Chronic daily headache is a debilitating condition affecting millions in the US. It involves headaches occurring more than 15 days per month for over 3 months. The document discusses the diagnosis and management of chronic daily headache. Key points include distinguishing between primary headache disorders like migraine from secondary disorders caused by other conditions. Treatment involves identifying medication overuse, treating any comorbid conditions, using preventive medications, and limiting the use of rescue medications to no more than 2 times per week to prevent rebound headaches.

1. Chronic Daily Headache
February 13, 2013
Brian Plato, DO

2. Why is it important?
• Chronic headache disorders are among the top 20
causes of disability in the US according to the
World Health Organization (WHO)
• 4% of Americans experience 4 hours of headaches
per day, at least 15 days per month
• Headache disorders are responsible for more than
$31B in economic costs in the US annually

3. What is it?
• Headache occurring more than 15 days per
month for more than three months
– Often times is daily
• Further divided into two subgroups
– Headaches lasting more than four hours
– Headaches lasting less than four hours

4. Where do we start?
• Realization
– It is NOT normal to have a headache every day

5. How many people in this room have a bottle
of Excedrin, Advil, Aleve, etc. in their purse
right now?

6. Meeting your doctor
• History
• Examination
• Testing
– Neuroimaging (CT, MRI, etc)
– Blood work
– Ophthalmologic evaluation
– Lumbar puncture
• Diagnosis
• Management

7. Diagnosis
• Primary vs. secondary headache disorders
• Primary headache disorders
– “The headache is the thing”
• Examples: migraine, tension-type, cluster
• Secondary headache disorders
– The headache is caused by something else
• Examples: medication overuse, cervical spine disease,
vascular disorders, trauma

8. Diagnosis
• Primary headache disorders
– Lasting >4 hours
• Chronic migraine
• Chronic tension-type headache
• New daily persistent headache
• Hemicrania continua
– Lasting <4 hours
• Cluster
• Other less common disorders
• Secondary headache disorders

9. Chronic Migraine
• Headache on ≥15 days per month for at least 3 months
– Has at least two of:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity (e.g.
walking or climbing stairs)
– And at least one of:
• Nausea and/or vomiting
• Light and sound sensitivity
– No medication overuse and not attributed to another
causative disorder

10. Chronic Migraine
• Usually a prior history of episodic migraine
• Eventually over time gradually develops in to a
daily pattern
• May or may not be associated with medication
overuse

12. Why is this important for women’s
health?
• Frequently stated that 18% of women have
migraine
• But at mid-life is closer to 30%
• By age 50, up to 40% of women have been
affected by migraine

13. What is migraine really?
• Rather complex and not fully understood
• Neurons of individuals with migraine are
hyperexcitable
• Migraneurs are more sensitive to external
stimulation
– Some interesting evolutionary theories regarding
migraine

14. Migraine Aura
• A reversible focal neurological deficit
– Most commonly visual
• Cortical spreading depression
– Think a wave of activity moving across the brain
followed by decreased activity
– The part of the brain inactivated causes the
neurological deficit
• Occipital lobes = vision

16. The Headache
• Trigeminal nerve and its blood supply
(neurovascular)
– Release of neuropeptides
• CGRP
• Substance P
• 5-HT (serotonin) --> “triptans”
• Nitric oxide
– Vasodilatation (CGRP) leads to further activation, and
the process spreads
– Brainstem, thalamus, cortex become activated leading
to “central sensitization”
• Amplified pain signaling in the central nervous system
– Allodynia: pain due to a non-noxious stimulant

17. Secondary Headache Disorders
• Medication overuse headache (MOH)
• Cervicogenic headache
• Post-traumatic headache
• Others

18. Medication Overuse Headache
• Headache present on ≥15 days/month
• Regular overuse for ≥3 months of one or more
drugs that can be taken for acute and/or
symptomatic treatment of headache
• Headache has developed or markedly
worsened during medication overuse
• Headache resolves or reverts to its previous
pattern within 2 months after discontinuation
of overused medication

19. Medication Overuse Headache
• Generally believed to occur when medication
usage exceeds 2-3 times per week
• Most patients have a history of episodic migraine
that has transformed into a daily headache
• 80% of patients in a headache specialty clinic
• Prior to diagnosis
– Duration of primary headache: 20 years
– Time of frequent medication intake: 10 years
– Time of daily headache: 6 years

