Frederick R. Taylor, MD FAAN FAHS
- An increase in headaches from a lower to higher number of days per month is called progression.
- Progression or transformation often leads to headache more than 15 days per month or “chronic headaches.”
- Progression occurs in about one in five headache sufferers with certain risk factors.
- Acute medication overuse, obesity and anxiety are critical risk factors for progression.
- Acute medication overuse must be recognized and removed for improvement.
You may have suffered your first headaches as a child or adolescent. Over months or years, a risk develops that headaches may become more frequent in number. Some people have headaches increase to a daily occurrence; some even have constant pain. This increase is called “headache progression or transformation.”
Transformation in this case means a turn or change to a greater frequency of headaches. One goal of current headache research is to understand the reasons for this progression. Might this change be largely due to physical, environmental or inherited tendencies, or some combination of the three?
Why is it important to understand what causes headache progression?
There are several reasons:
- Headache progression, while not always associated with more frequent severe headaches, is always associated with more limitation in daily life activities or disability.
- With headache progression understood, patient and provider may be informed of the risks for progression and seek to identify them.
- If patients at risk are identified, close observation and preventive methods can be aggressively encouraged and used.
- For those already progressed, knowing the factors for progression helps identify possible change(s) needed to improve the headaches.
Chronic or Transformed Headache
Any person can suffer from headache progression, and any headache type can increase in number. This is important, since most who experience headache do so at least periodically over time and therefore suffer headaches “chronically” over years or decades, sometimes a lifetime.
The most common headache types are tension-type (TTH) and migraine with chronic TTH and chronic migraine or transformed migraine of about equal number in the population. Migraine is more likely to progress than TTH with episodic migraine sufferers developing transformed migraine at the rate of 2.5% per year. With migraine more disabling for the individual, recognizing migraine as both episodically chronic over time and potentially progressive may encourage redefining migraine as a chronic disorder with episodic attacks that progresses to high frequency and more disability in some.
This becomes important considering that both the sufferer and medical provider often think of migraine in terms of the last headache and use acute treatments only. When migraines are recognized as chronic and potentially progressive both the sufferer and provider may think about preventing headache. Headache medicine practitioners “officially” make a diagnosis of chronic daily headache, when headache totals exceed 15 days per month, and chronic migraine when headache with migraine symptoms or medications used to treat the headache exceed eight days per month.
Other chronic conditions such as epilepsy, hypertension, asthma, or diabetes are managed and controlled by reducing trigger factors, appropriate lifestyle changes and additional treatments. Approaches to prevent progression of either TTH or migraine and manage either chronic condition should be to identify and manage triggers, use healthy lifestyles and other prevention as mutually agreeable between patient and provider.
What do medical studies tell us about chronic migraine?
- Certain migraineurs have greater risk of suffering more frequent attacks (clinical progression).
- The brain becomes sensitive and overactive to several kinds of stimuli during many migraine attacks, and sometimes between attacks despite no evident reason. This is known as central sensitization (CS). Allodynia is a term used to describe the result of CS, which is pain somewhere in the body caused by an otherwise non-painful cause. An example of allodynia is when pain is caused from pulling back the hair in a ponytail. Allodynia occurs in many, but not all migraineurs, and should be thought of as a marker for the need for prevention of headache due to this overactive nervous system (progression of function known as physiology).
- Specific brain changes occur in some of these migraine patients (progression of physical structure change known in medicine as anatomy):
- Iron deposits identified by special imaging (not available to providers) are found in a pain control area of the brain.
- White matter lesions, of unknown importance, have been identified in routine brain MRI imaging in those with progression.
What should the typical headache sufferer learn from these studies? That it is very important to identify any change in number of headaches. When any type of headache becomes more and more frequent, it is very important to consult your practitioner and discuss the risk of headache progression.
As a migraine sufferer, it is especially important to learn about risk factors for progression and manage them. This will reduce the chances of progression to chronic or transformed migraine or any chronic headache type or improve the chances of improving again to chronically episodic migraine.
What factors create risk for developing progression to chronic migraine?
Adaptable risk factors: factors that the patient can influence with lifestyle changes and appropriate treatment:
- Pain killer (analgesic) overuse, includes any use of barbiturates and opiates, triptans, and caffeine (medication or drink) at high frequency, while anti-inflammatories are protective or inducers depending on the headache frequency.
- Sleep troubles (poor sleep, typically 6 or less hours of sleep and snoring).
- Obesity (BMI ≥ 30 or waist ≥ 35 inches for women and 40 inches for men.
- Depression and anxiety.
- Stressful life events (particularly unresolved abuse or neglect).
Non-changeable risk factors: factors not easily altered.
- Central sensitization/allodynia
- Female gender
- Inherited genes/genetic susceptibility
- Closed head injury
- Societal and economic variables
- Possibly increased intracranial pressure without physical signs (papilledema).
Studies to better understand how to identify migraineurs at risk of headache progression and to establish effective treatment are ongoing. This undertaking is important, given the frequent presence of the condition among the general population and in women. The change in impression of migraine from one of an episodic to chronic illness with progression of disease in individuals at risk is an important idea. If we can influence the public and medical provider mind, then sufferers might benefit from a change in priorities of health insurers as well.
