In the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta),1)2) primary headache disorders other than migraine, tension-type headache and cluster headache are grouped together as “Other primary headaches disorders”. They are classified into primary cough headache, primary exercise headache, primary headache associated with sexual activity, primary thunderclap headache, cold-stimulus headache, external-pressure headache, primary stabbing headache, nummular headache, hypnic headache, and new daily persistent headache.
| Grade A |
In the first edition of the International Classification of Headache Disorders published in 1988 by the Headache Classification Committee (Chairman, Jes Olsen) of the International Headache Society,3) these headaches were grouped under “Miscellaneous headaches unassociated with structural lesion”.
The headaches were classified into the following types: idiopathic stabbing headache, external compression headache, cold stimulus headache, benign cough headache, benign exertional headache, and headache associated with sexual activity. Cold stimulus headache was further divided into two subtypes: external application of a cold stimulus, and ingestion of a cold stimulus. Headache associated with sexual activity was classified into dull type, explosive type, and postural type.
When the first edition of the International Classification of Headache Disorders was undergoing complete revision, the Japanese Headache Society (International Classification Promotion Committee) in collaboration with the Ministry of Health, Labour and Welfare Study Group (Study Group for Chronic Headache Clinical Guideline) translated the revised guidelines4) and published the Japanese Edition of the International Classification of Headache Disorders 2nd Edition.5) In the second edition, headache disorders other than migraine, tension-type headache and cluster headache have been classified under the new term “Other primary headaches”.
Headache disorders are classified according to the International Classification of Headache Disorders 3rd Edition (beta version) (ICHD-3beta), published in 2013.2) In the ICHD-3beta, primary headache disorders other than migraine, tension-type headache and cluster headache are grouped under “Other primary headaches disorders”, and classified into ten types as follows: primary cough headache, primary exercise headache, primary headache associated with sexual activity, primary thunderclap headache, cold-stimulus headache, external-pressure headache, primary stabbing headache, nummular headache, hypnic headache, and new daily persistent headache.
Primary stabbing headache is transient and localized stab-like headache that occurs spontaneously in the absence of organic disease in local structures or in the cranial nerves.
Primary cough headache is headache triggered by coughing or straining, in the absence of intracranial diseases.
Primary exercise headache is headache triggered by exercise (regardless of type). Subforms such as “weight-lifters’ headache” are recognized.
Primary headache associated with sexual activity is headache precipitated by sexual activity, usually starting as a bilateral dull ache as sexual excitement increases and suddenly intensifies at orgasm, in the absence of intracranial diseases.
Hypnic headache manifests as dull headache attacks that always awaken the patient from asleep.
Primary thunderclap headache is high-intensity headache of abrupt onset mimicking that of ruptured cerebral aneurysm.
Hemicrania continua is persistent, strictly unilateral headache responsive to indomethacin.
Hemicrania continua, originally grouped under “Other primary headaches disorders” in International Classification of Headache Disorders 2nd Edition (ICHD-II), is moved to “Trigeminal autonomic cephalalgias: TACs” in ICHD-3beta.
New daily persistent headache is headache that is daily and unremitting from very early after onset. The pain is typically bilateral, pressing or tightening in quality, and of mild to moderate intensity. Photophobia, phonophobia or mild nausea may occur.
Some of these headaches are symptomatic. Careful evaluations using neuroradiological imaging such as MRI, and other tests are necessary.
1) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of International Classification of Headache Disorders, 3rd edition (beta version). Igakushoin, 2014. (In Japanese)
2) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd Edition (beta version). Cephalalgia 2013; 33(9): 629-808.
3) Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988; 8(suppl 7): 1-96.
4) Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders; 2nd edition. Cephalalgia 2004; 24(suppl 1): 9-160.
5) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of the International Classification of Headache Disorders 2nd Edition. Igakushoin, 2007. (In Japanese)
• Search database: Ovid (2011/12/21)
Headache and Headache disorders 560
{Headache and Headache disorders} and Classification 87
• Search database: Ichushi Web for articles published in Japan (2011/12/21)
Headache 5576
Headache and classification 166
Headache and classification and clinical guideline 9
1. Diagnosis
Primary stabbing headache, primary cough headache, and primary exercise headache are diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta).
| Grade A |
2. Treatment
Although no randomized controlled trials of treatment for these headaches have been reported, indomethacin is considered effective in most cases for these headaches. As adverse effect of indomethacin, gastrointestinal symptoms may be an issue when used long-term. Other drugs have been tried, but are limited to case reports and small case series.
| Grade C |
Primary stabbing headache, primary cough headache, and primary exercise headache are included in primary headaches other than migraine, tension-type headache, and cluster headache. The objective of this section is to review the reports on the diagnosis and treatment of these disorders.
