attacks with conjunctival injection and

tearing (SUNCT).
When headache duration is greater
than 4 hours, the major primary disor-
ders for which there are operational
diagnostic criteria as defined by the
second edition of the International Clas-
Chronic Daily Headache sification of Headache Disorders (ICHD-
Stephen D. Silberstein, MD 2)2 are chronic migraine, hemicrania
continua, chronic tension-type headache
(CTTH), and new daily persistent
headache (NDPH).1 Chronic migraine is
used by the ICHD-2 in place of trans-
formed migraine (defined by the Silber-
stein and Lipton criteria). Chronic ten-
sion-type headache was included in the
first International Headache Society
(IHS) classification and inappropriately
equated to CDH.3 Chronic migraine,
Chronic daily headache represents a range of disorders characterized by the NDPH, and hemicrania continua are new
occurrence of long-duration headache 15 or more days per month. The classi- to the ICHD-2.2,4
fication of these disorders continues to undergo revision to make them more Long-duration CDH is a significant
clinically relevant, such as that which has been most controversial, the clas- public health concern. Approximately
sification of chronic migraine. The role of medication overuse in what has com- 3% to 5% of the population worldwide
monly been known as rebound headache can have a significant influence on have daily or near-daily headaches.5-9
these disorders. The diagnosis of the chronic daily headaches, including Patients with long-duration primary
chronic migraine and chronic tension-type headache, truly cannot be made if CDH, most of which is transformed
patients are having medication-overuse headache. This article reviews the migraine, account for the majority of
criteria for medication-overuse headache and the subset of headaches making headache subspecialty practice consul-
up chronic daily headache, as well as the epidemiologic and therapeutic tations in the United States.2,3,10 The dis-
aspects of these disorders. ability associated with this disorder is
substantial, as patients have a signifi-
cantly diminished quality of life and
gorized into primary and secondary mental health, as well as impaired phys-
T he term chronic daily headache (CDH)
refers to a group of disorders char-
acterized by very frequent headaches
varieties.1 Secondary CDH has an iden-
tifiable underlying cause such as acute
ical, social, and occupational func-
tioning.4,11,12
(
15 days a month), including those headache medication overuse, head
headaches associated with medication trauma, cervical spine disorders, vas- Transformed and Chronic Migraine
overuse. The CDH group can be cate- cular disorders, and disorders of Many studies have described the pro-
intracranial pressure. Primary CDH is cess and associated features of trans-
not related to a structural or systemic formed migraine.5,6,11-14 This headache
Dr Silberstein, a professor of neurology at Thomas illness, and is often subdivided into has been variously called transformed or
Jefferson University Hospital in Philadelphia, Pa, is long- or short-duration disorders, based evolutive migraine or mixed headache.
president of the American Headache Society.
Dr Silberstein is on the advisory panel or on whether the individual headache Patients with transformed migraine often
speakers bureau, or serves as a consultant for episodes last more or less than 4 hours have a past history of episodic migraine
Abbott Laboratories; Allergan, Inc; AstraZeneca; Eli on average. that began in their teens or twenties.14
Lilly and Company; GlaxoSmithKline; Johnson &
Johnson; Merck & Co, Inc; NPS Pharmaceuticals, When headache duration is less Most patients with this disorder are
Ortho-McNeil Pharmaceutical, Inc; Pfizer Inc; Pozen, than 4 hours, the differential diagnosis women, 90% of whom have a history of
Inc; UCB Pharma, Inc; and XCel Pharmaceuticals. He includes cluster headache, paroxysmal migraine without aura.
receives research support from Abbott Laborato-
ries; Allergan, Inc; AstraZeneca: Eli Lilly and Com- hemicrania, idiopathic stabbing Patients often report a process of
pany; GlaxoSmithKline; Johnson & Johnson; headache, hypnic headache, and short- transformation characterized by
Medtronics; Merck & Co, Inc; NPS Pharmaceuti- lasting unilateral neuralgiform headache headaches that become more frequent
cals; Pfizer Inc; Pozen, Inc; UCB Pharma, Inc; and
XCel Pharmaceuticals.
Address correspondence to Stephen D. Sil-
berstein, MD, FACP, Director, Jefferson Headache This continuing medical education publication supported by
Center, 111 S 11th St, Gibbon Bldg, Suite 8130,
Philadelphia, PA 19107-4824. an unrestricted educational grant from Merck & Co, Inc
E-mail Stephen.silberstein@jefferson.edu

