Headache syndromes suggested by statistical analysis of headache symptoms

Symptoms associated with headache in youth

OBJECTIVE

To determine the underlying relationships between a broad range of headache-associated symptoms and how they relate to headache burden.

BACKGROUND

Symptoms associated with head pain inform classification of headache disorders. However, many headache-associated symptoms are not included in the diagnostic criteria, which is largely based on expert opinion. Large symptom databases can assess headache-associated symptoms irrespective of pre-existing diagnostic categories.

METHODS

We conducted a large single-center cross-sectional study on youth (6-17 years old) assessing patient-reported outpatient headache questionnaires between June 2017 and February 2022. Multiple correspondence analysis, an exploratory factor analysis, was applied to 13 headache-associated symptoms.

RESULTS

6662 participants (64% female; median age 13.6 years) were included. Multiple correspondence analysis dimension 1 (25.4% of the variance) captured the absence or abundance of headache-associated symptoms. A greater number of headache-associated symptoms correlated with greater headache burden. Dimension 2 (11.0% of the variance) revealed three symptom clusters: (1) cardinal features of migraine (light, sound, and smell sensitivity, nausea, and vomiting), (2) nonspecific global neurologic dysfunction symptoms (lightheadedness, trouble thinking, blurry vision), (3) vestibular and brainstem dysfunction symptoms (vertigo, balance problems, ear ringing, double vision).

CONCLUSION

Assessing a broader range of headache-associated symptoms reveals clustering of symptomatology and a strong relationship with headache burden.

The long-term prognosis of tension-type headache

Tension-type headache (TTH) is a very common problem that usually causes only minimal to moderate discomfort and little disability. If episodic TTH evolves to chronic TTH, then the morbidity in terms of discomfort, disability, and use of medication escalates dramatically. There are no long-term studies, but inferences can be made from population surveys. These suggest that episodic TTH occurs in 15% to 75% of the population, but 30% to 40% is the most common estimate. There is a modest increase in prevalence between the ages of 30 and 50 years and a decrease to 25% to 35% prevalence after the age of 60 years. TTH appears to remain a problem for most sufferers throughout their lives.

The tension headache component of chronic daily headache

Chronic daily headache (CDH) is an overarching term that includes multiple types of frequent primary headaches that are not trigeminal-autonomic cephalgias. The components of typical CDH can be divided into a more severe or "big" headache and a less severe or "little" headache. The big headaches tend to have features of migraine while the little headaches have features of tension-type headache (TTH). Whether this represents a spectrum or continuum or whether it is the superimposition of two unique headache entities is open to debate. For subjects with big and little headache, the concept that the TTH component is part of a spectrum seems likely. Subjects with only TTH and no migrainous component seem to represent a different entity, pure chronic TTH. These patients have a daily moderate headache that is poorly responsive to current therapies and appears to be a different TTH than the migraine tension type of CDH. The TTH component of CDH may represent multiple subdivisions of TTH.

Chronic Daily Headache

The therapy of chronic daily headache (CDH) is complex and involves a combination of drugs, supportive psychotherapy, nondrug therapy, "tender-loving care," and "tough love." CDH is a chronic problem with exacerbations and remissions. Patients with CDH often manifest mood disorders, and recognition and treatment of these problems is a key component of success. The use of preventative antimigraine therapy is a major component of treatment of this condition. Patients with exacerbations may need judicious short courses of medications that can produce medication-overuse headache. Patients may switch to another physician to get opiates or other pain relief medications. The patient may later realize this mistake and return to the physician. Use of patient "contracts," in which the patient agrees not to take more than a prescribed amount of restricted medication or seek it elsewhere, may be helpful. In this area, there is no standard patient or standard therapeutic regimen. The treatment plan must be individualized for each patient. Taking a little extra time to talk with patients and discuss medications, procedures, and goals and objectives may pay bigger dividends in the therapeutic relationship later in the course of treatment.

A headache diagnosis project

BACKGROUND

Despite the availability of objective criteria, the diagnosis of migraine is thought to be missed frequently in primary practice.

OBJECTIVE

To determine the most important questions assisting in the clinical diagnosis of migraine headache.

METHODS

A cohort of 461 patients referred to headache specialists in Canada was assessed using a pro-forma questionnaire that was completed by the patients alone or administered by the physicians themselves. A final clinical diagnosis was recorded after a complete clinical evaluation. In a subsequent validation study, three questions derived from the results of the first phase of the study were administered to a new cohort of 128 patients, and diagnoses of "migraine" or "not migraine" were recorded according to the decision generated in the first part of the study. The final clinical diagnosis was taken as the "gold standard" for diagnosis, and the results from the two independently derived diagnostic methods were compared.

RESULTS

Statistical analysis of the responses from part 1 of the study yielded three questions (related to daily occurrence, unilaterally, and functional impairment) that distinguished between pure migraine and other headache diagnoses with high reliability and validity. The sensitivity and selectivity of the three-question protocol exceeded 91%.