20. Medication Overuse Headache
• Simple analgesics: • Opiates:
• Acetaminophen (Tylenol) – Lortab (hydrocodone)
• Ibuprofen (Advil, Motrin) – Percocet (oxycodone)
• Aspirin (Bayer)
• Naproxen (Aleve)
– Many others
• Combination products: • Triptans:
• Fioricet – Imitrex, Maxalt, Relpax,
• Excedrin Zomig, Frova, Amerge,
Axert, Treximet
• DHE

21. Medication Overuse Headache
The Cleveland Clinic Manual of Headache Therapy p. 156

22. Medication Overuse Headache
Bigal ME, et al. Headache. 2008;48:1157-1168.
Bigal ME, et al. Pain. 2009;142:179-182.

23. Medication Overuse Headache
• Serious consequences
– May reduce effectiveness of other medications
– Can cause kidney / liver problems
– Tolerance – same dose becomes less effective
– Dependence – physical need for medication
• Withdrawal

24. Why opiates are bad

25. Medication Overuse Headache
Mathew N, et al. Headache. 1990;30:634-638.

26. Medication Overuse Headache
• Treatment
– Must discontinue overused medication
– Detoxification
• Inpatient vs. outpatient
– Begin / adjust prophylactic medications
– More appropriate rescue medications

27. Cervicogenic Headache
• Pain referred from a source in the neck and
perceived in one or more regions of the head
and/or face
• Evidence of a disorder or lesion within the
cervical spine or soft tissues of the neck as a
cause of headache
• Pain resolves within 3 months after successful
treatment of the causative disorder or lesion

28. Post-Traumatic Headache
• Most patients with mild head injury are never
hospitalized, so exact estimates hard to
determine
• Estimated in 30-80% of patients with mild
head injury
• Of patients with postconcussive syndrome up
to 90% report headache
• 97% of patients with whiplash injury seeking
medical attention also have headache

29. Post-Traumatic Headache
• At 3 months post-injury up to 78% have
ongoing headache
• Most patients have headache remission
within 6 months
• 12 months post-injury up to 35%
• At 4 years 24%
• 6 months seems to be the timeframe that if
still having symptoms will likely continue

30. Comorbidity of CDH
• Depression is 35 times more likely
• Panic attacks and anxiety are three times more
likely
• Sleep-related breathing disorders occur in up
to 30% of patients
• These problems need to be considered and
addressed

31. CDH Treatment / Management
• Depends first on correct diagnosis
• Not always as easy at is sounds
• Medications
– Prescription and non-prescription
• Lifestyle modifications
• Physical / behavioral therapies
• Injections
• Hospitalization
• Surgical evaluation

32. Preventative Medications

33. Preventative Medications
• There are no “migraine specific” medications
used in the prevention of migraine
• Use medications from other classes
– Blood pressure medications
– Antiseizure medications
– Antidepressants
– Serotonin antagonists
– Vitamin supplements
– Botox

34. Preventative Medications
• Important to identify patients that are using
frequent rescue medications and may be on
the way to developing medication overuse
headache
• Patients who have disabling headache that is
not easily treated with rescue medications
• Ideally treat multiple conditions with a single
medication
– ie. high blood pressure and migraine

35. Antidepressants
• Tricyclic antidepressants
– Amitriptyline (Elavil)
– Nortriptyline (Pamelor)
– Protriptyline (Vivactil)
• Side effects
– Elavil and Pamelor are sedating and taken at night
(useful for patients with sleep trouble)
– Cause dry mouth, constipation, weight gain
– At high doses can cause heart related issues that may
require an EKG to be checked

36. SSRI / SNRI
• SSRI
– Fluoxetine (Prozac)
– Paroxetine (Paxil)
– Fluvoxamine (Luvox)
• SNRI
– Venlafaxine (Effexor)
– Duloxetine (Cymbalta)
– Desvenlafaxine (Pristiq)
• SNRIs tend to be more effective for migraine than
SSRIs
– Venlafaxine (Effexor) has the best evidence for use in
prevention of migraine

