Pediatr Drugs 2008; 10 (1): 23-29

THERAPY IN PRACTICE 1174-5878/08/0001-0023/$48.00/0

© 2008 Adis Data Information BV. All rights reserved.

Management of Chronic Daily Headache

in Children and Adolescents
Kenneth J. Mack1 and Jack Gladstein2
1 Child and Adolescent Neurology, Mayo Clinic, Rochester, Minnesota, USA
2 School of Medicine, University of MarylanD, Maryland, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1. Definition of Chronic Daily Headache (CDH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2. Epidemiology of CDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3. Headache Categories and Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4. Diagnostic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
5. Disability and Co-Morbid Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
6. Principles of Management of CDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
6.1 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
6.2 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
6.2.1 Practical (But Unproven) Aspects of Preventative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6.3 Additional Management Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Abstract Chronic daily headache (CDH) occurs in 1–2% of children and adolescents. It can evolve from either episodic
tension-type headache or episodic migraine, or can appear with no previous headache history. As with other
primary headache disorders, treatment is based on the level of disability. There are children and adolescents who
cope well, but there are others who are markedly disabled by their chronic headaches. As in adults, children and
adolescents with CDH are at risk for medication overuse.
CDH is a diagnosis of exclusion, based on a thorough history, normal physical examination, and negative
neuroimaging findings. Along with the chronic headaches, children with this condition may have co-morbid
sleep problems, autonomic dysfunction, anxiety, and/or depression. Principles of treatment include identifying
migrainous components, stopping medication overuse, stressing normalcy, using rational pharmacotherapy, and
addressing co-morbid conditions. Successful outcomes often involve identifying an appropriate headache
preventative, reintegration into school, and family participation in resetting realistic expectations.

1. Definition of Chronic Daily Headache (CDH) years 1980–2007. Search terms used were ‘chronic daily head-
ache’ and ‘chronic migraine.’
The consensus definition of chronic daily headache (CDH) is
based on the presence of headache for ≥15 headache days in 1 2. Epidemiology of CDH
month, over a period of 3 consecutive months, and with no This headache disorder tends to affect teenagers and adults but
underlying organic pathology.[1] The headaches last for >4 hours can occur in preteens. CDH occurs in 2% of middle school girls
per day. This definition was put forth for adult headache sufferers, and 0.8% of middle school boys aged 12–14 years.[2] It can occur
but has been adopted by experts in pediatric headache, despite the in up to 4% of young women and up to 2% of young men, with
fact that most acute headaches in children last for <4 hours. similar prevalence rates seen in studies from Asia, Europe, and the
This article discusses the current management of CDH in the US.[3] CDH has been shown to represent up to 60% of cases seen in
pediatriac population. A MEDLINE search was conducted for the pediatric headache specialty clinics.[4,5]
24
3. Headache Categories and Characteristics
Silberstein and others[6,7] have defined four different categories
of CDH, which are based on symptoms. These include trans-
formed or chronic migraine, chronic tension-type headache, new
daily persistent headache, and hemicrania continua. Many teenage
patients with CDH have a history of episodic migraine.[8] Trans-
formation to a chronic migraine may occur over a period of weeks
to months, or it may occur abruptly over a matter of hours.
Approximately one-quarter of teenagers with CDH have no signif-
icant history of headache.[5] In this latter group of patients, an
infection such as mononucleosis or a minor head injury may incite
a new daily persistent headache. A smaller number of patients will
have a history of tension-type headaches prior to their CDH.
Approximately 1% of patients will present with hemicrania con-
tinua.[8,9]
Most commonly, the pediatric patient with CDH will seemingly
complain of at least two types of headaches.[4] Prominent are
severe intermittent headaches that are migraine-like. They tend to
be pan-cephalic or in the front of the head. The headaches will be
described as throbbing, severe, crushing, knife-like, or hatchet-
like. They are often associated with nausea during the most severe
times, and the patient will frequently have photophobia, pho-
nophobia, and osmophobia. Sleep will sometimes help but the
patient will still have a persistent headache when they wake up.
The frequency of these severe headaches varies with the individu-
al; however, they typically occur multiple times a week.
