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Criteria for Chronic Daily Headache (CDH)
Posted Feb 2000
Excerpts from Dr. Robbins' upcoming 2nd edition of Management of Headache and Headache Medications

  1. Chronic tension headache: more than four hours per day, and 15 or more days per month. The chronic daily headaches usually evolve over a period of months or years.

  2. Transformed migraine: more than four hours per day, and 15 days per month. Previous history of migraine. There is usually a slow increase in tension type headache, with a concomitant decrease in migraine features. No organic causes; no hemicrania continua. Eighty percent of transformed migraine patients have been reported to overuse analgesics. The analgesic abuse may create the daily headaches in some of these patients.

  3. New daily persistent headache: sudden (over 1 to 3 days) onset of chronic daily headache. No significant previous migraine history, but they may have had episodic tension headaches in the past.

  4. Post-traumatic chronic daily headache: this is often present with migrainous features. Very difficult to effectively treat. Does not seem to be as responsive to the usual medications.

  5. Headache associated with cervical spine problems, particularly arthritis: this is usually posterior occipital and can be exceedingly difficult to effectively treat.


    Psychological correlates with headache are a complex situation. It is generally a mistake to "blame" the headaches on depression. However, anxiety and depression are increased in the migraine and tension headache population. Approximately 60% of headache patients have an anxiety disorder, usually mild, and 20% have either recurrent major depression or dysthymia. Bipolar illness, usually mild, is often underdiagnosed and unrecognized in this population. Most likely, four to six percent of headache patients do have bipolar illness. The high rate of psychological comorbidities does not mean that these necessarily cause the headaches. We need, and it is very important, to approach the headaches for what they are: a physiological, primarily medical, illness. Of course, we do not ignore the psychological comorbidities, and thus, biofeedback/relaxation techniques and psychotherapy are encouraged in headache patients. Patients often do become increasingly depressed because of uncontrolled headaches; depression does not usually fuel the headaches. Most headache patients are very frustrated by attempts to resolve their headaches through primarily psychological means; however, they will often pursue psychotherapy and relaxation if the headaches are being addressed concurrently.

    Stress does undoubtedly contribute to headache, as it is the major trigger (followed by hormones and weather changes). However, assessing which parts of stress contribute to headache becomes complicated. It appears as if daily hassles are more important than bad or negative stresses. When patients have too much going on in their lives, their daily hassles are increased. A day of severe "daily hassles" followed by a poor night of sleep often leads to a headache. Many patients do notice that migraines wait until after a major stress is over.


    While most patients primarily use medication, we need to minimize medication and achieve a balance between medication and the headaches. In an effort to limit the amount of medicine, we utilize other techniques. Relaxation or biofeedback is very helpful if people are willing to learn and practice it. Psychotherapy improves coping and is usually worthwhile even if it does not directly decrease the head pain. Physical therapy is helpful because the therapist can teach posture, exercises, and assess what the patient is doing occupationally, particularly in regard to neck muscle tension. Certain occupations, such as hairdressers, dental assistants, and receptionists (because of phone work) may lead to more neck muscle tension, which increases the posterior head pain as well. By learning stretching techniques and correct posture, and sometimes effecting changes at work, we can decrease the headache. Massage is helpful for some patients, but the results are often short lived. Chiropractic care does occasionally help, but overall has not been particularly successful with headaches. Acupuncture can be helpful, but again, is often temporary. Homeopathy has consistently not been able to do better than placebo in studies; there are several natural and herbal preparations that may help. We attempt to encourage at least 20 minutes of exercise per day, particularly walking, using a treadmill, or biking. Even ten minutes twice a day may be helpful. Ice is usually useful for most type of headaches, and for tension headache with neck pain, heat to the neck may be useful.