Chronic Headache — Full Text

Chronic Headaches are defined as occurring daily, or almost daily, for at least 3-4 weeks, sometimes years. The longer it’s been going on, the less worried we are that it might be dangerous. But we can’t forget that a new headache may develop along with the usual one; and the new one could be anything.

Here’s our list of possibilities for the Chronic Headache (see “Chronic Headache” for the clinician’s condensed thought-process when face-to-face with a patient):

Causes of Chronic Headaches

zzzzzzzzzzDangerouszzzzzzNot Dangerous (Usually)
** Tumors / Blood Clots / Hydrocephalus
xxx—  (increased intracranial pressure) *
** Temporal Arteritis *
** Idiopathic Intracranial Hypertension (I.I.H.)
** Depression AND Suicidal

*  unlikely to last much more than 1-2 months (without something terrible happening)

** Tension Headache
** Chronic Cluster Headache
** Chronic Migraine
** Allergic Rhinitis
(hay fever) / Sinusitis
** Neck Sprain or Strain
** Medication Overuse Headache
** Medications / Drugs / Toxins / Irritants
** Irritating Symptom Elsewhere in Body

** Stress
** Special Headaches
** Depression

Chronic Headaches are rarely dangerous; let’s start by considering the ones that are.

**  Increased Intracranial Pressure (↑ ICP)  —  Pressure in the brain!  The main danger is that it can force the brain down from the skull and pith it on the spine. This usually occurs early on in the course of a headache, unless pressure that’s gradually there increases suddenly.  Causes of ↑ ICP include:

  • Tumors (malignant or benign)
  • Blood clots (hematomas)
  • Hydrocephalus (excess cerebrospinal fluid build-up)

All are easily identified by a “Head CT Scan“.  But again, we don’t order them on everyone with headache (or we’d cause a couple of cancers in the long run; see Radiation Risks of X-Rays).  We certainly would if a patient has any of the following:

  • Daily headache that’s getting worse week by week
  • Daily nausea / vomiting
  • New memory or personality changes
  • Neurologic abnormalities on physical exam

The Neurologic Abnormalities just noted usually go along with a variety of new symptoms, including:

  • double vision
  • loss of part of a visual field, like you can’t see anything on the side of an eye while focusing straight
  • slurred speech; other speech problems
  • loss of balance or coordination
  • weakness of arms and/or legs
  • incontinence (can’t hold urine at all)

 “Daily Headache” is a key; obviously none of these conditions hurt one day but not the next.  Since they may grow slowly, we’re less concerned if the pain has been the same ever since onset.  We worry a little more about brain tumors if the pain gets worse with straining. 

We’re often more quick in obtaining Head CTs in certain cases:

  • Elderly
  • Head trauma (within the last few months)
  • Anticoagulant use: warfarin (Coumadin®) & newer “blood thinners,” not so much aspirin

By the way, CT scans aren’t as good as MRIs for finding brain tumors in general, but they’ll find those large enough to cause a headache.

**  Temporal Arteritis  —  Inflammation of the temporal artery, which curls around the side of the forehead (& has a pulse).  It brings blood circulation to the eye, so Temporal Arteritis can cause sudden [& permanent] blindness. This usually happens before a month has gone by, but anything is possible.

It’s an easy diagnosis if we think of it, because it never [hate to say “never”] occurs under 50-years-old; most patients are over 70.  Half of patients have “jaw claudication;” jaws ache with eating or speaking (which also means half don’t).  Other symptoms may include fatigue, weak arms, temporary visual loss, or fever (which may confuse the diagnosis).  But the key is always: new headache in person >50.

A simple, cheap non-specific blood test for any kind of inflammation is always [hate to say “always”] elevated: the Erythrocyte Sedimentation Rate (ESR; Sed Rate).  Normal = ½ your age, + 5 in women; in Temporal Arteritis it’s invariably over 50, usually around 100.  There’s usually a mild anemia of chronic disease.  Everyone >50-years-old with a new headache needs an ESR.

