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Chronic Daily Headache
Chronic Daily Headache in Depression and Sleep Apnea – Chronic Migraine – Tension Headache
Chronic Daily Headache
Chronic daily headache is a daily headache for a few months. This headache may be intermittent throughout the day or it may be constant and unremitting. Chronic daily headache may persist during the night or it may hide in the dark and wait for the sunrise. Patients often report headache upon awakening, or having difficulty sleeping due to the headache.
Please note that daily types of primary headaches, like hemicrania continua or hypnic headache, as well as some chronic type of secondary headaches, like pseudotumor cerebri, have nothing to do with this phenomenon.
Daily headache has no specific features. It can be in any location, of any quality, and of any reported intensity, except severe. There are no specific associated symptoms but…
This pain never comes alone. This daily headache is universally associated with a bunch of other unpleasant sensations. Complaints about dizziness, difficulty concentrating, fatigue, sensation of lack of balance, sometimes anxiety and/or depression are almost universal in chronic daily headache.
One more important association. This is about sleep. Chronic daily headaches are almost inevitably associated with chronic sleep deprivation for whatever reason. This association is so strong that I almost feel lost when someone tells me about daily headache and no sleep quality issues at all! It is always a sign of “something else is cooking”.
Any possible neurological work up has to be negative in chronic daily headache. Sleep study is the only exception.
Chronic Daily Headache due to Sleep Apnea
Sleep apnea is characterized by frequent pauses in breathing while being asleep. Lack of oxygen and excess of carbon dioxide cause either frequent awakenings the night or a shallow and inefficient sleep.
People with sleep apnea are typically unaware of any breathing problems at night. They are not even aware of a shallow sleep. Sleep apnea sufferers actually believe that they sleep very well. No matter how long they sleep, though, they wake up tired and unrefreshed.
Constant heaviness in the head, daytime sleepiness and fatigue are very typical. Longer sleep hours or taking naps do not improve the headache and fatigue.
Lack of morning refreshment, heartburn, and dry and sore throat upon awakening are common. The last three are caused by gastroesophageal reflux due to suction effect during attempts to breathe in against the closed airways while asleep.
Other associates are obesity, snoring, and a large collar size.
Reports about difficulty concentrating and urge to fall asleep during the day are universal.
Neurologist is often the first doctor who makes the diagnosis of sleep apnea based on the chronic headache and fatigue syndrome. Sleep apnea is typically managed by pulmonologists.
Successful management of sleep apnea improves all the symptoms including the headache. No treatment is going to be effective for the headache unless sleep quality gets better.
Chronic Daily Headache and Depression
Sleep disturbance is one of the most common symptoms of anxiety and depression. Besides difficulty falling asleep a depressed person has frequent awakenings at night and typically wakes up early. Sleep time is shortened and sleep structure is abnormal.
Depressed people spend very little time in the deep sleep stages. Shallow sleep dominates through the night. There is a phenomenon called sleep stage misinterpretation disorder. This is when the person feels that he or she did not sleep the whole night. At the same time, the outside observer states the opposite. EEG recording in conventional frequencies will document sleep. At higher frequencies an awake state will reveal itself. Basically, depressed people are often asleep and awake at the same time during the night.
Complaints about feeling tired and unrefreshed in the morning are very similar to patients with sleep apnea with one important catch. Depressed or anxious people can’t nap. They are absolutely unable to nap in spite of horrible sleep quality for a few previous nights.
Weeks or months of chronic sleep deprivation are probably responsible for the chronic headaches in these patients.
Adequate depression treatment results in sleep improvement, which in turn leads to rapid resolution of chronic headaches.
Chronic or Transformed Migraine
Chronic migraine is phenomenon, which is entirely different from the other two described above.
Episodic headache attacks in migraine sufferers may progress to chronic headache syndrome. The process is gradual. On the top of typical migraine attacks migraineurs may experience more frequent, less severe headaches, which may lack typical migraine associated symptoms.
Contributing factors in this transformation might be pain medications overuse, depression, sleep disorders and multiple general medical conditions. Presence of the above mentioned risk factors is not essential. Migraine may just turn chronic without precipitating factors.
Sophisticated imaging studies in chronic migraine sufferers demonstrate presence of iron deposition in some areas of the brain, which are responsible for natural pain control (periaqueductal gray matter). These findings prove that prolonged repetitive insult on the pain processing system can produce some physical damage to the brain.
Fortunately, chronic migraine transformation is not permanent. More than 70% will revert back to episodic migraine within 2 years.
There is no specific treatment for the transformed migraine. Preventive treatment, similar to preventive treatment in episodic migraine is a typical approach.
Tight control over the pain medication use is essential. Migraineurs always know when they have a migraine and when they have some other type of headache. Drugs with rebound headache potential, such as Excedrin and Triptans, have to be reserved for migraine attacks only. Milder headaches are treated with preventive treatment or with Motrin, Naproxen, Diclofenac or other NSAIDs.
Treatment of the associated (if present) depression or sleep disorder will improve the outcome.
Tension headache does not have to be chronic. It is more commonly episodic. The reason why I put tension headache together with chronic headaches is because they have something in common. Namely, it is the fact that they are provoked by some external factors. Unlike migraine and other primary headaches, tension headache always occurs for a reason. I call it “life style sins headache”. I perceive tension headache as an alarm warning us about a faulty life style.
The mechanism of tension headache is poorly understood.
Occurrence of tension headache in response to chronic sleep deprivation, shift work, stress, long hours spent in front of the computer screen, etc. does not surprise anyone. People don’t tend to visit doctors for tension headache because of its apparent association with the life style extremes.
The name “tension” probably comes from the sense of “tension” and heaviness usually in the back of the head and upper neck. Tension headache may be in the front of the head as well. Tension headache tends to be symmetrical.
There should be no associated symptoms of hypersensitivity, nausea, decreased concentration, and poor general sense of well-being. Tension headache brought up by sleep deprivation will obviously be associated with fatigue, irritability, and poor concentration but not because of the headache itself.
The diagnostic workup should be entirely normal in tension headache.
There is no specific treatment for tension headache besides the life style modification an removing risk factors known to trigger this phenomenon.