Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey

Use and overuse of sumatriptan. Pharmacoepidemiological studies based on prescription register and interview data

The serotonin agonist sumatriptan was marketed in Denmark in 1992 for the treatment of acute attacks of migraine and cluster headache. The clinical development program of the drug was impressive. However, knowledge of the long-term use of sumatriptan in unselected patients was lacking. Misuse of sumatriptan was reported in single patients shortly after the introduction of the drug. The aim of the present thesis was, therefore, to provide an epidemiological description of sumatriptan use with particular emphasis on overuse. The author conducted three studies, two of which were exclusively based on population-based data from a regional (Odense Pharmacoepidemiological Database) and a national (Registry of Drug Statistics, Danish Medicines Agency) prescription registry. Both registries record patient-specific information, thus enabling the conduct of longitudinal studies of drug use. The regional registry covers the county of Funen (reimbursable prescription drugs only), while the national registry records information on all prescriptions presented in the entire country. Consumption was described by means of the Defined Daily Dose (DDD) unit. One DDD of sumatriptan amounts to 100 mg orally or 6 mg subcutaneously. Subjects were classified as recipients of single or multiple prescriptions. Individuals in the latter category were characterized by the 30-day period with the most intensive dispensing of sumatriptan (peak use): low (less than 30 DDD/30 days), intermediate (30-59 DDD/30 days) and high-peak users (60 or more DDD/30 days). In 1995, 33,206 users of sumatriptan were identified in Denmark, corresponding to a 1-year period prevalence of use of 7.8 per 1,000 inhabitants (only persons aged > or = 16 years were included). A female-to-male ratio of 3.8:1 was found. Use was most common among women aged 35-54 years and was highest among 45 to 49-year-olds for both sexes. The standardized period prevalence of sumatriptan use varied regionally between the Danish counties from 6.4 to 9.6 per 1,000 inhabitants. The period prevalence of sumatriptan use in the county of Funen was highly comparable with that of the entire nation. Among the 43,389 sumatriptan users presenting prescriptions for sumatriptan in Denmark in 1994 and 1995, 507 (1.1%) and 1726 (4.0%) belonged to the high and intermediate-peak-use group, respectively. Patients belonging to these two groups were responsible for 38% of the total consumption of sumatriptan. For patients in the high-peak-use group the median span between first and last prescription was 693 days while the median quantity of sumatriptan purchased was 648 DDD. Highly comparable patterns of long-term intense sumatriptan use were found in the data from the regional registry, which covered the 27-month period after the introduction of the drug (February 1992). The register data were highly suggestive of overuse, but lacked essential information, e.g., the indication for use. A third study was therefore conducted using a combination of register and interview data. During a 14-day period, current users of sumatriptan were recruited through community pharmacies in the county of Funen. Respondents returned a signed consent form, including their unique personal identification number (CPR), allowing us to retrieve patient-specific data from the regional registry. For each respondent, all available relevant prescription data for the period 1992-96 were retrieved. Subjects were classified into high, intermediate, and low-peak-use groups according to register data from the 4-year period. The register data were used to evaluate representativity after anonymizing nonrespondent data. The response rates were 33% (7/21) in the high-peak-use group, 47% (30/64) in the intermediate-peak-use group, and 56% (196/350) in the low-peak-use group. Respondents and nonrespondents in the three groups were comparable with regard to age and use of other drugs. (ABSTRACT TRUNCATED)

Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache

OBJECTIVES

To conduct a systematic review of the randomized controlled clinical trials (RCTs) of complementary/alternative (CAM) therapies in the treatment of non-migrainous headache (i.e. excluding migraine, cluster and organic headaches).

DESIGN

Systematic review with quality scoring and evidence tables.

MAIN OUTCOME MEASURES

Number of RCTs per therapy, quality scores, evidence tables.

RESULTS

Twenty-four RCTs were identified in the categories of acupuncture, spinal manipulation, electrotherapy, physiotherapy, homeopathy and other therapies. Headache categories included tension-type (under various names pre-1988), cervicogenic and post-traumatic. Quality scores for the RCT reports ranged from approximately 30 to 80 on a 100 point scale.