1. Diagnosis
(1) Primary stabbing headache1)2)
A. Head pain occurring spontaneously as a single stab or series of stabs and fulfilling criteria B-D
B. Each stab lasts for up to a few seconds
C. Stabs recur with irregular frequency, from one to many per day
D. No cranial autonomic symptoms
E. Not better accounted for by another ICHD-3 diagnosis
(2) Primary cough headache1)2)
A. At least two headache episodes fulfilling criteria B-D
B. Brought on by and occurring only in association with coughing, straining and/or other Valsalva maneuver
C. Sudden onset
D. Lasting between 1 second and 2 hours
E. Not better accounted for by another ICHD-3 diagnosis
(3) Primary exercise headache1)2)
A. At least two headache episodes fulfilling criteria B and C
B. Brought on by and occurring only during or after strenuous physical exercise
C. Lasting <48 hours
D. Not better accounted for by another ICHD-3 diagnosis
2. Treatment
Several uncontrolled studies have reported response to indomethacin,3)4) but there are also reports of partial or even no response. Mathew5) treated 5 patients with 50 mg indomethacin 3 times a day and reported drastic reduction in mean headache frequency in a week compared to aspirin and placebo. On the other hand, Pareja et al.6) studied the clinical features of 38 patients, and reported that among 17 patients treated with 75 mg/day indomethacin for 15 days, 6 patients (35%) achieved complete remission and 5 patients had partial remission, while 6 patients (35) were refractory to treatment. Several case reports are available for drugs other than indomethacin. They include a report of a 71 year-old woman responding to nifedipine sustained release tablet 90 mg/day;7) a report of 3 cases recommending a treatment regimen of melatonin starting at a dose of 3 mg/day and increasing gradually;8) a report of 4 young onset cases responding to gabapentin 400 mg/day;9) and 3 cases responding to celecoxib, a cyclooxygenase-2 inhibitor.10)
This headache usually responds to indomethacin. Mathew5) conducted a double-blind study in 2 patients, and reported the effectiveness of indomethacin 150 mg/day. Raskin11) treated 16 patients with indomethacin 50 to 200 mg (mean 78 mg) per day, and observed complete remission in 10 patients, moderate improvement in 4 patients and no response in 2 patients. In the report of Pascual et al.,12) response was observed in 6 of 13 patients treated with indomethacin 75 mg/day. Indomethacin is considered to be the most effective drug for symptomatic relief.13) As for the other treatments, Calandre et al.14) reported cases responding to propranolol 120 mg and also cases responding to methysergide. In one case reported by Mateo and Pascual,15) naproxen 550 mg given every 12 hours achieved partial relief. Wang et al.16) studied the usefulness of acetazolamide in 5 indomethacin responsive patients. Acetazolamide was started at a dose of 125 mg three times a day and titrated until maximum effect was obtained, up to a maximum of 2,000 mg/day. The outcome was complete response in 2 patients, favorable response in 2 patients and no response in 1 patient. Raskin11) treated 14 patients by performing lumbar puncture to remove 40 mL of cerebrospinal fluid, and reported response in 6 patients; with response observed immediately after the procedure in 3 patients, and 2 days or longer later in the other 3 patients.
3. Primary exercise headache
Indomethacin has long been used as the drug of choice for prophylactic treatment of exertional headache. Diamond17) treated 15 patients with indomethacin starting from 25 mg/day and titrating to a maximum dose of 150 mg. Response was obtained in 13 patients (87%). After headache was controlled, indomethacin was discontinued and headache recurred within 7 days in 12 of 13 patients. As for the other drugs, Pascual et al.12) tried ergotamine tartrate in 16 patients who took the drug before exertion started, and 4 patients reported subjective response showing potential prophylactic effect. They also treated 5 patients with propranolol prophylactically; 3 patients had irregular attacks, 1 patient showed clear response, while 1 patient did not respond but improved with indomethacin. A study in Japan also reported the usefulness of propranolol as a prophylactic drug.18) Furthermore, flunarizine was administered to 2 patients, and response was obtained in 1 patient.12)
1) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of International Classification of Headache Disorders, 3rd edition (beta version). Igakushoin, 2014. (In Japanese)
2) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version), Cephalalgia 2013; 33(9): 629-808.
3) Dodick DW: Indomethacin-responsive headache syndromes. Curr Pain Headache Rep 2004; 8(1): 19-26.
4) Fuh JL, Kuo KH, Wang SJ: Primary stabbing headache in a headache clinic. Cephalalgia 2007; 27(9): 1005-1009.
5) Mathew NT: Indomethacin responsive headache syndromes. Headache 1981; 21(4): 147-150.
6) Pareja JA, Ruiz J, de Isla C, al-Sabbah H, Espejo J: Idiopathic stabbing headache (jabs and jolts syndrome). Cephalalgia 1996; 16(2): 93-96.
7) Jacome DE: Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia 2001; 21(5): 617-618.
8) Rozen TD: Melatonin as treatment for idiopathic stabbing headache. Neurology 2003; 61(6): 865-866.
9) Frana MC Jr, Costa AL, Maciel JA Jr: Gabapentin-responsive idiopathic stabbing headache. Cephalalgia 2004; 24(11): 993-996.
10) Piovesan EJ, Zukerman E, Kowacs PA, Werneck LC: COX-2 inhibitor for the treatment of idiopathic stabbing headache secondary to cerebrovascular diseases. Cephalalgia 2002; 22(3): 197-200.
11) Raskin NH: The cough headache syndrome: treatment. Neurology 1995; 45(9): 1784.
12) Pascual J, Iglesias F, Oterino A, Vzquez-Barquero A, Berciano J: Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996; 46(6): 1520-1524.
13) Chen PK, Fuh JL, Wang, SJ: Cough headache: a study of 83 consecutive patients. Cephalalgia 2009; 29(10): 1079-1085.
14) Calandre L, Hernandez-Lain A, Lopez-Valdes E: Benign Valsalvas maneuver-related headache: an MRI study of six cases. Headache 1996; 36(4): 251-253.
15) Mateo I, Pascual J: Coexistence of chronic paroxysmal hemicrania and benign cough headache. Headache 1999; 39(6): 437-438.
16) Wang SJ, Fuh JL, Lu SR: Benign cough headache is responsive to acetazolamide. Neurology 2000; 55(1): 149-150.
17) Diamond S: Prolonged benign exertional headache: its clinical characteristics and response to indomethacin. Headache 1982; 22(3): 96-98.
18) Ikeda K, Kawase T, Takasawa T, Yoshii Y, Kawabe K, Iwasaki Y: Prophylactic effect of propranolol hydrochloride for primary exertional headache: comparison with indomethacin. Neurol Therap 2008: 25(5): 605-608. (In Japanese)
1. Diagnosis
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{Headache and Headache disorders} and Classification 170
2. Treatment
• Search database: PubMed (2012/1/30)
{Stabbing headache} 60
{Primary cough headache} or {Benign cough headache} or {Valsalva manoeuvre headache} 119
{Exertional headache} 68
1. Diagnosis
Primary headache associated with sexual activity is diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta). This headache is precipitated by sexual activity, and is diagnosed after excluding intracranial disorders by brain imaging study and cerebrospinal fluid examination.
| Grade A |
2. Treatment
To treat primary headache associated with sexual activity, it is necessary for the patient and the partner to understand the disorder. Pharmacotherapy using indomethacin, triptans and propranolol is effective in some cases.
| Grade C |
Statistical data from headache clinics suggest that primary headache associated with sexual activity is rare. However, potential patients probable exist in relatively large numbers. Appropriate approach to this disorder is necessary.