In addition to these severe intermittent headaches, the patient
with CDH will sometimes complain of a continuous or baseline
headache that is present 24 hours a day, 7 days a week (‘24/7’).
This continuous headache may wax and wane in severity, often
being worse either in the morning or at the end of the school day.
The characteristics of the ‘all-the-time’ headache pain are similar
to those of severe headaches, only much less intense.[5]
Patients with transformed migraine appear to have two distinct
headaches. In a study of 178 pediatric patients with CDH, the
baseline headache was present for 27.3 ± 4.1 days per month with
a mean pain intensity of 5.9 ± 2.1 on a 10-point scale. The
superimposed episodic headache was present for 4.7 ± 3.8 days per
month with a mean pain intensity of 8.4 ± 1.4 and was more often
associated with migrainous symptoms. After logistic regression to
control for pain intensity, the only statistically significant differ-
ence between the two headache types was a lower prevalence of
tension-type pain with the superimposed headache. This suggests
that rather than having two coexistent headache types, children
and adolescents with CDH have a syndrome that – in many cases –
periodically worsens and gathers more severe migrainous fea-
tures.[10]
Based on the experience, there is variability in headache char-
acteristics. Not every chronic headache sufferer has headaches all
© 2008 Adis Data Information BV. All rights reserved.
Mack & Gladstein
the time. The occasional patient with CDH may have allodynia
over all or part of their head. Allodynia is a sensitivity to touch on
part of the scalp or face that occurs with severe headaches. A small
percentage of patients may have idiopathic stabbing headaches
(ice-pick headaches), which are severe, intermittent, stabbing-like
headache pains that are often multi-focal, occurring for seconds at
a time and happening many times during the day.
Headache is not the only symptom in CDH. Frequent co-
morbid symptoms include dizziness, sleep disturbance, pain at
other sites of the body including the neck, back, and abdomen,
fatigue, difficulty in concentration, sad mood, and increased anxie-
ty. It is important to recognize and treat these other symptoms as
well as the headache, and avoid medications that could exacerbate
these co-morbid conditions.
4. Diagnostic Considerations
One of the roles of a treating physician for patients with CDH is
to distinguish CDH, which is a primary headache syndrome, from
other secondary causes of headache. The evaluation of the young
person should include a thorough history and physical examina-
tion, as well as consideration of a neuroimaging study, blood tests,
and, in the occasional patient, a lumbar puncture. In selected
patients, tilt table testing or sleep studies may also be of value.
The physical examination of the patient with chronic headache
is important but rarely yields abnormal findings. Vital signs should
be assessed to exclude hypertension. Hints of either neurofibro-
matosis or tuberous sclerosis should be looked for on skin examin-
ation. Arrested development in younger children can be identified
by assessing growth curves. A fundoscopic examination is neces-
sary to rule out the presence of papilledema and increased intra-
cranial pressure. The possible presence of focal deficits or other
neurologic findings can be evaluated by neurologic examination.
Examination of the spine should also be performed because of the
frequent presence of neck and back pain in these patients. Palpa-
tion of the head and neck may reveal trigger points.
Perhaps the most useful role of neuroimaging in CDH is to
reassure the patient and family.[11] An imaging study is most likely
to be significantly abnormal if there are focal deficits on examina-
tion or a history of seizures.[12] Occasionally, white matter abnor-
malities, arachnoid cysts, or pineal cysts will be seen that are
generally believed to have no clinically significant consequence in
patients with CDH.[13] If a patient has had a significant history of
head or neck trauma, particularly at the onset of the CDH, a
magnetic resonance angiogram of the neck should also be consid-
ered to rule out a possible carotid dissection. When pseudotumor
cerebri is a strong consideration, a magnetic resonance venogram
should also be considered as sinus thrombosis can cause elevated
intracranial pressure.
Informative serum studies include evaluation of thyroid func-
tion. A thyroid-secreting hormone level is a useful screening test.
Pediatr Drugs 2008; 10 (1)
Management of Chronic Daily Headache
If there is an encephalopathy in addition to the headache, then a
thyroid receptor antibody test should be performed. Erythrocyte
sedimentation rates could be used to look for evidence of inflam-
mation or arteritis, although this is a fairly nonspecific test, and
false-positives and false-negatives are common. If there are other
clinical signs of lupus in addition to headache, then an antinuclear
antibody (ANA) test should be performed. However, when head-
ache is the only symptom, the ANA can add confusion rather than
clarity to the situation.