37. SSRI / SNRI
• Side effects
– Weight gain
– Sexual dysfunction
– Sedation
– Nervousness

38. Antiseizure Medications
• Recently have become most frequently used
medications for prevention of migraine
– Topiramate (Topamax)
– Valproate (Depakote)
– Gabapentin (Neurontin)
– Zonisamide (Zonegran)

39. Topiramate (Topamax)
• One of the most frequently used medications in
the prevention of migraine
• Has several advantages, but also does have some
side effects to be aware of
• Effective in nearly 50% of patients that use it
• Rather than weight gain, often times causes
weight loss
• Optimal dose is 50mg twice per day
– If side effects occur, sometimes may use nighttime only
dosing

40. Topiramate (Topamax)
• Side effects
– Up to 13% of patients experience cognitive dysfunction of
trouble with processing information and trouble finding words
– Numbness / tingling of fingers, toes, face
• Actually a predictor of which patients will benefit from topiramate use
• Potassium supplementation can help
– Risk of kidney stones
– Glaucoma
– Reduced sweating (important in athletes / overheating)
• Recently identified birth defects
– Oral cleft (palate, lip) 11 times higher than general population
– Rated as Category D for pregnancy
• Reduced oral contraceptive effectiveness
– At doses greater than 200mg / day

41. Valproate (Depakote)
• Quite effective, but less commonly used due to
side effect potential
• Optimal dose is 500 – 1,500mg per day
• Side effects
– Weight gain
– Hair loss
– Pancreatitis
– Liver problems
• Significant effects with women of child-bearing
potential
– Neural tube defects (ie. spina bifida)

42. Blood Pressure Medications
• Beta blockers
• Calcium channel blockers
• Other blood pressure medications
– Not frequently used
• Useful in patients with co-existent high blood
pressure

43. Beta Blockers
• Propranolol
• Timolol
• Atenolol
• Metoprolol
• Nadolol
– Lower blood pressure and heart rate
• Can lead to light-headedness
– Can reduce aerobic capacity
– Worsen asthma
– Avoid in diabetics
– Can worsen depression

44. Calcium Channel Blockers
• Verapamil
• Diltiazem
– Generally well tolerated
– Often times more useful in patients with migraine
with aura
– Side effects include light-headedness,
constipation, and swelling of legs

45. Vitamin Supplements
• Not as well studied as prescription medications
(product of financing of studies)
• Magnesium
– 400+mg / day
– Diarrhea
– Magnesium glycinate probably best tolerated form
• Riboflavin (B2)
– 25 – 400mg / day
– Will discolor urine
• Coenzyme Q10
– 100mg 3x / day – I recommend 200mg 2x/day
– Costly (sometimes)
• Butterbur and Feverfew also felt to be effective

46. Rescue Medications
• Primary goal is to achieve relief of pain,
associated symptoms, and disability within 2
hours of use
• Goal is to use rescue medications 2 or fewer
times per week to prevent developing
medication overuse headache

47. Rescue Medications
• It is important to treat the headache as soon as
possible, as time goes on the medications become
less effective
• Allodynia is defined as pain resulting from
stimulation that would not normally be perceived
as noxious (ie. light touch of the skin)
– To the patient this is perceived as scalp tingling or pain
when lightly touched during a migraine
– To physicians this means that the deep parts of the
brain have been stimulated by the migraine attack and
it is often times more difficult to treat

48. Rescue Medications
• Another note is that in treating migraine unlike
treating other conditions (ie. high blood pressure)
we often times suggest using higher dose
medications initially and backing down the dose if
side effects are experiences, rather than over time
escalating doses
– So it is important to understand what potential side
effects can occur with medications and understand that
the goal is being pain-free with TOLERABLE side effects
rather than being with pain and no side effects

49. Nonspecific Migraine Medications
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
• Over 20 forms of NSAIDs available in the US, many
available over-the-counter
• Have anti-inflammatory effects as well as analgesic (pain
relief) effects
• Not processed through the liver
• Kidney metabolism
– Very important for patients with kidney disease, on
other medications that have effects on the kidneys, and
in patients with extreme vomiting (dehydration can
lead to kidney problems)
• Can lead to stomach bleeding with frequent use

