Chronic headaches: triggers and comorbidities

Headaches can severely impact the quality of life and can get progressively worse, interfering with the simplest of day-to-day tasks.
 

We spoke to Dr Shankar Ramaswamy , an expert consultant in pain medicine, to find out what determines whether a headache is chronic, how comorbidities have an impact and how they should be treated.

In this latest article, Dr Ramaswamy shares some startling statistics on mental health conditions and chronic headaches, highlighting how they may be interlinked.
 

What determines whether a headache is chronic?

Chronic headache can be defined as the pain that occurs on at least 15 days a month per longer than 3 months. The duration of pain can be at least 2 hours if untreated, or several shorter attacks per day.
 

Based on the International Classification of Diseases (ICD) 11, there are two forms of chronic headache — chronic primary or Chronic primary headache such as chronic migraine, chronic temporary mandibular disorder pain, burning mouth and chronic primary oral pain.
 

Chronic secondary headache such as cranial neuralgias.

International Headache Society also classifies different types of headaches which doctors use to formulate individual patient’s headache diagnosis.
 

What are the possible triggers of chronic headache?

There are a number of triggers that can cause a headache:

Hunger, dehydration, stress change of routine, food, climate, sleep, caffeine, stress, anxiety and depression and smoking. Up to a 10 percent of chronic headaches are precipitated by food such as cheese and alcohol.
 

Do many of your headache patients have comorbidities? Are these taken into consideration during assessment?

Many patients with chronic headache tend to have a number of co-morbidities which needs to be taken into consideration when we manage them. Commonly they include anxiety, depression, PTSD and other psychiatric conditions and also a number of medical conditions.

Psychological comorbidities with a chronic headache:

Panic attacks, suicidal attempts and depression are particularly common in patients with migraine. In about 20% of people with episodic migraine, they also have depression.
 

Patients with chronic headaches have up to to 50% chance of having depression and as the frequency of the headaches increases the chances are said to be higher.
 

Anxiety disorders including generalized anxiety, PTSD and panic disorders are also very common in patients with chronic headache. In fact patients with chronic headache have 50 to 80% chance of having an anxiety disorder.

 

Medical comorbidities with a chronic headache:

Some of the common medical co-morbidities associated with chronic headache includes asthma, allergic rhinitis, IBS, Chron’s disease, hypertension, chronic fatigue syndrome, sleep disorders and other chronic pain conditions (for example, fibromyalgia) and joint dysfunction.
 

Few other comorbidities associated with chronic headache includes gastric ulcers, angina, hay fever, diabetes mellitus, epilepsy, multiple sclerosis and stroke.
 

In terms of treating chronic headaches, we take into account the comorbidities as well. For example we may consider avoiding certain medications or sometimes we may try certain medications, which can treat the headache as well as the comorbidity at the same time.
 

Treating the comorbidity such as anxiety, depression or another chronic pain condition simultaneously with CBT, anti-depressant medication and general pain killers can help manage headaches as well. But we would avoid recommending overusing pain killers as that in itself can result in another condition called medication overuse headache.
 

The focus of treatment would be to manage the headache, patient’s function and quality of life, impact of chronic pain and chronic headache condition on their life. We will discuss this further in the second part of our discussion.


Visit Dr Shankar Ramaswamy’s Top Doctors profile for more information on treatment options and details on appointment availability.