SYNOPSIS630 (39%) of 1600 patients seen in a Headache Clinic over a three year period had chronic daily headaches (CDH). In 78% of these CDH patients, the daily headaches evolved out of a prior history of episodic migraine; these patients we designate as having "transformed" or "evolutive" migraine. The other 12% had migraine headaches which were daily from the start.Patients with transformed migraine, in contrast to those with daily headaches from the start, have a significantly higher incidence of positive family history of migraine, menstrual aggravation of migraine, identifiable trigger factors, associated G.I. and neurological symptoms, and early morning awakening with headache.The CDH group in general over-used symptomatic medication and exhibited abnormalities on behavioral scale testing. Withdrawal of daily symptomatic medication, institution of a low tyramine low caffeine diet, initiation of prophylactic anti-migraine therapy, and biofeedback and behavioral therapy, gave worthwhile improvement in 76% of chronic daily headache patients.Factors which promote "evolution" of migraine from intermittent to chronic daily occurrence are not well-defined but may include medication abuse, medication withdrawal, and psychiatric disturbances. (Headache 27:102-106, 1987) The traditional teaching considers migraine as a purely episodic phenomena, and daily headaches are categorized as muscle contraction or tension headache. Clinical observation of Dalsgaard-Neilsen 1 indicated that 73% of patients with migraine get frequent low grade headaches between their attacks. He concluded that headache is not just an episodic phenomena, but a permanent deviation from normal, because their biologic threshold for headache is lower than in the normal population.Discussing the natural history of migraine, Graham 2 observed that in some individuals headache may show an increasing frequency of attack until they become daily in occurrence. In 1982, Mathew et al 3 reported a series of patients who had a clear-cut history of episodic migraine in the past, whose headaches, over the years transformed into a daily or near daily headache. This communication is an extension of that paper with additional observations and a larger number of patients. MATERIALS AND METHODSThe history and clinical features of 630 chronic daily headache patients were analyzed in detail. These 630 patients were selected from a series of 1600 patients seen in a headache clinic population between the years 1982 and 1985. The diagnostic breakdown of the 1600 patients in a headache clinic population is given in Table 1. Chronic daily headaches formed 39% of the patients seen.The diagnostic criteria for migraine is shown in Table 2, where certain points are allocated for individual clinical features of migraine. A minimum of 5 points out of 10 was considered essential to meet the diagnostic criteria for migraine. Chronic daily headaches were divided into three types: Type I: starts as daily or near daily headache with no change in the severity and lacks migrainous ...

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