Chronic daily headache in children and adolescents presenting to tertiary headache clinics

BACKGROUND: Adults with chronic daily headache often describe a transformation from episodic migraine and partial retention of migrainous features. Although chronic daily headache has not been investigated as carefully in the pediatric population, one study showed a predominance of coexisting daily headache and episodic migraine, without a clear history of transformation. OBJECTIVE: To identify the clinical features of chronic daily headache in children and adolescents, to evaluate the efficacy of current headache classification criteria, and to compare the features of coexistent daily and episodic headaches so as to determine whether they represent separate syndromes or different stages in the "transformation" process. DESIGN: We surveyed 189 consecutive patients, 18 years of age or younger, who presented for initial evaluation of daily or near daily headache at one of 9 tertiary headache clinics. Data were collected in semistructured interviews employing a standard questionnaire and analyzed using Statistical Analysis Systems and Stata statistical software computer programs. RESULTS: Of the patients enrolled, 70% were female and 87% were white. Mean age was 13.0 +/- 3.1 years. Male gender was associated with a higher degree of reported disability. A family history of headache (typically migraine) was described in 79%. Use of nonsteroidal anti-inflammatory drugs 5 days per week or more was reported by 44% of patients. The International Headache Society (IHS) criteria failed to classify 64% of patients and criteria proposed by Silberstein et al failed to classify 31% of patients. Participating physicians misclassified patients according to criteria of the IHS and Silberstein et al in one third of cases. Nearly one quarter of patients reported two separate headache types with distinguishing characteristics. "Baseline" headache was present 27.3 +/- 4.1 days per month with a mean pain intensity of 5.9 +/- 2.1 on a 10-point scale. Superimposed episodic headache occurred 4.7 +/- 3.8 days per month with a mean pain intensity of 8.4 +/- 1.4, and was more often accompanied by other migrainous symptoms. After logistic regression to control for pain intensity, the only statistically significant difference between the two headache types was a lower prevalence of tension-type head pain with the superimposed headache. CONCLUSIONS: Our data suggest that rather than having two coexistent headache types, children and adolescents with chronic daily headache have a single syndrome that, in many cases, will paroxysmally worsen and gather migrainous features.     

Chronic daily headache in children and adolescents: a clinic based study from India

Chronic Daily Headache (CDH) is uncommon in Indian children compared to their adult counterpart. This is a retrospective study looking at the headache phenomenology of CDH in Indian children and adolescents. The validity of the case definitions of subtypes of chronic primary headaches mentioned in the IHS 2004 classification have been evaluated. 22 children (age range 8-15 years; M : F-16 : 6) diagnosed as having primary CDH using a modified definition seen between 2002 and 2003 have been studied. CDH has been defined as daily or near daily headaches > 15d/month for > 6 weeks. The rationale for this modified definition has been discussed. Majority of children (15/22) had a more or loss specified time of onset of regular headache spells resembling New Daily Persistent Headache (NDPH) but did not fulfil totally the diagnostic criteria of NDPH as laid down by IHS 2004. In all cases headache phenomenology included a significant vascular component. Headache phenomenology closely resembled Chronic Tension Type Headache (CTTH) in 4 patients and Chronic Migraine in 3 patients. However, in no patient in these groups, a history of evolution from the episodic forms of the diseases could be elicited. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (19/22). Only a minority of patients (3/22) had anxiety and depression related to interpersonal relationships in the family. Medication overuse was not implicated in any patient. CDH in children in India is very much different from CDH in adults with the vast majority of patients exhibiting overlapping features of migraine and tension-type headache. There is need for a modified diagnostic criteria and terminology for chronic primary headaches in children.     

Chronic tension-type headache in children and adolescents

In this study, the causes, predisposing factors and clinical features of chronic daily headache in children and adolescents were studied within the population of patients attending a specialist headache. The International Headache Society's (IHS) criteria for the diagnosis of chronic tension type headache (CTTH) were assessed for their applicability in the paediatric age group. Over a period of three years, demographic and clinical data were collected prospectively on all children who attended the clinic and suffered from daily attacks of headache. One hundred and fifteen children and adolescents (32% of all clinic population) had chronic daily headache, of whom 93 patients (81%) fulfilled the IHS criteria for the diagnosis of CTTH. They were between 3-15 years of age (mean: 11.1, SD: 2.3) and their female to male ratio was 1.2 : 1. Around one third of the patients also suffered from migraine (mainly migraine without aura). The headache was described as mild in 60.9%, moderate 36.5% and severe 2.6%. Headache was located at the forehead in 53% or over the whole of the head in 29.6%. Pain was described as 'just sore' or dull by 73.9%. During attacks of headache, at least half the patients reported light intolerance, noise intolerance, anorexia or nausea. Thirty-two percent of patients had at least one underlying chronic disease that may have contributed to the pathogenesis of the CTTH. Eleven percent had serious stressful events related to family illnesses and in four patients headaches were triggered by family bereavement. Fourteen percent were investigated with neuroimaging and 22% were referred for clinical psychology assessment and management. In conclusion, CTTH is a common cause of headache in children attending a specialist headache clinic. The clinical features closely match those of adult population and the IHS criteria for the diagnosis of CTTH can be adapted for use in children. Predisposing stressful risk factors, physical or emotional, are present in a large proportion.     

