Chronic headaches: triggers and comorbidities

Written by: Dr Shankar Ramaswamy
Published: | Updated: 09/12/2020
Edited by: Robert Smith

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

woman with a headache


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.

Dr Shankar Ramaswamy

By Dr Shankar Ramaswamy
Pain medicine

An important note with regard to the COVID-19 pandemic: We are offering video consultations to all patients at flexible times and at short notice. This is authorised by all insurance providers. Our team also offers physiotherapy via video consultation and we are able to offer interventions quickly for 'low risk' patients at safe premises in London. We will risk-assess all patients prior to this.

Dr Shankar Ramaswamy is a leading consultant in anaesthesia, pain management and neuromodulation based in Central London, Southeast London and Kent. Among the wide range of conditions that he manages are neck and back pain, headache and facial pain, cancer pain, neuropathic pain, musculoskeletal pain including fibromyalgia and joint pain, abdominal and pelvic pain, sports injury and trauma and accident-related pain including whiplash injury.

He is the clinical lead for the busy inpatient pain service at the Royal London Hospital and also the lead for pain management for the Newham MSK Collaboration. He is also the lead for education in pain management for Barts Health and QMUL and a course director and honorary senior lecturer for MSc Pain Management, University of Edinburgh.

His first qualifications and training in the field of anaesthesia were earned in India, including at one of the most prestigious medical and research institutions in India, the PGIMER. Once in the UK, he continued his anaesthetic training and then underwent the Advanced Pain Fellowship at the renowned Imperial Healthcare, London.

Over the duration of his career, he has garnered extensive experience that he uses to provide care of the highest quality to his patients. He commits to providing comprehensive pain management plans that are centred on each patient's individual needs. He uses a variety of techniques including self-management advice, pharmacotherapy, and cutting-edge (X-ray-guided and ultrasound-guided) interventions such as epidural, facet joint injections, peripheral joint injections (e.g. hips, knees, shoulder), radiofrequency, laser disc therapy, regenerative medicine (PRP) and neuromodulation. He is part of a large multi-disciplinary team to facilitate and individualise pain management approach.

Dr Ramaswamy has also received training in medico-legal report writing and is familiar with civil procedure protocols including CPR part 35 and PD 35 protocol. He can provide detailed insights into causality, prognosis, assessing capacity to work understanding specific roles, assess the ability to function and also comment on the prospect of achieving pain relief. He also offers medicolegal appointments at short notice and can produce a report with a quick turn around time. He sees patients for personal injury claims and criminal negligence claims.

This website uses our own and third-party Cookies to compile information with the aim of improving our services, to show you advertising related to your preferences as well analysing your browsing habits. You can change your settings HERE.