The differential diagnosis of chronic daily headaches: an algorithm-based approach

Sex and gender differences in the epidemiology, clinical features, and pathophysiology of trigeminal autonomic cephalalgias

Emerging evidence suggests that primary headaches, classified as trigeminal autonomic cephalalgias (TACs), may exhibit sex and gender differences in clinical features, mechanisms, and treatment responses. While epidemiological and clinical gender-specific differences have been widely reported for cluster headache, limited evidence is available for other TACs. In this narrative review, we have analyzed the existing data on the influence of sex and gender on cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. Given the role of calcitonin gene-related peptide (CGRP) in migraine and cluster headache, sex and gender differences in the levels and function of CGRP in preclinical models and patients are reported. Future studies are warranted to elucidate the role of sex and gender in the complex interplay of genetic and neurochemical factors in TACs.

New Daily Persistent Headache in the Pediatric and Adolescent Population: An Updated Review

PURPOSE OF REVIEW

New daily persistent headache (NDPH) is a primary headache disorder characterized by the sudden onset of continuous pain and its intractability to treatment. It is more prevalent in the pediatric population than the adult population, but remains understudied and underdiagnosed. The purpose of the current article is to provide a current overview of new daily persistent headache in the pediatric and adolescent population, including history, pathophysiology, clinical findings, current and emerging treatment options, and the results of recent studies and meta-analyses.

RECENT FINDINGS

Despite recent studies and meta-analyses showing significant phenotypic overlap between chronic migraine and NDPH in the pediatric population, multiple recent studies have come to conflicting conclusions about the overlap of medication overuse in headache and pediatric NDPH. Recent studies reveal alterations in neuroimaging, particularly in functional connectivity, in patients with NDPH. Patients frequently remain treatment-refractory even to medications that have historically proven helpful in this population; however, new treatment options, including calcitonin gene-related peptide (CGRP) monoclonal antibodies, may be more effective.

SUMMARY

NPDH remains a perplexing and difficult-to-manage condition for both children and adults. Despite a higher prevalence in the pediatric population, there are relatively few studies to guide the evaluation and treatment of NDPH in pediatric and adolescent patients. Early treatment, both pharmacological and non-pharmacological, should be employed to reduce disability. Overall, further studies are needed to better understand pathogenesis and to identify more effective therapeutic strategies, both pharmacological and non-pharmacological.

Temporomandibular disorders in migraine and tension-type headache patients: a systematic review with meta-analysis

The simultaneous occurrence of primary headaches and temporomandibular disorders can pose a challenge in determining the best clinical management of patients. Therefore, we aimed to summarize evidence regarding the risk and prevalence of temporomandibular disorders (TMDs) in migraine and tension-type headaches (TTH) patients. Cross-sectional studies published in English comparing the presence of TMDs in adults with TTH or migraine to subjects without headaches were included, International Classification of Orofacial Pain, Diagnostic Criteria for Temporomandibular Disorders or Research Diagnostic Criteria for Temporomandibular Disorders, and large epidemiological studies (sensitive diagnostic criteria (SDC)). The methodological quality was assessed by Modified Newcastle-Ottawa Quality Assessment Scale. Odds ratio (OR) and random effects were calculated. 1405 articles were identified in PubMed, Embase and Central databases, and 13 cross-sectional studies were finally included. Overall Risk of TMDs was statistically significantly higher than control groups in both Migraine (SDC: 11 studies; OR: 3.79 (2.43, 5.90); I2 = 99%), with higher values in chronic migraine (OR: 24.27; (95% Confidence interval (CI): 5.84, 100.82); I2 = 0%) and TTH populations (SDC: 8 studies; OR: 4.45 (2.63, 7.53); I2 = 86%). Headache subjects presented a higher risk of muscular TMDs (5 studies; OR: 2.01 (1.62, 2.50); I2 = 0%), Combined TMDs (5 studies; OR: 2.74 (1.40, 5.36); I2 = 63%), or Painful TMDs (8 studies; OR: 5.31 (2.96, 9.54); I2 = 96%). Headache patients didn't show the risk of arthrogenous TMDs (4 studies; OR: 0.96 (0.54, 1.71); I2 = 33%) or nonpainful TMDs (2 studies; OR: 1.10 (0.28, 4.26); I2 = 84%). The high heterogeneity in the results was reduced following subgroup analysis. Migraine and TTH appear to increase the risk of painful, myogenous or combined arthrogenous and myogenous TMDs.

