7 Causes of Headache at 4 PM Every Day & How to Differentiate

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1. Chronic Migraine.

Migraine is a severe type of headache. Migraine is common, affecting about 15% of the world population. However, The chronic form of migraine comes every day or on a near-daily basis.

Chronic migraine affects about 2% of people, making it the most likely cause of headaches that comes every day (reference).

If you keep getting headaches at 4 PM every day, you should consider migraine as the most likely cause. People with chronic daily migraine often have the less frequent or episodic form of migraine headaches before.

Features (symptoms) suggestive for chronic migraine:

Migraine has more distinctive features that separate it from tension-type headaches. Migraine tends to be more severe, unilateral, pulsating, and associated with an aura (see below).

The typical migraine episode passes into four stages:

1. Migraine prodrome:

Occurs in most patients (77% of patients with migraine pass through the prodrome stage).
Prodrome symptoms are a group of affective or mood symptoms that proceeds with the headache.

Common symptoms include repeated yawning, euphoria, depression, irritability, food cravings, neck stiffness, and sometimes constipation.

2. Migraine Aura:

Affects about 25% of patients with migraine.

They are a group of neurological symptoms and are characteristic of migraine; they include:
Visual symptoms (bright lines, shapes, objects, or visual loss).
Hearing symptoms (tinnitus, hearing noises, music, or loss of hearing).

Abnormal movements or inability to move a part of your body.
Patients can experience one or more symptoms at the same time.
Duration: the symptoms develop gradually but disappear rapidly in no longer than an hour.

3. The migraine headache stage.

Starts after or during the aura stage.
It is often unilateral (70%), but it can be bilateral (30%).

Pulsation or throbbing in character is felt in the front and sides of the head.
The episode’s duration is at least 4 hours, and it can last for several days if left untreated.
Headache is often exacerbated by daily activities such as walking or climbing stairs (impairing the quality of life).

It can be associated with other symptoms such as nausea and vomiting.

4. Migraine postdrome.

Starts after the resolution of the headache.

The patient may feel pain when he turns his head or neck.
Exhaustion and fatigue.

Patients who get chronic migraine every day often have other conditions such as sleep disorders, psychiatric dysfunction, heart diseases, or respiratory diseases (such as obstructive sleep apnea).

2. Chronic Tension Headache.

Tension headache is the commonest type of headache worldwide. Alone, It represents more than 90% of primary headaches (reference).

The cause of tension headache is still unclear. Three patterns are recognized:

Episodic, infrequent TTH: Episodes less than one day a month

Episodic, Frequent TTH: Episodes from one to 14 days a month.
Chronic TTH: Episodes 15 or more days a month.

The third type (chronic tension headache) can cause your 4 PM headaches every day.

Symptoms (How to know?):

Unlike migraine and cluster headaches, The characteristics of TTH are generally non-specific (Called the featureless headache).
Location: Often bilateral and diffuse in nature (surround the head or neck as a cap.
Severity: Mild to moderate (often not severe as migraine and cluster headache.

Character: Dull constant ache in the head (not throbbing or pulsating).
Duration of the single episode: It is highly variable, but it is often at a lead of 30 minutes duration and may last for several days (in a single episode).
Frequency of episodes: In chronic tension headaches, the episodes may come every day or at least 15 days per month.

Associated symptoms such as nausea, vomiting, intolerance to light, or sounds are absent or very minimal.
Tenderness over the head or neck muscles at the headache location is common.

3. Medication Over-use headache.

The third most common cause (and most overlooked) of headaches every day at 4 PM is medications.

Moreover, Medication overuse headache is more likely to cause headaches at the same time every day because they are often taken at fixed times.

Both occasional and chronic use of medication can lead to headaches.

Taking large doses in shorter periods or prolonged medication use can result in chronic daily headaches. Also, withdrawal of certain medications can cause headaches every day.

Review your list of for these types of medications:

Simple pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs) as Paracetamol (Tylenol®), Ibuprofin (Advil®), Naproxen, and others.
Combination pain relievers: caffeine and NSAIDs or double NSAIDs such as Excedrin® and others.

Migraine meds: such as Imitrex, Zomig, Ergomar, and others.
Opiates.

The frequent use of these medications causes rebound headaches after its action and may cause withdrawal headaches.