Chronic Daily Headache

Types of chronic daily headache

Medication overuse headache

Taking acute headache medicines too often can make headaches more frequent. The thresholds are:

• simple pain relievers (acetaminophen, ibuprofen, aspirin) on 15 or more days a month
• triptans, combination pain relievers, opioids or butalbital on 10 or more days a month

Opioids and butalbital-containing medicines are especially likely to cause it and are generally not recommended for headache. Reducing or stopping the overused medicine, ideally with a preventive treatment started at the same time, usually reduces headache frequency within 2 to 3 months, although headaches can temporarily worsen during withdrawal.

Causes and risk factors

• an underlying migraine or tension-type headache disorder becoming more frequent over time
• frequent acute medicine use
• high caffeine intake or caffeine withdrawal
• poor or disrupted sleep and obstructive sleep apnea
• depression and anxiety
• obesity
• stressful life events
• neck problems and jaw clenching

Secondary causes to rule out

Less often, daily headache is caused by another condition: raised pressure in the brain (idiopathic intracranial hypertension), low CSF pressure, giant cell arteritis, brain tumors, sinus disease, medication side effects, high blood pressure, or carbon monoxide exposure.

Diagnosis

Diagnosis relies on a careful history. A headache diary for at least 4 weeks, recording headache days, severity, features, triggers and every dose of medicine, is very helpful. Your doctor will check your blood pressure and do a neurological and eye exam, including looking at the optic nerves. Brain imaging (MRI) is done when there are red flags, an atypical pattern, or a new daily headache.

Treatment

Reduce medication overuse

Limit acute medicines to no more than 2 to 3 days a week. Your doctor will help plan a withdrawal from overused medicines.

Preventive treatment

Preventive medicine is taken daily or monthly to reduce headache frequency. Options depend on the headache type and your other health conditions:

• For chronic migraine: onabotulinumtoxinA (Botox) injections every 12 weeks, CGRP monoclonal antibodies (monthly or quarterly injections or infusion), topiramate, propranolol, amitriptyline, candesartan, and gepants approved for prevention.
• For chronic tension-type headache: amitriptyline is the best-studied medicine.
• For hemicrania continua: indomethacin.
• For new daily persistent headache: treatment follows the type of headache it resembles.

It may take 2 to 3 months to judge whether a preventive works.

Non-drug treatment

• Cognitive behavioral therapy, relaxation training and biofeedback
• Regular aerobic exercise
• Consistent sleep schedule; treat sleep apnea
• Regular meals and hydration
• Limit caffeine to a modest, consistent amount
• Physical therapy for neck and shoulder tension
• Neuromodulation devices for migraine in some people

Outlook

Chronic daily headache can improve significantly. Many people with chronic migraine return to episodic migraine (fewer than 15 days a month) with treatment and stopping medication overuse. Early treatment and avoiding frequent pain reliever use give the best results.

Frequently asked questions

What causes headaches every day?

Most daily headaches are chronic migraine or chronic tension-type headache, often worsened by frequent use of pain relievers. Poor sleep, sleep apnea, caffeine, stress, depression and obesity contribute. Less often, a secondary cause such as raised brain pressure is responsible.

Can taking painkillers cause daily headaches?

Yes. Taking simple pain relievers on 15 or more days a month, or triptans, combination medicines or opioids on 10 or more days, can cause medication overuse headache. Reducing their use, with your doctor's help, usually lowers headache frequency.

What is the best treatment for chronic daily headache?

The best treatment depends on the type. For chronic migraine, effective options include Botox injections, CGRP-targeted medicines and topiramate. For chronic tension-type headache, amitriptyline is often used. Limiting acute medicines and improving sleep and exercise help in all types.

When should I worry about a daily headache?

See a doctor urgently if daily headaches are new after 50, worse lying down or on waking, accompanied by vision changes, weakness or confusion, or follow a head injury. Seek emergency care for a sudden, severe headache or one with fever and stiff neck.