Chronic Daily Headaches

Overview

Chronic daily headaches are a group of headache disorders that occur on at least 15 days of every month, for at least three months. They’re divided into two main categories based on the length of each headache episode:

• Long-duration chronic daily headaches: These headaches last more than 4 hours.
• Short-duration chronic daily headaches: These headaches last less than 4 hours.

Long-duration chronic daily headaches include:

• Chronic migraine: As one of the most common types of chronic daily headache, this involves a throbbing or intense, piercing pain in the head that may also be accompanied by nausea or a sensitivity to light or noise. 
• Chronic tension-type headache: The second most common type of chronic daily headache is a dull, pressing, or tightening headache, much like a rubber band squeezing around the head, with mild to moderate intensity.
• New daily persistent headache (NDPH): This type of headache starts suddenly, then doesn’t go away, becoming daily or near-daily for more than three months. 
• Hemicrania continua: This is a rare, long-lasting headache on one side of the head only, without ever switching to the other side. 

Short-duration chronic daily headaches include:

• Cluster headache: Cluster headaches cause sudden, severe pain on one side of the head, typically behind or around the eye, and last anywhere from 30 minutes to three hours.
• Paroxysmal hemicrania: This is a rare headache disorder characterized by short, frequent attacks of sharp, severe, one-sided pain. Each episode can last anywhere between 2 and 30 minutes and can occur multiple times a day. 
• Short-lasting unilateral neuralgiform headache attacks (SUNHA): These are brief, repetitive attacks of severe, piercing pain, usually around one eye or temple, that last just seconds to minutes, dozens of times a day. A red, watery eye, eyelid swelling, or eyelid drooping often accompanies this type of chronic daily headache. 

What causes chronic daily headaches?

While the causes of chronic daily headaches are not fully understood, what is known is that there’s often a combination of factors that create the ideal conditions for these persistent headaches. Those include:

• Episodic headache disorder progression: This is one of the most frequent ways chronic daily headaches develop: Migraines or tension headaches gradually increase in frequency until they exceed the 15-day threshold each month, due to the nervous system’s pain pathways becoming more reactive over time.
• Medication overuse: Using pain relievers too frequently to treat recurring headaches can actually cause more headaches, a well-documented phenomenon called medication overuse headache. This creates a frustrating cycle in which the treatment perpetuates the problem.
• Underlying triggers or conditions: Poor sleep, high stress, hormonal changes, depression or anxiety, jaw clenching or neck tension, and even head or neck injuries can all contribute to a headache pattern becoming chronic.
• Genetics and individual physiology: Much like how migraines tend to run in families, some people have a nervous system more prone to frequent head pain.

Sometimes, there’s no clear cause for chronic daily headaches. Some emerge suddenly with no identifiable trigger, like new daily persistent headaches (NDPH), which can be one of the more frustrating aspects of the condition.

• In chronic tension headaches, the primary symptom includes a dull, aching pain on both sides of the head that feels pressing or tightening, but not pulsating. Many patients describe chronic tension headaches as like wearing a hat that’s too tight, and the pain tends to be milder but more constant, like background static rather than a sharp spike.
• In new daily persistent headache (NDPH), the leading symptom is a mild-to-moderate headache that begins suddenly, with no clear trigger, affects both sides of the head, and becomes constant within three days of the first headache. These headaches often occur in people without a history of headaches. 
• In hemicrania continua, the main symptom is a continuous and moderate one-sided headache that doesn’t switch sides, along with symptoms on the same side as the pain, like tearing or redness of the eye, a droopy eyelid, nasal congestion or runny nose, and/or a drooping eyelid or narrowing of the pupil. In fact, the name hemicrania continua means “half the head, continuous.”
• In cluster headaches, the leading symptom is often described as one of the most severe pain conditions a person can experience because of its intensity. Cluster headaches cause excruciating, one-sided pain centered around or behind one eye, paired with same-side symptoms such as a red or teary eye, a drooping eyelid, or a stuffy or runny nostril. True to the name, cluster headache attacks often occur in clusters over weeks or months, followed by stretches of headache-free periods.
• In paroxysmal hemicrania, symptoms are similar to cluster headaches, but the attacks are shorter and occur more frequently throughout the day. 
• In short-lasting unilateral neuralgiform headaches attacks (SUNHA), a rarer type of chronic daily headaches, the leading symptom includes extremely brief, stabbing, one-sided pain—often just seconds to a couple of minutes per attack—that happens dozens or even close to 100 times a day, along with eye redness and tearing on the affected side. The extremely short duration and high frequency of SUNHA set it apart from other short-duration types.

Chronic Daily Headaches Diagnosis

An accurate diagnosis of chronic daily headaches largely rests on your provider’s understanding of your symptoms, since there’s no single, immediate test that can diagnose the condition. That said, following a certain diagnostic process is still important for ruling out anything that’s potentially more serious. 

