Chronic Daily Headache

and Cluster Headache

Manage CDH

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Cluster headaches are primary headaches consisting of a severe stabbing pain that usually lasts between fifteen minutes and two hours and affect one side of the head, usually around the eye.

Cluster headaches can occur several times per day and characteristically come in clusters of attacks, which can last weeks or months. Individual clusters can be separated by periods of remission lasting months or years. Age of onset is usually between 20-40 years. Less than 0.5% of the population are affected and it is 3-4 times more common in men.

The causes of cluster headache are unclear but biochemical, hormonal, and vascular changes are known to induce individual attacks. Attacks seem to be linked to changes in day length, and may also be triggered (during clusters only) by alcohol, tobacco, histamine, stress or exposure to nitroglycerine. Decreased blood oxygen levels can also act as a trigger, particularly during sleep.

About 10 – 20% of patients with Cluster Headache have Chronic Cluster Headache, which is defined as attacks occurring for more than one year without remission, or with remissions lasting for less than 1 month.

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I.H.S. Criteria for

Diagnosing Cluster Headache

A. At least five attacks fulfilling criteria B-D

B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes if untreated.

C. Headache is accompanied by at least one of the following:

    • Ipsilateral conjunctival injection and/ or lacrimation
    • Ipsilateral nasal congestion and / or rhinorrhoea
    • Ipsilateral eyelid oedema
    • Ipsilateral forehead an facial sweating
    • Ipsilateral miosis and/ or ptosis
    • A sense of restlessness or agitation

D. Attacks have a frequency of one every other day to eight per day

E. Not attributed to another disorder.

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Acute Drug Treatment

The goal of treatment for cluster headache is to decrease the pain, severity, and duration of each attack. Early intervention is critical yet difficult, since a single cluster headache can be as short as 15 minutes. Non-oral routes of administration for medications are therefore preferable.


Oxygen inhalation is the first line therapy for cluster headache. Treatment is initiated with 100% oxygen at max flow rate of 7 to 10 liters per minute. Treatment should continue for 15 minutes. Although up to 70% of patients experience relief within five to ten minutes, some patients report that oxygen suppresses rather than aborts the attack and that pain may return. There are no side effects with this treatment.


Sumatriptan, 6 mg administered subcutaneously is an effective acute treatment for episodic and chronic cluster headaches, but it is most useful for patients who report one or two cluster attacks per day. Cluster attacks usually respond within 10-15 minutes. Smaller doses of two to three mg may also be enough to relieve the attacks. It should be used with a prophylactic so as to avoid dependency.

Intranasal sumatriptan (20 mg) has been shown to have some efficacy but is generally regarded as not being as effective as the subcutaneous injection.

Note that subcutaneous sumatriptan is available on a named patient basis only.


Treatment Contd.

Prophylactic Drug Treatment

The two main goals of preventive treatment for cluster are:

  • To rapidly suppress individual attacks
  • Maintain that remission throughout the patient’s typical cluster period.


Verapamil is the gold standard in the treatment of Cluster Headache. Treatment can be initiated at 120 mg daily and titrated up to 480 mg a day. Side effects are rare, but constipation is common. Other side effects include dizziness, nausea, edema, bradycardia, fatigue, and hypotension.


Prednisone (60mg a day) and Dexamethasone (4-8mg a day)  are fast acting transitional prophylactic drugs that are used (usually in specialist centres) for Cluster headache prophylaxis.

Side effects include insomnia, restlessness, hyponatremia, edema, hyperglycemia, osteoporosis, myopathy, and gastric ulcers. The use of corticosteroids is discouraged in the long term in patients with chronic cluster headaches because the incidence of side effects increases with prolonged use.


Sometimes used in specialist centres, Lithium carbonate has been shown to be effective against episodic and chronic cluster headaches. Of cluster headache patients, 78% of patients with chronic clusters and 63% of patients with episodic clusters respond to lithium. The usual daily dose ranges from 600 to 900 mg in divided doses. Side effects might include tremor, polyuria, and diarrhea. Nephrotoxicity and hypothyroidism can occur with long-term use.

