Chronic headache

What is chronic headache?

"Chronic headache" is an umbrella term covering several distinct conditions: chronic migraine, chronic tension-type headache, cervicogenic headache, medication-overuse headache, and chronic cluster headache, among others. Each has its own diagnostic criteria under the International Classification of Headache Disorders, third edition (ICHD-3), the international taxonomy used by neurologists and headache specialists, and the one aligned with the World Health Organization's ICD-11 classification of chronic pain^1,2.

Most chronic headaches are primary headache disorders, meaning the headache is the condition itself, not a symptom of something else^1,3. Chronic migraine is defined as headache on fifteen or more days per month for more than three months, with at least eight of those days meeting full migraine criteria¹. Chronic tension-type headache shares the fifteen-days-per-month threshold but with different symptom features¹. Cervicogenic headache is referred from the cervical spine and is often responsive to physiotherapy⁴. Some chronic headaches are secondary (caused or worsened by another factor), and medication-overuse headache is the most common and most under-recognised of these⁵.

Chronic headache is common, especially migraine. The Australian Institute of Health and Welfare estimates 1.7 million Australians live with migraine, with women affected at more than twice the rate of men (9.2% versus 4.1%)⁶. Globally, migraine is the second leading cause of disability overall and the first among women under fifty⁷. The total annual economic cost of migraine in Australia has been estimated at $35.7 billion, including health system, productivity and carer costs⁸.

Chronic headache is real, treatable, and improving in care

Although migraine and chronic headache have more medical legitimacy today than some other chronic pain conditions, many people, particularly women, still report being dismissed with phrases like "just a headache". This is not consistent with current evidence. Migraine is a recognised neurological disorder with identifiable changes in central nervous system pain processing, formal diagnostic criteria, and a growing list of effective treatments^1,3,7.

The treatment landscape has also changed substantially in recent years. Several new classes of medication for migraine prevention have become available since 2018, and Australian and international guidelines have converged on a multimodal model that combines pharmacological treatment with lifestyle modification and, where relevant, physiotherapy^3,9,5. If your last serious conversation about headache treatment was more than five years ago, it is worth a new one.

What current evidence says about chronic headache care

International guidelines from the International Headache Society, the European Academy of Neurology, and Australian primary care guidance from the RACGP and Australian Pain Society recommend a stepped, multimodal approach to chronic headache^1,5,10,11. Effective management typically combines acute treatment for individual attacks, preventive treatment for those with frequent headaches, lifestyle modification, physiotherapy where the headache type responds to it (particularly tension-type and cervicogenic headache), and psychological support where stress or pain-related distress are major contributors^3,9.

A widely used framework for the lifestyle component is SEEDS: Sleep, Exercise, Eat (regular meals, hydration, stable caffeine), Diary (tracking attacks and triggers), and Stress⁹. Each element has its own evidence base and contributes to attack reduction. The "Diary" element is not optional. Identifying personal triggers requires sustained tracking: most people cannot reliably identify their own triggers from memory, and trigger patterns are usually multi-factorial rather than single-cause^9,12.

For tension-type and cervicogenic headache, physiotherapy has consistent evidence for reducing headache frequency, intensity and disability, particularly manual therapy combined with exercise^4,13. For migraine, the role of physiotherapy is more limited but emerging, and regular aerobic exercise has its own moderate evidence base as a preventive measure^4,14,9.

A note on medication-overuse headache. If you take acute headache medication on more than ten to fifteen days per month, for more than three months, you may develop medication-overuse headache: a chronic daily headache driven by the medications you are using to treat your headaches⁵. This is not unusual (medication-overuse headache affects roughly 1–2% of the general population), and it is not a moral failing. But it is critically important to identify, because it changes how the headache should be treated⁵. Tracking your acute medication use is the only reliable way to detect the pattern before it entrenches.