50. NSAIDs
• Can be used alone or in combination with
other medications (ie. triptans)
• Are non-sedating
• Have been shown to be effective in treatment
of patients with allodynia
• Because of the availability there is significant
problems with overuse, particularly leading to
medication overuse headache

51. Acetaminophen
• Acetaminophen (Tylenol)
• Most people do not find useful for severe
migraine
• Can be used for mild headache
• Typical dose is 1000mg at onset of headache
• Often times used in combination products (ie.
Fioricet, Midrin, etc)
• Can lead to medication overuse headache
• With heavy usage can lead to liver toxicity,
otherwise no significant side effects

52. Butalbital
• Combination product
• Butalbital / acetaminophen / caffeine
– Esgic, Fioricet
• Butalbital / aspirin / caffeine
– Fiorinal
• Side effects include incoordination, disinhibition,
memory problems, drowsiness
• If used for extended periods of time and then
discontinued can cause withdrawal seizures
• Significant risk of medication overuse headache
– Studies show when used as few as 5 times per month can lead
to MOH

53. Excedrin
• Combination of aspirin, acetaminophen, and
caffeine
• Can be used for mild to moderate migraine
• Due to the multiple products combined there is
significant risk of medication overuse headache
• Available OTC (unregulated by treating physicians
patients can take unlimited amounts)
• In specialty headache clinics this is probably the
most frequently overused medication and causes
more frequent headache

54. Anti-nausea medications
• Can often times alone or in combination be effective
in treating migraine
– Metoclopramide (Reglan)
– Prochlorperazine (Compazine)
– Promethazine (Phenergan) to a lesser extent
• Most common side effects are drowsiness and
dizziness
• More significant side effects include dystonia
(sustained muscle contraction) and akathisia (sense
of restlessness) which can be treated with Benadryl

55. Opiates
• Worth mentioning, but in the hands of
headache specialists are not frequently used
• In migraine, opiates are not well absorbed,
they are associated with increased nausea,
and sedation
• Very quickly can lead to physical dependence
and are quite notorious for causing
medication overuse headache

56. Migraine specific medications

57. Triptans
• Introduced in the 1990s
• Often times considered the drug of choice in
treating migraine
• Selective agonists (activators) of serotonin
blocking the release of other inflammatory
chemicals during a migraine attack

58. Triptans
• Available in many different brand names with
varying time of onset and duration of action
• Available in a variety of delivery methods
– Oral tablet
– Oral disintegrating
– Nasal
– Injection
– Patch (in development)

59. Triptans
• Side effects
– Narrow coronary blood vessels by 10-20% (cannot be
used in individuals with a history of coronary or
cerebro-vascular disease or uncontrolled risk factors)
– Tightening of the throat, chest, jaw, neck, and limbs
– Numbness of the limbs and around the mouth
– Hot and cold sensations
• Thought to be due to esophageal (not heart) related spasm
and muscle contractions
• If warned in advance, most patients can tolerate side effects
with the benefit that they give

60. Triptans
• “Patients vary more than triptans”
• Meaning, just because one did not help or caused
side effects does not mean that another will do
the same
– I give the example of Coke and Pepsi – it’s basically the
same stuff but some people like one and some people
like another, and you won’t know until you’ve tried
them
• Or that different routes of administration won’t
have a different effect

61. Triptans

62. Sumatriptan
• Imitrex, Statdose, Sumavel, Alsuma
• First triptan brought to market (1991)
• Available oral, nasal, subcutaneous injection and soon patch
• Available as a generic
• Oral dose is 25, 50, 100mg – maximum per 24 hours is 200mg
– Available in combination with naproxen as Treximet
• Subcutaneous (SC) forms (Statdose, Sumavel, Alsuma) are 4 and
6mg (max 12mg / 24 hours)
– Have much quicker onset of action (10 minutes) and are great
for patients with significant nausea and vomiting
– Statdose and Alsuma use a needle, Sumavel is needle-less

63. Ergots
• Ergotamine tartrate available since 1925
• Dihydroergotamine (DHE) more refined
version available since 1945
– These were the only available migraine specific
medications until triptans introduced in 1990s
• Effect many chemicals in the nervous system
which explains why they are so effective, but
also explains the side effects