Chronic daily headache with analgesics overuse in professional women breath-hold divers

Objective.— The object of this study is to investigate the prevalence and characteristics of headache in Korean professional women breath-hold divers, including their overuse of analgesics.
Background.— Headache is a common problem encountered in clinical practice, and undersea divers exhibit unique causes of headache in addition to other common primary headaches. Many scuba divers are known to use various types of drugs to overcome dive-related symptoms or to enhance their underwater performance.
Methods.— The target population of this study was women divers in the northern district of Jeju Island who were registered in the divers' union. Data were collected using telephone interviews with a structured questionnaire. Headache was diagnosed and classified according to criteria of the International Headache Society.
Results.— Nine hundred and eleven (80.3%) divers responded to the telephone interview. The prevalence rates of headache were 21.4% for tension-type headache and 9.1% for migraine. One hundred and four divers (11.4%) fulfilled the criteria for chronic daily headache (CDH). Overuse of combination analgesics was reported by 70.7% of divers. Women divers with CDH were significantly older and they complained more of tinnitus and dizziness, and had a greater history of hypertension than divers without headache.
Conclusion.— The prevalence of CDH is high in Korean professional women breath-hold divers, with many of them being combination-analgesics overusers.     

Caffeine-induced headache in children and adolescents

Caffeine is the most widely used behaviourally active substance. Excessive caffeine consumption, mostly in the form of coffee and tea, is a well-recognized cause of headache or migraine, and withdrawal can cause headache. Nevertheless, caffeine abuse headache is not listed as a separate category in the International Headache Society classification, 1988. We report our experience with children and adolescents with daily or near-daily headache and excessive consumption of caffeine in the form of cola drinks. Over a period of 5 years we have encountered, in a tertiary headache clinic in a general hospital, 36 children and adolescents (17 girls and 19 boys) with daily or near-daily headache related to excessive caffeine intake in the form of cola drinks. The mean age of the subjects was 9.2 years (range 6-18) and mean headache duration was 1.8 years (range 0.6-5). All were heavy cola drinks consumers; at least 1.5 L of cola drinks per day (192.88 mg of caffeine daily), and an average of 11 (range 10.5-21) L of cola drinks a week, which amounts to 1414.5 mg of caffeine (range 1350.1-2700.3). Patients were encouraged to achieve gradual withdrawal from cola drinks, which led to complete cessation of all headaches in 33 subjects, whereas one boy and two adolescent girls continued to suffer from migraine without aura not frequent enough to justify prophylactic medication. Children and adolescents with high daily caffeine consumption in the form of cola drinks may suffer from caffeine-induced daily headache. Gradual withdrawal can be achieved without withdrawal headache and with complete disappearance of the induced chronic daily headache.     

Chronic daily headaches in children and adolescents: a study of clinical characteristics

The clinical characteristics of chronic daily headache were studied in 40 children and adolescents, as well as the associated factors responsible for maintenance of the continuous headache pattern. The study of the clinical headache characteristics, showed a female preponderance (75%), mean age of 11 years old at the first consultation, and onset of headache symptomatology at a mean age of 8.5 years old. The average time interval for the evolution of sporadic headache into chronic daily headache was 1.4 years, and psychosocial stressors were present, acutely or chronically, during the period of headache-frequency increase in 47% of the children. Headaches were classified as transformed migraine (65%), mixed pattern (17.5%) and chronic tension-type headache (17.5%). Sixty per cent of patients had mothers with migraine. Data regarding common analgesic use showed an average intake of 11.2 days/month.     

