Chronic daily headaches

Diagnosis

Your doctor will likely examine you for signs of illness, infection or neurological problems and ask about your headache history.

If the cause of your headaches remains uncertain, your doctor might order imaging tests, such as a CT scan or MRI, to look for an underlying medical condition.

Treatment

Treatment for an underlying condition often stops frequent headaches. If no such condition is found, treatment focuses on preventing pain.

Prevention strategies vary, depending on the type of headache you have and whether medication overuse is contributing to your headaches. If you're taking pain relievers more than three days a week, the first step might be to wean yourself off these drugs with your doctor's guidance.

When you're ready to begin preventive therapy, your doctor may recommend:

• Antidepressants. Tricyclic antidepressants — such as nortriptyline (Pamelor) — can be used to treat chronic headaches. These medications can also help treat the depression, anxiety and sleep disturbances that often accompany chronic daily headaches.

  Other antidepressants, such as the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac, Sarafem, others), might help in treating depression and anxiety, but have not been shown to be more effective than placebo for headaches.

• Beta blockers. These drugs, commonly used to treat high blood pressure, are also a mainstay for preventing episodic migraines. These include atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL) and propranolol (Inderal, Innopran XL).
• Anti-seizure medications. Some anti-seizure drugs seem to prevent migraines and might be used to prevent chronic daily headaches, as well. Options include topiramate (Topamax, Qudexy XR, others), divalproex sodium (Depakote) and gabapentin (Neurontin, Gralise).
• NSAIDs. Prescription nonsteroidal anti-inflammatory drugs — such as naproxen sodium (Anaprox, Naprelan) — might be helpful, especially if you're withdrawing from other pain relievers. They can also be used periodically when the headache is more severe.
• Botulinum toxin. OnabotulinumtoxinA (Botox) injections provide relief for some people and might be a viable option for people who don't tolerate daily medication well. Botox would most likely be considered if the headaches have features of chronic migraines.

The use of one drug is preferred, but if one drug doesn't work well enough, your doctor might consider combining drugs.

Alternative medicine

For many people, complementary or alternative therapies offer relief from headache pain. It's important to be cautious, however. Not all complementary or alternative therapies have been studied as headache treatments, and others need further research.

• Acupuncture. This ancient technique uses hair-thin needles inserted into several areas of your skin at defined points. While the results are mixed, some studies have shown that acupuncture helps reduce the frequency and intensity of chronic headaches.
• Biofeedback. You might be able to control headaches by becoming more aware of and then changing certain bodily responses, such as muscle tension, heart rate and skin temperature.
• Massage. Massage can reduce stress, relieve pain and promote relaxation. Although its value as a headache treatment hasn't been determined, massage might be particularly helpful if you have tight muscles in the back of your head, neck and shoulders.

• Herbs, vitamins and minerals. Some evidence exists that the herbs feverfew and butterbur help prevent migraines or reduce their severity. A high dose of vitamin B-2 (riboflavin) also might reduce migraines.

  Coenzyme Q10 supplements might be helpful in some individuals. And oral magnesium sulfate supplements might reduce the frequency of headaches in some people, although studies don't all agree.

  Ask your doctor if these treatments are right for you. Don't use riboflavin, feverfew or butterbur if you're pregnant.

• Electrical stimulation of the occipital nerve. A small battery-powered electrode is surgically implanted near the occipital nerve at the base of your neck. The electrode sends continuous energy pulses to the nerve to ease pain. This approach is considered investigational.

Before trying complementary or alternative therapy, discuss the risks and benefits with your doctor.

Coping and support

Chronic daily headaches can interfere with your job, your relationships and your quality of life. Here are suggestions to help you cope with the challenges.

• Take control. Commit yourself to living a full, satisfying life. Work with your doctor to develop a treatment plan that works for you. Take good care of yourself. Do things that lift your spirits.
• Seek understanding. Don't expect friends and loved ones to instinctively know what's best for you. Ask for what you need, whether it's time alone or less attention paid to your headaches.
• Check out support groups. You might find it useful to talk to other people who have painful headaches.
• Consider counseling. A counselor or therapist offers support and can help you manage stress. Your therapist can also help you understand the psychological effects of your headache pain. In addition, there's evidence that cognitive behavioral therapy can reduce headache frequency and severity.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, you may be referred to a headache specialist.

Here's some information to help you get ready for your appointment.

What you can do

Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

• Keep a headache journal, including when each headache occurred, how long it lasted, how intense it was, what you were doing immediately before the headache started, and anything else notable about the headache.
• Write down your symptoms and when they began.
• Write down key personal information, including major stresses or recent life changes and family history of headaches.
• List all medications, vitamins or supplements you're taking, including doses and frequency of use. Include medications used previously.
• Write down questions to ask your doctor.

Take a family member or friend along, if possible, to help you remember information.

For chronic headaches, some questions to ask your doctor include:

• What's the likely cause of my headaches?
• What are other possible causes?
• What tests do I need?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• I have other health conditions. How can I best manage them together?
• Should I see a specialist?
• Are there printed materials I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, such as:

• Have your headaches been continuous or occasional?
• How severe are your headaches?
• What, if anything, seems to improve your headaches?
• What, if anything, appears to worsen your headaches?

What you can do in the meantime

To ease your headache pain until you see your doctor, you might:

• Avoid activities that worsen your headaches.
• Try over-the-counter pain relief medications — such as naproxen sodium (Aleve) and ibuprofen (Advil, Motrin IB, others). To avoid rebound headaches, don't take these more than three times a week.