Management of chronic headache in primary health care

Full article

https://doi.org/10.53453/ms.2025.11.8

Ieva Bružaitė

, Eivydė Dagiliūtė

, Aistė Česnulevičienė

Faculty of Medicine, Lithuanian University of Health Sciences. Kaunas, Lithuania

Lithuanian University of Health Sciences, Department of Family Medicine Kaunas, Lithuania

Abstract

Background. Chronic headaches—such as chronic migraine, tension-type headache, and medication-overuse

headache—are common, disabling conditions in primary care that significantly affect quality of life and strain

healthcare systems. Effective management requires accurate diagnosis and a multimodal approach, including

medication, lifestyle changes, and patient education.

Aim. To review recent literature on the types, causes, and treatment of chronic headaches.

Material and Methods. A literature review using PubMed, Google Scholar, and UpToDate was conducted with

keywords including “chronic headache,” “migraine,” “medication-overuse headache,” “tension headache,”

“causes,” and “treatment.” Only English-language studies from the past 10 years were included.

Results. Chronic migraine, chronic tension-type headache, and medication-overuse headache (MOH) are the most

prevalent forms. Risk factors include younger age, female gender, psychiatric disorders, poor sleep, obesity, stress,

and medication overuse. Diagnosis is clinical, imaging is used to exclude secondary causes. Management involves

both pharmacological (e.g., beta-blockers, antidepressants, calcitonin gene-related peptide inhibitors) and non-

pharmacological treatments (e.g., cognitive-behavioral therapy, physical therapy, lifestyle changes). MOH

requires medication withdrawal followed by preventive care.

Conclusion. Chronic headaches are a common complaint among patients in family medicine practice. Effective

management of the disease depends on establishing the correct diagnosis, selecting the right treatment, and

correcting risk factors.

Keywords: chronic headache, migraine, medication-overuse headache, tension headache.

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Medical Sciences 2025 Vol. 13 (5), p. 82-92, https://doi.org/10.53453/ms.2025.11.8

1. Introduction

The condition of chronic headache is

characterized by the presence of headaches

occurring 15 days or more per month for a

duration exceeding 3 months (1). The prevalence

of chronic pain (CP) varies, ranging from 11% to

40%, with chronic headache (CH) consistently

affecting a distinct population (2).

Headaches are classified into two main

categories: primary and secondary. Primary

headaches are not attributed to an underlying

medical condition, meaning the headache itself

is the primary pathology. Individuals with

primary headaches, by definition, typically show

no abnormalities upon physical and neurological

examination (3). In contrast, secondary

headaches are attributed to identifiable

underlying pathological conditions, such as

intracranial hemorrhage, tumors, or other

structural abnormalities (4).

The third edition of the international

Classification of Headache Disorders (ICHD-3),

chronic headaches categorized into distinct

subtypes, which are CM, chronic tension-type

headache (CTTH), medication-overuse

headache (MOH) (5). Chronic migraine (CM)

impacts about 2% of adults in the overall

population, whereas CTTH has a prevalence of

1.7% to 2.2%, and MOH occurs in 1% to 2% of

adults (6,7).

2. Methods

A detailed review of the current literature was

conducted by searching databases such as

PubMed, UpToDate, and Google Scholar to

gather information related to chronic headaches.

The focus was on understanding their

occurrence, contributing factors, biological

mechanisms, diagnostic methods, available

treatments, and strategies for prevention. The

search involved specific terms including

“chronic headache,” “migraine,” “medication-

overuse headache,” and “tension headache.”

Studies were selected based on the following

inclusion criteria:

• Published between 2015 and 2025 to ensure

relevance and recency.

• Written in the English language.

• Classified as peer-reviewed original

research, systematic reviews, meta-

analyses, or clinical practice guidelines.

• Specifically addressed chronic headache in

terms of its epidemiology, causes,

mechanisms, diagnosis, management, or

prevention.

• Conducted on human populations.

The exclusion criteria included:

• Publications in languages other than

English.

• Articles released before 2015.

