Headache Progression—What You MUST Know About the Development of Chronic Headache

Phillip Bain, MD and Frederick R. Taylor, MD

Key Points:

  1. Headaches (HA) usually start out as being noted as “off and on.” For some people, they progress to become more frequent.
  2. HA progression means going from occasional to frequent.
  3. Certain factors cause HA to progress from occasional to frequent, e.g. certain medications like butalbital and opioids.
  4. HA progression is identified when acute medications don’t work as well, HA frequency increases, HA become more disabling, and when previously non tender areas to touch become tender (e.g. on scalp, neck and sometimes other sites).
  5. Preventing HA progression may be easier than you think. Avoid use of butalbital or opioids. Use acute therapy that works consistently. When headache frequency increases, work with your provider to reduce frequency to prevent progression.

What is Progression?

Most patients begin noticing headaches in their teens and 20s. Typically, migraine headaches occur only on occasion, perhaps once every few months. Over time, headaches may become more frequent. In some, the pattern increases to headaches more often than not—i.e. more than 50% of the days with pain present about the head and/or neck. Less commonly, headaches become near daily, daily, or even a constant 24/7.

What causes progression from occasional to frequent migraine?

Many of the factors that cause progression have been identified. Several of the known risk factors are listed here:

1. Headache Frequency

The more headaches you have, the more headaches you may get. Just five (5) days, even parts of days, increases your risk for greater than 15 days per month in the next year to over 6 X those with fewer headaches. Ten (10) days with some degree of headache increases your risk 20 X compared to those with 0-4 HA days, sometimes even leading to everyday HA.

2. Medication Type and Frequency

While any symptomatic medication overuse may lead to progression, Butalbital compounds and narcotics/opioids significantly increase your risk of progression. Only five days use per month for barbiturates (e.g. Esgic, Phrenilin, Fioricet, Fiorinal, butalbital) may increase headaches, especially in women. Only eight days of use per month for narcotics/opioids (e.g. codeine, hydrocodone, meperidine, morphine, oxycodone, propoxyphene) may increase headaches especially in men.

Other medications—e.g. short-acting pain medications for acute HA such as acetaminophen, aspirin, Excedrin, ibuprofen etc. can increase the risk of progression, though not as much as butalbital and opioids. These medications, if taken more than two days per week, can lead to more frequent headaches. Many don’t consider caffeine a medication. Over 100mg caffeine or one, six ounce cup of coffee daily markedly increases progression risk.

3. Conditions that add to progression

Several conditions are known to add to risk of progression. These include-anxiety, depression, bipolar disorder, PTSD (post traumatic stress disorder), significant stress events in the prior two years, and insomnia.

4. Obesity

A female with waist 35 inches or larger is considered obese—40 inches for a male. Weight loss, though not scientifically proven to date, may reduce progression.

How do you know when your headaches are progressing?

  • When your head or neck pain frequency is increasing. Officially, progression to chronic migraine requires more than 15 days with some HA per month.
  • When your acute medication commonly runs out early. If you are having more frequent headaches and/or it takes more medication to treat the headache attacks, this may be a sign of progression.
  • When your headache regularly returns even after complete pain freedom. If your headache begins returning more frequently than before, this may be a sign of progression.
  • When touch hurts. Non-painful touch that hurts is called allodynia. Allodynia is an important marker for progression. Acute medications are often much less effective when allodynia is present.

How can you prevent progression from occasional headache to frequent migraine?

  • Do not use butalbital containing products.
  • Use opioid medications rarely if at all—certainly less than eight doses per month.
  • Avoid overuse of any short acting pain medication. Limit any short acting pain med to two days per week or less. If you are requiring more frequent use, talk to your doctor about reviewing your preventive strategy. Avoid caffeine excess.
  • Treat early at the mild stage with meds that are unlikely to cause progression. Use NSAIDs (e.g.naproxen, Aleve™) or triptans (Amerge, Axert, Frova, Imitrex/sumatriptan, Maxalt, Relpax, Treximet, Zomig).
  • Use prevention. Work with your doctor to develop an effective strategy that includes both non-drug and drug options.
  • Treat conditions that add to risk of progression. Make sure that insomnia, daytime drowsiness or loud snoring (indicators for possible obstructive sleep apnea), depression, anxiety and obesity are diagnosed and treated as well as possible.

For more information regarding headache progression and chronic migraine, visit www.achenet.org. This article is in printable page form under Articles.

Philip A. Bain, MD Dean Health System, Madison, Wisconsin. Frederick R. Taylor, MD, Newsletter Editor, ACHE and Adjunct Professor of Neurology, University of Minnesota and Director, Park Nicollet Headache Clinic and Research Center, Minneapolis, MN.