1. Diagnosis
The diagnostic criteria for primary headache associated with sexual activity are as follows1):
A. At least two episodes of pain in the head and/or neck fulfilling criteria B-D
B. Brought on by and occurring only during sexual activity
C. Either or both of the following:
1. increasing in intensity with increasing sexual excitement
2. abrupt explosive intensity just before or with orgasm
D. Lasting from 1 minute to 24 hours with severe intensity and/or up to 72 hours with mild intensity
E. Not better accounted for by another ICHD-3 diagnosis
When occurring at the first time, it is mandatory to exclude subarachnoid hemorrhage and internal carotid artery or vertebral artery dissection. Differential diagnosis also includes intracerebral hemorrhage, subdural hematoma, unruptured aneurysm, cerebral venous sinus thrombosis, Arnold-Chiari I malformation, posterior fossa neoplasm, increased intracranial pressure, decreased intracranial pressure, and cervical spinal cord disease.2) Reversible cerebral vasoconstriction syndrome (RCVS) has also been reported, emphasizing the necessity of diagnostic imaging study.3) Headache clinic surveys reported that patients with primary headache associated with sexual activity occupied 0.2 to 1.3% of all headache patients.4) A more recent case-control study estimated a prevalence of 0.9% in the general population.5) It is possible that the headache is underdiagnosed because patients are embarrassed to describe the circumstances in detail, and that the true prevalence may be considerably higher. The prevalence is 3 to 4 times higher in men than in women. The age at onset has two peaks, one in the early twenties and the other around 40 years of age.4)6) Type 1 and type 2 in the first edition of the International Classification of Headache Disorders are equivalent to preorgasmic headache (dull type, approximately 20%) and orgasmic headache (explosive type, approximately 80%), respectively, in the International Classification of Headache Disorders 2nd Edition (ICHD-II). Type 3 in the first edition, which is positional headache, is caused by cerebrospinal fluid leak and is coded as “headache attributed to spontaneous low CSF pressure” in ICHD-II.7) The pathogenetic mechanism has not been fully elucidated, but onset of preorgasmic headache is associated with tension-type headache and muscular contraction mainly in the neck,8) while orgasmic headache is associated with increased intracranial pressure accompanying an abrupt increase in blood pressure or heart rate.2) Patients’ blood pressure increases markedly during sexual activity, and the existence of metabolism-related impaired cerebrovascular autoregulation is speculated.9) Headache is bilateral and commonly occur in the occipital region. The pain lasts from several minutes to several hours or one day, and headache is severe usually during the first 5 to 15 minutes. The headache duration is longer in orgasmic headache than in preorgasmic headache. Headache occurs during coitus with the usual partner and also during masturbation. Comorbidity with migraine, tension-type headache, and primary exertional headache has been reported.2)6)
2. Treatment
To treat primary headache associated with sexual activity, the patient’s and partner’s understanding of the disorder is necessary.10) In preorgasmic headache, headache is usually relieved by discontinuing sexual activity. Therefore patients are advised to remain sexually inactive as much as possible until they are completely free of headache.4) The usefulness of taking indomethacin (50 to 100 mg) 1 to 2 hours before coitus,4) and the use of triptans (such as naratriptan) have been reported. Treatment with ergotamine and benzodiazepine compounds has also been used.11)12) For patients with prolonged headache duration, prophylactic therapy using propranolol, metoprolol, and diltiazem has been attempted.2)8) A report has shown the usefulness of greater occipital nerve blockade by injection of a steroid and local anesthetic combination.13) The prognosis of headache associated with sexual activity is relatively good. In the majority, the headache appears in a bout and remits, but 25% of patients have a chronic course.10)
1) International Headache Classification Promotion Committee of Japanese Headache Society (trans.): International Classification of Headache Disorders, 3rd edition (beta version), Japanese Edition. Igakushoin, 2014. (In Japanese)
2) Turner IM, Harding TM: Headache and sexual activity: A review. Headache 2008; 48(8): 1254-1256.
3) Yeh YC, Fuh JL, Chen SP, Wang SJ: Clinical features, imaging findings and outcomes of headache associated with sexual activity. Cephalalgia 2010; 30(11): 1329-1335.
4) Frese A, Eikermann A, Frese K, Schwaag S, Husstedt IW, Evers S: Headache associated with sexual activity: demography, clinical features, and comorbidity. Neurology 2003; 61(6): 796-800.
5) Biehl K, Evers S, Frese A: Comorbidity of migraine and headache associated with sexual activity. Cephalalgia 2007; 27(11): 1271-1273.
6) Pascual J, Gonzlez-Mandly A, Martn R, Oterino A: Headaches precipitated by cough, prolonged exercise or sexual activity: a prospective etiological and clinical study. J Headache Pain 2008; 9(5): 259-266.
7) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of International Classification of Headache Disorders 2nd Edition. Igakushoin, 2007. (In Japanese)
8) Pascual J, Iglesias F, Oterino A, Vzquez-Barquero A, Berciano J: Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996; 46(6): 1520-1524.
9) Evers S, Schmidt O, Frese A, Husstedt IW, Ringelstein EB: The cerebral hemodynamics of headache associated with sexual activity. Pain 2003; 102(1-2): 73-78.
10) Frese A, Rahmann A, Gregor N, Biehl K, Husstedt I W, Evers S: Headache associated with sexual activity: prognosis and treatment options. Cephalalgia 2007; 27(11): 1265-1270.
