Chronic Headache and Migraine

Chronic migraine and chronic tension-type headache are distinct primary headache disorders. Chronic migraine is diagnosed when headache occurs on 15 or more days per month for more than three months, with migraine features on at least eight days per month. Chronic tension-type headache also occurs on at least 15 days per month for more than three months, but has a different symptom profile. Medication-overuse headache should also be considered when frequent acute headache medicines are being used.

Chronic migraine commonly causes moderate to severe headache with migraine features such as nausea and sensitivity to light or sound, although the phenotype can vary from day to day. Chronic tension-type headache is typically bilateral, pressing or tightening and mild to moderate in intensity, without prominent nausea. Assessment should also consider red flags for secondary headache, medication overuse, sleep problems, neck pain and other comorbidities.

Management depends on the specific headache diagnosis and may include education, trigger and medication review, preventive medicines and appropriate acute treatments. For chronic migraine, onabotulinumtoxinA and newer migraine-specific preventive therapies can be effective for selected patients. Occipital nerve blocks and other procedures may be useful in selected cases, but should complement rather than replace evidence-based headache management. Medication-overuse headache requires specific assessment and a plan to reduce medication overuse.