Many patients with CDH will transition from a headache-free
period or episodic migraines to chronic migraines during an infec-
tion. Serologic testing for Epstein-Barr virus, West Nile virus, and
Lyme disease should be considered. Although there is no specific
treatment for some of the viral etiologies, many parents/caregivers
appreciate knowing that there was a physiologic underpinning for
the transition to a chronic headache.
Idiopathic intracranial hypertension (IIH) is a constellation of
symptoms and signs that include an elevated intracranial pressure;
the MRI scan is normal. The patient with IIH will complain of a
headache, diplopia, tinnitus, and eye pain. On examination, the
patient will have papilledema and may have a sixth nerve palsy.
The diagnosis is easy to make when all these signs and symptoms
are present. However, there are some patients who may have IIH
without showing significant papilledema, although this is rare.
Patients with CDH or migraine seem to be almost universally
prone to post lumbar puncture headache. Therefore, although a
lumbar puncture can be a valuable diagnostic tool, one should be
cautious about its use as it can make a patient with a headache
significantly worse rather than better. When measuring the cere-
brospinal fluid pressure, an effort should be made to ensure the
child is the least anxious as possible; sometimes the use of seda-
tion is necessary. The pressure should be measured with the legs
extended and the head relaxed.
5. Disability and Co-Morbid Symptoms
Disability in pediatric patients with CDH can be measured in
terms of school absence, abstinence from after school activities,
and family discord as a result of the headache. For research
purposes, there are validated tools to measure headache disability
in children and adolescents.[14] Problems in terms of school per-
formance and social isolation may be harbingers of depression.
The patient may be habituated to over-the-counter (OTC)
analgesics, decongestants, opioids, butalbital, isometheptene,
benzodiazepines, ergotamine, and triptans.[15] Combating rebound
headaches from these analgesic medications may be part of the
treatment. Other potential secondary illnesses that may occur as a
result of the medications used include gastritis, renal insufficiency,
ergotism, and gastroesophageal reflux.
Identifying co-morbid conditions is important in improving the
well-being of the patient. Psychosocial factors must also be ex-
© 2008 Adis Data Information BV. All rights reserved.
25
plored. Issues relating to school (bullying, possible learning disa-
bilities), family conflict (parental break-ups), grief and loss
(grandparent’s illness, or break up of a personal relationship), drug
and alcohol use, and other psychosocial factors can shed light on a
teenager’s world that will help the practitioner and patient under-
stand some of the issues that may complicate management.
Next, it is important to identify how the patient and their family
cope with pain. As a teenager is trying to separate and individuate,
chronic pain may infantilize the youngster and make it difficult for
him/her to grow up. It needs to be determined whether the patient
is getting secondary gain from the headaches, and whether the
family is falling apart because the youngster’s headaches have
engulfed other caretakers.
Sleep is frequently disrupted in patients who have CDH.[16] A
common sleep disturbance is a delayed onset in sleep; these
individuals will often not be able to fall asleep for 30 minutes to
several hours after they go to bed. In addition, many patients will
wake frequently during the night. Occasionally, there is a history
of pain and restless legs during the night. Consideration can be
given to a formal sleep study to evaluate these symptoms. The lack
of sleep seems to be a strong contributing factor to aggravation of
the headache symptoms. Typically, the headache syndrome will
not resolve until the quality of sleep is improved.
Many CDH patients have symptoms of dizziness, which is
associated with feeling weak and unsteady, and with changes in
(blurring or loss of) vision.[17] The dizziness is often positional,
and patients will complain of syncope or near syncope several
minutes after standing. There is typically no vertigo. The dizziness
is particularly prominent in the morning after the patient first gets
up. During the office examination, a difference in blood pressure
or pulse rate between sitting and standing may be noted; the
patient often experiences mild symptoms of dizziness if stood up
for several minutes in the office. If either a significant tachycardia
with standing (postural orthostatic tachycardia syndrome) and/or a
decrease in the systolic blood pressure with standing (neurocardi-
ogenic presyncope or syncope) are seen, a tilt-table test will help
confirm these impressions. Orthostatic symptoms can be treated
by increasing the child’s fluid and salt intake or, when necessary,
with the use of β-adrenoceptor antagonists (e.g. metoprolol) when
there is a significant orthostatic tachycardia, and/or vasopressors
(e.g. midodrine) when there is an orthostatic decrease in blood
pressure. Most patients with mild dizziness do not require such a
work-up unless symptoms are debilitating.