Advocacy for patients with headache disorders

Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.

Trial protocol for a multicenter randomized controlled trial to assess the efficacy and safety of intravenous ketamine for chronic daily headaches: the "KetHead" trial

BACKGROUND

Chronic daily headaches (CDH) are common and associated with significant morbidity, poor quality of life, and substantial burden on the healthcare system. CDH tends to be refractory to conventional medical management and/or patients cannot afford expensive treatments. It is stipulated that CDH share a mechanism of central sensitization in the trigeminocervical complex, mediated by activation of the N-methyl-D-aspartate (NMDA) receptors. Ketamine, a non-competitive NMDA antagonist, has been used in the treatment of chronic pain, but its role in CDH has not been completely established. This trial aims to evaluate the effect of high-dose IV ketamine infusions (compared to placebo) on the number of headache days at 28 days post-infusion.

METHODS

A multicenter, placebo-controlled, randomized controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessors. The study will include 56 adults with a CDH diagnosis as per ICHD-3 criteria. Participants will be randomized (1:1) to either ketamine (1 mg. kg^-1 bolus followed by infusion of 1 mg. kg^-1. h^-1 for 6 h) or placebo (0.9% saline in the same volume and infusion rate as the trial medication) bolus and infusion for 6 h. The impact on the number of monthly headache days, headache intensity, physical activity, mood, sleep, quality of life, analgesic consumption, and adverse effects will be recorded at baseline, immediately post-infusion, and from 1 to 28 days, 29 to 56 days, and 57 to 84 days after the infusion DISCUSSION: Despite advancements in treatment, many patients continue to suffer from CDH. This trial investigates whether high-dose IV ketamine infusions can effectively and safely improve the CDH burden as compared to a placebo infusion. This treatment could become a safe, affordable, and widely available option for patients living with refractory headache.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05306899. Registered on April 1, 2022.

Refractory Headaches

Medication overuse headache (MOH), new daily persistent headache (NDPH), and persistent refractory headache attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection represent a significant burden in terms of disability and quality of life, and a challenge in terms of definition, pathophysiology, and treatment. Regarding MOH, prevention without withdrawal is not inferior to prevention with withdrawal. Preventive medications like topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP) monoclonal antibodies improve chronic migraine with MOH regardless of withdrawal. The differential diagnosis of NDPH is broad and should be carefully examined. There are no guidelines for the treatment of NDPH, but options include a short course of steroids, nerve blocks, topiramate, nortriptyline, gabapentin, CGRP monoclonal antibodies, and onabotulinumtoxinA. The persistence of headache 3 months after SARS-CoV2 infection is a predictor of poor prognosis.

The Role of the Otolaryngologist in the Evaluation and Management of Headache

Headaches are a global health problem and are encountered by a variety of specialties, including otolaryngologists. These patients can present as a challenge, but an understanding of primary and secondary headache disorders and the accompanying broad differential diagnosis is critical. For secondary headache disorders, a differential diagnosis categorized by anatomic location can help organize the evaluation of these patients, which can then be narrowed by the history and examination findings. Additional ancillary tests such as laboratories and imaging can further aid in diagnosis but are not always necessary.

Does atorvastatin have augmentative effects with sodium valproate in prevention of migraine with aura attacks? A triple-blind controlled clinical trial

Background

Migraine is a painful and disabling nervous disorder which negatively affects the quality of life. Migraineurs may suffer from a generalized vasomotor dysfunction. Statins improve vasomotor and vascular function, with their pleiotropic effects. We aimed to assess efficacy and safety of adding Atorvastatin to prophylactic regimen in better control of migraine with aura.

Methods

This triple-blind controlled clinical trial was on 68 patients with migraine with aura. An interval of at least 1 month was given to evaluate vitamin D3 level and eligibility. In patients with vitamin D3 deficiency, the correction with vitamin D supplementation was provided. The patients were randomly assigned to receive atorvastatin 20 mg plus sodium valproate 500 mg or placebo plus sodium valproate 500 mg once a day for 2 months. The patients were evaluated based for the number of attacks and pain severity based on Visual Analogue Scale.

Results

There was a significant (p = 0.0001) improvement in severity of pain and number of migraine attacks by adding Atorvastin to the prophylactic regimen of patients with migraine with aura. After controlling for variable parameters, the differences between two arms of the study was yet statistically significant (p = 0.0001). A significant number of participants in intervention group were satisfied by their treatment (p = 0.001) with no remarkable side effects (P = 0.315).

