Constant Headache or Near-Constant Headaches

This is also known as Chronic Daily Headache.

Chronic Daily Headache is a situation of pain in your head most days i.e. more than 15 days per month).

There are two types of chronic daily headache.

1. Episodes of pain that usually last less than 4 hours each
2. Head pains lasting more than 4 hours (usually a constant pain)

1. Headache Episodes lasting less than 4 hours
• Ice-pick headaches
• These are brief, unprovoked stabbing pains that usually occur in or around the eye, but can happen anywhere in the head. More common in people with migraine
.
• SUNCT
• This is very rare, but causes Sudden, Unilateral (one-sided), Neuralgiform pain (very brief and sharp or shooting), and there is Conjunctival injection (a red eye) and Tears from the eye on the affected side. Requires specialist assessment including MRI scan. Lamotrigine helps some people.
• Hypnic Headache
This is usually a condition of the over 50s. You go to bed pain free.

About 3-4 hours into sleep you are woken by a diffuse severe headache that prevents sleep until the pain goes away.

Lithium carbonate relieves about 70% of cases.

• Primary Exertional Headache
• These headaches are provoked by exercise such as cycling, swimming or lifting.

  However, they can also be brought on by leaning, laughing or sex.

  Indomethacin can help.

  They always require investigation to rule out a structural problem in the brain - usually a Chiari Malformation.

  Heart Disease needs to be ruled out too - angina or heart attack pain is very rarely felt in the head only - Cardiac Cephalalgia.




• Primary Cough Headache
• Pain brought on exclusively by coughing.

  Might be due to "crowding" of structures at the base of the brain, but no-one really knows. Indomethacin can help.

  Need to work out if there is a reason for coughing as well

• Paroxysmal Hemicrania
• This is a cause of severe one-sided headache. It usually comes on fairly quickily (seconds) and lasts for about 5-30 minutes.

  It can return several times per day.

  Usually the person with this will want to lie down with the pain.

  This is different to cluster headache where the pain has a similar duration, but the patients will want to pace the floor due to their agitation.

  This headache is relieved by Indomethacin in the vast majority of cases.

• Chronic Cluster Headache
• This is the severe form of cluster headache which never goes into remission.

  It is daily bouts of cluster pain with eye watering, agitation and nasal symptoms.

  Difficult to treat, but will have had previous bouts of cluster headache before these headaches became permanent.

2. Headache Episodes lasting more than 4 hours (these are usually the constant headaches)
• Chronic Tension Type Headache
• Daily presure or tightness in the head, but no previous migraine and no current migrainous features.

  Very difficult to treat.

• Chronic Migraine (with or without medication overuse)
• Hemicrania Continua
• This rare headache is strictly one-sided.

  There is not the same eye watering or nasal symptoms are cluster headache, and there very little of the photophobia, sonophobia or nausea of migraine.

  This headache will respond very well to Indomethacin.

• New Daily Persistent Headache
• In New Daily Persistent Headache, the person can remember the exact onset of the headache, but within days the pain became established as a constant headache.

  This headache is brought on by viral illness, and can last for 18 or more months before eventually resolving.

  It is very difficult to treat, and the secondary conditions below need to be considered, before using this label.



Other causes of constant headaches

These usually require formal medical assessment or sometimes further investigation:

• Cervicogenic Headache
• Temporal Arteritis
• Raised Pressure within the skull ("intracranial hyper-tension")
• Idiopathic Intracranial Hypertension
• Cerebral Venous Sinus Thrombosis
• Dural Arteriovenous Fistula
• Mass lesion - brain tumour (only 2% of brain tumours will present with headache, and these are not normally chronic daily headache!)
• Low Intracranial Pressure
• Spontaneous Intracranial Hypotension
• Post-spinal anaesthetic headache
• Post-lumbar-puncture headache
• Isolated Sphenoid Sinusitis
• Carbon Monoxide Poisoning
• Medical Illnesses Associated with New Onset Headache
• Underactive Throid Gland
• Anaemia
• Other Endocrine Disorders
• High Blood Pressure
• Obesity

These other causes of constant headache need to be considered before going down the line of treating chronic migraine.

However almost everyone diagnosed as chronic migraine does turn out to have normal investigations, as the diagnosis of chronic migraine is normally very accurate.



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