Kenneth J. Mack, MD, PhD
Chronic daily headache presents a significant problem for many teenagers. For practitioners, patients, and their families, it is a challenging and frustrating entity to treat.
Individuals with a diagnosis of chronic daily headache experience at least 15 headache days in 1 month for 3 consecutive months and show no additional signs of underlying organic pathology. This headache disorder tends to affect teenagers and adults more so than preteens. It can occur in up to 4% of young women and up to 2% of young men. In middle school, 0.8% of boys and 2 % of girls acknowledge daily headaches. Often the affected patients have a personal history of migraine or have a family history of migraine.
Most teenage patients with chronic daily headache have a history of episodic migraines. The transformation to chronic migraine may occur over weeks, months, or years. It may occur abruptly over a matter of hours. Approximately one-quarter of teenagers with chronic daily headache have no significant past headache history. In these patients, an infection such as mononucleosis or a minor head injury may incite a new daily persistent headache (onset within 3 days or less). Some patients have a history of tension-type headaches before developing chronic daily headache. Approximately 1% of patients present with hemicrania continua.
Patients with chronic daily headache can experience and complain about multiple types of headaches. Many have severe intermittent headaches that are migraine-like. The severe headaches are described as throbbing, severe, crushing, knife-like, or hatchet-like. They are often associated with nausea, and avoidance of bright lights, loud noises, and strong odors. For this more severe headache pain, sleep sometimes helps, but patients will still have persistent headache when they awaken. The frequency of these severe headaches varies with the individual. Severe episodes typically occur multiple times a week.
In addition, many patients have a continuous headache that is present “all the time”. This continuous headache may wax and wane in severity, often worsening in the morning or at the end of the school day. The characteristics of the all-the-time headache pain are similar to the episodes of severe headaches, only much less intense.
Headache is not the only symptom of chronic daily headache. Frequent additional symptoms include dizziness, sleep disturbance, pain at other sites of the body (including neck pain, back pain, and abdominal pain), fatigue, difficulty in concentration, decreased mood, and increased anxiety. It is important to recognize and treat these symptoms as well.
One of the roles of a headache specialist in treating these patients is to separate out chronic daily headache, which is a primary headache syndrome, from secondary causes of headache. The evaluation for secondary causes of headaches includes a thorough history and physical exam, and consideration of a neuroimaging study, blood tests, and, in the occasional patient, lumbar puncture. In selected patients, tilt-table testing or sleep studies may also be of value.
Chronic daily headache is difficult to control. There are often no immediate answers or easy ways to the treatment and resolution of the pain. Many patients have had a sudden onset of their daily headache, and some can even point to a specific day when they transition from a headache-free life to an all-the-time headache. Unfortunately, it typically takes weeks to months to achieve headache control. The cornerstones of therapy are education, preventive medications, and attention to the routine.
It is difficult for many families to comprehend that the head pain can persist for such a long time, that there are no abnormalities showing up on diagnostic testing, and that the medications patients are prescribed are not immediately effective. It is not unusual for patients to see multiple doctors because of this frustration. To limit frustration, it is useful to spend adequate time discussing chronic daily headache with treating physician. The discussion should include asking about what chronic daily headache is, how secondary causes of headache have been ruled out, the role of medications, when not to use pain relievers, the role of nonmedicinal approaches (e.g., biofeedback or physical therapy), and what the family should expect in the near and long term.
Preventive medications are traditionally used in episodic migraines to reduce the frequency of the migraine headaches. Occasionally, they may reduce the severity of the chronic daily headaches as well. The term “preventive” may be somewhat of a misnomer for use in chronic daily headache because the headache continues to be there all the time. However, in chronic daily headache, a reasonable therapeutic goal would be to make severe, intermittent, headaches less frequent, and to make an all-the-time headache less intense. Multiple preventives are available for treating episodic migraine, including antidepressants, anti-seizure medications, blood pressure medications, and vitamins such as riboflavin or magnesium.