Conclusions

Adding atorvastatin to migraine with aura preventive regimen may help reduce the number of acute attacks and pain severity without causing considerable side effects and led to a better patient satisfaction.

Trial registration

IRCT20180106038242N1. Registered: 7 February 2018.

Effectiveness of chiropractic manipulation versus sham manipulation on recurrent headaches in children aged 7-14 years, Protocol for a randomized clinical trial

Background

Headache is one of the most common pain symptoms in childhood having a negative impact on many aspects of the lives of affected children, both short-term and long-term. Therefore, it is important to document safe and effective treatment options. Chiropractic spinal manipulation is a commonly used treatment option for these patients, although there are no randomized clinical trials documenting the effectiveness of this in pediatric headache. However, there is moderate evidence for effectiveness of spinal manipulation for adults with tension-type and cervicogenic headaches.This paper describes the protocol for a two-armed randomized superiority clinical trial aiming to investigate the effectiveness of chiropractic manipulation versus sham manipulation in the treatment of recurrent headache in children aged 7-14.

Methods

Children with weekly headaches for at least six months will be included if they have indications for chiropractic manipulation. The participants will be randomized to either chiropractic manipulation or sham manipulation. Both children and parents will be blinded for allocation. There will be 100 children in each arm and they will answer weekly text messages four weeks prior to treatment and during a four months treatment period. Potential primary outcomes are weekly number of headaches, intensity of headache, medication use and global perceived effect. Secondary outcomes include side-effects and headache status after one year.An initial outcome data analysis will be performed to inform the choice of primary outcome (adaptive design). Intervention effects will be reported as the difference in mean values between the two treatment arms, Cohen's effect size and numbers needed to treat.

Discussion

A major strength of this study is its pragmatic nature, where the active treatment group receives chiropractic manipulation according to their individual needs, while both groups continue their use of medication for headache according to their pre-trial habits. Other strengths include an elaborate sham procedure and the weekly outcome reports, reducing recall bias.If it is possible to develop effective treatment for headache in children, a life course of recurring problems may be altered with potential positive implications for both individuals and society.

Trial registration

ClinicalTrials.gov, identifier NCT02684916.

Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

Primary Headaches

The primary headaches are composed of multiple entities that cause episodic and chronic head pain in the absence of an underlying pathologic process, disease, or traumatic injury. The most common of these are migraine, tension-type headache, and the trigeminal autonomic cephalalgias. This article reviews the clinical presentation, pathophysiology, and treatment of each to help in differential diagnosis. These headache types share many common signs and symptoms, thus a clear understanding of each helps prevent a delay in diagnosis and inappropriate or ineffective treatment. Many of these patients seek dental care because orofacial pain is a common presenting symptom.

Cluster Headache and Other Trigeminal Autonomic Cephalalgias

PURPOSE OF REVIEW

This article covers the clinical features, differential diagnosis, and management of the trigeminal autonomic cephalalgias (TACs). The TACs are composed of five diseases: cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), and hemicrania continua.

RECENT FINDINGS

New classifications for the TACs have two important updates; chronic cluster headache is now defined as remission periods lasting less than 3 months (formerly less than 1 month), and hemicrania continua is now classified as a TAC (formerly classified as other primary headache). The first-line treatments of TACs have not changed in recent years: cluster headache is managed with oxygen, triptans, and verapamil; paroxysmal hemicrania and hemicrania continua are managed with indomethacin; and SUNCT and SUNA are managed with lamotrigine. However, advancements in neuromodulation have recently provided additional options for patients with cluster headache, which include noninvasive devices for abortive therapy and invasive devices for refractory cluster headache. Patient selection for these devices is key.

SUMMARY

The TACs are a group of diseases that appear similar to each other and to other headache disorders but have important differences. Proper diagnosis is crucial for proper treatment. This article reviews the pathophysiology, epidemiology, differential diagnosis, and treatment of the TACs.

Medication-overuse headache: a widely recognized entity amidst ongoing debate

Medication overuse in primary headache disorders is a worldwide phenomenon and has a role in the chronification of headache disorders. The burden of disease on individuals and societies is significant due to high costs and comorbidities. In the Third Edition of the International Classification of Headache Disorders, medication-overuse headache is recognized as a separate secondary entity next to mostly primary headache disorders, although many clinicians see the disease as a sole complication of primary headache disorders. In this review, we explore the historical background of medication-overuse headache, its epidemiology, phenomenology, pathophysiology and treatment options. The review explores relevant unanswered questions and summarizes the current debates in medication-overuse headache.