The treatment is steroids for 2 years.  Not anabolic home-run-hitting steroids, but corticosteroids, which have lots of long-term side effects.  But that’s still better than permanent blindness.  If the ESR is high, we begin treatment & schedule a biopsy for complete proof.  The biopsy is best done within 2 weeks, or the steroids may interfere with results.  Regular surgeons, plastic surgeons, and ophthalmologists can all do the biopsy; one might have scheduling availability before another.

**  Idiopathic Intracranial Hypertension (I.I.H.) —  Also called “Pseudotumor Cerebri,” the condition involves excess pressure within the brain.  “Idiopathic” means nobody knows why it occurs, which is never reassuring.  It primarily affects obese women of childbearing age, eventually causes permanent visual loss in 25% of persons, and tends to take a long time (years, even) for somebody to make the diagnosis.

The headache, which may be daily or may come & go, is often felt behind the eyes.  It’s commonly throbbing (but maybe not), and can be made worse by eye movement.  Brief, temporary visual shadows often occur, as might pulsating noises.  Recent weight gain should raise suspicion.  The condition is relatively uncommon (1/5,000 among obese women ages 15-44), but may be becoming more prevalent with our obesity epidemic.

Clinicians should suspect the condition by finding abnormalities on a careful and thorough eye examination.  Diagnosis is confirmed by finding an elevated pressure on spinal tap (if they remember to measure it).  If you fit the profile, and have a chronic headache with any of the associated symptoms noted above:

  • Mention the possibility to your medical provider
  • Ask about an ophthalmology referral, for thorough exam & visual field testing
  • Ask if an experienced neurologist should perform a spinal tap & measure “opening pressure” when doing it

** Depression PLUS Suicidality People who are depressed often have headaches, which itself may be mild.  But if the depression is severe, it can lead to suicide.  So whenever we think a person may be depressed, we gently question and explore their mood.  And if indeed they acknowledge their depression, we follow up by asking, “Does your depression ever get so severe that you ever think about killing yourself?”

We never worry about “planting the idea,” because that’s impossible.  Nobody would ever say, “Oh, I never thought about that; maybe I should.”  Quite the contrary, anyone who is the least bit suicidal can’t escape the torment.  They’re usually relieved when we ask.

Almost half of people who attempt suicide interact with healthcare professionals the week before, in one way or another.  And it’s not for depression.  Maybe they seek care for a runny nose, or a headache…

See also Depression.

The Vast Majority of Chronic Headaches are Not Dangerous

**  Chronic Sinusitis  –  We should all BEWARE of this diagnosis, primarily because it’s made way too commonly, & generates an antibiotic prescription (often for weeks or months).  This is not in anyone’s best interest.  Someone with chronic headache & prominent nasal symptoms most likely has the very common Allergic Rhinitis (hay fever; “Allergies”), which is easy to treat.  For diagnosis, we give a trial of allergy medication.  See discussion under topic Nasal Congestion.

One study found that of 125 patients diagnosed by their medical provider with Chronic Sinusitis, only 75 had abnormal CT scans.  Only 18 of those had pus on nasal endoscopy, of whom only 5 wound up having the usual germs on culture. That’s 120 wrong diagnoses (with a total of maybe 15 years of unnecessary antibiotics, breeding drug resistance not just in those people, but for all of us!).  The worse the facial pain, the more likely the CT was to be normal!  Read an abstract (with link to the full article; See Clin Infect Dis 2012;54:62-8.  [  ]

** Chronic Migraine —  This headache resembles migraines — perhaps one-sided, throbbing, or maybe with nausea, and/or lots of sensitivity to light & noises.  But since it occurs every day or almost every day, it lacks the key component of a migraine diagnosis: recurring in a cyclic fashion.  In general, if anything about a patient’s chronic headache reminds us of migraine, we’d consider the diagnosis: 

The key symptoms we use to diagnose migraines are:

  • pulsating or throbbing (not stabbing or pressure)
  • unilateral (one side of head only)
  • moderate or severe intensity, made worse by normal activity
  • nausea / vomiting
  • photophobia / phonophobia [light / sounds makes the discomfort much worse]
  • an aura, a variety of visual or other strange sensations, lasting 5-60 minutes immediately before headache onset

Head CT scans & MRIs are normal with migraines, so they aren’t usually necessary unless we find actual neurological abnormalities on physical exam. That would probably mean some other (worse) disease.

