Causes of Constant Headache: From Migraine to Hidden Factors

Introduction: What is a Constant Headache?

A constant or chronic headache is a condition that significantly reduces the quality of life for millions of people worldwide. It can manifest daily or almost daily, substantially affecting working capacity and overall well-being [7]. The World Health Organization (WHO) classifies migraine as the sixth leading cause of disability worldwide, and when taking medication-overuse headache into account, it rises to third place [5]. Understanding the causes of this condition is the first step toward effective treatment and returning to a full life.

Chronic Migraine: The Main Culprit

Chronic migraine is one of the most common and disabling neurological disorders, affecting 1% to 3% of the global population [3]. Overall, migraine affects about 14-15% of the world's population and is associated with a high level of disability [2].

Typically, migraine presents as a recurrent, pulsating headache, often unilateral, accompanied by nausea, increased sensitivity to light (photophobia), and sound (phonophobia) [2, 3]. Over time, episodic migraine can progress into a chronic form when headaches occur 15 or more days per month [5].

Chronic migraine significantly impacts work efficiency, with 43.8% of patients experiencing attacks lasting from 4 to 8 hours [7]. Diagnosing chronic migraine in children requires adapting criteria that take into account neuroontogenetic features, since existing classifications (e.g., ICD-11) were originally developed for adults [8].

Medication-Overuse Headache (MOH): A Hidden Threat

One of the key factors often overlooked in the treatment of chronic migraine is medication-overuse headache (MOH) [1]. More than 50% of patients with chronic migraine abuse pain relievers, which is directly linked to the development of MOH [5].

This condition occurs when a person regularly takes acute pain medications (e.g., triptans, as in one case—eletriptan) to relieve a headache. Paradoxically, such “treatment” leads to more frequent and intense headaches, creating a vicious cycle [1].

MOH can mask the true cause of chronic headaches, making them resistant to standard preventive treatments [1]. In one reported case, a 40-year-old woman with a 10-year history of migraine developed daily headaches after years of almost daily eletriptan use. Discontinuation of this drug led to remission of symptoms, confirming the diagnosis of MOH [1]. This underscores the critical importance of identifying and stopping medication overuse for successful treatment [1].

Other Factors and Comorbid Conditions

In addition to chronic migraine and MOH, other factors can influence the development and treatment resistance of headaches. Psychosocial stress is one such overlooked factor capable of exacerbating chronic headaches [1].

Sometimes a constant headache can be accompanied by unusual symptoms that complicate diagnosis. For instance, migrainous thoracalgia (MT) is chest pain that can have a neurological origin and is often associated with migraine attacks [4]. In one case, a 57-year-old woman with chronic migraine developed recurrent chest pain following migraine attacks. Despite numerous cardiological evaluations, she was found to have fibromuscular dysplasia, spontaneous coronary artery disease dissection, and microvascular heart disease, demonstrating the difficulty of diagnosis and symptom overlap between migraine and cardiovascular disease [4].

Diagnosis and Modern Treatment Approaches

Effective treatment of a constant headache begins with accurate diagnosis. Family medicine physicians play a key role in identifying conditions such as MOH and psychosocial stressors, which may cause treatment resistance [1].

Pharmacological Strategies:

• Preventive therapy: After discontinuing medications causing MOH, state stabilization is achieved using preventive treatment [1].
• Botulinum toxin type A (OnabotulinumtoxinA): Has proven effective in treating chronic migraine [5].
• Calcitonin gene-related peptide (CGRP)-targeted drugs: Monoclonal antibodies against CGRP (e.g., eptinezumab, ubrogepant) are among the most promising developments. They have shown good efficacy and safety in clinical trials and real-world practice, significantly improving the quality of life for chronic migraine patients and even easing comorbid symptoms such as migrainous thoracalgia [4, 5, 6]. Studies show sustained efficacy of eptinezumab for up to four years in patients with treatment-resistant chronic migraine [6].
• Other medications: In cases of refractory migraine, intravenous lidocaine, magnesium, ketorolac, and neuroleptics may be used [4].

Behavioral and physical therapy interventions: Self-management strategies, behavioral therapy, and physical therapy also play an important role in achieving sustained remission and restoring functional stability [1].

Traditional medicine: In some cultures, traditional methods are applied; for example, in Unani medicine, chronic migraine (Shaqīqa Sawdāwiyya) is treated with classical formulations and herbal poultices (Ḍimād), which can relieve pain and reduce disability [2, 3].

Conclusion

A constant headache is not just discomfort, but a serious neurological condition requiring an attentive approach. Whether it is chronic migraine, medication-overuse headache, or a combination of multiple factors, it is important not to ignore the symptoms and to seek qualified help. A comprehensive approach including accurate diagnosis, pharmacological treatment, behavioral strategies, and, if necessary, alternative methods can significantly improve the patient's condition and quality of life.

Sources

1. Chronic Migraine Resistance: A Case Report Highlights an Overlooked Factors in Family Medicine Clinics. https://pubmed.ncbi.nlm.nih.gov/42450884/
2. Management of Chronic Migraine Without Aura with Classical Unani Formulations: A Case Report. https://pubmed.ncbi.nlm.nih.gov/42360865/
3. Therapeutic evaluation of herbal poultice (Ḍimād) in the management of pain and disability of chronic migraine: A case report. https://pubmed.ncbi.nlm.nih.gov/42314279/
4. Migrainous Thoracalgia in a Patient with Chronic Migraine and Coronary Vasospasm: A Case Report. https://pubmed.ncbi.nlm.nih.gov/42220623/
5. Chronic migraine treatment: from OnabotulinumtoxinA onwards. https://pubmed.ncbi.nlm.nih.gov/27310178/
6. Eptinezumab in treatment-resistant chronic migraine: Four-year real-world effectiveness and treatment persistence. https://pubmed.ncbi.nlm.nih.gov/42153799/
7. Migraine in the Corporate Sector: Prevalence, Risk Factors, Job Efficiency Impact, and Management Strategies. https://pubmed.ncbi.nlm.nih.gov/42365430/
8. International classification of diseases-11 chronic primary headache diagnoses: data-based adaptations of criteria for the pediatric population. https://pubmed.ncbi.nlm.nih.gov/42455074/

The information in this article is for reference purposes only and cannot replace an in-person consultation with a qualified medical specialist. Always consult a physician for diagnosis and treatment.