Chronic daily headache: a scientist's perspective

Certain features of chronic daily headache, namely, increased headache frequency, expansion of headache area, and cutaneous allodynia, may imply sensitization of central nociceptive neurons in the trigeminal pathway. Repetitive activation of the trigeminal nerve can lead to a biologic and functional change in trigeminal nucleus caudalis neurons, characterized by a decrease in nociceptive threshold and receptive field expansion. Suppression of the endogenous pain control system can facilitate the process of central sensitization. Evidence of such suppression in patients with chronic daily headache includes decreased platelet serotonin, up-regulation of 5-HT2A receptors, increased platelet nitric oxide production, and increased levels of substance P and nerve growth factor in the cerebrospinal fluid. Results from a number of animal experiments have indicated that chronic analgesic exposure leads to changes in serotonin content and density of 5-HT2A receptors in the central nervous system. This plasticity of the serotonin-dependent pain control system may accelerate the process of sensitization; a biologic outcome that is expressed clinically by the development of chronic daily headache associated with analgesic overuse.     

Chronic daily headache in childhood and adolescence: clinical aspects and a 4-year follow-up

Chronic daily headache (CDH) represents a challenge in clinical practice and the scientific field. CDH with onset in children and adolescents represent a matchless opportunity to understand mechanisms involved in adult CDH. The aim of this study was to evaluate the diagnosis, prognosis and psychiatric co-morbidity of CDH with young onset in the young. Fifty-nine CDH patients has been followed from 1997 to 2001 in our department. Headache and psychiatric diagnoses were made on the basis of the international system of classification (International Headache Society, 1988; DSM-IV). Chi2 test and multinomial logistic regressions were applied to analyse factors predicting outcome. The current diagnostic system allows a diagnosis in 80% of CDH patients, even if age-related characteristics have been evidenced. Psychiatric disorders are notable in CDH (about 64% of patients) and predict (mainly anxiety) a poorer outcome. Surprisingly, analgesic overuse is not involved in the chronicization process. Diagnosis of CDH needs further study. Psychiatric disorders predict a worse outcome and greater account should be taken of them in treatment planning.     

Prevalence of new daily persistent headache in the general population. The Akershus study of chronic headache

The aim of the present study was to investigate the prevalence of new daily persistent headache (NDPH) in the general population, and compare the clinical characteristics of NDPH and chronic tension-type headache (CTTH). This is a population-based cross-sectional study. A random sample of 30 000 persons aged 30–44 years was drawn from the population of Akershus County, Norway. A postal questionnaire was screened for chronic headache. Those ( n  = 633) with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. A follow-up interview was conducted after 1.5–3 years. The headaches were diagnosed according to the International Classification of Headache Disorders, 2nd edn and relevant revisions. The response rate of the questionnaire was 71% and the participation rate of the interview was 74%. Four persons, three men and one woman, had NDPH. The overall 1-year prevalence of NDPH was 0.03%. The clinical characteristics of NDPH and CTTH were similar, except for the sudden onset in NDPH. Three of the four persons with NDPH had medication overuse. Follow-up disclosed that the symptomatology of NDPH is not unchangeable, since two persons had improvement of their NDPH. NDPH is rare and occurs in one of 3500 persons from the general population of 30–44-year-olds. It is often associated with medication overuse.     

Chronic daily bilateral headache responsive to indomethacin

Indomethacin is known to be specifically effective for chronic paroxysmal hemicrania, episodic paroxysmal hemicrania, and hemicrania continua. Different forms of idiopathic stabbing headaches have also been responsive to indomethacin, but less consistently than the others. Two cases of indomethacin-responsive headache are reported. One patient presented with what appeared to be new-onset, chronic, daily, bilateral headache aggravated by coughing. Both the chronic daily headache and the exacerbations induced by coughing were suppressed with indomethacin therapy. The second patient experienced hemicrania continua responsive to indomethacin, and the response persisted even when the headache evolved into bilateral continuous pain. There may be other idiopathic primary headache disorders that are peculiarly responsive to indomethacin. When any primary headache disorder does not respond to standard therapy, a brief therapeutic trial of indomethacin is warranted.     

Chronic daily headache in a paediatric headache centre

The prevalence and the clinical features of chronic daily headache (CDH) were studied in 968 children and adolescents observed during a period of one year in the Headache Centre of the Anna Meyer Paediatric Hospital of Florence. Nine hundred and fortyfour patients (97.52%) had primary headache according to ICHD-II, 24 subjects had secondary headache and 56 patients had CDH (5.93% of primary headaches). The mean age of subjects with CDH was higher than general (13.5 vs. 11.5 years), with a female preponderance (69.6% vs. 30.4%). According to the ICHD-II, headaches were classified as chronic migraine in 10 patients (1.5.2 ICHD-II), chronic tension-type headache in 36 (2.3 ICHD-II), new daily persistent headache in 8 (4.8 ICHD-II) and 2 patients reported mixed pattern (chronic migraine+chronic tension type headache). Medication overuse was not implicated in our patients.     