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 over months to years, with the associ-
ated symptoms of photophobia, phono-
phobia, and nausea becoming less severe
and less frequent.5,6,11,13,15 Patients often
develop (or transform into) a pattern of
daily or nearly daily headaches that phe-
nomenologically resembles a mixture of
tension-type headache (TTH) and
migraine. That is, the pain is often mild
to moderate and is not always associ-
ated with photophobia, phonophobia,
or gastrointestinal features.
Other features of migraine,
including aggravation by menstruation
and other trigger factors, as well as uni-
laterality and gastrointestinal symptoms,
may persist. Attacks of full-blown
migraine superimposed on a background
of less severe headaches occur in many
patients. The term transformed migraine
Table 1
Silberstein and Lipton Revised Criteria for Chronic Migraine*
1.8 Chronic Migraine
A. Daily or almost daily (15 days/month) head pain for 1 month
B. Average headache duration of 4 hours/day (if untreated)
C. At least one of the following:
1) History of episodic migraine meeting any International Headache Society
(IHS) criteria 1.1 to 1.6
2) History of increasing headache frequency with decreasing severity of
migrainous features over at least 3 months
3) Headache at some time meets IHS criteria for migraine 1.1 to 1.6 other
than duration
D. Does not meet criteria for new daily persistent headache (4.7) or hemicrania
continua (4.8)
E. Not attributed to another disorder
* Modified from Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near-daily headaches:
field trial of revised IHS criteria. Neurology. 1996;47:871-875.

has been used to refer to this process.

The term chronic migraine is now being
used by the IHS, in part because a history
of transformation is often missing.
Silberstein and Lipton’s revised cri-
teria for transformed migraine (Table 1)
provide three alternative diagnostic links
to migraine14:

a prior history of IHS migraine;

a clear period of escalating headache
frequency with decreasing severity of
migrainous features; or

current superimposed attacks of
headaches that meet all the IHS criteria
for migraine except duration.
Migraine transformation most often
develops when there is medication
overuse, but transformation may occur
without overuse. 5,16 About 80% of
patients with CDH seen in subspecialty
clinics overuse symptomatic medica-
tion.5,6,13,15 Headache frequency often
increases when medication use increases.
Stopping the overused medication fre-
quently results in distinct headache
improvement, although it may take days
to weeks. Many patients have significant
long-term improvement after detoxifi-
cation. When the original IHS (ICHD-1)
criteria 3 were used, a diagnosis of
headache induced by substance use or
exposure required that the headaches
remit after the overused medication is
discontinued. This criterion was difficult
to apply reliably, and diagnosis was
impossible until the overused medica-
tion was discontinued.4 The IHS now
attempts to get around this issue by using
the term probable chronic migraine.
The IHS, in its newest classification
(ICHD-2),2 classifies chronic migraine as
a complication of migraine. Its diagnosis
requires migraine headache occurring
on 15 or more days a month for more
than 3 months without medication
overuse (Table 2) When medication
overuse is present, the diagnosis is
unclear until 2 months after medication
has been withdrawn without improve-
ment. Medication overuse, if present (ie,
medication-overuse headache [MOH]), is
the most likely cause of chronic symp-
toms. Therefore, the default rule is to
code such patients according to the
antecedent migraine subtype (usually
migraine without aura) plus probable
chronic migraine plus probable MOH.
When these criteria are still fulfilled 2
months after medication overuse has
ceased, chronic migraine plus the
antecedent migraine subtype should be
diagnosed and probable MOH dis-
carded. If at any time sooner these criteria
are no longer fulfilled because improve-
ment has occurred, code for MOH plus
the antecedent migraine subtype and dis-
card probable chronic migraine.2
The requirement that the daily
headache must meet criteria for migraine
without aura each day is a significant
problem with the ICHD-2 criteria and
one of the major reasons for its lack of
generalizability in clinical practice. While
up to 80% of headaches experienced by
episodic migraine sufferers will fulfill
criteria for migraine or probable migraine
(1.1 or 1.6), migraineurs do experience a
spectrum of headaches that may pheno-
typically resemble or fulfill criteria for
TTH.
As headache frequency increases,
the phenotypic spectrum of individual
headache episodes broadens, and the
clinical distinction between migraine and
TTH may become less obvious. Many
clinicians and epidemiologists now
believe that most headaches experienced
by migraine sufferers that phenotypi-
cally resemble TTH are biologically sim-
ilar to migraine and responsive to
migraine-specific modes of therapy.5 Fur-
thermore, attacks are often treated early,
before severity increases and associated
symptoms develop.
Based on the clinical trial and clinic-
based data reviewed, the criteria for
ICHD-2 chronic migraine do not accu-
rately reflect the headache phenotype of
those patients with a history of migraine
that evolves into a pattern of frequent or
daily headache (
15 days per month).
Alternate diagnostic criteria are being
developed for this entity. To eliminate
confusion with the current IHS-defined
chronic migraine, this entity will be called
transformed migraine. By definition, of
course, all patients meeting the IHS cri-