Diagnosis and treatment for chronic migraine

Migraine is a debilitating headache disorder that is underdiagnosed and undertreated worldwide, partially attributable to misdiagnosis and expectations of poor treatment outcomes. This article provides a review of chronic migraine, including pathophysiology, burden, diagnosis, and management, with special emphasis on the role of NPs.

Migraine is a debilitating headache disorder that is underdiagnosed and undertreated worldwide, partially attributable to misdiagnosis and expectations of poor treatment outcomes. This article provides a review of chronic migraine, with special emphasis on the role of NPs.

Update of Inpatient Treatment for Refractory Chronic Daily Headache

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15 days per month) and last for more than 3 months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4 h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

The Impact of Peripheral Nerve Stimulation on Disability and Depression

BACKGROUND

Peripheral nerve stimulation (PNS) of the named nerves of the head has been shown to be effective in reducing pain levels in patients with chronic pain refractory to other treatments. However, the impact of cranial PNS on depression and disability has not been well documented.

OBJECTIVES

We prospectively examine the impact of PNS on quality of life via validated survey scores which assess symptoms of depression and daily functional capacities within patients.

METHODS

Patients who underwent permanent PNS implantation completed five validated questionnaires: Oswestry Disability Index (ODI), the Beck's Depression Inventory (BDI), the Pain Catastrophizing Scale (PCS), McGill Pain Questionnaire (MPQ), and the visual analog scale (VAS) score. These were completed at baseline, six months, and one year to assess changes in functioning levels. Results were analyzed via repeated measures ANOVA and bivariate analysis.

RESULTS

Compared with baseline, at six months patients showed significantly less depression on BDI (F = 7.9, p = 0.021), and at one year, a significant decrease in disability was observed on the ODI (F = 6.1, p = 0.036). At both six months and one year, patients showed a significant decrease in pain on VAS (F = 16.5, p = 0.012). We noted a trend for ODI to correlate with BDI at six months (R = 0.616, p = 0.077).

DISCUSSION

Our prospective data show PNS to be an effective modality in improving overall life quality by limiting depression and disability as well as pain.

The Positive Impact of Integrative Medicine in the Treatment of Recalcitrant Chronic daily Headache: A Series of Case Reports

People who suffer from recalcitrant chronic daily headache (CDH)-a primary, episodic headache occurring at least 15 days per month, and lasting four or more hours per day for at least three consecutive months(1)-have generally tried many pain relief medications with few positive results. These patients often continue to add more and more medications and travel from clinician to clinician seeking help, without relief. Patients with recalcitrant CDH are often caught in a vicious cycle of increasing pain which results in a substantial impact from their disease on productivity and quality of life. Studies in the United States and Europe indicate that four to five percent of the general population has recalcitrant CDH,(2) which encompasses transformed migraine and chronic tension-type headache.(3) The disability associated with recalcitrant CDH is substantial, as patients have a significantly diminished quality of life and mental health, as well as impaired physical, social, and occupational functioning.(4,5) Research shows that CDH may not be treated effectively with conventional medicine (CM). Integrative medicine (IM) offers a complex, personalized intervention necessary to treat CDH. Many integrative therapies have shown benefit, effectiveness, cost effectiveness and low side effect profile in patients with both chronic headache and chronic pain.(6-17) Yet even within the IM community, clinicians often struggle with the balance between providing evidence-based therapy and patient-centered, complex, personalized integrative approaches, which may use popular but unproven therapies. In this article, we present a series of cases comprising patients with CDH who had previously been recalcitrant to CM approaches. In each case, employing a five-pronged treatment algorithm resulted in the successful IM treatment of CDH. By using this five-pronged approach, clinicians can offer the standardized protocols and scientific rationale they are accustomed to when employing CM options while additionally offering the benefit of IM possibilities.

