Chronic daily headache The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Spierings, Egilius L. H. 2003. Chronic daily headache. The Journal of Headache and Pain 4(3): 111-124. Published Version doi:10.1007/s10194-003-0045-6 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:10579386 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA J Headache Pain (2003) 4:111–124 DOI 10.1007/s10194-003-0045-6 REVIEW Egilius L.H. Spierings Chronic daily headache Received: 5 March 2003 Abstract Chronic daily headache opioids in intractable patients. The Accepted in revised form: 16 April 2003 relates to the daily or almost daily review concludes with a discussion occurrence of headache in a non- of hemicrania continua, an paroxysmal pattern. In this review, I indomethacin-responsive headache discuss the presentation, develop- syndrome. ment, outcome, and treatment of chronic daily headache. In the con- Key words Daily headache • text of the development of chronic Chronic daily headache • E.L.H. Spierings (౧) daily headache, a headache continu- Presentation • Development • Department of Neurology, um is presented along with its under- Tension-type headache • Migraine • Brigham and Women’s Hospital, Harvard Medical School, lying pathophysiology. The treatment Headache continuum • Outcome • Boston, Massachusetts, USA section covers rebound headache, Treatment • Rebound headache • Tel.: +1-781-431-1118 analgesic and vasoconstrictor with- Hemicrania continua Fax: +1-781-431-0180 drawal, and the use of long-acting ble, to distinguish from chronic daily headache on the basis Introduction of its presentation alone. It differs from chronic daily headache in the somewhat more consistent and less variable Chronic daily headache refers to the daily or almost daily intensity of the headache and in the absolute response to occurrence of headache. However, not all daily or almost preventive treatment with indomethacin. daily headaches fall under this denominator, as is the case with the daily or almost daily headaches of (chronic) cluster headache and (chronic) paroxysmal hemicrania. These con- ditions are referred to as paroxysmal daily headaches, in Presentation which the headaches occur in well-defined attack patterns. In cluster headache, the attack pattern is that of headaches In a study of 258 patients from my private headache practice occurring once or twice per day, lasting for one-half to 2 with chronic daily headache, defined as headaches occurring hours; in paroxysmal hemicrania, it is that of headaches at least 5 days per week for at least 1 year, my colleagues occurring 5–15 times per day, lasting for 10–30 minutes. and I characterized the presentation of the headache condi- Of the non-paroxysmal daily headaches, hemicrania tion [1]. We excluded only those patients with daily continua is a condition that does not fall under the denomi- headaches who described well-established paroxysmal nator of chronic daily headache either. However, it is dis- headache syndromes, in order to capture as much of the clin- cussed in this review because it is difficult, if not impossi- ical features of the condition as possible. Of the 258 112 patients, 19% were men and 81% women; their average age terns. The most common pattern is that in which the at the time of consultation was 42 years. The distribution of headaches gradually increase in intensity as the day pro- the age at onset of (any) headache for the men and women gresses, to be worst in the afternoon or evening. According separately is shown in Fig. 1: 77% of all patients (69% of to the results of the study, this is the pattern in more than half men and 79% of women) experienced the onset of headache of the patients with chronic daily headache. The less com- before the age of 30 years. The onset of headache occurred mon pattern, which I refer to as the “reversed diurnal pat- in the second decade of life in 36% of the women, as tern”, is that in which the headaches are worst on awakening opposed to 24% of the men. The peak of headache onset in in the morning and gradually improve as the day progresses. the second decade in women is indicative of the importance This was the case in one-quarter of the patients while in the of the menstrual cycle in the development of headache in remaining quarter, the diurnal course of the headaches was women. variable. With regard to diurnal pattern, the daily headaches were The reversed diurnal pattern is associated with the present on awakening or came on in the course of the morn- most frequent nighttime awakenings with headache. In ing in 79% of the patients, came on in the afternoon or the study, nocturnal awakening by headache