Chronic daily headache: correlation between the 2004 and the 1988 International Headache Society diagnostic criteria

BACKGROUND: In a previous study, we compared the 1988 International Headache Society (IHS) criteria and the Silberstein-Lipton criteria (S-L) in a subspeciality clinic sample of 638 patients with chronic daily headache (CDH) assessed both clinically and with headache diaries. Both systems allowed for the classification of most patients with CDH. The 1988 IHS classification required multiple diagnoses and was more complex to apply. OBJECTIVES: The aim of this study was to revisit the same database, now comparing the prior classification systems with the new 2004 IHS classification. In contrast with the 1st edition, the 2nd edition includes criteria for chronic migraine (CM), new daily persistent headache (NDPH), and hemicrania continua (HC). METHODS: We reviewed the clinical records and the headache diaries of 638 patients seen between 1980 and 2001 at a headache center. All patients had primary CDH according to the S-L criteria. RESULTS: Using the S-L criteria as a reference, of the 158 patients with transformed migraine (TM) without medication overuse, just 9 (5.6%) met 2004 IHS criteria for CM. Most of the subjects were classified using combinations of migraine and CTTH diagnoses, much like the 1988 IHS classification. Similarly, using the new IHS system, just 41/399 (10.2%) subjects with TM with medication overuse were classified as probable CM with probable medication overuse. Most patients with NDPH without overuse were easily classified using the 2004 criteria (95.8%). Regarding NDPH with medication overuse, the diagnostic groups were much like results for the 1st edition. All patients with chronic tension-type headache (CTTH) and hemicrania continua (HC) according to the S-L system were easily classified using the 2004 IHS criteria. CONCLUSIONS: We conclude that the 2004 IHS criteria facilitate the classification of NDPH without medication overuse and HC. For subjects with TM according to the S-L system, the new IHS criteria are complex to use and require multiple diagnoses. Very few patients with TM in the S-L system could be classified with a single diagnosis in the 2004 IHS classification. In fact, CM was so rare that it would be virtually impossible to conduct clinical trials of this entity using the 2004 IHS criteria. Clinical trials of this entity should therefore be conducted using the S-L criteria. Finally, we propose that in the 3rd edition of the IHS classification, the diagnosis of NDPH be revised so as not to exclude migraine features.     

Cusums to measure chronic daily headache

OBJECTIVE: To investigate whether cumulated summed differences (cusums) can be used as a method for detecting effective interventions in chronic daily headache (CDH). If so, then can such interventions be detected sooner than 28 days? BACKGROUND: CDH probably represents the greatest current challenge in the field of headache treatment. Clinical trial methodologies for its study are not standardized but usually use fixed 28-day observation periods. Similarly, 28-day observation periods are common review intervals for stepped-care patient management strategies. METHODS: A theoretical patient was modeled, with daily headache scores that had maximal variation for 28 consecutive daily measures. The cusums for this "norm" or control data set were plotted and correlated with time using a simple spreadsheet. Departure of a postintervention cusum from the 95% confidence interval of the control data set was chosen as an indicator of sensitivity to various model perturbations that had clinical correlates. RESULTS: When 1 to 17 randomly distributed headache-free days were used to perturb the 28-day model, cusums consistently diverged from the norm. If at least 3 headache-free days occurred, then the cusum detected the intervention in less than 28 days of observation. Reanalysis of a previously published study of magnesium oxide suggests that its negative conclusions should be reconsidered. CONCLUSION: Cusums can be useful tools for detecting change in CDH, whether at the level of the clinical trial or when managing patients using stepped-care treatment algorithms.     

Chronic daily headache

Abstract Chronic daily headache relates to the daily or almost daily occurrence of headache in a nonparoxysmal pattern. In this review, I discuss the presentation, development, outcome, and treatment of chronic daily headache. In the context of the development of chronic daily headache, a headache continuum is presented along with its underlying pathophysiology. The treatment section covers rebound headache, analgesic and vasoconstrictor withdrawal, and the use of long-acting opioids in intractable patients. The review concludes with a discussion of hemicrania continua, an indomethacin-responsive headache syndrome.     