How Pain Coach is built for chronic headache

Pain Coach is a chronic pain tracking app designed to be used with your GP, neurologist or physiotherapist. For chronic headache, the daily check-in captures pain alongside the five lifestyle factors (sleep, exercise, nutrition, stress and social connection) that map closely to the SEEDS framework used in evidence-based headache care⁹.

Three things about chronic headache make tracking particularly useful. Triggers are usually multi-factorial: most people cannot reliably identify their own migraine or headache triggers from memory^9,12. A poor night's sleep alone may not trigger an attack, but a poor night's sleep on a stressful day after a skipped meal might. Pattern detection requires consistent data across weeks. Acute medication use also needs to be tracked, because medication-overuse headache is one of the most common and most preventable drivers of chronic daily headache, and knowing exactly how many days per month you have taken acute treatment is essential information for both you and your clinician⁵. And treatment response takes time to evaluate: preventive medications for migraine typically need eight to twelve weeks at therapeutic dose to assess effect, and lifestyle changes show their effect over a similar timeframe^9,3. Tracking over months, not just between appointments, is the only way to know what is and isn't working.

Pain Coach does not promise a cure. Chronic headache is usually a long-term condition, though many people significantly reduce their attack frequency with the right combination of treatment and lifestyle work³. The aim is clarity, fewer surprises, and steady progress on what you can change.

The five lifestyle factors and chronic headache

Each of the five factors Pain Coach tracks has a meaningful evidence base in chronic headache, and they interact. They map directly onto the SEEDS framework used in headache care, with the addition of social connection, which matters because of how isolating chronic headache can be⁹.

• Sleep. Both too little and too much sleep can trigger migraine, and irregular sleep schedules are particularly problematic^9,15. Standard sleep hygiene (consistent bedtimes and wake times, limiting screens before bed, a cool dark room) is recommended for most people with chronic headache. Tracking sleep duration and quality alongside headache days often surfaces patterns that aren't obvious from memory.
• Exercise and movement. Regular aerobic exercise is recommended for migraine prevention by current guidelines, with moderate evidence for reduction in attack frequency^9,14,4. For cervicogenic and tension-type headache, exercise often forms part of physiotherapy treatment alongside manual therapy¹³. The typical recommendation is thirty to sixty minutes, three to five times per week, built up gradually.
• Nutrition. Regular meals, adequate hydration and stable caffeine intake are core recommendations for migraine: irregular eating and caffeine withdrawal are common triggers⁹. Specific food triggers (chocolate, aged cheese, red wine, citrus) are commonly reported, but the evidence is mixed and triggers are highly individual^9,16. Pain Coach is designed to surface your own patterns rather than impose a generic diet.
• Stress. Stress, and the let-down period after stress, are among the most consistently reported migraine triggers, and persistent stress amplifies central pain processing in chronic headache more generally^17,18,9. Fear of attacks and unhelpful beliefs about pain can amplify the experience¹⁹. Psychological support, particularly cognitive behavioural therapy, has consistent evidence for reducing headache-related distress and disability²⁰.
• Social connection. Chronic headache is isolating in specific ways: cancelling plans during attacks, withdrawing during prodrome, avoiding triggers that come with social activity. Isolation and loneliness independently worsen chronic pain outcomes, and social pain shares neural pathways with physical pain^21,22. Small, regular contact with people who understand the condition tends to correlate with better days.

Find a headache-trained physiotherapist in Australia

Pain Coach Connect lists verified Australian physiotherapists who work with chronic headache, with telehealth and in-person consultations available. Physiotherapy is most effective for cervicogenic and tension-type headache; for migraine, it can be a useful component of a broader plan but is rarely sufficient on its own^4,13. The listings are filtered to physiotherapists who specifically work with headache populations.

If your headache is primarily migraine and lifestyle and pharmacological measures have not been enough, a referral to a neurologist, particularly one with a special interest in headache, is usually the appropriate next step, in addition to or instead of physiotherapy³. Your GP can advise.

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