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 only one of the symptom criteria (mild
Table 2 nausea, photophobia, and phonophobia),
New International Headache Society Criteria for Chronic Migraine* but excludes moderate or severe nausea
or vomiting. The ICHD-2 has an
appendix that provides alternate criteria
Diagnostic criteria:
for CTTH. The alternate criteria do not
A. Headache fulfilling criteria C and D for 1.1 Migraine without aura on
15 days/month
for 3 months
allow for nausea, photophobia, or phono-
B. Not attributed to another disorder
phobia.) The ICHD-2 still does not
require a minimum duration of
headache; therefore, a headache that lasts
* Headache Classification Committee of the International Headache Society. The International
Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160. 5 minutes a day for 15 days a month
could still be CTTH. Chronic tension-
type headache is still subclassified based
on the occurrence or absence of pericra-
nial tenderness
Table 3 Coexistent migraine and CTTH
New International Headache Society Criteria for Chronic Tension-Type Headache* could coexist with the proviso that the
nonmigrainous headaches have no
2.2 Diagnostic criteria: migrainous features. Guitera et al18 sug-
A. Headache occurring on
15 days per month on average for 3 months gest, based on population-based epi-
(
180 days per year) and fulfilling criteria B–D demiologic data, that CTTH and
B. Headache lasts hours or may be continuous migraine can coexist if, and only if, the
C. Headache has at least two of the following characteristics: current headache has no migrainous fea-
1. bilateral location tures and there is a remote history of
2. pressing/tightening (nonpulsating) quality migraine.
3. mild or moderate intensity Chronic tension-type headache may
4. not aggravated by routine physical activity such as walking or
climbing stairs
evolve from ETTH. Just as with chronic
migraine, when medication overuse is
D. Both of the following:
present, the diagnosis is uncertain until 2
1. no more than one of photophobia, phonophobia, or mild nausea
2. neither moderate or severe nausea nor vomiting months after the overused medication
E. Not attributed to another disorder has been withdrawn without improve-
ment. The introduction of chronic migraine
into the ICHD-2 creates a problem in
* Headache Classification Committee of the International Headache Society. The International relation to the differential diagnosis
Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160.
between chronic migraine and CTTH.
Both diagnoses require headache
(meeting the criteria for migraine or TTH,
teria of chronic migraine will also meet In contrast to patients with chronic respectively) on at least 15 days a month.
the modified Silberstein and migraine, prior or coexistent episodic Therefore, it is theoretically possible for
Lipton/American Headache Society cri- migraine is absent in patients with CTTH, a patient to have both these diagnoses.
teria for transformed migraine. as are most features of migraine. Diag- Silberstein and Lipton14 developed
nosis of CCTH requires head pain on at criteria in which the diagnosis of one dis-
Chronic Tension-Type Headache least 15 days a month for at least 3 order took precedence over the diagnosis
The IHS describes CTTH17 (Table 3) as: months (previously 6 months). Although of another. They suggest that a putative
the pain criteria are identical to those for diagnosis of CTTH has not met criteria
A disorder evolving from episodic ten- episodic tension-type headache (ETTH), for hemicrania continua, NDPH, or
sion-type headache, with daily or very the IHS classification allows nausea but chronic migraine. This diagnosis would
frequent episodes of headache lasting not vomiting.17 This inclusion of nausea handle the difficulty of a small group of
minutes to days. The pain is typically assumes that mild nausea or photo- patients who fulfill the IHS diagnostic
bilateral, pressing or tightening in
phobia or phonophobia are compatible criteria for both chronic migraine and
quality and of mild to moderate inten-
sity, and does not worsen with rou-
with the diagnosis of CTTH.5,17 How- CTTH. This solution would be possible
tine physical activity. There may be ever, the need to include any of these when two (and only two) of the four pain
mild nausea, photophobia or phono- migrainous features in the IHS defini- characteristics are present and headaches
phobia. tion of CTTH may be a result of the prac- are associated with mild nausea. These
tice of including chronic migraine under cases are most likely chronic migraine
The headaches frequently involve the rubric of CTTH. and have been shown to be associated
the posterior aspect of the head and neck. The ICHD-2 continues to permit with elevated calcitonin gene-related pep-