Mood problems and anxiety frequently co-exist with CDH. The
mood problems may precede or follow the onset of the headache.
In some patients it is possible to resolve the mood problems
without affecting the headache, and in other patients it is possible
to improve the headaches without improving the mood problem.
CDH should be considered a primary headache syndrome and not
Pediatr Drugs 2008; 10 (1)
26
a mood disorder. The symptoms of both headache and mood need
to be addressed.
Other frequent co-morbid symptoms include nonspecific abdo-
minal pain, back pain, neck pain, and diffuse muscle and joint
pain. Often no further organic etiology is found to explain these
additional pain symptoms. The longer the duration of the CDH
syndrome, the more prominent these other chronic pain symptoms
seem to become. Some patients go on to develop a much more
diffuse pain syndrome.
6. Principles of Management of CDH
The principles of managing CDH include identifying and treat-
ing the migrainous components of the headache syndrome, remov-
ing drugs that lead to rebound headaches, starting an appropriate
headache preventative agent, stressing the reintegration of the
patient into school and family activities, assessing prognosis, and
affording realistic expectations to the family.
6.1 Treatment
Pain control at the time of the headache exacerbation is a very
difficult problem for people coping with chronic headache.
Analgesics that are typically effective for episodic migraine head-
aches are not very effective for transformed migraine or CDH;
most patients report that analgesics are not effective for the all-the-
time, 24/7 headache. It is useful to discourage patients from trying
to use analgesics to treat the all-the-time headache, since this may
result in analgesic overuse and a potential analgesic rebound
headache. In contrast, for the more severe intermittent headache
episodes with migrainous qualities, triptans or NSAIDs should be
prescribed. The use of compounds that contain caffeine, barbitu-
rates, or opiates should be limited or avoided. Patients typically
find that when preventative medication (see section 6.2) starts
working, the analgesics will become more effective.
Patients who need to use analgesics more than twice per week
are at risk for developing a rebound headache, now called med-
ication overuse headache.[9,18] Rebound headaches are a self-
sustaining process that is rhythmic and predictable, resulting in
persistent headache. Inception of rebound is insidious. Eventually,
the medications themselves drive headache frequency and refrac-
toriness. Medication withdrawal will often bring initial misery, but
eventual benefit is achieved after medication washout. If the
effects of medication withdrawal are anticipated to be severe,
inpatient treatment may be needed. For most patients, however,
withdrawal can be done slowly and cautiously as an outpatient.
While withdrawing, careful substitution of drugs that do not cause
rebound should be initiated. Low-dose NSAIDs and metoclopro-
mide can be used. Nausea, vomiting, and increased headache are
often seen in this phase. If patients are habituated to barbiturates or
opioids, inpatient therapy may be needed to monitor for seizures or
© 2008 Adis Data Information BV. All rights reserved.
Mack & Gladstein
narcotic abstinence syndromes. An appropriate migraine prevent-
ative agent should be initiated during the withdrawal of these
analgesic agents.
Rapid withdrawal of the offending agent seems to work better
in adults with CDH than in the pediatric population, when done
safely.[19] When the offending drug is abruptly stopped in a child
or adolescent, several bridging approaches may be used alone or in
combination. Dihydroergotamine mesilate is effective for status
migrainous, and some patients will achieve pain relief for their
chronic headache pain with this agent.[20] Valproate in an intrave-
nous formulation has been used to abort severe headache epi-
sodes.[21] Finally, some patients respond to the short-term use of
oral or intravenous corticosteroids.[22]
Many chronic headache sufferers will feel better while hospi-
talized for these treatments, but may revert back to their typical
headache pattern after leaving the hospital. Hospitalization does
provide the patient with an opportunity for education about head-
aches, introduction to biofeedback, and, in some cases, physical
therapy. It also gives the physician a window into the family
dynamics that are often unassailable in the busy office setting.