Chronic daily headache in a primary care population: prevalence and headache impact test scores

BACKGROUND: Population-based surveys estimate the prevalence of chronic daily headache (CDH) in the general community to be approximately 4%. The prevalence of CDH among patients seen in the primary care setting in the United States, however, is unknown. PURPOSE: To estimate the prevalence and associated burden of suffering of CDH in a primary care patient population. METHODS: Cross-sectional survey of a randomly selected sample of 1500 adult patients in an academic Family Medicine Center was done. Outcome measures include self-reported headache frequency and Headache Impact Test scores. RESULTS: Completed questionnaires were returned by 853 (57%) patients. The mean age of respondents was 49 years (SD = 16), with a range of 18 to 94 years. Two hundred ninety-six (58%) patients reported having had 1 or more severe headaches in the past month. Seventy-four (9%) patients reported a frequency of headache consistent with CDH, defined as the occurrence of headache 15 or more days in the past month. Twenty-four patients (32%) with CDH either believed that none of their doctors know that they experienced headaches or were not sure if their doctors were aware of their headaches, and 21 (28%) reported that they have not needed a doctor's care for their headaches. CONCLUSIONS: The prevalence of CDH is greater among a primary care patient population compared to the general community. A substantial proportion of patients with CDH do not bring their headaches to the attention of their health-care providers. In light of the advances in the development of effective medications for migraines and the growing body of evidence implicating medications as a contributing cause of CDH, it may be appropriate to encourage patients to inform their health-care providers about their headaches and to encourage providers to identify patients with frequent headaches.     

Chronic daily headache in Taipei, Taiwan: prevalence, follow-up and outcome predictors

We conducted a two-stage population-based headache survey among subjects aged > or = 15 in Taipei, Taiwan. Subjects with chronic daily headache (CDH) in the past year were identified, interviewed and followed-up. CDH was defined as a headache frequency > 15 days/month, with a duration > 4 h/day. Of the 3377 participants, 108 (3.2%) fulfilled the criteria for CDH, with a higher prevalence in women (4.3%) than men (1.9%). TM was the most common subtype (55%), followed by CTTH (44%). Thirty-four per cent of the CDH subjects overused analgesics. At the 2-year follow-up, 35% of the CDH subjects still had CDH. The significant predictors for persistent CDH at follow-up included: older age ( > or = 40 years) (RR = 2.4), CDH onset after 32 years (RR = 1.8), CDH duration > or = 6 years (RR = 2.0), medication overuse (RR = 1.8), and "daily" headache (RR = 2.1). We found that CDH is not uncommon in the community and its prevalence is similar among different populations. Older subjects and those with medication overuse may have a more protracted course of illness.     

Prophylactic pharmacological treatment of chronic daily headache

Objective.—To review all the prophylactic pharmacological treatments for chronic daily headache from the past decade.
Background.—Chronic daily headache is among the most common diagnoses seen in specialized headache centers. Prior to 1988, there were no criteria for the diagnosis of chronic tension-type headache and chronic daily headache. An expanded chronic daily headache classification has been proposed.
Methods.—A MEDLINE search was performed using the following key words: chronic daily headache, intractable headache, transformed migraine, chronic tension headache, and chronic tension-type headache. We limited our review to those studies published in English in the last decade, including published abstracts and letters to the editor. Double-blind studies carried out prior to 1988 were also included.
Results.—Pharmacological treatments for chronic daily headache include antidepressants (tricyclics, tetracyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors), anticonvulsants, muscle relaxants, 5-HT₁ agonists, ergots, 5-HT₂ antagonists, antianxiety agents, and miscellaneous drugs. Many of these reports are anecdotal, and most are open rather than double-blind studies.
Conclusions.—There is a great variety of pharmacological treatments available for chronic daily headache. Only the antidepressants have been extensively studied. Other medications may be used if these fail. Recommendations based on our experience at the Headache Unit of the Montefiore Medical Center are outlined here.     

The challenge of new daily persistent headache

New daily persistent headache is a rare chronic daily headache of long duration characterized by the abrupt onset of persistent headache that generally develops over less than 3 days and does not remit. While it was initially thought to be a benign, self-limiting disorder, further research has shown that a significant percentage of patients continue to suffer for many years, often experiencing pain that is refractory to treatment. This article reviews the symptoms, pathophysiology, diagnostic criteria, diagnostic testing, treatment, and prognosis.     

Unilateral Chronic Daily Headache in Children

Unilateral chronic daily headache occurs in approximately 2% of adult patients, and often represents a trigeminal autonomic cephalalgia. We now describe the characteristics of 23 children who presented with a persistently unilateral chronic daily headache. The clinical features of our patients' headaches were primarily migrainous; however, the diagnosis of a trigeminal autonomic cephalalgia or a secondary headache disorder was frequently made.