Chronic Headache and the use of Analgesics for Control and Relief

Chronic Daily Headache (CDH) is defined as headache which is present on most days i.e. > 15 days a month, typically occurring over a six-month period or longer and it can be daily and unremitting. In some patients, an episode of chronic headache resolves in a much shorter time, it can occur in children and in the very old. Twice as many men have it compared to women. The symptoms can last for decades and typically patients may have suffered for up to five years before presenting to a specialist centre.

About 50% of patients attending a doctor with a headache will have chronic daily headache. Many different classifications have been used to describe chronic headache including medication misuse headache, hemicrania continua and transformed migraine. Chronic headache is characterised by a combination of background, low-grade muscle contraction-type symptoms, often with stiffness in the neck, and superimposed migrainous symptoms. Patients might have had migraine in the past and experienced a difficult patch of high frequency headache, prompting them to increase their analgesic intake. These analgesics can then lead to a worsening of the chronic headache pattern resulting in analgesic dependence.

In the United Kingdom, the most commonly implicated drugs are those containing codeine but all simple analgesics and ergotamine compounds have been implicated. In recent times, the triptan class of drugs has also been reported to cause chronic headache, although it is our opinion that this situation is uncommon. However, the medication probably does not actually cause the condition. It is more likely that patients achieve transient relief from this class of drug, leading them to repeat dosing. Risk factors appear to include not only a past history of migraine and high analgesic intake, but also injuries to the head and neck, such as a whiplash injury. The aim of management in chronic headache is to return patients to their original acute headache pattern, which requires a combination of treatments including:

1. Identify Stressors in your life and reduce sources of stress, take the (SPIĀ© test).
2. Physical measures in the neck and shoulder areas (eg, exercises or formal physiotherapy, acupuncture or osteopathy or chiropractic).
3. Avoidance of analgesics and ergotamine to break the cycle.
4. Use of effective, regular prescription medicines, usually drawn from the antidepressant or antiepileptic groups.

Specific Drug Treatments for Chronic Daily Headache

Tricyclic antidepressants (prothiaden, amitriptyline) and anti-epileptics (sodium valproate, gabapentin, topiramate) were found by chance to be effective and are introduced at lower doses. There is no firm evidence that selective serotonin reuptake inhibitors (SSRI) are useful as yet.

This package of care is clearly different from that required for straightforward migraine and it is, therefore, critical that chronic daily headache is not misdiagnosed and subsequently mistreated. Approximately 2 per cent of the population may have chronic headache at any time and 4 per cent at some time in their lives. The seriousness of the impact of this form of headache to patients must not be underestimated.

Source: Dr Andrew Dowson

Publication Date: July 2003

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