Controlling headache pain is a very difficult problem for patients. Analgesics that are typically effective for an episodic migraine are not very effective for chronic migraine or chronic daily headaches. Most patients report that pain relievers are not effective for the an all-the-time headache. Analgesics may result in medication overuse headaches and rebound pain.
Nonpharmacologic approaches to treating headache are also very important. Patients who experience chronic headache pain should consult with a psychologist to at least be introduced to the techniques of relaxation therapy and biofeedback. Anxiety is highly prevalent in migraine patients; some studies have shown that one-half of all adults with migraine have symptoms of anxiety. A psychologist, therefore, also is useful in addressing the issues of mood and anxiety.
Many patients have also been ill for months to years and have become physically “deconditioned.” Starting a reconditioning exercise program is very important. Patients should be encouraged to start slowly. We have our most severely affected patients do 10 minutes of aerobic exercise a day, increasing that amount by 10% a week. The key is to slowly but persistently increase activity level. A physical therapy consult can be useful in these situations.
Identifying specific trigger factors for chronic daily headache is difficult because the headache is daily, often “24/7.” However, important environmental factors do play a role in these headaches. There is an interesting seasonal variability in the degree of chronic daily headache symptoms. Most patients fare better in the summer and frequently have a worsening of their headaches around the start of the school year. In some patients, you can observe that the need for preventive medication is greatly reduced in summer but may need to be increased again in the fall. The reason for this variability is unknown, but may relate to such factors such as stress, loss of sleep, bright lights in the school, decreased exercise, decreased time for relaxation, and propensity of some teenagers to skip breakfast to make it to school on time.
School absence is a significant problem. Once patients have been out of school for weeks, it is very difficult for them to return to a regular school schedule. Frequently patients will observe that after returning to 2 or 3 days of a full-day schedule, they come back home with a more severe headache. Some patients do best with gradual reintroduction to the school system. These patients have more success returning to school on an abbreviated schedule, often with one or two class periods that are around the lunch hour. It is difficult for these patients to start off with early morning classes, because many of them have sleep disturbances and lack a full night’s sleep.
Sleep disturbances are very common and occur in approximately two-thirds of patients. The most common complaint is a delay in onset of sleep. The typical child this age will need about 9 and a half hours of sleep. Often these patients put themselves to bed at 9 p.m., but may not fall asleep until midnight. Then they have to awaken at 6 a.m. for school the next morning. If they have a 3-hour sleep deficit every day, it usually results in poor concentration and a propensity to get more severe headaches. Melatonin may also be helpful in some patients to improve the onset of sleep. A smaller percentage of patients will present with symptoms of restless legs syndrome. They will have an itching or unusual feeling in their legs right before falling asleep, and then during sleep, they will be restless and have frequent nocturnal awakenings. As patients improve with treatment, the sleep disturbance will often improve before the headaches do.
Patients will frequently complain of dizziness, particularly with standing. The dizziness may persist and worsen during times when they have severe headaches. Some patients may respond positively to dietary increases in fluid and salt intake.
Follow-up should be scheduled on a routine basis with your doctor until symptoms come under satisfactory control. It is not unusual to make frequent adjustments in management, and it may take months before matching up the right therapeutic approach with the individual patient. It is very difficult to work with these patients over the phone. Although the parents can report a score for severity over the phone, it is harder for them to describe the child’s affect, mood, function, and appearance. These target symptoms are just as valuable treatment indicators as their pain scale.
Natural history studies have shown that chronic daily headache can resolve in many children although the symptoms may last months to years. It is hoped that with successful identification of this syndrome and aggressive pharmacologic and nonpharmacologic management the average duration of chronic daily headache in children could be considerably less.
In my personal experience with teenagers with chronic migraine, when they do get better, typically sleep needs to improve first. Then, their severe migraine episodes become less frequent, and later their all-the-time headaches start to break up. They gradually experience the onset of headache-free days. When these young people do show significant improvement, often they will return to their earlier functioning and resume normal life.
Kenneth J. Mack, MD, PhD, Department of Neurology, Mayo Clinic, Rochester, MN.