• Studies for which the full text was not

accessible.

3. Results and discussion

A total of 50 studies were included in this

literature review, all of which met the predefined

inclusion criteria (Table 1). Research has

recently zeroed in on chronic headaches,

including CM, CTTH, and MOH. The most

recent and relevant evidence—from systematic

reviews, meta-analyses, and clinical trials

published in the last five years—has been

selected to shed light on their causes, risk

factors, diagnosis, and management. While some

studies highlight the power of non-drug

approaches, like cognitive-behavioral therapy

and lifestyle changes, others are exploring

cutting-edge treatments such as CGRP

(calcitonin gene-related peptide) monoclonal

antibodies. Interestingly, one study uncovered a

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strong connection between MOH and metabolic

syndrome in female patients. Other research

confirms that CGRP antagonists are highly

effective, not only at reducing headache

frequency but also at preventing them from

coming back in people suffering from CM and

MOH.

1 table. Analysis of Included Studies.

Authors, country,

Titles

Study Type

Aim

Key Findings

Ashina et al., 2023 (USA)

Medication-overuse headache

(MOH) (7)

Systematic

Review

Systematic review of

recent studies and

guidelines on MOH.

MOH is a common and challenging

condition; CGRP antibodies are

promising.

Lampl et al., 2023 (USA)

The Comparative Effectiveness of

Migraine Preventive Drugs: A

Meta-analysis (8)

Meta-analysis

Comparative efficacy

of migraine

preventive

medications

CGRP monoclonal antibodies and

topiramate are superior for prophylaxis.

Diener et al., 2019 (Germany)

Pathophysiology, Prevention, and

Treatment of MOH (9)

Narrative

Review

MOH

pathophysiology and

prevention

Emphasizes medication withdrawal and

a multimodal treatment approach

including behavioral strategies.

Dodick et al., 2018 (USA)

Fremanezumab for Chronic

Migraine: A Randomized Trial (10)

Randomized

Clinical Trial

Fremanezumab for

chronic migraine

Fremanezumab significantly reduced

migraine days and had a favorable

safety profile.

Klan et al., 2022 (Germany)

Efficacy of Cognitive-Behavioral

Therapy for the Prophylaxis of

Migraine in Adults (11)

Randomized

controlled trial

To assess the

effectiveness of

cognitive-behavioral

therapy (CBT) in

preventing migraine

episodes.

CBT significantly reduced the number

of migraine days and improved

patients’ quality of life and stress

management. It supports CBT as an

effective non-pharmacological

prophylactic intervention.

Fan et al., 2022 (China)

A Bibliometric Analysis of

Tension-Type Headache Research

(12)

Bibliometric

Analysis

Research trends in

tension-type headache

Non-pharmacological therapies (e.g.,

physical therapy) are receiving growing

attention in TTH research.

3.1. Risk factors

The chronification of headache illnesses is

multifactorial, involving a combination of

biological, psychological, and behavioral

determinants. Epidemiological data indicate that

individuals under 50 years of age, females, and

those with lower educational attainment are at

increased risk. Chronic physical conditions,

especially those affecting the musculoskeletal

and gastrointestinal systems, are linked to a

higher chance of headache chronification (13).

Disrupted sleep patterns, including conditions

like insomnia and sleep apnea, are significantly

correlated with higher headache occurrence and

lowered pain tolerance (14). Conditions like

anxiety, depression, and chronic psychological

stress can lower migraine thresholds and

promote central sensitization, largely due to

imbalances in the hypothalamic-pituitary-

adrenal (HPA) axis (15). Lifestyle factors,

including tobacco use, physical inactivity, and

excessive caffeine consumption (defined as

>540 mg/day), are independently correlated with

headache progression (13). Obesity is believed

to be linked to greater pain intensity and a

reduced effectiveness of treatment. People

associated with increased pain intensity and a

poorer response to treatment with a body mass

index (BMI) between 25 and 29 have

approximately three times the risk of developing

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chronic daily headache (CDH), whereas those

with a BMI of 30 or higher face a fivefold

increased risk (14).

