Chronic Daily Headache (CDH)
울산대병원 신경과 남 병 극
IHS Classification
Primary headache disorders
1. Migraine
1.1Migraine without aura
1.2 Migraine with aura
1.3 Ophthalmoplegic migraine
1.4 Retinal migraine
1.5 Childhood periodic syndromes that may be precursors to or
associated with migraine
1.6 Complications of migraine
1.7 Migrainous disorders not fulfilling above criteria
2. Tension-type headache
2.1 Episodic tension-type headache
2.2 Chronic tension-type headache
2.3 Headache of the tension-type not fulfilling above criteria
IHS Classification
Primary headache disorders
3. Cluster headache and chronic paroxysmal hemicrania
3.1 Cluster headache
3.1.1 Cluster headache periodicity undetermined
3.1.2 Episodic cluster headache
3.1.3 Chronic cluster headache
3.2 Chronic paroxysmal hemicrania
3.3 Cluster headache-like disorder not fulfilling above criteria
4. Miscellaneous headaches unassociated with structural lesion
4.1 Idiopathic stabbing headache
4.2 External compression headache
4.3 Cold stimulus headache
4.4 Benign cough headache
4.5 Benign exertional headache
4.6 Headache associated with sexual activity
IHS Classification
Secondary headache disorders
5. Headache associated with head trauma
6. Headache associated with vascular disorders
7. Headache associated with nonvascular intracranial disorder
8. Headache associated with substances or their withdrawal
9. Headache associated with noncephalic infection
10. Headache associated with metabolic disorder
11. Headache or facial pain associated with disorder of cranium, neck, eyes,
ears, nose, teeth, mouth or other facial cranial structures
12. Cranial neuralgias, nerve trunk pain and deafferentation pain
13. Headache not classifiable
Red-flags for Secondary Headaches
History
Physical Examination
* Abrupt new onset of headache (intracranial bleeding)
* Change in headache pattern, unexplained worsening
* Prominent neck pain and stiffness
* Age greater than 40
Meningeal irritation from infection or subarachnoid blood
Onset of primary headache disorders is rare in this age group
* Altered consciousness (including syncope or seizures)
Prevalence of secondary headache disorders is higher
Serious CNS process such as bleeding, infection, or neoplasm
* Effort induced or positional pain
* Focal neurologic complaints or findings
* History of head trauma within the past few months
* Exposure to products of combustion or co-habitants/co-workers
* Anticoagulant use (intracranial bleeding)
will with similar symptoms
* Setting of chronic illness (e.g. cancer, AIDS)
* Papilledema
* Fever, immunosuppression, or other symptoms of infection
especially in a parameningeal focus, suggesting an intracranial infection
Definition
Primary headache
including those associated with medication overuse
presenting more than 15days per month
lasting more than 4 hours per day untreated
Classification (CDH)
Primary variety Secondary variety
Headache duration >4 hours 1. Posttraumatic headache
1. Transformed migraine 2. Cervical spine disorders
2. Chronic tension-type headache 3. Headache associated with vascular
3. New daily persistent headache disorders: arteriovenous
malformation; arteritis, including
4. Hemicrania continua giant cell arteritis; dissection;
subdural hematoma
Headache duration 1/2 of CDH
• TM : 1.5~2%, 1/3 of CDH
• NDPH : 0.1%
• HC : 0~0.25%
Risk Factors
1. Female
2. Low education : Inversely related to years of education
3. Migraineur (8% vs 5% of non-migraineur)
4. High medication
5. Habitual snoring & sleep disturbance
6. Stressful life event
Analgesic Overuse in CDH (1)
Prevalence
1~2% of general population, 5~10% of patients in headache centers
Analgesic overuse for non-headache pain : not cause CDH (e.g. arthritis)
CDH with drug overuse
60~80% of CDH used analgesics daily or near-daily basis
In chronic drug-induced headache
migarine in primary headache : 65%
TTH in primary headache : 27%
mean duration of headache : 20.4yrs
mean duration of frequent drug intake : 10.3yrs
mean duration of daily headache : 5.9yrs
average consumption of tablet or suppositories : 4.9/day
average 2.5~5.8 different pharmacologic component
success rate of withdrawal therapy within time window of 1~6 months : 72.4%
relapse rate within 5 years : 40%
Analgesic Overuse in CDH (2)
Drugs inducing overuse headache
* All analgesics or drugs for treatment of migraine attack
* >90% : take more than one compound
* Combination analgesics containing butalbital, caffeine, aspirin, codeine
: Leading candidate in one study
* New migraine aborting drugs [Triptan (sumatriptan, naratriptan, zolmitriptan)]
Also cause drug-induced headache
Cause headache faster & with lower dosages
Shorter lasting withdrawal symptoms
Time delay of headache after frequent intake
Triptan (1.7Yrs), ergots (2.7Yrs), analgesics (4.8Yrs)
Intake frequency
Triptan (18 single dasages/month),
ergot (37/month), analgesics (114/month)
Analgesic Overuse in CDH (3)
Clinical features of medication overuse headache in patients using different drugs
and with different primary headaches
Primary headache Migraine Tension-type headache
Original headache Mostly unilateral, pulsating, Dull, pressing, diffuse
features throbbing, occurring in
attacks
Headache features with Like tension-type headache Like original tension-type
overuse of combination plus intermittent migraine headache, improves after
analgesics attacks withdrawal
Headache features with Daily migraine-like Does not apply
overuse of triptans headache
Analgesic Overuse
Criteria for medication overuse in chronic