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Chronic Daily Headache

Successful management of CDH depends on

  • Identification of the cause of the CDH  e.g. medication reliance, co-morbidities, injury.
  • Commitment from patient and doctor. There is no simple answer so a thorough approach to the patient is highly recommended.
  • Managing patients with chronic headache disorders, especially those not attributable to medication overuse often demands intensity beyond the scope of general primary care teams. Some patients with CDH also require interdisciplinary treatment from a variety of medical specialists and in extreme cases they may require hospitalisation.

Chronic Daily


Chronic daily headache (CDH) is a descriptive term rather than a specific diagnosis. It can evolve from any primary headache disorder or can be de novo. Studies in the US and Europe indicate that 4-5% of the general population are affected by CDH. It is becoming more frequent in general practice and is a major reason for consultation in Headache/ Migraine clinics.Like migraine, CDH can significantly affect an individual’s ability to function within the family, in society, and in the workplace.In general, headache occurring more often than fifteen days per month, over at least six months and lasting for four hours a day can be considered CDH. The leading cause is chronic tension-type headache followed by chronic migraine.
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Chronic Migraine

Chronic migraine is diagnosed when a patient has migraine on fifteen or more days each month over a period of at least six months. Also known as transformed migraine, patients usually have a history of migraine attacks that gradually worsen over a period of months or years.

The I.H.S. criteria for diagnosing chronic migraine are outlined below.

Headache pain and the other symptoms usually associated with migraine become less severe as the frequency increases, but also become less responsive to treatment. As the nature of the headaches transform, many patients will experience ‘breakthrough’ migraine attacks on top of the ‘background’ headache.

Like with CTTH, the overuse of acute treatments for migraine (including analgesics, ergot derivatives and triptans) can be responsible for transforming migraine into a chronic condition.  However, the transformation may also occur as part of the natural history of the condition.

In cases of Chronic Migraine, attention should be paid to the possible existence of comorbid conditions such as anxiety and depression, both of which have been shown to be more frequent in patients who have migraine than in non-migraine control subjects. It is believed that migraine and depression share the same etiologies, rather than the depression resulting from the disability caused by chronic migraine. Some features of comorbid depression show improvement when the cycle of CDH is broken. Treatment options for chronic migraine include Amitriptyline or Gabapentin.

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I.H.S. Criteria for

Diagnosing Chronic Migraine

A. Headache fulfilling criteria B and C on ≥15 days a month for > 3 months
B. Headache has at least two of the following characteristics

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity

C. During headache at least one of the following

  • Nausea and / or vomiting
  • Photophobia / Phonophobia

D. Not attributed to another disorder

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Medication Overuse Headache


In cases where the patient is clearly overusing acute medications, then the medication must be stopped. This can be frightening to the patient because the medication is considered the lifeline to a normal life. Gradual tapering off the offending medication (e.g. 10% weekly reduction in the consumption of the medication) is usually easier than abrupt withdrawal and compliance is more likely.

Patient-Doctor Dialogue

To encourage compliance the patient needs to be made aware that it may take a few months of being off the offending medications before CDH will improve. The patient must also be told that the headaches are likely to worsen in the short term if an abrupt withdrawal is initiated. Using a diary will also provide key information in the management of CDH.


Prophylactic treatments such as Amitriptyline, Gabapentin or Topiramate can also be prescribed, but only after a detoxification programme is underway. Otherwise, the preventive drug is unlikely to be beneficial. Standard migraine preventative drugs can be used in the prophylaxis of Transformed Migraine.

Acute treatment of breakthrough attacks

The patient will also require a suitable acute treatment (e.g. a Triptan) if the daily headaches are accompanied by breakthrough migraine attacks. If the patient has been overusing Triptans a prophylactic treatment plan is recommended instead. Generally, once a patient has overused a specific medication, future treatment programmes should avoid that particular therapeutic class.


Co-morbid conditions include stress, anxiety and depression and are important predisposing risk factors. If present, anxiety and depression should be treated separately.

Non-drug Measures

Physiotherapy, biofeedback or chiropractic may be useful to some patients, especially those whose headaches are related to a history of head/neck injury. Massage and stress management may also benefit patients. In some cases, counselling may be used. Botilinum Toxin has been suggested for CDH in recent years, but its effectiveness has not yet been ascertained.

Migraine is a




That Affects Different Areas of The Brain

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