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OB/GYN Editorial JULY 2003

Chronic Daily Headaches: Focus on Prevention

Cheryl D. Bushnell, MD, MHS

The May, June, and July issues of The Female Patient have featured a series of CME articles on migraine headaches by Unger et al.^1-3 These clearly written articles highlight the importance of migraine diagnosis, as well as acute and preventive treatments specific to women. The authors also describe chronic daily headache (CDH) and the progression from episodic to chronic headaches. I would like to expand upon the discussion of CDH in terms of the incidence and scope of the problem, and to suggest methods to identify and prevent progression to CDH in the primary care setting.

Chronic daily headache is defined by the International Headache Society as daily or near-daily headache lasting greater than 4 hours/day for greater than 15 days/month. Within this category are transformed migraines, chronic tension-type headache, new daily persistent headache, and hemicrania continua.⁴ About 75% of CDHs are migraines that have transformed from episodic to chronic.⁴ About 4% to 5% of the population have CDH, the vast majority of whom are women.⁵ Chronic daily headache is a result of increasingly frequent episodic migraine attacks (transformed migraine), often brought about by overuse of analgesics. As Unger et al point out, this transformation may be gradual, and the migrainous features of the headache may slowly dissipate as the headaches become chronic.¹

Although analgesic overuse is thought to be a major cause of transformed migraines, this does not account for every patient’s development of CDH. Retrospective observational research has revealed other factors that were more frequent in those with transformed chronic versus episodic migraine, such as a history of allergies, asthma, hypothyroidism, hypertension, and consumption of caffeine.⁶ In addition, stressful life events such as divorce or separation, moving, work changes, or problems with children were identified as risk factors for CDH.⁷ Although the prevalence of migraine attacks typically decreases with increasing age, a study of women showed that active migraines in older women were associated with stress susceptibility and somatic trait anxiety.⁸ Knowledge of these factors may aid in identifying women with episodic migraines who may be at risk of developing CDH.

Besides awareness of the factors associated with transformation, there are several steps that primary care physicians (PCPs) can take toward prevention of CDH in migraineurs. Once the migraine diagnosis has been established, the appropriate abortive therapies outlined by Unger et al should be prescribed.^1,2 Education regarding when and how to take these medications is very important, and during this same office visit, clinicians should provide patients with a headache diary to document the effectiveness of the medicines taken for each headache. For female patients, correspondence of head-aches to menses or other perimenopausal signs or symptoms³ may present an opportunity to reduce headache frequency and severity, and therefore transformation to CDH.

Patients who have a headache frequency requiring acute treatment greater than twice per week should be considered for preventive medications.² These patients should also be screened for comorbid disorders, such as depression, bipolar disorder, panic/anxiety disorder, and thyroid abnormalities. In addition, screening for life-style changes and stressful life events that may be temporally related to increased frequency may be helpful. Also, repeat screening for migraine triggers that may have been previously unrecognized may provide some insight regarding headache frequency.

One very important step for PCPs is to avoid prescription of analgesics that are most notorious for causing rebound (and therefore analgesic overuse) headaches. These include combination analgesics such as codeine/acetaminophen, acetaminophen/propoxyphene, or aspirin/butalbital/ caffeine. Better choices for mild to moderate migraine attacks include nonsteroidal anti-inflamatory drugs such as naproxen, ibuprofen, or ketoprofen limited to 2 to 3 doses per week. If migraine attacks are severe, consider one of the triptans if there are no contraindications. Headache sufferers need to be educated regarding the appropriate use of abortive and preventive headache medications. For example, some patients take the preventive medicine only when they have a migraine attack, but not on a daily basis as prescribed. Patients should also be educated regarding the potential for analgesic overuse at the onset of the treatment plan when the headaches are still manageable.

Although patients with CDH make up a small proportion of all headache sufferers, the majority of those with CDH begin with episodic migraines. The diagnosis, treatment, and patient education of episodic migraines are most often in the hands of PCPs. Likewise, awareness and recognition of the progression to CDH could also be detected in this setting. General screening for headaches (including frequency, severity, duration, and associated symptoms) may allow PCPs to discover patients who are self-treating with over-the-counter medications and identify those who would benefit from more appropriate and effective therapy, or referral to a headache specialist.

Chronic daily headache is one of the most common referrals to headache centers, but once patients have progressed to this point, they are very difficult to treat. Analgesic withdrawal, for instance, is a process that only motivated patients will pursue, and frequently the headache gets worse before it gets better. The ability to identify patients at risk of CDH with biomarkers or diagnostic tests obviously would be ideal for headache patients. But until additional diagnostic tests become available (if ever), knowledge of the warning signs for transformation to CDH is important for both physicians and patients so that this disabling condition can be prevented.

Cheryl D. Bushnell, MD, MHS
Advisory Board Member

References:

1. Unger J, Cady RK, Farmer-Cady K. Migraine headaches, Part 1: Presentation and diagnosis. The Female Patient. 2003;28(5):32-39.
2. Unger J, Cady RK, Farmer-Cady K. Migraine headaches, Part 2: Treatment options. The Female Patient. 2003;28(6):22-29.
3. Unger J, Cady RK, Farmer-Cady K. Migraine headaches, Part 3: Hormonal factors. The Female Patient. 2003;28(7):
4. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology. 1996;47 (4):871-875.
5. Castillo J, Munoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache. 1999;39:190-196.
6. Bigal ME, Sheftell FD, Rapoport AM, et al. Chronic daily headache: Identification of factors associated with induction and transformation. Headache. 2002;42(7):575-581.
7. Stewart W, Scher A, Lipton RB. Stressful life events and risk of chronic daily headache: results from the frequent headache epidemiology study (FRHE). Cephalalgia. 2001; 21:278.
8. Mattsson P, Edlselius L. Migraine, major depression, panic disorder, and personality traits in women aged 40-74 years: a population-based study. Cephalalgia. 2002;22 (7):543-551.

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