Chronic daily headache

Who gets chronic daily headache?
It is surprisingly common. About one in 20 people develop this problem at some time in their lives. It is more common in women than men, and it also happens in children.

What are the symptoms of chronic daily headache?
The main feature is very frequent headache. This varies, but is often a dull pain. Other common symptoms, alongside headache, are feeling tired, feeling sick, being irritable and difficulty sleeping. Sometimes headache seems relentless, although it may change as you go through the day. Medication-overuse headache is often at its worst on waking in the morning.

Will my chronic daily headache get better? How chronic daily headache is treated depends on the diagnosis and the cause. Getting the right treatment is very important, so medical care is usually necessary.

All types of chronic daily headache may be temporarily relieved by painkillers or anti-migraine treatments, but in many cases this relief is only partial and the effect diminishes over time. These treatments are not appropriate because they will make the condition worse. If your headache is already being caused by overusing medication of this sort, then it is likely to improve once you stop taking the medication, and not otherwise.

Do I need any tests?
Whatever the type of chronic daily headache, there are no tests to confirm the diagnosis. This is based on your description of your headaches and the lack of any abnormal findings when you are examined. Therefore, it is very important that you carefully describe your symptoms and how they developed.
It is also very important that you say how many painkillers or other medications you are taking for your headaches, and how often you are taking them.

Your doctor should be able to tell quite easily whether you have an illness more serious than chronic daily headache. If he or she is not sure about the diagnosis, or there is any sudden change in your headache, tests including a brain scan may be carried out to rule out other causes of your headache.
However, these are not often needed. If your doctor does not ask for a brain scan, it means that it will not help to give you the best treatment.

What is medication-overuse headache?
Any medication you use to treat the symptoms of headache, when taken too often for too long, can cause medication-overuse headache. Aspirin, paracetamol, ibuprofen, codeine – in fact, all painkillers, even those bought over the counter – are associated with this problem. And it is not just painkillers. Drugs that specifically treat migraine headache also lead to this problem when used too often. These include triptans and, most of all, ergotamine.

A similar headache (although not strictly medication-overuse headache) can result from taking too much caffeine. The usual source of this is coffee, tea or cola drinks, but it can come from caffeine tablets or from caffeine included in many painkillers.

The exact way medication-overuse headache develops is not known, and may be different according to the nature of the medication. Triptans and ergotamine may cause a rebound effect, with headache returning after they wear off.
Painkillers are believed to cause, over time, a change in pain-signalling systems in the brain. This means they become used to the effects of the medication so that you need more and more of it.

For most people with occasional headaches, painkillers are a safe and effective treatment. However, medication-overuse headache may develop in anyone taking headache treatments regularly on more than three days a week. Usually, the person with medication-overuse headache begins with occasional attacks of tension-type headache or (more commonly) migraine. For varying reasons, the headaches begin to happen more often.
This may be through natural variation or because an extra headache has developed, perhaps due to stress or muscular pain. The increase in headache leads to use of more medication to try to control the symptoms, eventually until both happen every day.
Many people in this situation know that they are taking more medication than is wise, and try to reduce the amount. This leads them to have a withdrawal syndrome of worsening headache, for which they take more medication. It is easy to see how this results in a vicious cycle, which can be difficult to break.
It makes not so much difference how much you take – if you regularly use the full dose of painkillers on one or two days a week only, you are unlikely to develop medication-overuse headache. However, take just a couple of painkillers on most days and you may well be making your headaches worse. It is frequent use over a period of time that causes the problem.

What can I do to help myself?
The only way of treating this condition is to stop the overused medication (withdrawal). Clinical studies show that most people who withdraw from overused medication improve greatly. However, it can take up to three months before you see the full benefit. Even if headaches continue after that time, despite stopping the medication, their cause usually becomes clear and they will respond better to correctly-prescribed specific treatment.

You can withdraw either by stopping in one go or by gradually reducing the amount taken over two to three weeks. Whichever way you choose, drink plenty of fluids while doing this (but avoid taking more caffeine). If you stop in one go, you will almost certainly have withdrawal symptoms – worsening headache, feeling sick, perhaps being sick, anxiety and difficulty sleeping. These symptoms will appear within 48 hours and may last, at worst, for up to two weeks. However, people who try to stop slowly seem more likely to fail, perhaps because it takes so much longer.

It makes sense to choose when to withdraw, and not begin shortly before an important event. Do warn your work colleagues that you may be unable to come into work for a few days.

What if I just carry on as I am?
If medication overuse is causing your frequent headaches, carrying on as you are is not an option. You will continue to have ever-more frequent headaches, which will not respond to painkillers or to preventative medicine. Eventually you may do yourself other harm as well, such as damage to your liver and kidneys.

Are there other treatments I can take?
There are medications, which a doctor can prescribe, that you can take every day to help you withdraw. They work only if you stop all other headache medication, and even then it is uncertain how much they help. You will also have to stop these at some point, and, for most people, it is better to do without them.

How can I make sure it doesn’t happen again?
As it develops, medication-overuse headache largely replaces the original headache (migraine or tension-type headache) for which you took the medication in the first place. This means that, as your medication-overuse headache improves after withdrawal, you can expect your original type of headache to return.

There are separate leaflets on both migraine and tension-type headache. You may find one of these useful at this stage.

If you need to, you can cautiously restart using medication for this headache once the pattern of headache has returned to normal. This is likely to be after at least several weeks.

Be careful, because there is a risk of following the same path as before. To prevent this, avoid treating headaches on more than three days in a row or on a regular basis on three or more days in a week. Always read the leaflet and packaging that come with any medicine.

If a headache doesn’t get better, or keeps returning, never continue taking medication without consulting your doctor or nurse.

For people at risk of medication-overuse headache, diaries are especially important as they help keep track of just how much medication you are taking.