International Journal of Current Research and Review (IJCRR)

Full Html

IJCRR - Vol 08 Issue 19, October

Pages: 25-35

Date of Publication: 30-Nov--0001

Print Article   Download XML  Download PDF


Author: Maqsood Ahmad Dar, Baseerat Ali, Rajasheikar Redid, Rommel Roshan Tickoo, Owais Hamid Dar

Category: Healthcare

Abstract:Introduction: Chronic daily headache defined as headache occurring on 15 or more days in a month for at least three months affects around 4% of the general population causes significant distress with substantial impact on the quality of life of an individual and huge economic cost to the society through occupational disability and healthcare consultations.
Objectives of the Study: To study the prevalence of chronic daily headaches in people of age group 18-80 years in Max Super Specialty Hospital and to identify risk factors associated with CDH (stressful life events, obesity, and medicine overuse.)
Material and Methods: It was a prospective study conducted in Max Super Specialty Hospital, Saket, and New Delhi between Aug 2014 to May 2015. Patients coming with complaints of headache in age group of 18-80 yrs and fulfilling the inclusion criteria and exclusion criteria were enrolled in the study. Sample size was calculated by using n-Master (2.0) software and 176 subjects were enrolled. History of the patient including the precipitating factors and drug history was taken. MIDAS and HIT score was used to know the severity of headache; medical conditions were noted by taking brief interviews. Data was analyzed by using chi square test, Pearson's correlation coefficient.
Result: Of the 4500 subjects presented to our hospital with complaints of headache, 176 fulfilled the criteria of chronic daily headache (CDH) with a prevalence of about 4.5%.In our study we observed that 103 (58.5%) had migraine without aura, 30.6(20.5%) migraine with aura, 33(18.8%) tension type headache (TTH), 2 (1.1%) hemicranias continua and 2(1.1%) mixed-migraine and TTH.We observed that out of 176 patients in age group of 18-80 years ,maximum number of patients were in age group of 30-39 yrs- 67 patients(38.1%) and the least common age group was >70yrs where only 1 patient had chronic daily headache(CDH). It was observed that out of 176 patients 123 (69.9%) were females and 53 (30.1%) were males and type of headache was statistically significantly (p=0.00) associated with gender.
Conclusion: We conclude that Migraine without aura was the most common type (58.5%) and least common type being mixed chronic migraine and tension type headache and Hemicrania continua 1.1%. We found chronic daily headache was more prevalent in females as compared to males, 123 (69.9%) were females and 53 (30.1%) were males. The most common age group affected was 30-39 years and was more common in married. We observed that most of the patients (61.9%) had BMI between 18.5 and 25.After analyzing risk factors it was observed that history of drug intake was present in 154 subjects, most common being Acetaminophen, Naproxen, Triptans, Ergotamine the rest were using preventive. In our study prevalence of medication overuse headache (MOH) among 176 patients of chronic daily headache is (108/176) 61.36% whereas prevalence of MOH in subjects coming to our hospital with headache is 2.4% (108/4500). Stress was the most common precipitating factor of chronic daily headache (CDH), stress was present in 146 patients (85.9%) others being lack of sleep, hunger, working on computer, noise, menstruation, sunlight, travel. Recommendations: Chronic daily headache is under estimated due to lack of awareness; screening of patients should be done on primary and secondary care centers to estimate the actual burden of disease. Stress, anxiety should be handled as early as possible to prevent transformation of episodic headache to chronic daily headache.

Keywords: Hemicranias continua, Chronic daily headache, Tension type headache, Medication overuse headache

Full Text:


Chronic Daily Headache (CDH) is a descriptive term and not a diagnosis per se. It is commonly defined as headache occurring on 15 or more days in a month for at least three months and affects around 4% of the general population [1].  It causes significant distress with substantial impact on the quality of life of an individual and huge economic cost to the society through occupational disability and healthcare consultations. In comparison to episodic headache disorders, CDH is less responsive to acute and preventive treatments. The term CDH is mainly referred to the primary headache disorder, although secondary CDH must be excluded. It includes chronic migraine, chronic tension type headaches, and new daily persistent headache and hemicrania continue. Common ones being chronic migrane and chronic tension type headache [2]. CDH may evolve from episodic headache through gradual transformation over months to years. An estimated 3-6% of patients move from episodic to chronic and vice versa each year [3] 


Chronic migraine: Headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month. [4]

Migraine without aura: Headache attack lasting for 4- 72hrs (untreated or successfully treated) .Two of following characteristics should be present:

Unilateral location, pulsating quality, moderate or severe pain intensity, aggravated by or causes avoidance of routine physical activity.