CONCLUSION

RCTs for CAM therapies of the treatment of non-migrainous headache exist in the literature and demonstrate that clinical experimental studies of these forms of headache can be conducted. Evidence from a sub-set of high quality studies indicates that some CAM therapies may be useful in the treatment of these common forms of headache.

Headache medication-use among primary care headache patients in a health maintenance organization

OBJECTIVE

Medication-use among headache patients 2 and 5 years after a primary care headache visit is assessed, and the pattern of medication-use compared before and after the introduction of subcutaneous sumatriptan among migraineurs.

SETTING AND PATIENTS

The study was carried out among headache patients visiting a primary care physician at the Group Health Cooperative of Puget Sound in 1989-90.

METHODS

We report medication-use patterns 2 and 5 years later for the 530 subjects completing both a 2-year (1991-92) and a 5-year (1994-95) follow-up interview. Medication-use was determined by self-report for the month prior to the interview. Medication-use to control or prevent headache is shown for all headache patients and for those meeting International Headache Society criteria for migraine at the 2-year and the 5-year follow-up.

RESULTS

The overall pattern of medication-use was similar at the 2-year and the 5-year follow-up, before and after the introduction of subcutaneous sumatriptan (March, 1993). There was a modest but statistically significant decline in the use of opioid and sedative-hypnotic medications, and in the use of ergotamine. At 5 years, 11% of migraineurs reported use of sumatriptan in the prior month. The large majority of study patients used symptomatic medications, usually non-prescription analgesics, sedative-hypnotics, and opiates. Only one-fifth of the migraineurs reported use of a prophylactic medication for headache.

CONCLUSIONS

Continuing use of symptomatic headache medications was characteristic of patients with migraine and other common forms of headache. The introduction of subcutaneous sumatriptan was not associated with notable change in this pattern, although a modest reduction in use of sedative-hypnotics and opiates was observed. Overall, the pattern of use of headache medications was similar before and after the introduction of subcutaneous sumatriptan.

Primary headache care delivery by nonspecialists in Brazil. Brazilian Headache Care Cooperative Group

Headaches are common disorders usually examined by nonneurologists. In order to assess how primary headache patients (IHS groups 1, 2, and 3) are generally managed by nonspecialists, 414 patients were asked about their previous headache care. Correct diagnosis had previously been made in only 44.9%, 6.7%, and 26.7% of the migraine, tension-type headache, and cluster headache patients, respectively. The patients underwent 501 investigative procedures motivated by the headache, averaging 1.21 examinations per patient, mostly EEGs. Preventive treatment was largely overlooked irrespective of the headache type. It is concluded that scientific improvements in headache care may be ineffective unless educational programs improve headache knowledge in general.

Nitrous oxide for the treatment of acute migraine headache

The objective of this study was to determine the efficacy of nitrous oxide in the therapy of acute migraine symptoms in emergency department (ED) patients. This was a prospective, randomized, double blind study of patients presenting to an ED. All eligible patients had a prior diagnosis and symptoms consistent with migraine headache and a normal neurological examination. Patients were randomized to receive either 50% nitrous oxide and 50% oxygen or 100% oxygen over 20 minutes. All patients completed a visual analog pain scale before and immediately after intervention. Initial pain scores and change in pain scores between the two groups were compared. There were 22 patients enrolled, 10 in the nitrous oxide group and 12 in the oxygen group. The groups were similar in age, gender, duration of headache, and initial pain scores. Pain scores decreased significantly in the nitrous oxide group (median change, 69 to 21 mm, P = .02). The oxygen group did not show significant change in pain scores (median change, 78.5 to 72, P = .09). Eighty percent of patients receiving nitrous oxide required no rescue medication at the completion of the intervention, compared with 17% of those receiving 100% oxygen (P = .008). Twenty minutes after termination of intervention, 60% of patients who had received nitrous oxide still required no rescue medication, compared with 8% of those who had received 100% oxygen (P = .02). Nitrous oxide shows efficacy in ED short-term treatment of acute migraine headache.