One way to diagnose chronic migraine is with a “Treatment Trial.” If a medicine helps, that’s probably what you have.  But of course, placebo helps too, so clinicians who order treatment trials should maintain a certain degree of healthy intellectual skepticism.

For chronic migraines, we’d only use medications for migraine prevention; see our topic Migraines for mention of these. We would not use the medication to abort the headache (stop it right at onset), nor would we use simple pain medicines. That’s because chronic migraines by definition occur often, and frequent use of these latter medications can cause Medication Overuse Headache (see below).

Treatment Trials should aim for maximum dose of medication, building up to it as tolerated.  If you just try a low dose, and it doesn’t work, you’ll never know if more actually might have helped.

**  Chronic Cluster Headache  —  These are like regular cluster headaches which occur in short bursts several times a day, on one side of the head (usually behind the eye).  Cluster headaches are diagnosed by the following criteria:

  • Each attack lasts 15 minutes to 3 hours.  They may strike 1 to 8 times a day.
  • The headache is severe, one-sided, felt around the eye or temple.
  • There’s at least one other finding on the same side as the headache:
    • red eye or tearing, eyelid swelling, pupil constriction, or droopy eyelid
    • runny nose [nostril] or congestion
    • one-sided forehead or facial sweating
    • restlessness or agitation [this would be in general]

But regular cluster headaches disappear for at least a month, usually much longer. Chronic Cluster Headaches don’t go away; if they do, they recur within a month.  They can be simply terrible; there have been suicides among persons with regular cluster headaches, so imagine if they’re chronic!.  The condition is very rare, but any possibility of it would lead to a referral to a neurologist (preferably a headache specialist).

If Cluster Headache is diagnosed, an MRI is usually recommended, because a disproportionate number of patients with typical signs & symptoms of cluster headache happen to have brain abnormalities, suggesting that some of these may be related.

**  Medication Overuse Headache —  This commonly mimics Tension Headache.  A person complains of a headache, takes over-the-counter medication or gets a prescription, uses them continuously.  When they stop (or run out), a rebound headache occurs.  So they seek refills for more medication.  Vicious cycle.

The main drugs responsible seem to be narcotics like codeine, hydrocodone (Norco®,Vicodin®) or oxycodone (Percocet®, Oxycontin®), combination products with the barbiturate butalbital (e.g. Fiorinal®), and acetaminophen (Tylenol®).  Those with aspirin + acetaminophen + caffeine have also been implicated, triptans too, and even NSAIDs (ibuprofen, naproxen, etc.).

We consider this diagnosis if a single headache medication is taken over 10 days per month, or if various meds are mixed for over 15 days.  To diagnose it, we discontinue all possible offending medications, and begin a migraine-prevention regimen (see Migraines).  It’s often hard to convince people that their beloved pain medicine is working against them.

** Post-Concussive Syndrome — A concussion is a disruption of nerve connections in the brain, due to trauma or anything that shakes the brain around (whiplash, etc.). There’s sometimes loss of consciousness at the moment, but not always. Post-Concussive Syndrome refers to a variety of symptoms lasting at least 3 months afterwards. They include various types of headache, dizziness, memory problems, sleep difficulty, and general trouble concentrating or thinking. 

Most persons with Post-Concussive Syndrome do not require X-rays, CT Scans or MRIs (called “imaging”), although most wind up receiving some sort at one point or another.  Imaging only shows major brain or skull damage, not the most common disruption of nerve circuits which can cause significant disability.  I’ve seen patients distressed because they’re experiencing symptoms, and get told “the CT was normal,” or “it didn’t show anything; there’s nothing there.”  That’s not fair, because there certainly is damage, but it’s microscopic and can’t be seen, although possibly quite extensive.