During headache at least one of the following:

Nausea/or vomiting and photophobia / phonophobia

Migraine with Aura: At least two attacks as follows:

One or more of the following fully reversible aura symptoms:

Visual, sensory, speech and/or language, motor, brainstem, retinal

At least two of the following four characteristics:

1. At least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession

2. Each individual aura symptom lasts 5-60 minutes

3. At least one aura symptom is unilateral

4. The aura is accompanied, or followed within 60 minutes, by headache

Not better explained by another diagnosis

New Daily Persistent Headache (NDPH)] [4]

Previously used terms:  Chronic headache with acute onset, de novo chronic headache.

New daily persistent headache (NDPH) is a persistent headache is daily from onset, which is clearly remembered, with pain becoming continuous and unremitting within 24 hours and very soon unremitting, it is present for more than 3 months.

It   typically occurs in individuals without a prior headache history.

Patients with prior headache (Migraine or Tension-type headache) are not excluded from this diagnosis, but they should not describe increasing headache frequency prior to its onset.

Similarly, patients with prior headache should not describe exacerbation followed by medication overuse.

Chronic Tension Type Headache (CTTH) [4]

Chronic tension type headache (CTTH) is a featureless bilateral headache occurring on 15 days or more in a month for more than three months lasts hours to days, or unremitting.

It has following features:

  At least two of the following four characteristics:

1. Bilateral location

2. Pressing or tightening (non-pulsating) quality

3. Mild or moderate intensity

4. Not aggravated by routine physical activity such as walking or climbing stairs


And both of the following:

1. No more than one of photophobia, phonophobia or mild nausea

2. Neither moderate nor severe nausea not vomiting

   Not better accounted for by another disorder.


Chronic tension-type headache is of two types:

1. Chronic tension-type headache associated with pericranial tenderness

2. Chronic tension-type headache not associated with pericranial tenderness

Hemicrania Continua [4]


Persistent, strictly unilateral headache >3 months, with exacerbations of moderate or greater intensity associated with either or both of the following:

1. Atleast one of following signs or symptoms ipsilateral to headache:

conjunctival injection and /or lacrimation, nasal congestion and/or rhinorrhoea, eyelid edema, forehead and       facial sweating, forehead and facial flushing, sensation of fullness in the ear, miosis and /or ptosis,

2. Sense of restlessness or agitation or aggravation of pain by movement.

   It is not better accounted by other disorder.



Aims and Objectives:

To study the prevalence of chronic daily headaches in people of age group 18-80 years in Max Super Specialty Hospital, Saket New Delhi. To identify risk factors associated with CDH (stressful life events, snoring, obesity and medicine overuse)

Material and Methods:

Study Design:

This study was carried out in the department of internal medicine and department of neurology in Max Superspeciality Hospital Saket New Delhi. All patients who were fulfilling inclusion and exclusion criteria & coming to internal medicine and neurology department of Max Hospital, Saket, New Delhi, as outpatient & indoor patients were enrolled in the study. The study was a prospective study of 176 patients who fulfilled the criteria of chronic daily headache in age group of 18 to 80 years. The study was conducted over a period of one year from august 2014 to July 2015.

Method of Measurement of Outcome of Interest:

 Patients fulfilling the inclusion and exclusion criteria were recruited in the study after informed consent. Data was collected for basic demographics, alcohol/tobacco/any drug intake history, past medical history, history of any head or cervical trauma, their socioeconomic status.

Data was also collected regarding medication intake for acute attacks of headache and adherence of patients to any preventive medication (if present).

We also collected data regarding the relevant lab investigations, radiological imaging and certified headache scoring systems -Migraine Disability Assessment Score (MIDAS), Headache Intensity (HIT) Score. Subjects were enrolled in this study after informed consent.

Inclusion Criteria:

Patients coming to hospital with headaches > 15 episodes /month for >3 months in age group 18-80 years either Male or Female.