Zolmitriptan provides consistent migraine relief when used in the long-term

Migraine is a chronic disease that significantly reduces quality of life between, as well as during, attacks. Treatments that provide consistent relief may reduce the burden of the disease. In the open-label phase of a two-part study, patients could choose to treat initial, persistent or recurrent migraine headache of any intensity with 2.5 mg or 5 mg zolmitriptan. This novel study design allowed patients to manage and maximise their migraine relief. Headache response rates and pain-free response rates were assessed within two hours of dosing with zolmitriptan, and response rates were compared across migraines with and without a history of aura, and associated or not with menses. Consistency of response was also assessed in those patients treating at least 20 attacks. Of 49,784 attacks treated, 66% (32,737 attacks) were treated with a single dose of zolmitriptan. Two-hour headache response rates to an initial dose of 2.5 mg or 5 mg zolmitriptan were 85% (median 95%) and 79% (median 88%), respectively, across all attacks. Corresponding pain-free response rates were 69% and 59%. Responses were independent of gender and age and were similar in patients with and without aura and in attacks associated or not associated with menses. Consistent response rates were achieved within individual patients; during months 1 to 3, 64% of patients reported a headache response in > 75% of their migraine attacks. In patients treating at least 20 attacks, 2.5 mg and 5 mg zolmitriptan produced consistently high headache response rates (range 84-91% and 76-84%, respectively) and pain-free response rates (range 70-76% and 58-65%, respectively) across attacks. In the minority of attacks requiring a second dose of zolmitriptan for persistent or recurrent headache, response rates to a second dose were also consistent across attacks. In conclusion, zolmitriptan 2.5 mg and 5 mg show consistent effectiveness in the treatment of multiple migraine attacks in individual patients and are unaffected by gender, age and the presence of aura or the relationship to menses.

The UK migraine patient survey: quality of life and treatment

This research confirms that a majority of migraine sufferers in the UK acknowledge an incidence, frequency and symptomatology that have a significant effect on quality of life (both activity-based and on personal relationships); despite this, a significant proportion self-medicate with unsuitable and ineffective agents owing to the low level of efficacy and general lack of satisfaction with recommended and prescribed therapies. 50,000 migraineurs (sample derived from the Consumer Research Bureau) in the UK were invited to self-complete a questionnaire (during Q2-Q3, 1998). 9770 questionnaires were included in the analysis. With the advent of improved diagnosis and medications, the present study was undertaken to assess the impact and severity of migraine on the normal activities, attitudes and relationships of known migraineurs. The efficacy and control achieved by a range of therapeutic interventions were also considered. In order to identify the headache characteristics of this self-selected migraine patient population, diagnosis was confirmed by information relating to quality of headache (frequency, duration and symptomatology); the extent of restrictions on specific daily activities was also used to provide severity characteristics. A majority believed that they could not control their migraine and a significant proportion believed that migraine controlled their day-to-day life. Despite this, sufferers may not consult general practitioners (GPs) owing to previous experience, expectations of inadequate therapeutic intervention and/or perceived lack of physician empathy. This study is both opinion-based and awareness-based, and confirms known statistics while also providing further clarification on the overall effect of migraine on associated emotional and physical relationships, and on migraineurs' use and opinion of a range of available medications.

[Prevalence and indirect costs of headache in a Brazilian Company]

Employees from a Brazilian oil company research centre (n = 993) were interviewed on the occurrence of headache during a 30 days period. Headache prevalence was 49.8%, with a mean frequency of 4.3 +/- 7.0 attacks per month, lasting 12.2 +/- 21.4 hours each. According to the International Headache Society diagnostic criteria, migraine (5.5%), episodic tension-type headache (26.4%), chronic tension-type headache (1.7%) and headaches not fulfilling the criteria for such disorders (16.2%) were observed. Women suffered comparatively more headache and specifically migraine than men. The pain interfered with work productivity in 10% of the subjects, corresponding to 538.75 hours off. According to an indirect costs estimation for each headache, the company may loose up to US$125.98 per employee annually. Since among headaches migraine has the highest indirect cost, migraine prevention and treatment is particularly important at the working environment. Migraine frequency may be prevented to a large extent, resulting on positive effects in both the quality of life and productivity. The cost-benefit ratio clearly favours therapeutic and preventive programs against chronic headaches.