Inherited genetic factors play a significant role in

migraine susceptibility. While common

migraines are polygenic, involving multiple

genetic variants each contributing modestly to

risk, rare monogenic forms like familial

hemiplegic migraine (FHM) are caused by

mutations in single genes. Notably, mutations in

genes such as CACNA1A, ATP1A2, and

SCN1A have been implicated in FHM, affecting

ion channels and neuronal excitability (16).

Medication overuse remains one of the most

significant modifiable risk factors for the

development of CM. Recurrent use of acute

pharmacologic therapies—particularly triptans,

opioids, and nonsteroidal anti-inflammatory

drugs (NSAIDs)—can lead to increased

headache frequency and central sensitization (9).

Clinical studies have shown that females often

have more acute, severe pain, and use analgesics

more than males (1). Hormonal changes,

especially those related to menstruation,

pregnancy, and menopause, are thought to affect

migraine patterns in women, likely by altering

estrogen levels and neuropeptide function (17).

3.2. Medication-overuse chronic headache

MOH was first described in 1951, when

clinicians observed that patients with frequent

migraines or tension-type headaches improved

after stopping ergotamine (18). Often called

rebound headache, MOH may arise from the

habitual use of medications designed to relieve

acute headache symptoms. The International

Headache society defines overuse as the use of

triptans, ergotamine, or opioids on at least ten

days per month over three months, or taking

aspirin or other NSAIDs on 15 or more days per

month over a three-month period. Individuals

who take different acute headache drugs are

more prone to developing medication overuse

headache (14).

While the exact biological mechanism

underlying MOH is not fully understood, current

theories suggest that prolonged use of abortive

headache medications may lead to serotonin (5-

HT) depletion. This can increase neuronal

excitability in the cerebral cortex and trigeminal

system, potentially triggering cortical spreading

depression and contributing to peripheral and

central sensitization. A drop in serotonin levels

may also enhance the release of CGRP from the

trigeminal ganglia, further facilitating

nociceptive sensitization (19).

Clinicians should remain vigilant and consider

secondary causes of chronic headache in patients

suspected of medication overuse. Conditions

such as idiopathic intracranial hypertension or

cerebral venous sinus thrombosis can mimic

MOH and require specific diagnostic evaluation.

Medication overuse should be specifically

assessed in patients presenting with chronic

migraine, chronic tension-type headache, or

chronic daily headache (20).

Effective management of MOH involves a

combination of acute medication withdrawal,

preventive pharmacologic treatment, and non-

pharmacologic strategies (21). Topiramate and

onabotulinumtoxinA have demonstrated

efficacy in patients with CM and MOH (22).

More recently, CGRP monoclonal antibodies

such as erenumab, fremanezumab, and

galcanezumab have shown strong evidence of

reducing headache days and resolving

medication overuse in a significant number of

patients (18).

3.3. Chronic tension-type headache

Among all headache types, CTTH is the most

prevalent (23). CTTH often arises from the

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progression of episodic TTH (tension-type

headache) due to prolonged nociceptive input

from the myofascial tissues surrounding the

pericranium (24). This sustained nociceptive

stimulation leads to central sensitization, a

process that heightens pain sensitivity and

lowers the pain threshold (25).

According to the ICHD-3, CTTH is defined as a

headache occuring 15 or more days every month

over a minimum period of three months. The

headaches associated with CTTH can last for

hours or even days, and they often are persistent.

Diagnostic features include bilateral pain, a

compressing or tightening (non-pulsating)

sensation, mild to moderate intensity, and the

absence of exacerbation involved in regular

activities like walking or ascending stairs (26).

Effectively managing CTTH requires a holistic

approach that integrates both pharmacological

therapies and non-pharmacological interven-

tions, focused on decreasing headache rate and

severity, while also addressing the underlying

contributing factors (12).