11) Porter M, Jankovic J: Benign coital cephalalgia. Differential diagnosis and treatment. Arch Neurol 1981; 38(11): 710-712.
12) Johns DR. Benign sexual headache within family. Arch Neurol 1986; 43(11): 1158-1160.
13) Selekler M, Kutlu A, Dundar G: Orgasmic headache responsive to greater occipital nerve blockade. Headache 2009; 49(1): 130-131.
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Headache
& {Sexual activity} 134
& {Migraine} 27
Sexual Headache 649
& {Migraine} 474
& {Treatment} 21
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Sexual headache 340
& {Migraine} & {Treatment} 9
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Sexual headache 5
1. Diagnosis
Hypnic headache is diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta).
| Grade A |
2. Treatment
Caffeine is used not only as an acute treatment but also as a prophylactic drug. Lithium is another frequently used prophylactic drug.
| Grade C |
Although hypnic headache is a rare headache disorder, over 170 cases have been reported. Reported for the first time by Raskin in 1988, this headache is also called “alarm clock headache” because it awakens the patient from sleep. In the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta), hypnic headache is classified in the group “Other primary headache disorders”.1) The pathophysiology has not been fully elucidated.
1. Diagnosis
The diagnostic criteria of hypnic headache are as follows1):
A. Recurrent headache attacks fulfilling criteria B-E
B. Developing only during sleep, and causing wakening
C. Occurring on ≥10 days per month for >3 months
D. Lasting ≥15 minutes and for up to 4 hours after waking
E. No cranial autonomic symptoms or restlessness
F. Not better accounted for by another ICHD-3 diagnosis
Hypnic headache is a rare headache, and is estimated to occupy 0.07 to 0.35% of headache patients.2)3) The male to female ratio is 1: 1.2 to 1: 1.7, with a female preponderance. The mean age of onset is around 60 years. although hypnic headache occurs typically in older persons,4)-8) pediatric cases have also been reported.3) Only a small number of cases have been reported in Japan.9) Headache is typically mild to moderate in intensity, dull and bilateral, but one-third is pulsating with severe intensity. The duration ranges from 15 to 180 minutes (mean 80 minutes), although headache may last 6 hours. The frequency of attack is 1 to 2 times per night, and the mean frequency of headache episodes is 23 per month. When patients are woken up by the headache at night, they read books, watch television, drink or eat, or walk inside the room. These characteristics are in contrast to the excited and restless states in cluster headache.5)-8) Polysomnographic studies have reported that headache arises during REM sleep,10)-13) but recent research contradicts the association between hypnic headache and sleep stage.7)14) A MRI study with voxel-based morphometry (VBM) has reported a decrease in posterior hypothalamus gray matter.15) The characteristic clinical picture of chronobiological abnormality in addition to pain suggests impairments of pain sensation and sleep rhythm at the trigeminal nerve in the hypothalamo-pituitary system. It is important to conduct imaging studies to differentiate from secondary headaches such as posterior fossa tumor, pontine infarction and pituitary tumor. Other headache disorders that should be differentiated include cluster headache, trigeminal-autonomic cephalalgias, and hemicrania continua.
2. Treatment
Caffeine is used not only as an acute treatment but also as a prophylactic drug.3)16)17) Drinking a cup of coffee when awaken by pain or before going to sleep is effective. As prophylactic drugs, lithium is usually effective, while topiramate, indomethacin, melatonin, and amitriptyline have also been used. Some cases remit spontaneously, while others remit upon treatment but relapse later.
1) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33(9): 678-679.
2) Dodick W, Mosek AC, Campbell JK: The hypnic (“alarm clock”) headache syndrome. Cephalalgia 1998; 18(3): 152-156.
3) Lanteri-Minet M, Donnet A: Hypnic headache. Curr Pain Headache Rep 2010; 14(4): 309-315.
4) Ghiotto N, Sances G, Di Lorenzo G, Trucco M, Loi M, Sandrini G, Nappi G: Report of eight new cases of hypnic headache and mini-review of the literature. Funct Neurol 2002; 17(4): 211-219.
5) Evers S, Goadsby PJ: Hypnic headache: clinical features, pathophysiology, and treatment. Neurology 2003: 60(6): 905-909.
6) Donnet A, Lantri-Minet M: A consecutive series of 22 cases of hpnic headache in France. Cephalalgia 2009; 29: 928-934.
7) Liang JF, Fuh JL, Yu HY, Hsu CY, Wang SJ: Clinical features, polysomnography and outcome in patients with hypnic headache. Cephalalgia 2008; 28(3): 209-215.
8) Holle D, Naegel S, Krebs S, Katsarava Z, Diener HC, Gaul C, Obermann M: Clinical characteristics and therapeutic options in hypnic headache. Cephalalgia 2010; 30(12): 1435-1442.
9) Fukuhara Y, Takeshima T, Ishizaki K, Burioka N, Nakashima K: Three Japanese cases of hypnic headache. Clin Neurol 2006; 46(2): 148-153. (In Japanese)
10) Dodick DW: Polysomnography in hypnic headache syndrome. Headache 2000; 40(9): 748-752.
11) Pinessi L, Rainero I, Cicolin A, Zibetti M, Gentile S, Mutani R: Hypnic headache syndrome: association of the attacks with REM sleep. Cephalalgia 2003; 23(2): 150-154.
12) Manni R, Sances G, Terzaghi M, Ghiotto N, Nappi G: Hypnic headache: PSG evidence of both REM-and NREM-related attacks. Neurology 2004; 62(8): 1411-1413.
13) De Simone R, Marano E, Ranieri A, Bonavita V: Hypnic headache: an update. Neurol Sci 2006; 27(Suppl 2): S144-148.
14) Holle D, Wessendorf TE, Zaremba S, Naegel S, Diener HC, Katsarava Z, Gaul C, Obermann M: Serial polysomnography in hypnic headache. Cephalalgia 2011; 31(3): 286-290.
