Summary
Definition
History and exam
Key diagnostic factors
- underlying primary headache disorder
- headache on ≥15 days per month
- overuse of acute headache medication for >3 months
Other diagnostic factors
- normal neurological examination
- absence of red flag symptoms and/or signs
Risk factors
- migraine as the underlying primary headache disorder
- female sex
- use of opioid, barbiturate, triptan, or ergot derivative
- anxiety and/or depression
- chronic musculoskeletal disease
- chronic gastrointestinal disease
- low-level education
Diagnostic investigations
1st investigations to order
- clinical diagnosis
Investigations to consider
- MRI brain
- CT brain
- CRP/erythrocyte sedimentation rate (ESR)
- lumbar puncture (LP)
- cerebrospinal fluid (CSF) culture
Treatment algorithm
adults: uncomplicated
adults: complex
children and adolescents
Contributors
Authors
Sait Ashina, MD, FAHS
Director
BIDMC Comprehensive Headache Center
Beth Israel Deaconess Medical Center
Assistant Professor of Neurology and Anesthesia
Department of Neurology and Anesthesia
Critical Care and Pain Medicine
Harvard Medical School
Boston
MA
Disclosures
SA declares that he has received fees for consulting from Allergan, AbbVie, Eli Lilly, Impel NeuroPharma, Linpharma, Lundbeck, Satsuma, and Theranica. He has received fees for teaching from Eli Lilly and Teva. He has received unrestricted research grants from AbbVie, Eli Lilly, and NINDS, paid to his hospital/institution. SA also serves as Associate Editor for the journals Neurology Reviews, Frontiers in Neurology, and BMC Neurology, and is an advisory board member for the Journal of Headache.
Hsiangkuo Yuan, MD, PhD
Associate Professor of Neurology
Department of Neurology
Director of Clinical Research
Jefferson Headache Center
Thomas Jefferson University
Philadelphia
PA
Disclosures
HY declares that he has received a grant from the National Institutes of Health (reference R44NS115460). He has served as a site investigator for Teva, AbbVie, Trillen, and Thermaquil. He has also served on advisory boards or as a consultant for Silva, Clexio Biosciences, and Pfizer.
Peer reviewers
Benjamin Wakerley, FRCP, PhD
Consultant Neurologist
Headache Lead
University Hospital Birmingham NHS Foundation Trust
Honorary Clinical Associate Professor
University of Birmingham
Birmingham
UK
Disclosures
BW declares that he has received speaking fees from AbbVie. He is the founder of Ceftronics Ltd and a creator of the CEFREF headache app.
Alyssa Ann LeBel, MD
Director
Chronic Headache Program
Boston Children's Hospital
Associate Professor of Anesthesia
Harvard Medical School
Boston
MA
Disclosures
AAL declares that she has no competing interests.
Differentials
- Chronic primary headache disorder
- Idiopathic intracranial hypertension (pseudotumor cerebri)
- Spontaneous intracranial hypotension and/or cerebrospinal fluid (CSF) leak
More DifferentialsGuidelines
- European Academy of Neurology guideline on the management of medication-overuse headache
- International classification of headache disorders, 3rd edition
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