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 tide (CGRP) levels (a marker for
migraine). The headaches should be
coded as CTTH and episodic migraine
only if the daily baseline headache has no
migrainous features. If the daily baseline
headache is migrainous, the headaches
should be coded as chronic migraine,
despite what the new criteria state.
Chronic tension-type headache is
often associated with medication overuse.
Similar diagnostic classification rules per-
tain here as they do for chronic migraine.
New Daily Persistent Headache
New daily persistent headache (Table 4)
is characterized by the relatively abrupt
onset of an unremitting primary
CDH.19,20 The IHS now includes NDPH
in the classification. (Previously used
terms included de novo chronic headache
and chronic headache with acute onset). The
Table 4
New International Headache Society Criteria for New Daily Persistent Headache*
Diagnostic criteria:
A. Headache that, within 3 days of onset, fulfills criteria B–D
B. Headache is present daily, and is unremitting, for 3 months
C. At least two of the following pain characteristics:
1. bilateral location
2. pressing/tightening (nonpulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking
or climbing
D. Both of the following:
1. no more than one of photophobia, phonophobia, or mild nausea
2. neither moderate or severe nausea nor vomiting
E. Not attributed to another disorder
* Headache Classification Committee of the International Headache Society. The International
Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160.

daily headache develops abruptly, over

less than 3 days. The IHS states that the
pain is typically bilateral, pressing or
tightening in quality, and mild to mod-
erate in intensity. Photophobia, phono-
phobia, or mild nausea may be present.
Silberstein and Lipton14 elected not to
classify NDPH as a type of de novo
CTTH, for it is not clear whether this con-
dition is etiologically related to TTH. The
absence or presence of a past history of
headache distinguishes NDPH from
CTTH and chronic migraine. New daily
persistent headache is likely to be a het-
erogeneous disorder. Some cases may
reflect a postviral syndrome.19 Patients
with NDPH are generally younger than
those with transformed migraine.19,20
New daily persistent headache
requires the absence of a history of evo-
lution from migraine or ETTH. In the
absence of rapid development, it is coded
as CTTH or chronic migraine. Excluding
all patients with a history of ETTH is
problematic, as almost 70% of men and
90% of women have had a TTH in the
past. Silberstein and Lipton14 allowed a
diagnosis of NDPH in patients with
migraine or ETTH if these disorders do
not increase in frequency to give rise to
NDPH. New daily persistent headache
may or may not be associated with med-
ication overuse. A diagnosis of NDPH
takes precedence over chronic migraine
and CTTH.
The ICHD-22 recognizes NDPH as
distinct from CTTH. New daily persistent
headache is unique in that headache is
daily and unremitting almost from the
moment of onset, typically in individ-
uals without a prior headache history.
New daily persistent headache can
have features suggestive of either
migraine or TTH. I believe that the pro-
posed IHS criteria inappropriately
exclude headaches that are phenomeno-
logically migraine with sudden onset.
Secondary headaches, such as low cere-
brospinal fluid (CSF) volume headache,
raised-CSF pressure headache, post-
traumatic headache, and headache
attributed to infection (particularly viral
infection) should be ruled out by appro-
priate investigations.1
If medication overuse exists or has
been present within the previous
2 months, the rule is to code for any pre-
existing primary headache plus probable
MOH, but not for NDPH. New daily
persistent headache may take either of
two subforms: a self-limiting subform
that resolves within several months
without therapy or a refractory subform
that is resistant to aggressive treatment.
Hemicrania Continua
Hemicrania continua is a rare,
indomethacin-responsive headache dis-
order characterized by a continuous,
moderately severe, unilateral headache
that varies in intensity, waxing and
waning without disappearing com-
pletely.21,22 It may rarely alternate sides.23
Hemicrania continua is frequently asso-
ciated with jabs and jolts (idiopathic stab-
bing headache). Exacerbations of pain
are often associated with autonomic dis-
turbances, such as ptosis, miosis, tearing,
and sweating.
Hemicrania continua is not triggered
by neck movements, but tender spots in
the neck may be present (Table 5). Some
patients may have photophobia, phono-
phobia, and nausea. The IHS now
includes hemicrania continua in the clas-
sification. It is described as a “persistent
strictly unilateral headache responsive
to indomethacin.”3
Although the disorder almost invari-
ably has a prompt and enduring
response to indomethacin, the require-
ment of a therapeutic response as a diag-
nostic criterion is problematic. It effec-
tively excludes the diagnosis of
hemicrania continua in patients who
were never treated with indomethacin
(perhaps because another agent helped),
and patients who failed to respond to
indomethacin. Treatment response is
generally not part of IHS case definitions
of headache disorders. Cases have been
described that did not respond to
indomethacin but meet the phenotype;
for this reason, Goadsby and Lipton24