Post-Concussive Syndrome is a difficult topic to define, because its manifestations are so varied, and may be complicated by health issues a person had before the injury.  It has also been recognized, for virtually any type of injury, that pending lawsuits or disability applications get in the way of recovery (it doesn’t make sense to our subconscious minds for us to feel better while still trying to sue).

Neurological and psychological testing doesn’t seem to help much.  Treatment, both medication and psychological, is by trial and error, although one recommendation that has been debunked is “mental rest.”  People should return to their normal activities to the extent they feel comfortable.

** Medications / Drugs / Toxins / Irritants

Almost any medicine might be able to cause a headache.  We diagnose this if there’s no other cause for a patient’s headache, and they had recently begun taking something new.  Then we’d look it up in our resources for medication side effects, and see if the medication had ever been reported to be associated with a headache (but we’re careful with our conclusions; please see Beware Reading About Medication Side Effects).

The same goes for herbs, supplements, and street drugs.  In terms of the latter, not only might the drug cause headache, but withdrawing from it might also.  Same holds true for medicines & any substance.

If a person gets a headache repeatedly in a certain environment, we’d suspect an environmental cause.  These can range from life-threatening (like carbon monoxide), to simply annoying (like ammonia).  Diagnosis takes detective work.

**  Special Headaches  —  Certain stimuli may cause brief headaches.  They include:

  • “Ice-Cream Headache” (“brain freeze”), when enough cold hits the roof of the mouth fast enough.
  • “Cough Headache” occurs after coughing.
  • “Post-Coital Headache” occurs during or right after sex; it can be emotionally traumatic.
  • “Chinese Restaurant Headache” from eating products with monosodium glutamate.
  • “Hot-Dog Headache” from foods with nitrites.

 These headaches should only be diagnosed after numerous occurrences have set a pattern, not with the first episode.  Because of the intense straining, a Subarachnoid Hemorrhage from a brain aneurysm leak can also occur during sex; that would be an Acute Headache.

**  Irritating Symptom Elsewhere in Body  —  People with constipation may complain of headache.  Walking around with a broken ankle can cause a headache. And people suffering from any chronic disease or condition or Stress can get a headache.  Usually this correlation is obvious to the person, but some don’t get it.

**  Depression  —  Depressed persons frequently seek care for “headache.”  Some know they’re depressed, others don’t recognize it, or are in denial.  An inventory of the following queries usually turns up many positive responses — “Do you often have…”

Profound sadness
Urge to cry
Few interests, not much fun in life
No interest in sex (poor libido)
No energy in the morning (want to just stay in bed)
No appetite (or eat all the time)
Trouble sleeping (or sleep way too much)
Trouble concentrating
Feeling of uselessness, inferiority, hopelessness, helplessness
Thoughts of death (often intruding on other thoughts)
Desire to die (including suicidal thoughts)  

If lots of these seem to apply, either depression is causing the headache, or visa versa.  But either way, mental health evaluation & probably treatment would be beneficial.

**  Tension Headache  —  Most patients with chronic daily headaches will have tension headaches.  This is far & away the most likely cause, and the only way to diagnose it is by asking questions & doing a decent neurological exam to rule out anything else (especially anything serious).  Chronic tension headaches have been characterized as “featureless.”   Rarely would we need to order a CT scan or MRI.

The best treatments are special medications for chronic pain.  Daily common pain medicines like acetaminophen (Tylenol®) and NSAIDs should be avoided (they can then cause Medication Overuse Headache).

Actually, the International Headache Society defines many other uncommon types of chronic daily headaches.  Neurologists who are headache specialists can sort through the wide variety when diagnosis and treatment aren’t going well.  If interested, see Cephalalgia 2004;24 Suppl 1:9.  []

See Chronic Headache for the clinician’s condensed thought process when face-to-face with a patient.

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