However, for patients with chronic tension type headaches, these
migraine-specific approaches may not work.
6.2 Prevention
Preventative medications are traditionally used in headache
patients to reduce the frequency of migraine headaches. Occasion-
ally they may reduce the severity of the headaches as well. The
term ‘preventative’ may be somewhat of a misnomer in CDH since
the headache is present all of the time. However, in CDH, a
reasonable therapeutic goal would be to make the severe intermit-
tent headaches less frequent, and to make the all-the-time head-
ache less intense.
There are multiple choices of preventative agents for episodic
migraine including β-adrenoceptor antagonists, calcium-channel
agents, antidepressants, anticonvulsants, riboflavin, and magnesi-
um.[23] The patient’s co-morbid symptoms will influence the selec-
tion of the most appropriate preventative medication. For example,
β-adrenoceptor antagonists exacerbate depression, asthma, and
exercise intolerance. They should not be used for the depressed or
asthmatic patient or for athletes.[24] Topiramate is a good choice
for an obese person,[25,26] while cyproheptadine[27] or a tricyclic
antidepressant[28] would help a patient to gain weight. The anticon-
vulsants valproate, gabapentin, and topiramate could help a patient
with migraine and epilepsy.[29] Valproate is helpful in patients with
conduct disorder, so it therefore could be helpful in a person with
violent tendencies.[30] Newer antidepressants such as fluoxetine[31]
and venlafaxine[32] may help alleviate anxiety as well as depres-
sion. Nonprescription medicinal products have been used as well.
Feverfew, magnesium, ubidecarenone (coenzyme Q-10), and ribo-
Pediatr Drugs 2008; 10 (1)
Management of Chronic Daily Headache 27

flavin may have a role in migraine prophylaxis.[33] The use of Since many CDH patients have disturbances in sleep, partic-
botulinum toxin shows promise as well.[34] ularly sleep onset, amitriptyline is an attractive choice to start with.
It is important to state the expectations of preventative therapy This can be given at the evening meal or a couple hours before bed.
to the patient and the family. Preventative therapy may improve Typically, a dose of 0.5–1.0 mg/kg of bodyweight is given every
the headaches but will not eliminate the headaches in the short evening initially. This dose can be titrated up to 3 mg/kg/day. At
term. After 1 month of an effective therapy, a reasonable expecta- higher dosages, amitriptyline levels and ECG findings (to assess
tion would be to have less frequent severe headache episodes, and for prolongation of the QT interval) should be assessed. The
a decrease in the intensity of the all-the-time, 24/7 headache. It is patient should be monitored for tachycardia, constipation, sadness,
rare to see complete resolution of the headaches after a short weight gain, dizziness, and worsening of restless leg syndrome.
period of time. Once a trend towards improvement is seen, the Nortriptyline or protriptyline may offer less sedation and possibly
dose of medication is adjusted for optimal control of the head- less of an increase in appetite, although there are no controlled
aches, and the patient is continued on the preventative for at least 6 trials of these agents in CDH.
months of good (but rarely complete) symptom control. Anticonvulsants are another class of preventative medications
used in CDH. Topiramate can be started at 0.5–1 mg/kg/day
6.2.1 Practical (But Unproven) Aspects of Preventative Treatment (typically at 25 or 50 mg), and increased by that amount every
Unfortunately, there have been few prospective randomized week until improvement in the headache, or a target dose of
controlled studies in the pediatric population to give us guidance 100–200 mg/day is reached. Mental clouding can occur frequent-
as to what is the most effective or safe medication to use in ly, and some patients will have a decreased appetite, paresthesias,
CDH.[23] Even less is known about optimal dosing. or decreased sweating. Valproate is also used at dosages between
10 and 30 mg/kg/day in children. A typical starting dosage in a
There is no consensus of opinion as to what the first choice or
teenager is 500 mg every evening in the extended-release form.
