Chronic daily headaches

Most people have headaches from time to time. But if you have a headache more days than not, you might have chronic daily headaches.

Rather than a specific headache type, chronic daily headaches include a variety of headache subtypes. Chronic refers to how often the headaches occur and how long the condition lasts.

The constant nature of chronic daily headaches makes them one of the most disabling headache conditions. Aggressive initial treatment and steady, long-term management might reduce pain and lead to fewer headaches.

By definition, chronic daily headaches occur 15 days or more a month, for longer than three months. True (primary) chronic daily headaches aren't caused by another condition.

There are short-lasting and long-lasting chronic daily headaches. Long-lasting headaches last more than four hours. They include:

• Chronic migraine
• Chronic tension-type headache
• New daily persistent headache
• Hemicrania continua

Chronic migraine

This type typically occurs in people with a history of episodic migraines. Chronic migraines tend to:

• Affect one side or both sides of your head
• Have a pulsating, throbbing sensation
• Cause moderate to severe pain

And they cause at least one of the following:

• Nausea, vomiting or both
• Sensitivity to light and sound

Chronic tension-type headache

These headaches tend to:

• Affect both sides of your head
• Cause mild to moderate pain
• Cause pain that feels pressing or tightening, but not pulsating

New daily persistent headache

These headaches come on suddenly, usually in people without a headache history. They become constant within three days of your first headache. They:

• Often affect both sides of your head
• Cause pain that feels like pressing or tightening, but not pulsating
• Cause mild to moderate pain
• Might have features of chronic migraine or chronic tension-type headache

Hemicrania continua

These headaches:

• Affect only one side of your head
• Are daily and continuous with no pain-free periods
• Cause moderate pain with spikes of severe pain
• Respond to the prescription pain reliever indomethacin (Indocin)
• Can become severe with development of migraine-like symptoms

In addition, hemicrania continua headaches are associated with at least one of the following:

• Tearing or redness of the eye on the affected side
• Nasal congestion or runny nose
• Drooping eyelid or pupil narrowing
• Sensation of restlessness

When to see a doctor

Occasional headaches are common, and usually require no medical attention. However, consult your doctor if:

• You usually have two or more headaches a week
• You take a pain reliever for your headaches most days
• You need more than the recommended dose of over-the-counter pain remedies to relieve your headaches
• Your headache pattern changes or your headaches worsen
• Your headaches are disabling

Seek prompt medical care if your headache:

• Is sudden and severe
• Accompanies a fever, stiff neck, confusion, seizure, double vision, weakness, numbness or difficulty speaking
• Follows a head injury
• Gets worse despite rest and pain medication

The causes of many chronic daily headaches aren't well-understood. True (primary) chronic daily headaches don't have an identifiable underlying cause.

Conditions that might cause nonprimary chronic daily headaches include:

• Inflammation or other problems with the blood vessels in and around the brain, including stroke
• Infections, such as meningitis
• Intracranial pressure that's either too high or too low
• Brain tumor
• Traumatic brain injury

Medication overuse headache

This type of headache usually develops in people who have an episodic headache disorder, usually migraine or tension type, and take too much pain medication. If you're taking pain medications — even over-the-counter — more than two days a week (or nine days a month), you're at risk of developing rebound headaches.

Factors associated with developing frequent headaches include:

• Female sex
• Anxiety
• Depression
• Sleep disturbances
• Obesity
• Snoring
• Overuse of caffeine
• Overuse of headache medication
• Other chronic pain conditions

If you have chronic daily headaches, you're also more likely to have depression, anxiety, sleep disturbances, and other psychological and physical problems.

Taking care of yourself might help ease chronic daily headaches.

• Avoid headache triggers. Keeping a headache diary can help you determine what triggers your headaches so that you can avoid the triggers. Include details about every headache, such as when it started, what you were doing at the time and how long it lasted.
• Avoid medication overuse. Taking headache medications, including over-the-counter medications, more than twice a week can increase the severity and frequency of your headaches. Consult your doctor about how to wean yourself off the medication because there can be serious side effects if done improperly.
• Get enough sleep. The average adult needs seven to eight hours of sleep a night. It's best to go to bed and wake up at the same time every day. Talk to your doctor if you have sleep disturbances, such as snoring.
• Don't skip meals. Eat healthy meals at about the same times daily. Avoid food or drinks, such as those containing caffeine, that seem to trigger headaches. Lose weight if you're obese.
• Exercise regularly. Regular aerobic physical activity can improve your physical and mental well-being and reduce stress. With your doctor's OK, choose activities you enjoy — such as walking, swimming or cycling. To avoid injury, start slowly.
• Reduce stress. Stress is a common trigger of chronic headaches. Get organized. Simplify your schedule. Plan ahead. Stay positive. Try stress-reduction techniques, such as yoga, tai chi or meditation.
• Reduce caffeine. While some headache medications include caffeine because it can be beneficial in reducing headache pain, it can also aggravate headaches. Try to minimize or eliminate caffeine from your diet.

Your doctor will likely examine you for signs of illness, infection or neurological problems and ask about your headache history.

If the cause of your headaches remains uncertain, your doctor might order imaging tests, such as a CT scan or MRI, to look for an underlying medical condition.