Prevalence of post-mastectomy pain syndrome and associated risk factors: a cross-sectional cohort study

This study was designed to determine the prevalence of post-mastectomy pain and its associated risk factors in women submitted to surgical treatment for breast cancer. A cross-sectional cohort study was conducted involving 250 women treated surgically for breast cancer. The variables evaluated were (a) post-mastectomy pain syndrome (PMPS) (as a dependent variable or outcome) and (b) the patients' social characteristics (schooling, marital status), biological characteristics (body mass index, skin color, age), prior history of headache and dysmenorrhea, occurrence of acute postoperative pain, and type of surgery (mastectomy or quadrantectomy) (as independent or predictive variables). The prevalence ratios (PR) and their respective 95% confidence intervals (95% CI) were calculated as a measure of the risk of PMPS. Multivariate analysis was performed using a hierarchical model of stepwise logistic regression that included possible explanatory variables, calculating the adjusted risk of PMPS from the odds ratio (OR) and the 95% CI at a significance level of 5%. PMPS was found in 44.4% of patients. The variables that remained strongly associated with PMPS following multiple logistic regression analysis were quadrantectomy with axillary lymphadenectomy (OR = 2.83; 95% CI: 1.60-5.02), prior history of headache (OR = 1.92; 95% CI: 1.10-3.34), and age <50 years (OR = 4.37; 95% CI: 2.43-7.86). PMPS is a common condition, particularly in women submitted to quadrantectomy with axillary lymphadenectomy, those under 50 years of age, and those with a prior history of headache. Attention should be paid to these factors at preoperative evaluation and counseling, and they should be taken into consideration in postoperative management.

Epidemiology and clinical characteristics of chronic daily headache in a clinic-based cohort of Iranian population

Although CDH is a major health care problem encountered in headache clinics, our knowledge about the epidemiological features of CDH is limited in developing countries. The objective of this study was to survey the frequency and clinical features of chronic daily headache (CDH) and its subtypes among Iranian population presenting to a referral tertiary Headache clinic in a University Hospital. This cross-sectional survey was carried out between September 2011 and March 2012. Data of patients with CDH including their age, sex, educational level, and marital status were recorded using structured face-to-face interview. Subtypes of the CDH were determined by history, physical examination and appropriated laboratory or imaging findings. A total number of 177 cases (32.71%) fulfilled the CDH criteria. The frequency of CDH was higher in 40-49 age groups (n = 54) and among women with a female to male ratio of 2.12/1. Chronic migraine was the most common subtype of CDH in 75 cases (44.4%). Chronic tension-type headache and secondary causes were second and third frequent subtypes of CDH in 27.8 and 20.1% of cases, respectively. Cervicogenic headaches (10.7%) and medication overuse headache (4.1%) were the most common causes of secondary headaches. The present study confirmed previous findings which showed a high prevalence of CDH and chronic migraine in clinic setting, with preponderance for women. In addition, we found the highest prevalence of cervicogenic headaches among secondary causes of CDH.

Elevated blood pressure and analgesic overuse in chronic daily headache: an outpatient clinic-based study from China

BACKGROUND

Many studies have reported that hypertension is common in chronic daily headache (CDH) and its subtype chronic migraine (CM), but the reason is still poorly understood. Our clinical literature review suggested that analgesic overuse may be associated with elevated blood pressure (BP), so we performed the present study to investigate the frequency of elevated BP and its link with analgesic overuse in CDH and its subtypes.

METHODS

A cross-sectional study was conducted in neurology outpatients with a diagnosis of CDH according to International Headache Society criteria. CDH patients were classified into CM and non-CM groups, and subclassified with or without analgesic overuse.

RESULTS

Elevated BP was present in 27.96% of CDH patients. Compared with non-CM patients, patients with CM had a longer duration of headache and more severe pain intensity, and a family history of headache and analgesic overuse were also more common, but the elevated BP frequency was not different between the two groups. Almost one-third of the patients had analgesic overuse; 96.8% of which comprised acetaminophen-containing agents. Those with analgesic overuse had a higher frequency of headache than those without analgesic overuse in both the CM and non-CM groups.

CONCLUSIONS

Although the CM patients had a longer duration of headache, more severe intensity, the frequency of elevated BP wasn't higher than non-CM group. Analgesic overuses maybe the reason of higher frequency of elevated BP in CDH and its subtypes. This may have predictive value for clinicians to improve CDH management.

