Chronic daily headache

Introduction
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By James R Couch MD PhD and Chaouki Khoury MD

Chronic daily headache is a highly prevalent problem affecting 3% to 5% of the population as determined by studies in many parts of the world. The syndrome consists mainly of chronic migraine and chronic tension-type headaches. Chronic daily headache produces intermittent disability and a great deal of economic and psychosocial burden with loss of time from work, from family responsibilities, and from recreational activities. Chronic daily headache often leads to the overuse of symptomatic headache and pain medications and then to an additional dimension of medication overuse or rebound-withdrawal headache. Much progress has been made in the understanding and management of this condition. New therapies for chronic daily headache have been introduced, including approval of botulinum toxin and additional evidence for use of amitriptyline and topiramate. This review summarizes the background and progress in dealing with this medical as well as socioeconomic problem. The review will deal primarily with chronic migraine and chronic tension-type headaches.

Key points

  • Chronic daily headache is a complex chronic problem with long-term relapses and remissions.
  • The disease may have long-term psychosocial effects that drastically alter relations to family and job.
  • There is no “cure”; however, many patients can have a good response to appropriate management.
  • Management of chronic daily headache requires ongoing contact between patient and physician, and the understanding of this condition as a potentially chronic disease with pain and psychosocial morbidity. There must be ongoing vigilance to the factors noted above. Subjects often relapse into periods of frequent headache and may become discouraged or depressed.
  • There may be occurrence of medication overuse headache as a complication of treatment of chronic daily headache, or relapse of medication overuse headache due to the original medication overuse headache inducing agent, or due to another symptomatic medication that has become a new medication overuse headache inducing agent.
  • Because of the chronicity of the disease, patients may become discouraged and see other physicians who may or may not know much about chronic headache. Patients may, against the physicians’ advice, resume taking symptomatic medications that result in medication overuse headache and worsening of condition. The physician must continue to see his/her role as a healer that will do the best for the patient and continue to care for and work with the patient if and when the patient returns to the practice.
  • All these factors require the patient and physician to have a good understanding of the disease and its course and to work together to achieve the best outcome.