Treatment for an underlying condition often stops frequent headaches. If no such condition is found, treatment focuses on preventing pain.

Prevention strategies vary, depending on the type of headache you have and whether medication overuse is contributing to your headaches. If you're taking pain relievers more than three days a week, the first step might be to wean yourself off these drugs with your doctor's guidance.

When you're ready to begin preventive therapy, your doctor may recommend:

• Antidepressants. Tricyclic antidepressants — such as nortriptyline (Pamelor) — can be used to treat chronic headaches. These medications can also help treat the depression, anxiety and sleep disturbances that often accompany chronic daily headaches.

  Other antidepressants, such as the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac, Sarafem, others), might help in treating depression and anxiety, but have not been shown to be more effective than placebo for headaches.

• Beta blockers. These drugs, commonly used to treat high blood pressure, are also a mainstay for preventing episodic migraines. These include atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL) and propranolol (Inderal, Innopran XL).
• Anti-seizure medications. Some anti-seizure drugs seem to prevent migraines and might be used to prevent chronic daily headaches, as well. Options include topiramate (Topamax, Qudexy XR, others), divalproex sodium (Depakote) and gabapentin (Neurontin, Gralise).
• NSAIDs. Prescription nonsteroidal anti-inflammatory drugs — such as naproxen sodium (Anaprox, Naprelan) — might be helpful, especially if you're withdrawing from other pain relievers. They can also be used periodically when the headache is more severe.
• Botulinum toxin. OnabotulinumtoxinA (Botox) injections provide relief for some people and might be a viable option for people who don't tolerate daily medication well. Botox would most likely be considered if the headaches have features of chronic migraines.

The use of one drug is preferred, but if one drug doesn't work well enough, your doctor might consider combining drugs.

For many people, complementary or alternative therapies offer relief from headache pain. It's important to be cautious, however. Not all complementary or alternative therapies have been studied as headache treatments, and others need further research.

• Acupuncture. This ancient technique uses hair-thin needles inserted into several areas of your skin at defined points. While the results are mixed, some studies have shown that acupuncture helps reduce the frequency and intensity of chronic headaches.
• Biofeedback. You might be able to control headaches by becoming more aware of and then changing certain bodily responses, such as muscle tension, heart rate and skin temperature.
• Massage. Massage can reduce stress, relieve pain and promote relaxation. Although its value as a headache treatment hasn't been determined, massage might be particularly helpful if you have tight muscles in the back of your head, neck and shoulders.

• Herbs, vitamins and minerals. Some evidence exists that the herbs feverfew and butterbur help prevent migraines or reduce their severity. A high dose of vitamin B-2 (riboflavin) also might reduce migraines.

  Coenzyme Q10 supplements might be helpful in some individuals. And oral magnesium sulfate supplements might reduce the frequency of headaches in some people, although studies don't all agree.

  Ask your doctor if these treatments are right for you. Don't use riboflavin, feverfew or butterbur if you're pregnant.

• Electrical stimulation of the occipital nerve. A small battery-powered electrode is surgically implanted near the occipital nerve at the base of your neck. The electrode sends continuous energy pulses to the nerve to ease pain. This approach is considered investigational.

Before trying complementary or alternative therapy, discuss the risks and benefits with your doctor.

Chronic daily headaches can interfere with your job, your relationships and your quality of life. Here are suggestions to help you cope with the challenges.

• Take control. Commit yourself to living a full, satisfying life. Work with your doctor to develop a treatment plan that works for you. Take good care of yourself. Do things that lift your spirits.
• Seek understanding. Don't expect friends and loved ones to instinctively know what's best for you. Ask for what you need, whether it's time alone or less attention paid to your headaches.
• Check out support groups. You might find it useful to talk to other people who have painful headaches.
• Consider counseling. A counselor or therapist offers support and can help you manage stress. Your therapist can also help you understand the psychological effects of your headache pain. In addition, there's evidence that cognitive behavioral therapy can reduce headache frequency and severity.

You're likely to start by seeing your family doctor or a general practitioner. However, you may be referred to a headache specialist.

Here's some information to help you get ready for your appointment.

What you can do

Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

• Keep a headache journal, including when each headache occurred, how long it lasted, how intense it was, what you were doing immediately before the headache started, and anything else notable about the headache.
• Write down your symptoms and when they began.
• Write down key personal information, including major stresses or recent life changes and family history of headaches.
• List all medications, vitamins or supplements you're taking, including doses and frequency of use. Include medications used previously.
• Write down questions to ask your doctor.

Take a family member or friend along, if possible, to help you remember information.

For chronic headaches, some questions to ask your doctor include:

• What's the likely cause of my headaches?
• What are other possible causes?
• What tests do I need?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• I have other health conditions. How can I best manage them together?
• Should I see a specialist?
• Are there printed materials I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, such as:

• Have your headaches been continuous or occasional?
• How severe are your headaches?
• What, if anything, seems to improve your headaches?
• What, if anything, appears to worsen your headaches?

What you can do in the meantime

To ease your headache pain until you see your doctor, you might:

• Avoid activities that worsen your headaches.
• Try over-the-counter pain relief medications — such as naproxen sodium (Aleve) and ibuprofen (Advil, Motrin IB, others). To avoid rebound headaches, don't take these more than three times a week.