15) Holle D, Naegel S, Krebs S, Gaul C, Gizewski E, Diener HC, Katsarava Z, Obermann M: Hypothalamic gray matter volume loss in hypnic headache. Ann Neurol 2011; 69(3): 533-539.
16) Diener HC, Obermann M, Holle D: Hypnic headache: Clinical course and treatment. Curr Treat Options Neurol 2012; 14(1): 15-26.
17) Lisotto C, Rossi P, Tassorelli C, Ferrante E, Nappi G: Focus on therapy of hypnic headache. J Headache Pain 2010; 11(4): 349-354.
• Search database: PubMed (2011/12/31)
Hypnic headache 118
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Hypnic headache 4
1. Diagnosis
Primary thunderclap headache is diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta).
| Grade A |
2. Treatment
Differentiating primary thunderclap headache from diseases that cause thunderclap headache secondarily is most important. There is no established treatment.
| Grade C |
In the diagnosis of thunderclap headache, the first and foremost step is to exclude a wide variety of secondary headaches. Accurate diagnosis and treatment by headache specialists are important.
1. Diagnostic criteria
The diagnostic criteria of primary thunderclap headache are as follows.1)
A. Severe head pain fulfilling criteria B and C
B. Abrupt onset, reaching maximum intensity in <1 minute
C. Lasting for ≥5 minutes
D. Not better accounted for by another ICHD-3 diagnosis
The most important step in diagnosis is to differentiate from disorders that may cause secondary thunderclap headache. It is mandatory to exclude subarachnoid hemorrhage due to ruptured cerebral aneurysm,2) unruptured saccular cerebral anrurysm,3)4) carotid or vertebral artery dissection,5) intracerebral hemorrhage,6) cerebral infarction,7) cerebral venous sinus thrombosis,8) and pituitary apoplexy.9) Other disorders that require differentiation include central nervous system angiitis, colloid cyst of the third ventricle, cerebrospinal fluid hypotension, acute sinusitis (especially barotrauma), retroclival hematoma, primary cough headache, primary exertional headache, primary headache associated with sexual activity,10) and bath-related headache.11) In recent years, reversible cerebral vasoconstriction syndrome (RCVS)12)13) as a cause of secondary thunderclap headache has drawn attention. For the diagnosis of headaches associated with subarachnoid hemorrhage, dissecting aneurysm and pituitary apoplexy, see the CQs for “Headache: General Considerations”.
Primary thunderclap headache is known to occur commonly in female adults, and is diagnosed only after all organic underlying diseases have been excluded. Secondary thunderclap headaches are treated according to the treatments for the underlying diseases, while treatment for primary thunderclap headache has not been established. The pathophysiology of primary thunderclap headache remains largely unclear, although failure of the afferent sympathetic nerve system that modulates intracranial vascular tone causing acute vasoconstriction or alteration in vascular tone has been suggested to case the headache.10)
2. Treatment
Nimodipine has been reported to be effective,14) but there is no established treatment.
1) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33(9): 675.
2) Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP Jr, Feinberg W, et al: Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25(11): 2315-2328.
3) Wijdicks EF, Kerkhoff H, van Gijn J: Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage. Lancet 1988; 2(8602): 68-70.
4) Raps EC, Rogers JD, Galetta SL, Solomon RA, Lennihan L, Klebanoff LM, Fink ME: The clinical spectrum of unruptured intracranial aneurysms. Arch Neurol 1993; 50(3): 265-268.
5) Silbert PL, Mokri B, Schievink WI: Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 1995; 45(8): 1517-1522.
6) Melo TP, Pinto AN, Ferro JM: Headache in intracerebral hematomas. Neurology 1996; 47(2): 494-500.
7) Gorelick PB, Hier DB, Caplan LR, Langenberg P: Headache in acute cerebrovascular disease. Neurology 1986; 36(11): 1445-1450.
8) de Bruijn SF, Stam J, Kappelle LJ: Thunderclap headache as first symptom ofcerebral venous sinus thrombosis. CVST Study Group. Lancet 1996; 348(9042): 1623-1625.
9) da Motta LA, de Mello PA, de Lacerda CM, Neto AP, da Motta LD, Filho MF: Pituitary apoplexy. Clinical course, endocrine evaluations and treatment analysis. J Neurosurg Sci 1999; 43(1): 25-36.
10) Schwedt TJ, Matharu MS, Dodick DW: Thunderclap headache. Lancet Neurol 2006; 5(7): 621-631.
11) Wang SJ, Fuh JL, Wu ZA, Chen SP, Lirng JF: Bath-related thunderclap headache: a study of 21 consecutive patients. Cephalalgia 2008; 28(5): 524-530.
12) Singhal AB, Hajj-Ali RA, Topcuoglu MA, Fok J, Bena J, Yang D, Calabrese LH: Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol 2011; 68(8): 1005-1012.
13) Valena MM, Andrade-Valena LP, Bordini CA, Speciali JG: Thunderclap headache attributed to reversible cerebral vasoconstriction: view and review. J Headache Pain 2008; 9(5): 277-288.
14) Chen SP, Fuh JL, Lirng JF, Chang FC, Wang SJ: Recurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder? Neurology 2006; 67(12): 2164-2169.
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thunderclap headache215
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thunderclap headache 948
1. Diagnosis
Hemicrania continua is diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta).
| Grade A |
2. Treatment
Complete remission is obtained by treatment with indomethacin.
| Grade A |
Hemicrania continua is a rare disorder.1)2) Since the disorder was first described by Sjaastad in 1984, over 150 cases have been reported.3)-11) Although hemicrania continua is characterized by association with autonomic symptoms and marked response to indomethacin, the pathophysiology, clinical picture, treatment and prognosis remain undefined.