The following exams, tests, and imaging may be used in chronic headache diagnosis:

• Physical and neurological exam: First, your provider will ask detailed questions about your symptoms, when they began, how long each one lasts, what the pain feels like, and any other symptoms that accompany it, like nausea or a red, watery eye. Next, they’ll assess your neurological function, including reflexes, coordination, strength, and sensation, to determine whether muscle tension, sinus problems, or another underlying issue may be at play, as well as to look for any abnormalities in nervous system function.
• Headache diary: You may be asked to track your headache frequency, duration, severity, triggers, and associated symptoms over two or more weeks to capture patterns. A headache diary also helps confirm whether your headache meets the 15-day-per-month threshold that defines the diagnosis.
• Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan: These imaging studies are crucial for visualizing the brain and identifying abnormalities if there are concerning findings during your assessment. However, imaging the brain will not aid in the diagnosis of chronic daily headaches or change how you manage the condition. Most people with chronic daily headaches do not need an MRI or CT of the brain.
• Indomethacin trial: For certain suspected types of chronic daily headaches, doctors will use a treatment response as a diagnostic clue. If hemicrania continua or paroxysmal hemicrania is suspected, the anti-inflammatory medication indomethacin is prescribed. Both types of chronic daily headache respond to this medication with a dramatic, near-resolution of the headache, which helps confirm the diagnosis.
• Blood tests: While blood tests aren’t typically used to diagnose chronic daily headaches, they can help rule out other conditions that may cause similar symptoms.
• Screening for medication overuse: Your provider will ask about the frequency and type of pain reliever you use—both over-the-counter and prescription—since a common contributor to chronic daily headache patterns is medication overuse. This targeted question can dramatically change your treatment plan if overuse is identified as a contributing factor.

The most conservative treatments for chronic daily headaches include:

• Sleep regulation, stress management, hydration, and trigger avoidance: These four pillars—prioritizing adequate rest, effectively managing stress, staying hydrated throughout the day, and avoiding known headache triggers—are essential for many headache types.
• Regular exercise: Regular exercise also supports headache prevention through stress reduction and improved sleep quality, provided it is appropriate for your age and fitness level. Overexertion can make headaches worse.
• Biofeedback and cognitive-behavioral therapy (CBT): These therapies can teach you to recognize and control your bodily stress responses to headache triggers. In fact, more than 50% of patients benefit from behavioral approaches as part of their treatment plan. 
• Addressing medication overuse: A common contributor to chronic daily headaches, tapering off an overused medication can also aid in treatment.
• Abortive medications: The job of abortive medications is to stop a headache once it starts, rather than preventing it. These medications can be prescribed as pills, self-injections, nasal sprays, or even skin patches for fast relief. However, abortive medications can also cause medication-overuse headaches when taken too frequently. 
• Oral preventive medications: Many daily oral medications can be prescribed for headache prevention, like beta-blockers, antidepressants, and antiseizure medications.

Targeted Treatments

If your chronic daily headache symptoms don’t improve with conservative treatments alone, one or more of the following targeted treatments may be used: 

• Botulinum toxin (also called onabotulinumtoxinA and commonly referred to as Botox) injections: As one of the most established treatments for chronic migraine, a series of botulinum toxin injections every three months targets nerves in the head and neck to modulate pain signals. Patients often begin noticing results within 4–6 weeks, and while it doesn’t cure the underlying condition, it can substantially improve quality of life when paired with other treatments. Botox injections are FDA-approved for migraine in adults 18 and older who experience 15 or more migraine days per month.
• Nerve blocks: Injections of local anesthetic around specific nerves, such as occipital nerve blocks, typically provide 2–12 weeks of relief, particularly for occipital neuralgia and cervicogenic headache. These nerve blocks are often used for headache types with a strong occipital nerve component, or as an interim chronic daily headache therapy while longer-term preventives take effect. 
• Indomethacin: This medication belongs to the NSAID family, along with aspirin, ibuprofen, and naproxen. But beyond its anti-inflammatory action, indomethacin reduces blood flow to the brain, calms certain nitric oxide pathways, and reduces oxidative stress, which are believed to be especially relevant in hemicrania continua and paroxysmal hemicrania. As a result, both of these chronic daily headaches respond dramatically to this medication.
• Calcitonin gene-related peptide (CGRP) antibodies and targeted drugs: CGRP is a protein that helps control your blood pressure by expanding blood vessels. However, if you’re prone to migraine, your body creates an excess of CGRP, which activates nerves that can make these pain signals worse. CGRP antibodies and targeted medications work by blocking this process during migraine. As a newer class of medication, these are often used when standard oral preventives haven’t worked well and are given as either monthly or quarterly injections or as oral pills.
• Non-Invasive neuromodulation devices: As a newer treatment category, these devices stimulate specific nerves without requiring surgery or injections. They include:
• Non-invasive vagus nerve stimulation (nVNS): Vagus nerve stimulation is a minimally invasive procedure involving implantation of a pacemaker-like device that delivers small pulses of electrical energy to the vagus nerve, a major nerve that runs from the brain through the neck and into the body. It’s an especially promising add-on treatment for chronic cluster headache.
• External trigeminal nerve stimulation: This is a non-invasive treatment that uses a small device worn on the forehead, held in place with an adhesive electrode, to deliver gentle electrical pulses to the trigeminal nerve—a major nerve involved in headache pain—to help calm overactive pain-signaling pathways. External trigeminal nerve stimulation is typically used at home, for a set amount of time each day as preventive care or during an active headache attack. 
• Transcranial magnetic and electric stimulation (TMS): Transcranial magnetic and electric stimulation are non-invasive treatments that use magnetic pulses or a mild electrical current placed on or near the scalp to gently stimulate specific areas of the brain thought to be involved in headache pathways. Both are typically used as preventive treatments, often as an add-on to medication or other therapies.

As a whole, combination treatments for chronic daily headaches tend to outperform any single treatment—pairing a preventive medication with behavioral therapy and lifestyle changes yields better results than any single approach alone.

Often, individualized care from a headache specialist provides the most accurate and useful picture of a patient’s situation and the appropriate treatment. This is why our experts at the Lewis Headache Center are highly skilled in diagnosing and treating headache disorders, including headache neurologists, a headache-certified physician assistant, and a headache fellow. As part of Barrow Neurological Institute, our experts work closely with neurosurgeons and neurologists in other subspecialties to treat complex conditions that cause headaches and pain.

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