Unusual headaches

Headache represents one of the most common somatic complaints seen in the emergency department, accounting for 1% to 3% of all emergency department visits. Although most headaches seen in the emergency department are benign, as many as 10% of all headaches are secondary to an underlying pathologic condition. The emergency physician is well-trained to exclude stoke, subarachnoid hemorrhage, and meningitis as potential causes of headache. This article focuses on seven unusual headache syndromes, all of which are associated with significant morbidity and mortality. Particular emphasis is placed on clinical features and diagnostic modalities of choice.

The burden of migraine to the individual sufferer: a review

This review of the literature reveals that migraine is a common, chronic condition featuring episodic attacks which vary in severity and symptomatology. Throbbing, unilateral headache, which is aggravated by activity, is the most prominent feature, although a high proportion of sufferers also experience phonophobia, photophobia and nausea, which may lead to vomiting. Preceding aura is a less common feature of the attack. The frequency and duration of migraine attacks varies widely between individuals, though the median frequency is around 1 attack per month and median duration is roughly 24 h. Migraine attacks can have a profound effect on the day-to-day lives and well-being of the sufferer. In the long term, migraine may cause profound emotional changes and result in coping strategies that interfere with working, social and family life and many normal daily activities. These effects are apparent in quality of life studies on migraine patients. Thus, the impact of migraine on many quality of life parameters is similar to that of other chronic conditions such as osteoarthritis, diabetes and depression. Reduction in the personal burden of migraine can be facilitated by encouraging migraine sufferers to consult their doctor, through accurate diagnosis of migraine headaches and assessment of the disability suffered by the migraineurs, and through improved and well-executed treatment strategies. Copyright 1998 Lippincott Williams & Wilkins

[Headache incidence in a hospital community]

The purpose was to describe the main features of headache incidence in a hospital community, its frequency and the most requested medical investigation. Due to the stressful work environment, hospital is considered to hold a high-risk population. Interviews and questionnaires were utilized. Of a 1006 files, which were randomly filled out, 987 could be analyzed. Of all, 38.5% were from headache sufferers. By using a table of pain symptoms taken from the International Headache Society classification as a pattern, headaches were assigned as migraine, tension-type and other. The mean age was 31.18 and the frequency in females was higher than in males, at any type. Family occurrence in first-degree relatives was 76.8%. Frontal location, medium intensity and pulsation were the most described features. Stress was the most frequently mentioned trigger factor. A physician was consulted only by 41.3%. Cranium X-ray was the most frequently requested exam.

Medication patterns of recurrent headache sufferers: a community study

This community-based telephone survey determined medication patterns of 274 frequent headache sufferers who reported 12 or more headaches a year. Headaches were classified using the International Headache Society's (IHS) criteria. Participants reported on 465 types of headaches: 129 tension headaches, 158 migraine headaches, 8 chronic tension headaches, and 148 headaches which were unclassifiable using IHS criteria. Females (n = 133) reported an average of 1.9 types of headache and males (n = 141) reported 1.5 headache types. Fifty-six percent of respondents used acetaminophen for tension-type and 60% used acetaminophen for migraine. One percent used prescription medication for tension headache and 12% used prescriptions for migraine. The perceived effectiveness of over-the-counter medication was approximately 7 on a scale of 0-10 for tension headaches and 6 for migraine. Both tension-headache and migraine-headache sufferers waited about 1 h before taking any medication. Tension-headache sufferers waited until the headache was above 5 on a 0 to 10 scale (4.6 for migraine). It is possible that more aggressive use of medication might improve headache management.