1. Diagnostic criteria
The diagnostic criteria of hemicrania continua are as follows.1)2)
A. Unilateral headache fulfilling criteria B-D
B. Present for >3 months, with exacerbations of moderate or greater intensity
C. Either or both of the following:
1. at least one of the following symptoms or signs, ipsilateral to the headache:
a) conjunctival injection and/or lacrimation
b) nasal congestion and/or rhinorrhoea
c) eyelid edema
d) forehead and facial sweating
e) forehead and facial flushing
f) sensation of fullness in the ear
g) miosis and/or ptosis
2. a sense of restlessness or agitation, or aggravation of the pain by movement
D. Responds absolutely to therapeutic doses of indomethacinNote 1
E. Not better accounted for by another ICHD-3 diagnosis
1. In an adult, oral indomethacin should be used initially in a dose of at least 150 mg daily and increased if necessary up to 225 mg daily. The dose by injection is 100-200 mg. Smaller maintenance doses are often employed.
Hemicrania continua is a rare disorder and evidence is limited to case series.3)-11) In summary, the male to female ratio is approximately 1: 2, with a female preponderance. The mean onset age is in the thirties. Headache is unilateral and does not shift to the other side, and is lasting pain with mild to moderate intensity. The sites of headache are mainly in the frontal, temporal, orbital and occipital regions. Exacerbation of headache occurs sometimes and intense pain greatly impairs daily living. During exacerbation, ipsilateral autonomic symptoms including lacrimation and conjunctival injection often occur. Headache may be accompanied by the associated symptoms seen in migraine. Hemicrania continua is characterized by chronically persistent pain. When recurrence occurs after a remission, the pain usually takes a chronic course thereafter. Complete remission is obtained by indomethacin. Only a few cases of hemicrania continua have been reported in Japan.12)13) However, cases of pain shifting to the other side, cases not responsive to indomethacin, cases with no autonomic symptoms, and cases manifesting autonomic symptoms not listed in the diagnostic criteria of ICHD-3beta have been reported. Although PET examination demonstrated activation in contralateral posterior hypothalamus and ipsilateral dorsal rostral pons, the exact pathophysiology remains unknown.14) Both hemicrania continua and paroxysmal hemicrania exhibit indomethacin responsiveness and autonomic symptoms, thereby raising a possibility that they share a common pathophysiological basis.8)10)
Differential diagnosis includes unilateral localized chronic migraine, new daily persistent headache, cervicogenic headache, trigeminal-autonomic cephalalgias, chronic post-traumatic headache, headache attributed to arterial dissection, and headache attributed to brainstem infarction.
In ICHD-3 beta, hemicrania continua is classified as one of the trigeminal-autonomic cephalalgias.
2. Treatment
Headache responds absolutely to therapeutic doses of indomethacin. In Japan, the maximum dose is 75 mg/day for oral formulation, and 100 mg/day for rectal administration.2) In overseas countries, however, indomethacin is used at a starting dose of 25 to 75 mg/day, increasing gradually if there is no response, and the responsive dose has been reported to range from 50 to 300 mg/day.3)-7)10) Oral indomethacin has to be taken for long term, and adverse effects including vertigo and gastrointestinal symptoms are an issue. To reduce gastrointestinal adverse effects, the use of indomethacin farnesil, a prodrug of indomethacin, is sometimes effective from experience. Most of the other analgesics are not effective. Ibuprofen, naproxen, and aspirin have been tried, but results are inconsistent.5) Supraorbital nerve or greater occipital nerve block has been reported to be effective in patients with tenderness.15) In a crossover study of occipital nerve stimulation therapy in 6 patients, good result was reported16) but the method has not be established for general use.
1) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version), Cephalalgia 2013; 33(9): 629-808.
2) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of the International Classification of Headache Disorders, 3rd edition (beta version). Igakushoin 2014. (In Japanese)
3) Newman LC, Lipton RB, Solomon S: Hemicrania continua: ten new cases and a review of the literature. Neurology 1994; 44(11): 2111-2114.
4) Peres MF, Silberstein SD, Nahmias S, Shechter AL, Youssef I, Rozen TD, Young WB: Hemicrania continua is not that rare. Neurology 2001; 57(6): 948-951.
5) Matharu MS, Boes CJ, Goadsby PJ: Management of trigeminal autonomic cephalgias and hemicrania continua. Drugs 2003; 63(16): 1637-1677.
6) Trucco M, Mainardi F, Maggioni F, Badino R, Zanchin G: Chronic paroxysmal hemicrania, hemicrania continua and SUNCT syndrome in association with other pathologies: a review. Cephalalgia 2004; 24(3): 173-184.
7) Antonaci F, Pareja JA, Caminero AB, Sjaastad O: Chronic paroxysmal hemicrania and hemicrania continua. Parenteral indomethacin: the ‘indotest’. Headache 1998; 38(2): 122-128.
8) Goadsby PJ, Lipton, RB: A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases. Brain 1997; 120(Pt 1): 193-209.
9) Pareja JA, Vincent M, Antonaci F, Sjaastad O: Hemicrania continua: diagnostic criteria and nosologic status. Cephalalgia 2001; 21(9): 874-877.
10) Cittadini E, Goadsby PJ: Hemicrania continua: a clinical study of 39 patients with diagnostic implications. Brain 2010; 133(Pt 7): 1973-1986.
11) Marmura MJ, Silberstein SD, Gupta M: Hemicrania continua: who responds to indomethacin? Cephalalgia 2009; 29(3): 300-307.
12) Ishizaki K, Takeshima T, Ijiri T, Fukuhara Y, Nakashima K: Hemicrania continua: the first Japanese case report. Rinsho Shinkeigaku 2002; 42(8): 754-756. (In Japanese)
13) Saito Y, Manaka S, Kimura S: Coexistence of cluster headache and hemicrania continua: a case report. Rinsho Shinkeigaku 2005; 45(3): 250-252. (In Japanese)
14) Matharu MS, Cohen AS, McGonigle DJ, Ward N, Frackowiak RS, Goadsby PJ: Posterior hypothalamic and brainstem activation in hemicrania continua. Headache 2004; 44(8): 747-761.