Preventive Antidepressants: for frequent or

chronic TTH, daily prophylactic medication may

reduce headache frequency. Tricyclic

antidepressants like amitriptyline are the most

established preventive treatment – it can

significantly reduce headache frequency,

intensity, analgesic use, and disability in CTTH

(12). Other antidepressants with supporting

evidence for CTTH treatment include

mirtazapine (a tetracyclic antidepressant) and

venlafaxine (an SNRI). Guidelines (EFNS)

recommend amitriptyline, mirtazapine, or

venlafaxine as preventive options for CTTH

(26). These can modestly reduce headache

frequency, though mirtazapine and venlafaxine

are usually considered if amitriptyline is poorly

tolerated. Some other drugs are occasionally

used off-label for CTTH, though evidence is

limited. For example, certain anticonvulsants

(antiepileptic drugs) like topiramate or

gabapentin have been tried in chronic tension

headache prophylaxis. An open-label study

suggested topiramate might help reduce CTTH

frequency, but robust clinical trial data are

lacking (27).

Non-drug therapies are central to managing

CTTH and can be used alone or alongside

medications. They aim to reduce headache

frequency, relieve muscle tension, and improve

coping. CBT and stress management techniques,

including relaxation help reduce headache

frequency and improve coping in CTTH

patients. CBT teaches patients to modify stress

responses and coping strategies (12). Overall,

CBT and relaxation training are effective at

lowering headache days and improving quality

of life (28).

Physical therapy and exercise: a range of

physical approaches can alleviate CTTH.

Aerobic exercise and stretching/strengthening

exercises for the neck and shoulder girdle may

reduce the frequency and intensity of headaches

over time. Cervical muscle mobilization, spinal

manipulation, and myofascial release (massage)

are effective techniques for reducing muscle

tension. Trigger-point therapy (e.g. pressing or

needling muscle knots in the neck/shoulders) can

also relieve pain: it has been demonstrated to

decrease headache intensity in tension-type

headache (26).

3.4. Chronic migraine

According to the ICHD-3 criteria, CM involves

experiencing headaches on at least 15 days a

month for a duration of three months or more,

fulfilling specific diagnostic criteria. The

condition must occur in a patient with a history

of migraine, having experienced at least five

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attacks that meets the diagnostic criteria for

migraine with or without aura. In addition, for at

least eight days each month over a period of no

less than three months, the headaches must either

fulfill the diagnostic criteria for migraine

without aura, meet the criteria for migraine with

aura, or be considered by the patient to be a

migraine at onset and respond to treatment with

a triptan or ergot derivate (26).

Chronic migraine is typically characterized by

moderate to severe headache pain described

often unilateral and has a pulsating or throbbing

quality (5). Routine physical activities often

worsen the pain, which may be accompanied by

nausea, sensitivity to light, and sensitivity to

sound (29).

While migraine is already a prevalent episodic

disorder, approximately 2–3% of episodic

migraine cases transition into chronic migraine

each year. The process of chronification — the

shift from episodic migraine to its chronic form

— is multifactorial, involving an interplay

between genetic, environmental, behavioral, and

physiological factors (30).

The pathophysiology of CM is intricate,

involving both peripheral and central processes

involved to the persistence and intensification of

migraine episodes. Whereas episodic migraine

typically involves short-term activation of pain

pathways, chronic migraine is marked by lasting

alterations in the central nervous system (CNS)

that lower the threshold for headache

initiation (30).

One of the central components implicated in

migraine pathogenesis is the stimulation of the

trigeminovascular system. During migraine

attacks, trigeminal afferents release vasoactive

neuropeptides, including a neuropeptide known

as CGRP, substance P, and neurokinin A,

leading to neurogenic inflammation and

vasodilation of cranial blood vessels (31).

Cortical spreading depression (CSD) involves a

slow wave of brain cell depolarization, after

which neural activity is temporary silenced, is

implicated particularly in migraines with aura,

but may also trigger inflammatory responses that

sensitize trigeminal afferents and contribute to

migraine perpetuation (32). These central

abnormalities contribute to the widespread non-

headache symptoms often seen in chronic

migraine, including fatigue, cognitive

impairment, and mood disturbances (33).