Digestive Enzyme Adjunct to Oral Headache Medication to Improve Absorption and Reduce Vomiting

Objective:

To report a case in which a digestive enzyme complex (Nature's Plus Digestive Enzymes: pancreatin, pepsin, ox bile extract, malt diatase, and papain) apparently improved the absorption and efficacy of an oral headache medication and alleviated vomiting associated with the headache.

Case Summary:

A 47-year-old white woman with a history of adverse drug reactions and allergies had been experiencing one to four disabling headaches per week for 2 years. One or two headaches each week would be accompanied by vomiting. This patient experienced adverse effects with most standard headache medications. For 40 months since taking a complex of digestive enzymes as an adjunct to her headache medication, the patient's vomiting has been eliminated, and her postheadache symptoms have been reduced.

Discussion:

Altered digestive processes are a common finding in severe headache episodes. Exogenous digestive enzymes may facilitate the absorption of oral medication during gastric disruption and consequently increase drug efficacy and the relief of symptoms.

Conclusions:

Digestive enzymes merit further study to ascertain their effectiveness in increasing the absorption and efficacy of oral medications prescribed for headaches accompanied by emesis.

Lost workdays and decreased work effectiveness associated with headache in the workplace

Little is known about the impact of different types of headache on lost work time and work effectiveness in the United States. Estimation of the distribution and magnitude of the impact of headache in the workplace is necessary before workplace interventions can be developed. During 1993 and 1994 in Baltimore County, Maryland, study subjects were contacted by random-digit dialing and interviewed by telephone about their headaches. Headache diagnoses were assigned using International Headache Society criteria for migraine and episodic tension-type headache. Measures of workplace impact were derived based on self-reports of missing work because of headache and frequency and magnitude of reduced work level because of headache. Of the 13,343 respondents, 9.4% reported missing work more than rarely because of headache, 31% reported that their work level was reduced more than rarely by headache, and 9.2% reported that their work level was reduced more than 50% by headaches during work. In accounting for both actual lost workdays and reduced effectiveness at work, individuals lost the equivalent of 4.2 days per year because of headache. Of the 9922 annual estimated actual lost workdays because of headache, 57% were due to migraine and 43% were due to tension-type and other headache types. Of the 23,287 annual estimated reduced effectiveness workday equivalents, 64% were due to tension-type and other headache types, and 36% were due to migraine. Headache type, headache severity, and education level were each independent predictors of workplace impact of headache. Subjects with migraine headache were much more likely to report actual lost workdays because of headache, whereas tension-type and other headache types accounted for a large proportion of decreased work effectiveness because of headache. The results have implications regarding the control of indirect costs in the workplace because of headache, and on workplace-based treatment and prevention programs.

Opioids in headache treatment. Is there a role?