starting dose should be for preventive therapy in patients with
This can be titrated up on a weekly basis as tolerated. Liver
CDH. Many headache doctors feel that a preventative agent should
dysfunction and pancreatitis are rare adverse effects but weight
be given an adequate trial of 1–3 months before giving up on the
gain is frequent. Caution is needed when used in female patients
medication. Just as our patients with medically intractable epilep-
because of the potential teratogenic effects of valproate. Gabapen-
sy may require higher doses of anticonvulsants for symptom
tin can be started at a dosage of 300 mg twice daily. In many
control, we should not be surprised if our CDH patients may
patients, this will then be titrated up by 300 mg every week until an
require higher doses of preventatives than our patients with epi-
sodic migraine. A summary of prevention drugs for CDH is effective dosage is reached, or until a maximum daily dosage of
presented in table I. A prevention approach for children and 3600 mg/day is reached. Many patients may need dosages be-
adolescents with CDH based on the experience of one of the tween 1800 and 3600 mg/day. This may be helpful in patients who
authors (KJM) is as follows. also have restless legs syndrome. Weight gain and irritability are
occasionally seen in some patients taking gabapentin. Other an-
Table I. Prevention drugs for chronic daily headache ticonvulsants are also beginning to be used, including leve-
tiracetam and pregabalin. The dosage ranges for and effectiveness
Drug Dosage range in the Common problems
pediatric population
of these medications have yet to be determined for CDH.
Amitriptyline 10–75 mg qhs Sleepiness and weight gain In patients with orthostatic symptoms or tremor, β-adre-
Cyproheptadine 2–18 mg qd Sleepiness and weight gain noceptor antagonists such as propranolol, atenolol, or metoprolol
Valproate 125–500 mg bid Sleepiness and weight gain can be useful. A typical dosage is 1 mg/kg/day. Atenolol is
semisodium formulated in 25 and 50 mg tablets, and there are long-acting
Flunarizine 5–10 mg qd Not available in the US forms of propranolol in 60 and 80 mg tablets that can be given
Gabapentin 300–1200 mg tid Sleepiness once daily. Nightmares and irritability occur in some patients.
Propranolol 40–120 mg tid Exercise intolerance, Caution should be used in patients with asthma or diabetes mel-
asthma litus.
Topiramate 25–100 mg bid Learning difficulties, weight Verapamil can be started at a dosage of 120 mg/day in a
loss teenager, and a typical dosage for children is in the range of
Verapamil 80–240 mg tid Constipation, orthostatic 2–6 mg/kg/day, with the dosage titrated up as needed. Experience
changes shows that this medication will frequently lower blood pressure,
bid = twice daily; qd = once daily; qhs = every bedtime; tid = three times and these patients should be appropriately monitored. Weight
daily.
gain, dizziness, and constipation can also be adverse effects.

© 2008 Adis Data Information BV. All rights reserved. Pediatr Drugs 2008; 10 (1)
28
Hemicrania continua is a rare headache syndrome, occurring in
<1% of CDH patients. It is a persistent unilateral headache pain.
The pain may be characterized by a stabbing sensation, and may be
associated with autonomic changes. Daily doses of indomethacin
will improve this condition. Therefore, a trial of indomethacin
should be considered in CDH patients who present with a primari-
ly unilateral headache. A reasonable trial of indomethacin would
be 25 mg three times daily for 3 days, increasing, if needed, to
50 mg three times a day for 3 days, and then, if needed, to 75 mg
three times a day for 3 days. Most patients with hemicrania
continua will respond with this approach. Indomethacin should be
continued for as long as the patient needs, which can vary from
days to months. Indomethacin can be quite irritating on the stom-
ach, and concurrent use of a proton pump inhibitor may be
warranted.
6.3 Additional Management Approaches
Patients with CDH can become debilitated. They may have
missed a lot of school, become isolated from friends and after
school activities, and refrain from exercise. The physician must be
an advocate to reinforce normalcy whenever possible. This may
involve intervening with the guidance counselor at school or
educating school administrators about chronic headache. Students
must be able to have flexible scheduling with a gradual re-
integration process, starting at as little as 1 hour per day. The stress
of a chronic headache patient being forced to either be in school
full time or out of school full time makes recovery difficult. Since
patients with chronic headache look normal, there is often a heavy
degree of skepticism in the school system that needs to be ad-
dressed.