15) Guerrero L, Herrero-Velzquez S, Peas ML, Mulero P, Pedraza MI, Cortijo E, Fernndez R: Peripheral nerve blocks: a therapeutic alternative for hemicrania continua. Cephahalgia 2012; 32(6): 505-508.
16) Burns B, Watkins L, Goadsby PJ: Treatment of hemicrania continua by occipital nerve stimulation with a bion device: long-term follow-up of a crossover study. Lancet Neurol 2008; 7(11): 1001-1012.
• Search database: PubMed (2012/6/4)
Hemicrania continua 254
& Indomethacin 138
Indomethacin farnesyl 13
• Search database: Ichushi Web for articles published in Japan (2012/6/4)
Hemicrania continua 9
Hemicrania continua (Japanese) 5
Hemicrania continua9
1. Diagnosis
New daily persistent headache is diagnosed according to the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta).
| Grade A |
2. Treatment
There are no clearly established treatment criteria, and also no treatments with established efficacy. There are two types; a type that resolves spontaneously, and a refractory type that is resistant to aggressive treatments.
| Grade C |
The International Classification of Headache Disorders 2nd Edition (ICHD-II) recognizes New daily persistent headache (NDPH) as a new separate entity. However, details of the headache properties, treatment effects and prognosis are not known. The mode of onset is important in diagnosis, and excluding secondary headaches is important.
1. Diagnostic criteria
The diagnostic criteria of new daily persistent headache described in the ICHD-3beta are as follows.1)2)
A. Persistent headache fulfilling criteria B and C
B. Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours
C. Present for >3 months
D. Not better accounted for by another ICHD-3 diagnosis
New daily persistent headache is a relatively rare disorder, and evidence is limited to case series.3)-5) This headache has also been reported in Japanese, but the number of cases is relatively small.4)6) In summary, the male to female ratio is slightly higher in female. The mean age of onset is in the thirties. The day of headache onset is usually clearly remembered by the patient. While the headache often has features resembling those of tension-type headache, it may also manifest characteristics of migraine such as nausea, photophobia and phonophobia. The headache may remit, or recur and remit repeatedly, or persist, but many patients follow a chronic course. Robbin et al.5) divided new daily persistent headache according to headache properties into two groups: a group with migraine-like headache that has a female preponderance and frequently a history of anxiety or depressive disorder, and a group with features of tension-type headache in which patients recall accurately the day of headache onset. Their report emphasizes that new daily persistent headache may manifest migraine-like headache. In a Norwegian population-based study of a sample aged 30 to 40 years, the 1-year prevalence was 0.03%.7) Among children and adolescents who are less likely to overuse medications than adults, onset of new daily persistent headache is typically secondary to infection and trauma.8)9)
Differential diagnosis includes chronic migraine, chronic tension-type headache, hemicrania continua, headache attributed to low cerebrospinal fluid pressure, headache attributed to increased cerebrospinal fluid pressure, headache attributed to head and/or neck trauma, and headache attributed to infection. Although many symptoms resemble those of chronic tension-type headache, the unique features are that headache is not evolved from episodic tension-type headache and that headache is daily and unremitting from the day of onset.
2. Treatment
No prospective placebo-controlled trial has been reported, and clear treatment criteria have not been established.3)-5) New daily persistent headache has two types: a self-limiting type that resolves spontaneously, and a refractory subtype that is resistant to aggressive treatment. In line with tension-type headache and migraine, abortive drugs and prophylactic drugs such as gabapentin and topiramate have been tried, with no consistent results.
1) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33(9): 629-808.
2) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of the International Classification of Headache Disorders, 3rd edition (beta version). Igakushoin 2014. (In Japanese)
3) Li D, Rozen TD: The clinical characteristics of new daily persistent headache. Cephalalgia 2002; 22(1): 66-69.
4) Takase Y, Nakano M, Tatsumi C, Matsuyama T: Clinical features, effectiveness of drug-based treatment, and prognosis of new daily persistent headache (NDPH): 30 cases in Japan. Cephalalgia 2004; 24(11): 955-959.
5) Robbins MS, Grosberg BM, Napchan U, Crystal SC, Lipton RB: Clinical and prognostic subforms of new daily-persistent headache. Neurology 2010; 74(17): 1358-1364.
6) Oguru M, Tachibana H, Yokota M, Nishimura H, Shibuya N, Kawabata K: Clinical study of new daily persistent headache. Japanese Journal of Headache 2009; 35(3): 71-75. (In Japanese)
7) Grande RB, Aaseth K, Lundqvist C, Russell MB: Prevalence of new daily persistent headache in the general population. The Akershus study of chronic headache. Cephalalgia 2009(11); 29: 1149-1155.
8) Mack KJ: What incites new daily persistent headache in children? Pediatr Neurol 2004; 31(2): 122-125.
9) Kung E, Tepper SJ, Rapoport AM, Sheftell FD, Bigal ME: New daily persistent headache in the paediatric population. Cephalalgia 2009; 29(1): 17-22.
• Search database: PubMed (2012/6/4)
New daily persistent headache 144
• Search database: Ichushi Web for articles published in Japan (2012/6/4)
New daily persistent headache 7
Chronic daily headache is a headache classification proposed by Silberstein, Lipton and colleagues,1)2) and is defined as headache that lasts 4 or more hours per day and occurs on 15 or more days per month. This disorder is classified into four types: transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. There is no clear evidence. With the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta) now being established, each headache type and medication-overuse headache should be diagnosed according to ICHD-3 beta, and chronic daily headache should be used as an umbrella term that includes various types of chronic headache.
| Grade C |
Since the International Headache Society first published the diagnostic criteria for headache disorders in 1988, the debate on how to diagnose and classify headaches that occur daily has continued. Chronic daily headache is a headache classification proposed by Silberstein, Lipton and colleagues1)2) in 1994. It is defined as headache that lasts 4 or more hours per day and occurs on 15 or more days per month, and is classified into four types. The International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3 beta) published in 20133)-6) does not recognize chronic daily headache as a separate entity. However, the name is still used due to the convenience of allowing evaluation of all the headaches that occur on a daily basis.