There may be a population of patients subject to frequent headache and in whom optimal analgesic effect is obtained only by frequent but controlled use of opiate drugs and in whom adverse drug effects are minimal. It is emphasized again that the reality is that there are currently a large amount of opioids being prescribed for headache patients because of patients' demands. One of the major considerations for physicians prescribing such treatment is familiarity with the legal guidelines. The federal law requires physicians to register if they are to maintain or detoxify with opioids addicts defined as "any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his addiction." A subsequent regulation, however, stated that the law was not intended to impose any limitation on prescription of narcotics for intractable pain. There are also many different state regulations covering, for example, limitations on amounts to be prescribed and reporting of patients who are habitual narcotic users. Obviously, headache patients who request liberal amounts of opioids must be screened. There has been considerable recent effort to provide guidelines regarding which patients with nonmalignant pain might be poor candidates for opioid treatment by reason of both probable treatment failure and risk of drug overuse. Many of these guidelines are not relevant to headache patients in whom pain is rarely continuous and rarely demands scheduled analgesia, as is often the case with pain of other types. There is general agreement that any previous history of any type of substance abuse is an important indicator of danger of recurrence of such behavior. Evaluation of psychological state and personality structure is of great importance. The more evidence of emotional disturbance, the greater the danger both of poor results and of drug abuse. In the chronic daily headache population, treatment failure has been found to correlate with abnormalities on the Minnesota Multiphasic Personality Inventory (MMPI). It is possible that formal psychological testing prior to the prescription of opioid drugs will prove of value in identifying those headache patients at greatest risk for drug abuse. The importance of making opioid treatment part of a multifaceted pain program has been emphasized. Portenoy emphasizes the need for (1) careful discussion with the patient (and often family) of the potential side effects of the drugs, and (2) scrupulous monitoring of adherence to the appropriate dosage and maintenance of prescription by a single physician. The more psychological disturbance evidenced by the patient, the more the risk with failure of drug treatment and of drug abuse. Finally, the analgesic needs of the patient with frequent migraine are different from those of the patient with tension-type headache. Migraine infrequently occurs more than two or three times a week for any period and usually responds to ergotamine, dihydroergotamine, sumatriptan, or a phenothiazine. Addition of codeine or oxycodone for the occasional intractable attack may be needed. When demands in a migraine patient for opioids in amounts greater than 10 to 15 tablets per month occur, there is obvious cause for concern. The opioid agonist-antagonist butorphanol, now available in nasal inhalation form, is alleged to have low abuse potential because it tends to produce dysphoria (an unpleasant emotional state) rather than the euphoria of other opioids. It is therefore unscheduled. The drug, however, does have abuse potential, and the limits needed to be placed on its use are still uncertain. Markley recently recommended a restriction to not more than two bottles (30 treatments) per month. The population with frequent tension-type headaches presents the major problem. Large numbers of these patients use drugs--often in combination

Prevalence of migraine in Japan: a nationwide survey

This study presents the first nationwide survey of migraine in Japan. A representative sample of 4029 subjects aged 15 years or older was selected from the Japanese population according to the quota method. A combination of telephone interview and mailed questionnaire methods was used. Diagnosis of migraine was based on the International Headache Society (IHS) Classification. The overall prevalence of migraine in the past year was 8.4%; 5.8% was migraine without aura and 2.6% was migraine with aura. Significant correlation was found between the prevalence of migraine and such variables as gender, age and district of residence. Doctor attendance rate was very low and 69.4% with migraine had never consulted a physician for headache. Yet, 74.2% complained that migraine headache impaired their daily activity significantly. Only 11.6% were aware that their headache was migraine and 56.9% were using only the over-the-counter drugs. The study revealed a comparably high prevalence of migraine in the general population of Japan compared with other countries. A genetic factor was speculated as the cause of regional difference in migraine prevalence.

Tension-type headache in different age groups at two headache centers

At two headache centers, one for children and adolescents and the other for adults, we investigated patients aged 5-80 years with episodic or chronic tension-type headache to evaluate the relation between age and headache characteristics as well as analgesics intake. We found an increasing headache frequency and duration, an increasing variability of the headache location, and an increasing frequency of nausea with increasing age. All other headache features did not depend on age. Additionally, our study revealed a marked increase of analgesics use in adults compared to children and adolescents. In conclusion, children, adolescents, and adults referred for tension-type headache show minor differences in some headache features, but a marked change of analgesics intake. The different headache symptoms may be causally related to age, but an influence of medication or other factors must also be considered.

Work-related disability: results from the American migraine study

Migraine headache is a highly prevalent, often severely painful and frequently disabling disorder. The indirect costs related to disability greatly exceed the direct cost of medical care. The objective of this paper is to describe work-related disability associated with migraine headache and predictors of disability. In a two-stage survey of the US population, we estimate missed workdays and impairment at work in a sample of 1663 migraine suffers, age 18 years and older. Lost workday equivalents (LWDE) was derived as the sum of actual missed workdays and the product of percentage effectiveness at work and days at work with the most severe headache. Overall, reported actual lost workdays and reduced effectiveness at work contributed approximately equally to total LWDE. A total of 51.1% of females and 38.1% of male migraineurs experienced six or more LWDE per year. This subgroup of migraine sufferers accounted for about 90% of the total LWDE experienced by all respondents. Among women, headache duration was the strongest predictor of LWDE followed by less significant associations with number of symptoms and pain level. Among men, only pain level was significantly associated with LWDE. Among sociodemographic factors, disability was more likely among older (40+) subjects and less likely among individuals with higher education and higher income (females only), even after adjusting for headache features. Health-care interventions may yield the greatest individual benefit (by reducing pain and disability) and the greatest societal benefit (by reducing indirect costs) if they are directed to those who account for the greatest proportion of disability.

