication overuse, head headaches associated with medication trauma, cervical spine disorders, vas- Transformed and Chronic Migraine overuse. The CDH group can be cate- cular disorders, and disorders of Many studies have described the pro- intracranial pressure. Primary CDH is cess and associated features of trans- not related to a structural or systemic formed migraine.5,6,11-14 This headache Dr Silberstein, a professor of neurology at Thomas illness, and is often subdivided into has been variously called transformed or Jefferson University Hospital in Philadelphia, Pa, is long- or short-duration disorders, based evolutive migraine or mixed headache. president of the American Headache Society. Dr Silberstein is on the advisory panel or on whether the individual headache Patients with transformed migraine often speakers bureau, or serves as a consultant for episodes last more or less than 4 hours have a past history of episodic migraine Abbott Laboratories; Allergan, Inc; AstraZeneca; Eli on average. that began in their teens or twenties.14 Lilly and Company; GlaxoSmithKline; Johnson & Johnson; Merck & Co, Inc; NPS Pharmaceuticals, When headache duration is less Most patients with this disorder are Ortho-McNeil Pharmaceutical, Inc; Pfizer Inc; Pozen, than 4 hours, the differential diagnosis women, 90% of whom have a history of Inc; UCB Pharma, Inc; and XCel Pharmaceuticals. He includes cluster headache, paroxysmal migraine without aura. receives research support from Abbott Laborato- ries; Allergan, Inc; AstraZeneca: Eli Lilly and Com- hemicrania, idiopathic stabbing Patients often report a process of pany; GlaxoSmithKline; Johnson & Johnson; headache, hypnic headache, and short- transformation characterized by Medtronics; Merck & Co, Inc; NPS Pharmaceuti- lasting unilateral neuralgiform headache headaches that become more frequent cals; Pfizer Inc; Pozen, Inc; UCB Pharma, Inc; and XCel Pharmaceuticals. Address correspondence to Stephen D. Sil- berstein, MD, FACP, Director, Jefferson Headache This continuing medical education publication supported by Center, 111 S 11th St, Gibbon Bldg, Suite 8130, Philadelphia, PA 19107-4824. an unrestricted educational grant from Merck & Co, Inc E-mail [email protected] Silberstein • Chronic Daily Headache JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S23 over months to years, with the associ- ated symptoms of photophobia, phono- Table 1 phobia, and nausea becoming less severe Silberstein and Lipton Revised Criteria for Chronic Migraine* and less frequent.5,6,11,13,15 Patients often develop (or transform into) a pattern of 1.8 Chronic Migraine daily or nearly daily headaches that phe- A. Daily or almost daily (Ͼ15 days/month) head pain for Ͼ1 month nomenologically resembles a mixture of Ͼ tension-type headache (TTH) and B. Average headache duration of 4 hours/day (if untreated) migraine. That is, the pain is often mild C. At least one of the following: to moderate and is not always associ- 1) History of episodic migraine meeting any International Headache Society (IHS) criteria 1.1 to 1.6 ated with photophobia, phonophobia, 2) History of increasing headache frequency with decreasing severity of or gastrointestinal features. migrainous features over at least 3 months Other features of migraine, 3) Headache at some time meets IHS criteria for migraine 1.1 to 1.6 other including aggravation by menstruation than duration and other trigger factors, as well as uni- D. Does not meet criteria for new daily persistent headache (4.7) or hemicrania laterality and gastrointestinal symptoms, continua (4.8) may persist. Attacks of full-blown E. Not attributed to another disorder migraine superimposed on a background of less severe headaches occur in many * Modified from Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: patients. The term transformed migraine field trial of revised IHS criteria. Neurology. 1996;47:871-875. has been used to refer to this process. The term chronic migraine is now being used by the IHS, in part because a history attempts to get around this issue by using generalizability in clinical practice. While of transformation is often missing. the term probable chronic migraine. up to 80% of headaches experienced by Silberstein and Lipton’s revised cri- The IHS, in its newest classification episodic migraine sufferers will fulfill teria for transformed migraine (Table 1) (ICHD-2),2 classifies chronic migraine as criteria for migraine or probable migraine provide three alternative diagnostic links a complication of migraine. Its diagnosis (1.1 or 1.6), migraineurs do experience a to migraine14: requires migraine headache occurring spectrum of headaches that may pheno- Ⅺ a prior history of IHS migraine; on 15 or more days a month for more typically resemble or fulfill criteria for Ⅺ a clear period of escalating headache than 3 months without medication TTH. frequency with decreasing severity of overuse (Table 2) When medication As headache frequency increases, migrainous features; or overuse is present, the diagnosis is the phenotypic spectrum of individual Ⅺ current superimposed attacks of unclear until 2 months after medication headache episodes broadens, and the headaches that meet all the IHS criteria has been withdrawn without improve- clinical distinction between migraine and for migraine except duration. ment. Medication overuse, if present (ie, TTH may become less obvious. Many Migraine transformation most often medication-overuse headache [MOH]), is clinicians and epidemiologists now develops when there is medication the most likely cause of chronic symp- believe that most headaches experienced overuse, but transformation may occur toms. Therefore, the default rule is to by migraine sufferers that phenotypi- without overuse.5,16 About 80% of code such patients according to the cally resemble TTH are biologically sim- patients with CDH seen in subspecialty antecedent migraine subtype (usually ilar to migraine and responsive to clinics overuse symptomatic medica- migraine without aura) plus probable migraine-specific modes of therapy.5 Fur- tion.5,6,13,15 Headache frequency often chronic migraine plus probable MOH. thermore, attacks are often treated early, increases when medication use increases. When these criteria are still fulfilled 2 before severity increases and associated Stopping the overused medication fre- months after medication overuse has symptoms develop. quently results in distinct headache ceased, chronic migraine plus the Based on the clinical trial and clinic- improvement, although it may take days antecedent migraine subtype should be based data reviewed, the criteria for to weeks. Many patients have significant diagnosed and probable MOH dis- ICHD-2 chronic migraine do not accu- long-term improvement after detoxifi- carded. If at any time sooner these criteria rately reflect the headache phenotype of cation. When the original IHS (ICHD-1) are no longer fulfilled because improve- those patients with a history of migraine criteria3 were used, a
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