Estudio con imágenes de la cefalea

El objetivo de este artículo es brindar al clínico pautas para el uso racional y adecuado de los avances tecnológicos en imaginología, para de esta manera lograr un criterio multidisciplinario en el momento de tomar una decisión buscando el beneficio del paciente sin someterlo a exámenes de poca utilidad. Se realizó una búsqueda sistemática de la literatura médica acerca de la cefalea abarcando su fisiopatología, clasificación y, específicamente, el uso de imágenes diagnósticas. Para ello se hizo búsqueda en diferentes bases de datos según las palabras claves indicadas. El abordaje clínico y la diferenciación entre el tipo de cefalea es primordial para decidir el beneficio y la necesidad del uso de imágenes diagnósticas. Las neuroimágenes no son comúnmente solicitadas en pacientes con cefalea primaria, se comienza la sospecha clínica ante la presencia de señales de alarma. Las cefaleas secundarias requieren un estudio más extenso en los cuales se incluye la toma de imágenes radiológicas. Teniendo en cuenta los beneficios de la TC y la RM que se exponen en esta revisión, la TC es preferida en situaciones de urgencia, y para aquellas que no lo son, la RM es más adecuada. [Ortiz, C. Estudio con imágenes de la cefalea. MedUNAB 2012; 15(1):38-45].

Chronic migraine classification: current knowledge and future perspectives

In the field of so-called chronic daily headache, it is not easy for migraine that worsens progressively until it becomes daily or almost daily to find a precise and universally recognized place within the current international headache classification systems. In line with the 2006 revision of the second edition of the International Classification of Headache Disorders (ICHD-2R), the current prevailing opinion is that this headache type should be named chronic migraine (CM) and be characterized by the presence of at least 15 days of headache per month for at least 3 consecutive months, with headache having the same clinical features of migraine without aura for at least 8 of those 15 days. Based on much evidence, though, a CM with the above characteristics appears to be a heterogeneous entity and the obvious risk is that its definition may be extended to include a variety of different clinical entities. A proposal is advanced to consider CM a subtype of migraine without aura that is characterized by a high frequency of attacks (10-20 days of headache per month for at least 3 months) and is distinct from transformed migraine (TM), which in turn should be included in the classification as a complication of migraine. Therefore, CM should be removed from its current coding position in the ICHD-2 and be replaced by TM, which has more restrictive diagnostic criteria (at least 20 days of headache per month for at least 1 year, with no more than 5 consecutive days free of symptoms; same clinical features of migraine without aura for at least 10 of those 20 days).

Prevalence and burden of chronic migraine in adolescents: results of the chronic daily headache in adolescents study (C-dAS)

OBJECTIVE

To estimate the prevalence of chronic migraine (CM) among adolescents and to describe the epidemiologic profile, headache characteristics, disability, and healthcare utilization of adolescents with CM in the USA.

BACKGROUND

Chronic daily headache (CDH) and CM occur in children and adolescents, but are poorly understood in these populations because their presentation is different from that in adults. It may be difficult to assign a definitive diagnosis to young people suffering from CDH because symptoms may fail to meet the criteria for one of the CDH subtypes.

METHODS

A large sample of households with at least one resident aged 12 to 19 years was selected in balance with the US Census. Data were collected in 3 phases: (1) mailed questionnaire; (2) telephone interview; and (3) 30-day interactive voice response system diary. CM prevalence was estimated by adapting the second edition of the International Classification of Headache Disorders criteria for CM to include pediatric migraine diagnostic criteria. The population was stratified for medication overuse. Medication overuse was defined as 15 or more days per month of acute medication use. Included in the study were measures of headache characteristics, headache impact (Headache Impact Test), disability (Pediatric Migraine Disability Assessment), and healthcare and medication use. Data are reported on subjects 12 to 17 years of age only.

RESULTS

The US adolescent (12-17 years) prevalence rate for CM was 0.79% (0.00-1.70) excluding those with medication overuse and 1.75% (0.62-2.89) when adolescents with medication overuse were included. The majority of adolescents with CM had Headache Impact Test scores greater than or equal to 60, indicating severe headache impact, and mean Pediatric Migraine Disability Assessment scores greater than 17, indicating severe headache and disability. The majority of adolescents with CM (approximately 60%) had not visited a healthcare provider in the previous year and less than one in 5 reported taking medications to prevent headaches during the last month.

CONCLUSIONS

Results suggest that CM occurs less frequently in adolescents than adults, but like adults, adolescents are severely burdened by the disorder. Data support an unmet medical need; however, the development of optimal criteria for diagnosing adolescents with CM is critical to fully understanding how medical needs can be met within this complex population.