Exclusion criteria:

Patients having secondary headaches

Patients having abnormal LFT, TFT, RFT, vitamin B12 (2 times the upper limit)

Any organic pathology                                                                                                                      


Blood/urine tests (chemistry, hematology, drug screen, endocrine workup)

CT/MRI scans (Head, cervical spine, sinuses) if required

Statistical Analysis:

Descriptive statistical methods were used to calculate the number of subjects (n), mean, median, standard deviation (SD) for continuous data and frequencies and percentages for categorical data. Pearson correlation was used to calculate the correlation between continuous variables or Spearman correlation for categorical variables. Chi- square test or Fisher exact test was used to find the association between the categorical variables. STATA 9.0 software was used for statistical analysis

Institutional Ethics Committee (IEC) Review:

 The study was carried out only after getting approved by institutional ethics committee.

There was not any conflict of interest with the study and not much funding was involved in the study as this was a prevalence study. 


A total of 4500 patients presented with headache to our hospital during the study period, out of these 176 fulfilled criteria for chronic daily headache (CDH), prevalence of CDH was found to be 4.5%. We observed that out of 176 patients in age group of 18-80 years maximum patients were in the age group of 30-39 years (67 patients 38.1%) and minimum patients were in age group of more than 70 years (1 patient 0.6%). Figure 1 is showing the age distribution of the subjects with respect to the percentage of the CHD. Among 176 patients with CDH, 123(69.9%) were females and 53 (30.1%) were males (Table 1)


1. Ahmed F, Parthasarathy R , Khalil M. Annals of Indian Academy of Neurology:  2012; Volume 15, Issue 5 [p. 40-50]

2. Castillo J, Muñoz P, Guitera V, Pascual J. Kaplan Award 1998: Epidemiology of chronic daily headache in the general population. Headache. 1999; 39:190–6.

3.Bigal ME, Lipton RB :what predicts the change from episodic to chronic migraine. Curr Opin Neurology. 2009; 22:269

4. International Headache Society 2013, International  classification of headache disorders 3rd edition cephalalgia.2013;33(9) 629-808

5. Coeytaux RR, Linville JC.Chronic daily headache in a primary care population: prevalence and headache impact test scores. 2007; 47(1):7-12.

6.Wiendels NJ, Knuistingh Neven A, Rosendaal FR, Spinhoven P, Zitman FG, Assendelft WJ, Ferrari MD. Chronic frequent headache in the general population: prevalence and associated factors. Cephalalgia. 2006 ;26(12):1434-42.

7. Queiroz  LP,  Peres  MFP,  Kowacs  F,  Piovesan  EJ,  Ciciarelli  MC,  Souza  JA  &Zukerman  E.  Chronic  daily  headache  in  Brazil:  a  nationwide  population-based study. Cephalalgia 2008;  28:1264–1269. 

8.Castillo J, Munoz P, Guitera V, Pascual J  Epidemiology of chronic daily headache in the general population. Headache .1999; 39:190-196 

9.Lanteri-Minet M, Auray JP, El HA, Dartigues JF, Duru G, Henry P, Lucas C, Pradalier A, Chazot G, Gaudin AF Prevalence and description of chronic daily headache in the general population in France. Pain,2003; 102:143-149.

10. Mitsikostas DD, Tsaklakidou D, Athanasiadis N, Thomas A. The prevalence of headache  in Greece: correlations to latitude and climatological factors. Headache.1996; 36:168-173 

11.  Pascual J, Colas R, Castillo. Epidemiology of chronic daily headache. Curr Pain Headache Rep. 2001; 5:529-536 

12. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998; 38:497-506

13. Seyed Saadat SM, Hosseininezhad M, Bakhshayesh B, Hoseini M, Naghipour M. Epidemiology and clinical characteristics of chronic daily headache in a clinic-based cohort of Iranian population.Neurol Sci. 2014;35(4):565-70.

14. Zebenholzer K , Andree C , Lechner A, Broessner G , Lampl C , Luthringshausen G ,  Wuschitz A, Maria-S, Obmann, Berek K, and Wöber C. Prevalence, management and burden of episodic and chronic headaches:A Cross-Sectional Multicentre Study in Eight Austrian Headache Centres. Journal of Headache and Pain, 2015;10.1186

15. AS Dabhi, M Vadivelan, J Modia.A study of sixty cases of chronic daily headache. Original article- JIACM. 2013; 14(2):119-2 .