CM poses significant treatment challenges due

to its frequency, severity, and significant impact

on quality of life (33). For treating headaches,

the best approach is a combination of medication

and non-drug methods. The goal is to not only

lessen how often, how bad, and how long the

headaches last but also to help the person feel

better overall. (8).

There is strong evidence that certain drugs can

help with headaches. These include beta-

blockers like propranolol, antiepileptic drugs

such as topiramate, and tricyclic antidepressants

like amitriptyline. Among these, amitriptyline

may offer additional benefits for patients with

comorbid depression or insomnia, supporting a

more individualized approach to migraine

prevention based on coexisting conditions (8).

The introduction of CGRP monoclonal

antibodies (erenumab, fremanezumab,

galcanezumab, and eptinezumab) marks a

significant advancement, providing targeted

therapy with demonstrable efficacy and

favorable safety profiles (10,34).

Acute migraine episodes are typically managed

with triptans (e.g., sumatriptan, rizatriptan),

which are serotonin receptor agonists that

effectively alleviate migraine attacks (35).

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Recently developed CGRP receptor antagonists

(gepants, such as ubrogepant and rimegepant)

and serotonin 5-HT1F receptor agonists (ditans,

like lasmiditan) offer viable alternatives for

patients contraindicated or non-responsive to

triptans (36,37).

Non-pharmacological interventions are essential

adjuncts to medication. OnabotulinumtoxinA

(Botox) injections administered every 12 weeks

have demonstrated efficacy in significantly

reducing the frequency of headache days in

patients with CM (38). Neuromodulation

devices, such as transcutaneous supraorbital

neurostimulation (e.g., Cefaly) and non-invasive

vagus nerve stimulation (e.g., gammaCore),

have proven to be effective for both preventive

and acute management of chronic migraine (39).

Lifestyle interventions play a critical role in the

management of migraine and can complement

pharmacological therapies to improve outcomes

(40). Regular aerobic exercise has been shown to

reduce the frequency and intensity of migraine

attacks, possibly through modulation of

neurovascular and neuroinflammatory

mechanisms. Consistent sleep patterns and stress

management techniques, such as mindfulness

and relaxation training, are associated with

decreased migraine burden (11).

4. Discussion

An important aspect in the evaluation of CDH in

primary care is the timely exclusion of secondary

causes (41). Family physicians play a central

role in this process, as they are often the first to

assess patients with persistent headaches (42).

While diagnostic tools such as neuroimaging are

available when indicated, the challenge lies in

recognizing clinical warning signs that may

suggest more serious underlying conditions,

including tumors, infections, or vascular

abnormalities (14).

Imaging is indicated in cases of sudden or severe

changes in headaches, onset after the age of 50,

thunderclap headaches and new neurological

signs (e.g. visual disturbances, focal deficits or

papilledema) (41–43). Imaging is also warranted

in cases of systemic signs (e.g. fever or weight

loss), immunosuppression, or a history of cancer,

with magnetic resonance imaging being

preferred for its sensitivity (42,44). A careful

assessment ensures both safety and efficient use

of resources (43).

5. Conclusion

Chronic headaches significantly impact patients’

daily lives and overall well-being, making them

a common concern in primary care. The three

most common subtypes — CM, CTTH and

MOH — share some features, but also have

distinct underlying mechanisms that inform

treatment.

Despite their differences, all three conditions

benefit from a comprehensive, individualised

approach combining pharmacological and non-

pharmacological strategies. Key aspects of

management include the use of preventive

medication, such as CGRP inhibitors or

antidepressants, when appropriate; the

withdrawal of overused drugs in MOH; and

lifestyle modifications, such as improved sleep

hygiene, regular physical activity and stress

reduction. Non-drug interventions, such as

cognitive behavioural therapy and

physiotherapy, are also important.

Primary care providers play a pivotal role in

offering early recognition, coordinated

management and long-term follow-up. Their

involvement is vital in preventing progression,

reducing disability and improving quality of life.

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Management of chronic headache in primary health care