Hypnic headache

Hypnic headache is a rare short-lasting headache occurring exclusively during sleep in the elderly population. First described in 1988 by Raskin, this headache syndrome was adopted by the International Classification of Headache Disorders in 2004 within the "other primary headache" group (code 4.5). Since then, additional case reports and case series were published and provided data to best understand hypnic headache. This review highlights new findings to discuss the relevance of actual diagnostic criteria and the treatment approach of this nocturnal headache syndrome. We also consider hypnic headache pathophysiology that remains speculative.

Chronic daily headache in children and adolescents

Chronic daily headaches (CDH) in children and adolescents is reviewed. Three major forms of CDH exist: transformed migraine, chronic tension type headache, and new-onset daily persistent headache. Diagnostic criteria, epidemiology, pathophysiology, evaluation, differential diagnosis, and treatment options are discussed.

Chronic daily headaches in children and adolescents

Headaches, which are common in children and adolescents, represent a significant portion of patient complaints in a child neurology practice. Patients with episodic headaches, such as migraines with interval-free periods, and patients with chronic daily headaches with very few headache-free days, are often evaluated and treated differently from each other. The evolution of the classification of chronic daily headache has aided epidemiologic efforts. The disorder can be primary or related to other neurologic or systemic conditions. Comorbid conditions should be identified, and the contributing variables in the child's social, emotional, medical, and educational arenas should be assessed. The level of disability in terms of school attendance and function can help clinicians determine to what extent and how aggressively to treat these children. Rescue medications, such as barbiturates and narcotics, which can cause worsening of headaches, should be avoided.

Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial

Background

Migraine affects approximately 20% of the population. Conventional care for migraine is suboptimal; overuse of medications for the treatment of episodic migraines is a risk factor for developing chronic daily headache. The study of non-pharmaceutical approaches for prevention of migraine headaches is therefore warranted. Craniosacral therapy (CST) is a popular non-pharmacological approach to the treatment or prevention of migraine headaches for which there is limited evidence of safety and efficacy. In this paper, we describe an ongoing feasibility study to assess the safety and efficacy of CST in the treatment of migraine, using a rigorous and innovative randomized controlled study design involving low-strength static magnets (LSSM) as an attention control intervention.

Methods

The trial is designed to test the hypothesis that, compared to those receiving usual care plus a treatment with low-strength static magnets (attention-control complementary therapy), subjects receiving usual medical care plus CST will demonstrate significant improvement in: quality-of-life as measured by the Headache Impact Test (HIT-6); reduced frequency of migraine; and a perception of clinical benefit. Criteria for inclusion are either gender, age > 11, English or Spanish speaking, meeting the International Classification of Headache Disorders (ICHD) criteria for migraine with or without aura, a headache frequency of 5 to 15 per month over at least two years. After an 8 week baseline phase, eligible subjects are randomized to either CST or an attention control intervention, low strength static magnets (LSSM). To evaluate possible therapist bias, videotaped encounters are analyzed to assess for any systematic group differences in interactions with subjects.

Results

169 individuals have been screened for eligibility, of which 109 were eligible for the study. Five did not qualify during the baseline phase because of inadequate headache frequency. Nineteen have withdrawn from the study after giving consent.

Conclusion

This report endorses the feasibility of undertaking a rigorous randomized clinical trial of CST for migraine using a standardized CST protocol and an innovative control protocol developed for the study. Subjects are able and willing to complete detailed headache diaries during an 8-week baseline period, with few dropouts during the study period, indicating the acceptability of both interventions.

Trial Registration

ClinicalTrials.gov NCT00665236

Clinical evaluation of cervicogenic headache: a clinical perspective

Headache is a common complaint that affects the majority of the population at some point in their lives. The underlying pathological bases for headache symptoms are many, diverse, and often difficult to distinguish. Classification of headache is principally based on the evaluation of headache symptoms as well as clinical testing. Although manual therapy has been advocated to treat a variety of different forms of headache, the current evidence only supports treatment for cervicogenic headache (CGH). This form of headache can be identified from migraine and other headache forms by a comprehensive musculoskeletal examination. Examination and subsequent diagnosis is essential not only to identify patients with headache where manual therapy is appropriate but also to form a basis for selection of the most appropriate treatment for the identified condition. The purpose of this paper is to outline, in clinical terms, the classification of headache, so that the clinician can readily identify those patients with headache suited to manual therapy.