occurred at evening in 6%, and had a variable time of onset in 15% (Fig. least once per week in 36% of the patients. Of the patients 2). In 25%, the headaches were worst on awakening or in the who were woken up by headache at least once per week, course of the morning; in 53% they were worst in the after- 48% experienced the worst headache on awakening or in noon or evening, and in 22% they were worst at a variable the course of the morning, as opposed to 22% of the time of the day. The results agree with my clinical observa- patients who were woken up by headache less than once tion that daily headaches come in two distinct diurnal pat- per week. Fig. 1 Age at onset of (any) headache, by gender (n=251). (From [1] with permission) Fig. 2 Diurnal pattern of the daily headaches (n=214). (From [1] with permission) 113 With regard to associated symptoms, the daily headaches chronic daily headache who seek specialty care for their were at least twice per week associated with nausea in 35% headaches do not have chronic tension-type headache. They and with vomiting in 9%. With regard to the laterality of the have chronic tension-type headache combined with migraine daily headaches, 36% were unilateral, 50% bilateral, and or, as I prefer to call it, tension-type vascular headache. This 14% either unilateral or bilateral. The unilateral headaches conclusion is based on the view that, with regard to clinical had a fixed lateralization in 83% and alternated between the presentation, intensity is the predominant distinguishing fea- left and right sides in 17%. The aggravating factors of the ture between migraine and tension-type headache. daily headaches are shown in Table 1. Apart from light and With regard to laterality, the severe headaches were uni- noise, most common were physical activity, bending over, lateral in 43%, bilateral in 42%, and either unilateral or stress or tension, and menstruation. bilateral in 15%. The unilateral headaches had a fixed later- Overall, 94% of the patients experienced severe alization in 79% and alternated between the left and right headaches in addition to the daily headaches (Fig. 3). sides in 21%. One would expect the severe headaches to be Twenty-six percent of the patients experienced severe lateralized more often than the daily headaches, but this was headaches more than 15 days per month, while the majority not the case. With regard to associated symptoms, the severe (63%) experienced severe headaches 10 days per month or headaches were at least twice per month associated with less. The results suggest that the majority of the patients with nausea in 76% and with vomiting in 38%. In the development of chronic daily headache, medica- Table 1 Aggravating factors of the daily headaches (n=258). (From tion intake is considered to play an important role, in partic- [1] with permission) ular the intake of analgesic and vasoconstrictor medications [2]. A widely used vasoconstrictor for the abortive treatment Patients, % of headache is caffeine, in beverages, especially coffee, but Light 40 also in prescription and non-prescription medications. Physical activity 33 Therefore, we measured the caffeine intake of our patients Bending over 33 with chronic daily headache, by looking at their coffee and Noise 30 medication intakes. A cup of coffee was considered to con- Stress or tension 29 tain 100 mg caffeine. We found that 43% of the patients used Menstruationa 28 less than 100 mg caffeine per day, 35% between 100 and Alcohol 20 300 mg, and 22% more than 300 mg. The average caffeine Coughing or sneezing 15 intake was 170 mg per day, which is approximately the Foods or drinks 13 equivalent of two cups of coffee. This is less than what was Lack of sleep 12 found in the population of Sydney, Australia, where the Not eating on time 11 Straining 10 average caffeine intake was 240 mg per day, with 30% con- Weather changes 10 suming more than 300 mg [3]. Exhaustion 10 With regard to analgesic use, we only considered the non-opioid medications because opioids were hardly used a For women only; n=208 by the patients for the treatment of headaches. Furthermore, Fig. 3 Frequency of severe headaches in days per month (n=197). (From [1] with permission) 114 of the barbiturate-containing medications, we did not take abrupt onset of the daily headaches and 145 (81%) a grad- into account the barbiturate component because it is not ual onset. The distribution of the age at onset of the daily strictly an analgesic. With these limitations, we found that headaches in those patients with abrupt-onset secondary 26% of the patients used less than 500 mg aspirin-equiva- chronic daily headache is shown in Fig.