In 1994, Silberstein, Lipton and colleagues1)2) defined chronic daily headache as headache that lasts 4 or more hours per day and occurs on 15 or more days per month. They classified this group into four types and set out diagnostic criteria. The four types are:
1. Transformed migraine (TM)
2. Chronic tension-type headache (CTTH)
3. New daily persistent headache (NDPH)
4. Hemicrania continua (HC)
The above classification is currently used worldwide. The criterion of at least 4 hours a day excludes cluster headache. Regarding the duration of headache, various articles have described durations ranging from 1 month to 1 year. In accordance with the diagnostic criteria of the International Classification of Headache Disorders, 3rd Edition (beta version) (ICHD-3beta) for chronic migraine, new daily persistent headache and hemicrania continua,3)-6) a duration of over 3 months is generally accepted.7)-9) The prevalence of chronic daily headache in the general population has been reported to be approximately 3 to 4%, while a prevalence of approximately 1.5% has been reported among subjects aged 12 to 14 years in population-based studies.7)9)-13) In a study comparing 638 adults aged 18 years or older and 170 adolescents aged 13 to 17 years, transformed migraine associated with medication overuse was significantly more frequent in adults while transformed migraine without medication overuse and chronic tension-type headache were significantly more common in adolescets.12) In a prospective cohort 8-year follow-up study of 122 adolescents aged 12 to 14 years, one-fourth of the patients continued to have disability in daily living due to chronic daily headache.14)
In the ICHD-3beta, chronic daily headache is not recognized as a separate entity, and transformed migraine is handled as chronic migraine and classified as various types in the group of primary headaches, differentiated from medication-overuse headache. Compared with the Silberstein-Lipton diagnostic criteria, the criteria in the ICHD-3beta are stricter. Transformed migraine with increased headache frequency due to medication overuse is considered almost equivalent to the ICHD-3beta codes of “migraine” + “medication-overuse headache”, while transformed migraine with no medication overuse or no increased headache frequency even though there is medication overuse is considered similar to the ICHD-3beta code of “chronic migraine”. Likewise, chronic tension-type headache with increased headache frequency due to medication overuse is considered to be “tension-type headache” + “medication-overuse headache”, while chronic tension-type headache with no medication overuse or no increased headache frequency even though there is medication overuse to be “chronic tension-type headache”. Furthermore, the ICHD-3beta places importance on the presence of autonomic symptoms in hemicrania continua, and the elements of tension-type headache in new daily persistent headache. With the ICHD-3beta being well established, it has been recommended to discontinue using the term chronic daily headache and to diagnose according to ICHD-3beta. However, the term continues to be used currently, because when individual headaches cannot be classified accurately, it offers the convenience to evaluate these headaches under the umbrella term of chronic daily headache.
1) Silberstein SD, Lipton RB, Solomon S, Mathew NT: Classification of daily and near-daily headaches: proposed revisions to the IHS criteria. Headache 1994; 34(1): 1-7.
2) Silberstein SD, Lipton RB, Sliwinski M: Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology 1996; 47(8): 871-875.
3) Headache Classification Committee of the International Headache Society: The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33(9): 629-808.
4) International Headache Classification Promotion Committee of Japanese Headache Society (translator): Japanese Edition of International Classification of Headache Disorders, 3rd edition (beta version). Igakushoin 2014. (In Japanese)
5) Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Gbel H, Lainez MJ, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J, Steiner TJ: International Headache Society. The International Classification of Headache Disorders, 2nd Edition (ICHD-II) revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005; 25(6): 460-465.
6) Headache Classification Committee, Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Gbel H, Lainez MJ, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J, Silberstein SD, Steiner TJ: New appendix criteria open for a broader concept of chronic migraine. Cephalalgia 2006; 26(6): 742-746.
7) Scher AI, Stewart WF, Ricci JA, Lipton RB: Factors associated with the onset and remission of chronic daily headache in a popuration-based study. Pain 2003; 106(1-2): 81-89.
8) Bigal ME, Sheftell FD, Rapoport AM, Lipton RB, Tepper SJ: Chronic daily headache in atertiary care popuration: correlation between the International Headache Society dianostic criteria and proposed revisions for chronic daily headache. Cephalalgia 2002; 22(6): 432-438.
9) Kavuk I, Yavuz A, Cetindere U, Agelink MW, Diener HC: Epidemiology of chronic daily headache. Eur J Med Res 2003; 8(6): 236-640.
10) Lantri-Minet M, Auray JP, El Hasnaoui A, Dartigues JF, Duru G, Henry P, Lucas C, Pradalier A, Chazot G, Gaudin AF: Prevalence and description of chronic daily headache in the general popuration in France. Pain 2003; 102(1-2): 143-149.
11) Lu SR, Fuh JL, Chen WT, Juang KD, Wang SJ: Chronic daily headache in Taipei, Taiwan: prevalence, follow-up and outcome predictors. Cephalalgia 2001; 21(10): 980-986.
12) Bigal ME, Lipton RB, Tepper SJ, Rapoport AM, Sheftell FD: Primary chronic daily headache and its subtypes in adolescents and adults. Neurology 2004; 63(5): 843-847.
13) Wang SJ, Fuh JL, Lu SR, Juang KD: Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 2006; 66(2): 193-197.
14) Wang SJ, Fuh JL, Lu SR: Chronic daily headache in adolescents: an 8-year follow-up study. Neurology 2009; 73(6): 416-422.
• Search database: PubMed (2012/6/4)
Daily headache 4502
chronic daily headache 31338
& definition 224
& diagnostic criteria 2155
& prevalence 4655
& frequency 6238
• Search database: Ichushi Web for article published in Japan (2012/6/4)
Chronic daily headache 14
Chronic daily headache (Japanese) 5329