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 after cessation, the diagnosis of prob-
Table 5 able MOH should be applied. If
New International Headache Society Criteria for Hemicrania Continua* improvement does not then occur
within the 2-month period, this diag-
4.7 Hemicrania continua nosis must be discarded.
Diagnostic criteria: The most common cause of
A. Headache for 3 months fulfilling criteria B–D migraine-like headaches or mixed-
B. All of the following characteristics: migraine–like and TTH-like headaches
1. unilateral pain without side-shift that occur on 15 or more days per month
2. daily and continuous, without pain-free periods is overuse of acute headache drugs.
3. moderate intensity, but with exacerbations of severe pain Overuse is now defined in terms of treat-
C. At least one of the following autonomic features occurs during exacerbations and ment days per month. What is crucial is
ipsilateral to the side of pain: that treatment occurs both frequently
1. conjunctival injection and/or lacrimation and regularly (ie, several days each
2. nasal congestion and/or rhinorrhea week). For example, the diagnostic cri-
3. ptosis and/or miosis terion of use on 10 days or more per
D. Complete response to therapeutic doses of indomethacin month translates into 2 to 3 treatment
E. Not attributed to another disorder days every week. Bunching treatment
days and going for long periods without
* Headache Classification Committee of the International Headache Society. The International medication intake, as practiced by some
Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160. patients, is much less likely to cause med-
ication-overuse headache.
The amount of use that constitutes
have provided an alternate means of headache attributed to the substance. overuse depends on the drug. Ergo-
diagnosis. A case that responded to This is also true if the headache has the tamine-overuse headache requires intake
piroxicam--cyclodextrin further sug- characteristics of migraine, TTH, or on 10 or more days per month on a reg-
gests that though the nonsteroidal anti- cluster headache. When a preexisting pri- ular basis for 3 or more months. (Bioavail-
inflammatory drug response is of great mary headache is made worse in close ability of ergots is so variable that a min-
interest, it points to, rather than expresses, temporal relation to substance exposure, imum dose cannot be defined.) The
the pathophysiology. two possibilities exist: Patients can either headache is often daily and constant.
Although there are no reports of sec- be given only the diagnosis of the pre- Triptan-overuse headache is usually fre-
ondary hemicrania continua, it can be existing primary headache, or they can be quent, intermittent, and migrainous.
aggravated by a C7 root irritation due given both this diagnosis and the diag- Triptan intake (any formulation) on 10
to a disc herniation.25 A case of a mes- nosis of headache attributed to the sub- or more days per month may increase
enchymal tumor in the sphenoid bone stance. Factors that support adding the migraine frequency to that of chronic
in which the response to indomethacin latter diagnosis are: migraine. Evidence suggests that this
faded after 2 months has also been
a very close temporal relation to the occurs sooner with triptan-overuse than
reported.26 These cases suggest that substance exposure; with ergotamine-overuse.29,30
physicians should be suspicious of esca-
a marked worsening of the preex- Analgesic-overuse headache
lating doses or loss of indomethacin’s isting headache; requires the intake of simple analgesics
efficacy and reevaluate the patient. Hem-
very good evidence that the substance on 15 or days per month for more than
icrania continua is also seen in non-Cau- can aggravate the primary headache; 3 months.29,31-34 This criterion is based on
casian populations.27 and, finally, expert opinion rather than formal evi-

improvement or resolution of the dence. Opioid-overuse headache requires
Drug Overuse and Rebound headache after the substance’s effects are opioid use on 10 or more days per
Headache terminated. month. Prospective studies indicate that
Medication overuse headache, previously A diagnosis of headache attributed patients who overuse opioids have the
called rebound headache, drug-induced to a substance usually becomes definite highest relapse rate after withdrawal
headache, and medication-misuse headache only when the headache resolves or treatment.
(Table 6), is an interaction between a ther- greatly improves after exposure to the Combination-medication–overuse
apeutic agent used excessively and a sus- substance is terminated. In the case of headache requires the intake of combi-
ceptible patient. Patients with frequent MOH, an arbitrary period of 2 months nation medications1 on 10 or more days
headaches often overuse analgesics, opi- after overuse cessation is stipulated by per month for more than 3 months.31
oids, ergotamine, and triptans.28-31 When the IHS; if the diagnosis is to be defi- Combination medications typically impli-
a new headache occurs for the first time nite, improvement must occur in that cated are those that contain simple anal-
in close temporal relation to substance time frame. Prior to cessation, or gesics combined with one or more of the
exposure, it is coded as a secondary pending improvement within 2 months following: opioids, butalbital, or caffeine.