daily headache
At least one of the following for at least 1 month:
1. Simple analgesic use (1000 mg ASA/acetaminophen) 6 days/week
2. Combination analgesics (3 tablets/day) 3 days/week
3. Narcotics (1 tablet/day) 3 days/week
4. Ergotamine use (1 mg PO or 0.5 mg PR) 2 days/week
Pathophysiology
Peripheral Sensitization
Changes in nociceptor function
: innervating cranial vessels & pericranial myofascial tissues
Activation of nociceptive fiber
-> trigger release of algogenic peptides (substance P & CGRP) from its terminal
-> coupling with receptor (G-protein-coupled ligand)
-> trigger phosphorylation of protein (sodium & calcium ion channel)
-> decrease threshold of nociceptive membrane
Pathophysiology
Central Sensitization
Changes in neural pathway
: transmission & modulation of cranial nociceptive information
Wind-up
: progressive increasing activity in dorsal horn cell
following repetitive activation of primary afferent C-fiber
by summation of changes in synaptic potential
Pathophysiology
Dysfunction of central serotonin system
Analgesics administration (acute response)
* Increased tissue 5-HT level (?by enhancement of release process)
* Downregulation of 5-HT2A receptor
* Upregulation of 5-HT transporter
Prolonged analgesic administration
* Decrease in degree of receptor downregulation & transporter upregulation
Coincide with decrease in analgesic efficacy
* Alteration in central 5-HT system
i) Induction of low 5-HT state
-> Alteration in central pain modulation system
-> Reduction of nociceptive inhibitory control
-> Central sensitization
Activation of nociceptive facilitation system
Enhancing kindling process
ii) 5-HT2A receptor upregulation
Treatment & prophylaxis
Strategies for management
* Verification of correct diagnosis
* Screening for comorbidity
* Consider possibility of new serious intracranial process
* Physician-patient communiction
i) Clear understanding of management plan, guideline
& outcome expectation
ii) Instruction about therapy (therapeutic expectation, side effect, toxicity)
iii) Keep headache diary
for medication use, headache pattern, trigger factors
* Addressing any psychosocial issues relevant & treat if necessary
Treat psychiatric comorbidity with medication or psychotherapy
Treatment & prophylaxis
Pharmacological therapy
Preventive medication
* For migraine : beta-blockers, flunarizine, valproic acid
* For tension type headache : tricyclic (amitriptyline)
* Neuronal stabilizing agents
i) Na-, Ca-ion channel blockage, GABA-nergic
Prophylaxis for migraine but no study yet to CDH specifically
Gabapentin, lamotrigine, topiramate, tiagabine,
oxcarbazepine, levetiracetam, zonisamide
ii) Adrenergic alph2-agonist
Tizanidine
Central acting muscle relaxant for spasticity
Positive effect in double-blind study for CDH
* CGRP-antagonist
* 5-HT2 receptor blocker
* NO synthase inhibitor
* Botulinum toxin
Abortive medication
* Tailored to aberrant biologic changes
Treatment & prophylaxis
Non-pharmacological therapy
* Stress management
* Behavioral relaxation therapy
* Biofeedback & cognitive therapy
* Physical therapy
Need to incorporate wellness Psychological treatment
Regular exercise Cognitive behavioral therapy
Good sleep hygiene EMG biofeedback training
Eat "healthy," avoid skipping meals Relaxation training
Avoid excessive caffeine Positive psychological coping
Address mood disorder Stress management
Guided imagery
Physiotherapy Questionable efficacy
Physical therapy Cold/heat to head or neck
Treat TMJ in noninvasive manner Massage
TENS
Treatment & prophylaxis
Treatment of drug overuse headache (1)
TOC : abrupt drug withdrawal
Withdrawal symptoms
* Lasting for 2~10 days
* Withdrawal headache, nausea, vomiting, hypotension, tachycardia, insomnia,
restlessness, anxiety, nervousness
* Rarely seizure or hallucination in barbiturate-containing drugs
Inpatient treatment
* Indication
Drug overuse headache lasted more than 5 years
Intake of tranquilizer, barbiturates, opioids
Concomitant depression or anxiety disorders
Failure of outpatient treatment
* Fluid replacement & antiemetics for vomiting
* Treatment for withdrawal headache
Naproxen 500mg twice a day
Aspirin injection 1000mg every 8~12 hours
Dihydroergotamine 1~2mg every 8 hours
Prednisone 100mg first day then tapering for next days
Clonidine for opioid withdrawal : 0.1~0.2mg 3 times a day
Anxiolytics
* Behavioral therapy
* Relaxation therapy & stress management
Initiated as soon as withdrawal symptoms fade
Treatment & prophylaxis
Treatment of drug overuse headache (2)
Outpatient treatment
* Migraine prophylactic medication
* For migraine as original headache
4 weeks before withdrawal
* Tricyclic
For cronic tension type headache
4 weeks before
Amitriptyline 10mg increasing to 25~75mg at night time
* Withdrawal
Ergots, triptans, nonopioids : abrupt stopping
Opioids, barbiturate : withdrawn slowly
* Withdrawal headache
NSAIDs : naproxen 500mg t.i.d for 5~7 days
Long-term treatment
* Prophylactic medication for migraine
Beta-blockers, flunarizine, valproic acid
Ergotamine, triptans, possibly analgesic counteract the action of
* Careful instruction to using specific antimigraine drugs only for migraine attack
(in patients with mixed type headache)
Conclusion
• CDH
1. Not rare condition
2. Not only psychosocial base but also biologic mechanism
3. Relation to underlying primary headache
4. Relation to medication overuse
5. Management
Early preventive medication & psychobehavioral manage
Quit overused drugs
Proper instruction