CHRONIC DAILY HEADACHE

Objective: Chronic primary daily headache is more common than originally thought. It does not appear to be a singular disorder but rather one with various subtypes, including chronic migraine (evolved migraine or transformed migraine), chronic tension‐type headache, newly defined daily persistent headache, hemicrania continua, and posttraumatic headache. These subtypes and their mangement are the focus of this review. Summary: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, which the author believes is an inherited predisposition. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and phamacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be idetnified and treated as well. Comment: Dr. Gary Ruoff has a very large headache practice, and has been thinking about the clinical issues of CDH for many years. He is also an original thinker and fastidious clinical researcher, so when he writes, I always find it illuminating. He is in the process of completing a large study on CDH, migraine, and comorbidity from his family practice, and this article is the first of what I hope will be many from that project.—Stewart J. Tepper, MD