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Table 6
New International Headache Society Criteria for Medication Overuse*
8.2.6 Headache attributed to medication overuse
Diagnostic criteria:
A. Headache present on 15 days/month fulfilling criteria C and D
Characteristics depend on drug
B. Regular overuse for  3 months of a medication
Amount depends on drug
Ergotamine, triptans, opioids, and combination analgesics
10 days/month
Simple analgesics
15 days/month
C. Headache has developed or markedly worsened during medication overuse
D. Headache resolves or reverts to its previous pattern within 2 months after
discontinuation of overused medication
* Headache Classification Committee of the International Headache Society. The International
Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9-160.
Epidemiology
In population-based surveys using the
Silberstein and Lipton criteria, primary
CDH occurred in 4.1% of Americans,8
4.35% of Greeks, 3.9% of elderly Chi-
nese,10 and 4.7% of Spaniards.9 Scher et
al8 ascertained the prevalence of primary
CDH in 13,343 individuals aged 18 to 65
years in Baltimore County, Maryland.
The overall prevalence of primary CDH
was 4.1% (5.0% women, 2.8% men; 1.8:1
ratio of women to men). In both men
and women, prevalence was highest in
the lowest educational category. More
than half (52% women, 56% men) met
criteria for CTTH (2.2%), almost one third
(33% women, 25% men) met criteria for
transformed migraine (1.3%), and the
remainder (15% women, 19% men) were
unclassified (0.6%). Overall, 30% of
women and 25% of men who were fre-
quent headache sufferers met IHS cri-
teria for migraine (with or without aura).
On the basis of chance, migraine and
CTTH would co-occur in 0.22% of the
population; the fact that transformed
migraine occurred in 1.3% of this popu-
lation would suggest that the co-occur-
rence of migraine and CTTH is more
than random.
Prognosis
The “natural history” of primary CDH,
and MOH in particular, has never been
studied and probably never will be for
ethical and technical reasons. Recogni-
tion of medication overuse is probably
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therapeutic in and of itself and could
affect the patient’s behavior or the physi-
cian’s approach. Retrospective analysis
suggests that there may be periods of
stable drug consumption and periods of
accelerated medication use. Patients
treated aggressively generally improve.
The medical literature contains
reports of spontaneous improvement of
CDH headache in population-based
studies.35 Silberstein and Silberstein36 con-
ducted follow-up evaluations on 50 hos-
pitalized patients with primary CDH and
medication overuse who were treated
with repetitive intravenous administra-
tion of dihydroergotamine mesylate and
became headache-free.
Once detoxified, treated, and dis-
charged, most patients did not resume
daily analgesic or ergotamine use. Sev-
enty-two percent continued to show sig-
nificant improvement at 3 months, and
87% continued to show significant
improvement after 2 years. This rate
would suggest at least a 70% improve-
ment at 2 years in the initial group (35 of
50), allowing for patients lost to follow-up.
Comment
Chronic daily headache is common. Most
patients have transformed migraine often
associated with medication overuse.
Therefore, physicians should be alert to
the possibility of medication overuse by
their patients and the role it plays as an
underlying cause of headache disorders.
References
1. Silberstein SD, Lipton RB. Chronic daily headache
including transformed migraine, chronic tension-
type headache, and medication overuse. In: Sil-
berstein SD, Lipton RB, Dalessio DJ, eds. Wolff’s
Headache and Other Head Pain. New York, NY:
Oxford University Press. 2001:247-282.
2. Headache Classification Committee of the Inter-
national Headache Society. The International Clas-
sification of Headache Disorders: 2nd edition.
Cephalalgia. 2004;24(Suppl 1):9-160.
3. Headache Classification Committee of the Inter-
national Headache Society. Classification and diag-
nostic criteria for headache disorders, cranial neu-
ralgia, and facial pain. Cephalalgia. 1988;8(Suppl
7):1-96.
4. Silberstein SD, Lipton RB, Solomon S, Mathew NT.
Classification of daily and near daily headaches:
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