Medication Overuse Headache
Pain killer (analgesic) overuse is the most widely recognized and best agreed upon risk factor associated with migraine progression. The current concept of medication overuse headache (MOH) is defined as greater than 15 days of headache/month. Regular overuse of pain drugs for greater than three months is also required. The overuse consists of one or other medication greater than ten days per month or any combination of drugs greater than 15 days per month regularly. Finally, headache has worsened during this overuse. Beware: The risk of overusing acute medications is the risk of creating MOH.
Simple MOH is defined as less than one year’s overuse with modest doses of the agent. The individual also has limited psychological difficulties and no failures in past removal. Complex MOH is everyone else. Simple MOH may require only short-term prevention and an optimal acute therapy used properly, while complex MOH absolutely requires behavioral headache management.
Each practitioner and provider system will manage MOH differently as each sufferer is unique. Several overarching ideas to any management program are outlined here. Treatment of MOH requires stopping use of the offending medication(s). Removal is nearly always successful as an outpatient for simple MOH in a patient who strongly desires to rid themself of overuse and its problems. For complex MOH an inpatient stay is frequently necessary.
Outpatient therapy can proceed as a slow or fast taper of the overused medication. In selected instances, based on your decision, abrupt withdraw with another medication used “to bridge” the initial week of withdrawal is typically considered.
Success is likely with strong support of family or friends in highly motivated individuals. Necessary steps to successful removal include:
- Removal of the offending medication
- Possible ” bridge therapy” to treat withdrawal symptoms
- Medication prevention with non-pharmacologic interventions where appropriate
- Specific acute treatment, without contraindications, with limits on usage
- A time to follow up within the month ideally.
Education includes helping patients understand the differences in overuse from abuse, habituation, dependency, and addiction—which is nearly always appropriate to do. Expect that improvement will take time, typically longer than one expects or hopes and that worsening is typical before experiencing improvement.
Improvement occurs in the majority, and headache frequency improves with prolonged avoidance or abstinence of prior offending medications. Sticking with a program and follow-up are crucial. Behavioral management has been shown to produce additional benefits beyond pharmacotherapy alone. Behaviors include regular eating, exercise, and sleep hygiene with active better than passive therapies. The headache calendar identifies possible triggers, medication intake and effect of treatment. Biofeedback training, stress and time management, which includes understanding “my time” with cognitive therapy and less likely psychotherapy, make for long-term success.
Slow taper of the overused acute medication(s) takes place over about four to five weeks, typically with standard migraine therapies for age for both acute and prevention therapy. Onabotulinumtoxin, a multiple injection therapy, is Federal Drug Administration approved for chronic migraine and may assist in MOH therapy. Acute therapy is restricted to no more than 2 days per week with limited quantities. A short course of steroids is often added. Rapid elimination is used for the individual with three or less tablets per day use of acute medication often with a short seven to ten day bridge of anti-inflammatory, steroid, or triptan use dependent on the history of use. Prevention is typically increased more rapidly and botulinum neurotoxin when possible offered.
What is the medical literature on progression or chronification of headache?
Unfortunately the most complete review of this topic dates back to the January 2008 edition of Headache: the Journal of Head and Face Pain. This series of comprehensive reviews is written for medical professionals on the chronification of headache. While very difficult for the average patient (unless you are very acquainted with medical writing), if you want in-depth reviews on the mechanisms of migraine chronification, risk factors for progression, treatment of chronic headache, and behavioral strategies aimed at prevention and progression of chronic headache these may be worth your reading efforts.
Specific reviews in this edition include:
- Migraine Chronification
- Concepts and Mechanisms of Migraine Chronification
- Risk Factors for Headache Chronification
- Screening and Behavioral Management: Medication Overuse Headache—the Complex Case
- Chronic Headache and Potentially Modifiable Risk Factors: Screening and Behavioral Management of Sleep Disorders
- Stress and Headache Chronification
- Headache Chronification: Screening and Behavioral Management to Co-Morbid, Depressive and Anxiety Disorders
- Screening and Behavioral management: Obesity and Weight Management
- Looking to the Future: Research Designs for Study of Headache Disease Progression
Paste this URL into your web browser for free downloads to the best scientific articles. http://onlinelibrary.wiley.com/doi/10.1111/hed.2008.48.issue-1/issuetoc.
Action Plan to Prevent Headache From Worsening
Migraine progression can be minimized as a risk with attention to identifying and managing triggers, maintaining healthy lifestyles and avoiding overuse of acute medication for headache or any other pain condition. When headache increases seek your providers help. Cut back on acute therapy no matter how hard it is to cope if more than two days per week. Know your prevention options and ask for prevention methods before headache control is lost. Emphasize your preventive lifestyles. Consider the role of any anxiety or obesity and life stressors. Stick with a program that begins to pay off.
By Frederick R. Taylor, MD: Past ACHE On-Line Articles and Newsletter Editor; Clinical Professor of Neurology, University of Minnesota School of Medicine; fellow of the American Academy of Neurology and American Headache Society and former Director, Park Nicollet Headache Clinic & Research Center; Minneapolis, MN