64. Ergots / DHE
• Nausea is the major side effect
– May actually increase nausea of migraine rather than improve
it
• Again contraindicated in patients with vascular disease,
coronary artery disease, etc.
• Available IV (hospital use)
• Intramuscular – can be administer at home
• Intranasal (Migranal) – very easy to use at home
– Inhaled in each nostril and then repeated in 15 minutes
– Much less effective than IV / IM
• Orally inhaled DHE (Levadex) coming to market soon
– Inhaled orally at home with blood levels as high as IV, but with
less nausea

65. Lifestyle Modifications
• Diet
– Tyramine containing foods
• Cheeses: blue, cheddar, parmesan, swiss
– MSG
– Nitrates
• Processed foods / meats
– Chocolate
– CAFFEINE
• About two per day
– Water
• More than 2.5 liters per day

66. Lifestyle Modifications
• Sleep
– Too much (>8.5 hours) and too little (<6 hours)
• Maintain regular sleep schedule
– Snoring / not rested after sleep
• Sleep apnea
– Relaxation techniques for sleep
– Avoid caffeine, alcohol, nicotine
– Avoid “activating” activities in bed
• TV, phone, video games

67. Physical / Behavioral Modifications
• Physical therapy
• Normalize the musculoskeletal system as much as possible
in order to reduce stress and tension on soft tissues and
joints
• Biofeedback
• Method of gaining control of the body processes to
increase relaxation, relieve pain, and develop healthier,
more comfortable life patterns
• Progressive muscle relaxation
• Technique that teaches you to concentrate on relaxing
every muscle in your body

68. Injections
• Occipital nerve block
– Combination of local
anesthetic (lidocaine) and
steroid
– Studies vary, but up to
50% of patients report
improvement

69. Injections
• Botox
– Patients with 15 or more
days of migraine per
month
– Up to 9 days less per
month of headache
– Patients on opiates and
butalbital did worse
– FDA approved

70. Botox
• OnabotulinumtoxinA
• Famous for being used for “wrinkles”
• Found to be effective in patients with chronic
migraine
– Greater than 15 days of headache per month for
greater than 3 months
• In clinical trials patients using opiates and
butalbital were excluded as they tend to do
worse

71. Botox
• 155 units injected into 31 sites given every 3
months
• Minimal side effects
– Injection site pain is largest
• Up to 9 days less per month of headache
• FDA approved

72. Outpatient Infusion Therapy
• Treatment with IV infusions of medications
under direction of physician
• Outpatient
• Break the daily cycle
• Transition to new therapies

73. Hospitalization
• Management of withdrawal
from overused medication
• Repeated infusions of IV
medications
• Adjustment of prophylactic
medications

74. Prognosis / Outcome
• Goal is to transition from daily headache to
episodic
• Studies report up to 80% of patients can have a
50% reduction in headache at 2 years
• Many of these patients require inpatient
management initially

75. What can you do?
• Track headaches
• Paper diary
• iHeadache
• www.iheadache.com
• Evaluate lifestyle factors
• Diet
• Caffeine
• Sleep

76. What can you do?
• Evaluate medicine use
• Work with your physician
• Set reasonable expectations
• Not a cure, management

77. What can you do?
• Get involved!
• Headache school
• Alliance for Headache Disorders Advocacy
• American Headache Society (AHS) Committee for
Headache Education (ACHE)

78. Headache School
• What is a migraine?
– March 14
• Medication maze
– April 11
• How diet affects headaches
– May 16
• Women and Headaches
– June 13

79. What can you do?
• American Headache Society Committee for Headache Education
• www.achenet.org
• American Headache Society
• http://www.americanheadachesociety.org
• The International Headache Society
• www.i-h-s.org
• OUCH - Organization For The Understanding Of Cluster Headache
• www.ouch-us.org
• Southern Headache Society
• www.southernheadache.org
• Alliance for Headache Disorders Advocacy
• www.allianceforheadacheadvocacy.org

80. What can we do for you?
• Outpatient neurologists / headache specialists
• 629-1234
• Inpatient neurologists / headache specialists
• IV infusion services
• Elective hospitalization
• Occipital nerve blocks
• Botox
• Psychological counseling
• Neurosurgical consultation

81. Thank you!
Questions?