16. Verma A, Transformed migraine: Study of 420 consecutive patients from central India. Annals of Neurosciences.2007;Volume 14, issue 2.

17. Bhatia MS and Gupta R. Migraine:Clinical pattern and psychiatry comorbidity.Indsustrial Psychiatry Journal,2012; 21(1): 18–21.

18.Scher AI, Midgette LA, Lipton RB: Risk factors for headache chronification. Headache. 2008;48:16-25. 

19. Scher AI, WF Stewart, JA Ricci, RB Lipton. Factors associated with the onset and remission of chronic daily headache in a population-based study.Pain. 2003;106(1-2):81-9

20. Crisp AH, Kalucy RS, McGuinness B, Ralph PC, Harris G. Some clinical, social and psychological characteristics of migraine subjects in the general population. Postgrad Med J.1977;53:691–7

21. Waters WE, O'Connor PP. Prevalence of migraine. J Neurosurg Psychiatry. 1957;38:613–6.

22. Jette N, Petten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders-A national population-based study. Headache. 2008;48:501–16.

23. Schurks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: Systematic review and meta-analysis. BMJ. 2009; 339:b3914.

24. Silberstein  S. Migraine and Pregnancy. Journal SOGC. Sept. 2000, visited on

25. Lipton RB. Tracing transformation: Chonic migraine classification, progression, and epidemiology. Neurology. 2009;72:S3–7.

26. Mehuys E, Paemeleire K, Van Hees T, Christiaens T, Van Bortel LM, Van Tongelen I, De Bolle L, Remon JP, Boussery K. Self-medication of regular headache: a community pharmacy-based survey. European Journal of Neurol.2012; (8) 1093-9.

27. Relja G, Granato A, Maria Antonello R, Zorzon M. Headache induced by chronic substance use: Analysis of medication overused and minimum dose required to induce headache.  Headache. 2004; 44:148–53. 

28. Vlajinac H, Šipeti? S, Dolji? E, Maksimovi? J, Marinkovi? J, Kosti? V.Some lifestyle habits of female Belgrade university students with migraine and non-migraine primary headache. J Headache Pain.2003; 4:67-71  

29. Martin VT, Behbehani MM. Toward a rational understanding of migraine trigger factors. Med Clinic  North America.2001; 85:911-941 

30. Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache.2010 ;50(8):1366-70.

31. Albers L, Ziebarth S, Von Kries R.Modifiable risk factors for primary headache. A systematic review. 2014; 952-60.

32. Santos IS, Griep RH, Alves MG, Goulart AC, Lotufo PA, Barreto SM, Chor D, Benseñor IM.Job stress is associated with migraine in current workers:the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Eur J Pain. 2014;18(9):1290-7

33. Becker WJ. Migraine and Oral Contraceptives. Canadian Journal of Neurological Sciences. 1997;24: p16-21

 34. Fettes Ivey. Migraine and the Menopause. Journal SOGC ;2000 visited on

35. Loder, Elizabeth. Headache and Oral Contraceptive Use. Seminars in Headache Management. Sex Hormones and Headache. 1998; Vol. 3 Number 2 June p9-12

36. Loder, Elizabeth. Migraine and Menstruation. Journal SOGC. 2000; Vol. 22 number 7, p512-517

37.  Spierings EL, Donoghue S, Mian A, Wöber C. Headache. Sufficiency and necessity in migraine: how do we figure out if triggers are absolute or partial and, if partial, additive or potentiating? Curr Pain Headache Rep. 2014; 455.

38. Turner DP, Smitherman TA, Penzien DB, Porter JA, Martin VT, Houle TT. Nighttime snacking, stress, and migraine activity. J Clin Neurosci. 2014; 21638-43.

39. Zivadinov R, Willheim K, Sepic-Grahovac D, Jurjevic A, Bucuk M, Brnabic-Razmilic O, Relja G, Zorzon M. Migraine and tension-type headache in Croatia: a population-based survey of precipitating factors. Cephalalgia..2003;23(5):336-43.

40. Spierings EL, Ranke AH, Honkoop PC. Precipitating and aggravating factors of migraine versus tension-type headacheHeadache. 2001;41(6):554-8.