Gender variations in clinical pain experience

This review is a critical summary of research examining gender variations in clinical pain experience. Gender-comparative pain research was identified through Medline and Psychlit searches and references obtained from bibliographies of pertinent papers and books. Review of this research demonstrates that women are more likely than men to experience a variety of recurrent pains. In addition, many women have moderate or severe pains from menstruation, pregnancy and childbirth. In most studies, women report more severe levels of pain, more frequent pain and pain of longer duration than do men. Women may be at greater risk for pain-related disability than men but women also respond more aggressively to pain through health related activities. Women may be more vulnerable than men to unwarranted psychogenic attributions by health care providers for pain. Underlying biological mechanisms of pain and the contribution of psychological and social factors as they contribute to the meaning of pain for women and men warrant greater attention in pain research.

A new approach to chronic pain in the ED

Patients presenting to emergency departments (EDs) for primary management of chronic or recurrent nonmalignant pain conditions and their physicians frequently report dissatisfaction, in part because of the impressions created by a small percentage of such patients that frequently visit EDs requesting opioids. Treating such patients with opioids is contrary to many published guidelines, but refusing them increases dissatisfaction. Narcotic registers serve to label patients who are suspected of seeking drugs, thus creating anxiety and often distrust in health care professionals treating them. The four Calgary adult EDs have developed a system that will attempt to remove labels associated with some of these patients, insure communication between patients, their family doctors, and ED staff, and facilitate optimal care of the patients' real problems, be they difficult home management of pain, drug dependence or addiction, or other social issues. Emphasis will be shifted to home management and the family doctor's office. If successful, the system will minimize ED visits by frequent attendees seeking medication for pain control, and should also decrease overall expenditure to the health care system.

Psychological treatments for migraine

Psychological and behavioral treatments for migraine are described and evidence for their efficacy is reviewed. Treatments for children, adolescents, and the elderly, and for menstrual migraine are then discussed. Biofeedback, relaxation, and stress-coping treatments have all demonstrated effectiveness. These treatments are effective for the majority of migraine sufferers and treatment effects are reliably maintained for periods of at least one year. Little is known about the mechanism behind the efficacy of psychological treatments. Suggestions for future research on treatment mechanisms, enhancement of treatment effectiveness, and increasing the acceptance of psychological treatments are provided.

The prognosis and treatment of headaches in children--a ten year follow-up

The prognosis and methods of treating headaches were studied in a group of children, 10 years after their initial diagnosis in 1983. Follow-up was achieved for 77 patients (81%). Headaches persisted in 72.7% but were much improved in 81.3%. Medication use was uncommon, with non-prescription medications used by 30.3% and prescription medications by only two. These data suggest that although childhood onset headaches are likely to persist, children who receive early education regarding the use of non-pharmaceutical methods of headache control appear to rely on these methods even after an interval of 10 years.

Classification of primary headaches

In 1988, the International Headache Society (IHS) classification committee published operational diagnostic criteria for the primary headaches and a broad range of other headache disorders. These criteria have been translated into more than ten languages, providing uniform terminology for clinical practice, multinational clinical trials, and biologic and epidemiologic research. The criteria have also been evaluated in a number of field studies intended to address their generalizability, exhaustiveness, reliability, and validity. In the present publication the IHS criteria for migraine and tension-type headache are presented.

Epidemiology of migraine

The introduction of operational diagnostic criteria for the primary headaches in 1988 has provided new opportunities for comprehensive epidemiologic headache research. In recent years, several studies on the epidemiology of migraine have emerged. This review deals with methodologic considerations and provides a snapshot of the main findings in these studies. The importance of epidemiologic studies in clarifying the natural history of migraine is elucidated.