Chronic headaches: Triggers and comorbidities

Written by: Dr Adrian Miller
Published: | Updated: 23/11/2023
Edited by: Robert Smith

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


We spoke with Dr Adrian Miller, renowned Consultant Neurologist, to find out what determines whether a headache is chronic, how comorbidities have an impact, and how they should be treated. Dr Miller shares some startling statistics on mental health conditions and chronic headaches, highlighting how they may be interlinked.


woman with a headache


What determines whether a headache is chronic?


Chronic headache can be defined as the pain that occurs on at least 15 days a month for longer than three months. The duration of pain can be at least two 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.


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


What are the possible triggers of chronic headache?


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

  • stress, anxiety, depression
  • hunger and dehydration
  • sleep
  • food, including caffeine
  • the weather and the climate
  • smoking
  • change of routine


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 comorbidities which need to be taken into consideration when we manage them. Commonly, these comorbidities 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 patients with episodic migraine, they also have depression.


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


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

Medical comorbidities with a chronic headache:


Some of the common medical comorbidities associated with chronic headache includes:

Few other comorbidities associated with chronic headache include:


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 cognitive behavioural therapy (CBT), anti-depressant medication, and general painkillers can help manage headaches as well. However, we would avoid recommending overusing painkillers as that in itself can result in another condition called medication overuse headache.


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



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

By Dr Adrian Miller

Dr Adrian Miller is a highly esteemed Consultant Neurologist based in Basingstoke, Winchester and Southampton. He specialises in the diagnosis and management of a variety of neurological symptoms and conditions, including headaches, blackouts, funny turns, weakness, numbness and dizziness. He has specialist interest in neuromuscular disorders (diseases of peripheral nerve and muscle), headaches and clinical trials.

After qualifying from the University of Cambridge with distinction, Dr Miller completed the ‘golden circuit’ of post-graduate medical and neurological training at London’s leading teaching hospitals including The National Neurological Hospital (Queen Square), Hammersmith, Royal Brompton, St George’s, St Mary’s, Guy’s and St Thomas’. He was awarded a prestigious MRC research fellowship and obtained a PhD from MRC Centre for Neuromuscular Diseases, University College London, for laboratory and clinical trial research on sporadic inclusion body myositis.

Dr Miller was appointed Consultant Neurologist in Winchester, Basingstoke and Southampton, and has been Clinical Lead of Neurology at Hampshire Hospitals since 2018. He is the Principal Investigator of several international clinical trials.

Dr Miller practices privately at The Candover Clinic, Sarum Road Hospital, The Hampshire Clinic and Healthshare Winchester Clinic.

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