CDH patients should be encouraged to exercise a little every
day. If a patient does not go to school and does not remain mobile,
they are at increased risk for sleep disturbance, depression, and
autonomic dysfunction. Using a treadmill at low speed for as little
as 5–10 minutes a day should be tried.
Biofeedback, relaxation therapy, hypnosis, and cognitive-be-
havioral therapy work well for patients motivated to practice on a
daily basis.[35] Attention to mood disorders and anxiety may re-
quire referral to a psychologist. It has been our experience that
busy, organized people like to take control of their lives, and do
well with these modalities, whereas, people who tend to be disor-
ganized and are poor time managers may not be able to commit to
the rigors of daily practice. Patients with chronic pain often have
muscle tightness and trigger points. Referral to a physical therapist
is an important part of the management plan.
There is an interesting seasonal variability in the degree of
CDH symptoms. Most patients will do better in the summertime,
and frequently have a worsening of their headaches at the start of
the school year. The reason for the latter is unknown, but may
relate to factors such as stress, loss of sleep, bright lights in the
© 2008 Adis Data Information BV. All rights reserved.
Mack & Gladstein
school, decreased access to exercise, decreased time for relaxation,
and the propensity of some teenagers to skip breakfast in order to
make it to school on time.
There are limited data looking at the outcome of CDH in
children.[9,36,37] The average duration of CDH symptoms in child-
hood is unknown, but it is not unusual to see children who have
CDHs that persist for months to years. According to a study by
Hershey et al.,[5] the prognosis for CDH in childhood is based on
the following general patterns: the best prognosis is for patients
with a headache that occurs not every day and not all day; an
intermediate prognosis is for patients with headache occurring
every day but not all day; and the worst prognosis is for patients
with a headache all day every day. Patients in the worst prognostic
category need to be offered more aggressive treatment, and those
with the best prognosis may need less intervention.
Realistic expectations for CDH are often hard to accept. There
are often no immediate or easy answers to the difficult treatment
issues; hard work, fighting through the pain and reintegration into
school are required. It is difficult for many families to comprehend
that the head pain can persist for such a long time, that there are no
abnormalities showing up on diagnostic testing, and that the
medications prescribed are not immediately effective. It is not
unusual for patients with chronic headache to see multiple doctors
because of this frustration. To limit this, it is useful to spend
adequate time discussing the nature of CDH, how secondary
causes of headache have been ruled out, the role of medications,
how to avoid OTC pain relievers, the role of biofeedback or
physical therapy, and stressing normalcy whenever possible.
Follow-up should be scheduled on a routine basis until symp-
toms are well controlled. It is not unusual to make frequent
adjustments in the management approach, and it may take months
before the right preventative medication or the right therapeutic
approach is identified for an individual patient. Effective manage-
ment becomes a partnership with many visits and contacts. It is
hoped that with successful identification of this syndrome and
aggressive pharmacologic and non-pharmacologic management,
the misery of CDH can be alleviated or at least mitigated for
children and their families.
7. Conclusion
CDH in children and adolescents, a diagnosis of exclusion, is
often the consequence of an evolution from episodic migraine or
tension-type headache. Reasons for this transformation at present
are only conjecture. There is very little currently in the literature to
support consensus treatment, and we do not know what the long-
term outcome is for these young patients. Therefore, this area of
study begs for drug trials, trials of nonpharmacologic approaches,
and long-term outcome studies. Do these children grow up to be
debilitated or healthy adults, successes in life or burnt-out head-
ache sufferers with a poor future? How does leaving one’s home
Pediatr Drugs 2008; 10 (1)
Management of Chronic Daily Headache
after high school affect psychosocial functioning and ultimate
outcome? It is our hope that these questions will be studied, so we
will be able to offer children and their parents good treatment and
realistic advice.
Acknowledgments
No sources of funding were used to assist in the preparation of this review.
Jack Gladstein is on the Speakers Bureau for GlaxoSmithKline, Pfizer and
AstraZeneca.
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Correspondence: Dr Kenneth J. Mack, Child and Adolescent Neurology,
Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA.
E-mail: Mack.Kenneth@mayo.edu
Pediatr Drugs 2008; 10 (1)