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Management of Chronic Headache

A review of assessment and treatment of outpatient chronic headache patients along with a commentary on aggravating and mitigating factors.
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When we assess patients who seek medical treatment for headache pain, they usually suffer from migraine, tension, or chronic daily headache. Only about 5% of patients fall outside of that realm. Cluster headache is another type of primary headache, but cluster headache is relatively uncommon; it is only found in about one out of 250 men and one out of 700 women.1 In contrast, migraine is common; it occurs in 18% of women and 7% of men in the U.S. Chronic daily headache (CDH) often results in a markedly decreased quality of life for patients. Including triptans and other new preventives, we have numerous medications for migraine, but we don’t have much that is new or effective for chronic daily headache. The following discussion reviews what we currently know about the various types of headaches, comorbidities, triggers, and treatments.


Migraine, of course, is the more severe type of headache. There are twenty-five to twenty-eight million people in the U.S. with migraine, making it one of the most common of illnesses. Many migraine patients can successfully take care of their headaches with over-the-counter medicines, but most are disabled to one degree or another during their migraine. I look at migraine as an inherited, chronic illness. It is characterized by moderate to severe pain, often unilateral, although it certainly may be bilateral. Migraine is usually accompanied by associated features such as nausea, dizziness, photophobia, sonophobia, or osmophobia. Exacerbation of the headache from bending or other movement is common, as is neck pain. Aura is fairly common; up to 25% of migraineurs experience an aura, but not with every headache. It is common to have prodromal and/or postdromal fatigue and mood changes. Migraine may begin at any age and is surprisingly common in children and adolescents. At least 1% of 6-year-olds and increasing to 4% by age 10. Until the age 12, boys and girls suffer from migraine in equal numbers but, during puberty, the familiar women-to-men ratio of 3:1 is reached and that ratio is maintained throughout the rest of life.2

In diagnosing migraine, it helps to look at consistent triggers—such as menses, weather, and under-sleeping. If weather changes bring on migraine it is always confusing since the migraineur is told (and feels) that they have a sinus headache and so they take an OTC sinus medicine, which often helps. Most sinus headaches turn out to be migraines. There have been several large studies on this and 95% of people presenting with chronic sinus headaches are found to have migraines, not sinus headaches. So one must think “migraine first” regarding pain in the sinus area.3


With a new onset headache—especially in a patient in middle or later life—more extensive work-up is needed. This is also true for new neurological symptoms such as numbness, a change in mental status, or visual problems. The patient with chronic daily headaches warrants an MRI more often than the patient with sporadic migraines. Children with migraine may not need an MRI. If a 12-year old presents with two migraines per month since age 6, an MRI is not absolutely necessary. However, when the kids are followed as far as college age, often there will be an incident where they will call and complain of a severe, prolonged headache and usually end up having a scan at some point. Most headache patients should undergo routine hematologic exams, primarily to assess liver and kidney function. Patients are often taking OTC medicines that they don’t tell us about. Either they don’t remember or don’t have a sense of how many OTC’s they take for pain relief. It is not unusual for headache sufferers to consume 8 to 10 ibuprofen or Excedrin on a daily basis and so the liver and kidneys may be affected.


One of the primary things we can do is educate patients about triggers. Unfortunately, we can’t do very much about certain triggers, but when a patient has a headache every time the weather changes, or the first day of every menstrual period, we might be able to use medicine the day or night before as a preventative. The top triggers tend to be stress (daily hassles), menses, and weather. When they occur simultaneously is when patients get the worst, most prolonged migraines. Of course, missing meals, under- or over-sleeping, bright lights, and certain foods also contribute, but the role of foods tends to be overemphasized. People are given a forbidden-food list and told, “Avoid these foods and you won’t have headaches,” and then they are disappointed. Many books concentrate on diet and foods, but these are low on the list of important triggers. Caffeine, however, is a major trigger. We need to limit the patient’s intake, although the limit varies. Some people can consume 800mg a day of caffeine and not incur rebound headaches or withdrawal. Other people get headaches from a small amount of caffeine in their diet. Caffeine is an adjunct for pain relief as it does help enhance analgesics. Small amounts often help people with their headaches. We have to watch out for the specialty coffeehouse effect: Starbucks coffee has 23 mg. of caffeine per ounce so that, in that oversized cup of Starbucks, you are going to get about 400 mg. of caffeine, which is twice the daily maximum recommended. But most home-brewed coffees have manageable doses. Coffees such as Folgers or Hills Brothers have about 150 mg. per cup, while instant coffee has half that amount. Tea, if it has caffeine, will generally have 30-60 mg per cup. Cola drinks have 40-60 mg. and Mountain Dew has a little more. The new energy drinks may have 200 mg. in 12 ounces. Watch for accumulated caffeine from these and from OTC medication; each tab of Excedrin has 65 mg. of caffeine, while Anacin has only 33 mg. I attempt to limit a patient’s daily caffeine intake to 150 mg.—with 200 mg. as the maximum.4

Psychological Comorbidities

Comorbidities guide where we go with headache patients. Psychiatric comorbidities are relatively common in headache patients, primarily due to shared genetic susceptibilities. I tell patients that migraine is an inherited medical problem just like having asthma. Similarly, in those with patients suffering anxiety and depression, a genetic tendency can make them susceptible—the same as with diabetes. So, refrain from telling patients that it’s all in their heads since they’ve been told that their entire lives. If we “medicalize” these ailments and remove some of the stigma, patients will allow us to explore more of their psychological conditions. The psychological conditions often drive where we go with treatment.

Last updated on: August 7, 2014
First published on: November 1, 2008