CONCLUSIONS

The use of three questions related to headache frequency, laterality, and impact on functioning may represent an attractive screening instrument in primary care practice, alerting physicians to the diagnosis of migraine in patients or to the possibility of a second or alternative headache diagnosis in patients in whom their diagnosis of migraine previously has been made. The presence of multiple headache syndromes in individual patients, as is common in tertiary referral practice, may reduce the discriminating power of the three-question protocol.

Responsiveness of non-IHS migraine and tension-type headache to sumatriptan

In a long-term efficacy and safety study, 424 patients were treated with sumatriptan (6 mg sc) for 1,904 migraine attacks. The patients were diagnosed with migraine based on IHS criteria but individual migraine attacks treated in the study were physician diagnosed; not necessarily required to meet IHS criteria. A re-analysis of the treatment response to open label sumatriptan (6 mg sc) indicated that 43 patients had treated at least one migraine that fulfilled IHS criteria for tension-type headache. Analysis of this population revealed they treated 232 headaches. Of these headaches, 114 were classified per IHS criteria as migraine; 76 as tension-type; and 42 as non-IHS migraine (not classifiable as IHS migraine or IHS tension-type headache). Of the 114 migraines, a positive response to sumatriptan occurred in 109 (96%) cases; of the 76 tension-types, 73 responded to sumatriptan (97%); of the 42 non-IHS migraine, 40 (95%) responded to sumatriptan. An equivalent response to sumatriptan among three diagnostic groups of headache supports the concept of a common biologic mechanism involving 5HT1 receptors that spans a range of clinical presentations.

A comparison of tension-type headache in migraineurs and in non-migraineurs: a population-based study

The prevalence, sex-ratio and clinical characteristics of tension-type headache were analyzed in 4000 people from the general population. The one-year-period prevalence of tension-type headache was not significantly different in people with migraine without aura (83%), in people with migraine with aura (75%) and in people who had never had migraine (76%). The male/female ratio varied from 1:1.19 to 1:1.23 and was not significantly different in the three subgroups. Tension-type headache was significantly more frequent within the last year and lasted longer in migraineurs than in people who had never had migraine. The pain characteristics and accompanying symptoms were very similar in the three subgroups. Tension-type headache was often precipitated by stress, mental tension and tiredness. Only migraineurs had episodes of tension-type headache precipitated by alcohol, over-matured cheese, chocolate and physical activity. We conclude that tension-type headache and migraine are separate disorders and not part of a continuum of headache disorders. However, migraine may aggravate and precipitate tension-type headache possibly due to convergence of various noxious peripheral input into the trigeminal nucleus.

Epidemiology of disabling neurological disease: how and why does disability occur?

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Transformed migraine

Chronic tension-type headache, which is included in the International Headache Classification, is present in only a minority of patients who present with chronic daily headache. The majority have what is termed transformed migraine, with a history of distinct episodes of migraine in the initial years which progresses into chronic daily headache. These patients with transformed migraine exhibit mixed features of migraine and chronic tension-type headache. Two distinct types of transformed migraine are identifiable, namely those related to excessive intake of medications (drug-induced transformed migraine) and those unrelated to excessive use of medications. The clinical features of transformed migraine and the drug-induced variety are described. The need for revision of the International Classification to include chronic daily headache and the subtypes of transformed migraine is pointed out.

Diagnostic criteria for migraine and psychogenic headache in children

The headache histories obtained from 214 children were analysed by computer to see whether it was possible to identify and classify migraine, and to distinguish children with psychogenic headache. During headache attacks, most children had no or very few associated symptoms. For classification, 175 patients were divided into four homogeneous groups; the remaining 39 could not be grouped. An overlap between the different groups was found. Psychogenic headache emerged as a clearly definable syndrome, characterised by psychological problems and daily headache for a period of at least one month (10 patients). When the 214 patients were grouped according to the classification of the Headache Classification Committee of the International Headache Society, distinguishing those children with psychogenic headache was no longer possible.

Pharmacology of migraine

Stabilization of serotonergic neurotransmission by depressing the activity of serotonergic neurons may be the common mode of action of drugs effective in migraine. By serotonin receptor agonism, by prolonging the biologic half-life of serotonin in the synaptic cleft (through blockade of its re-uptake or metabolic degradation), by an increase in its synthesis, by inhibiting the release of serotonin, or by activation of cyclic AMP (fig), a unitary expression for the action of these drugs can be formulated which is corroborated, for many of the drugs, by direct measurement of serotonergic neuronal firing rates. However, there are at least three serotonin receptor sites in brain at which drugs would be effective, as assessed by differential responsiveness to agonists and antagonists and by different types of postsynaptic responses: presynaptically, postsynaptically, and at the autoreceptor itself. The locus of action for the antimigraine drugs may be primarily at the raphe, upon the serotonin neurons per se, but it will probably prove to be more complex as more data are generated.

The relationship of headache symptoms with severity and duration of attacks

Efforts to develop clinically useful headache classification schemes have generally focused on linking specific symptom groupings with specific headache subtypes. An alternative conceptual approach, the "severity model" of headache, considers a continuum of headache ranging from mild to severe forms with specific headache subtypes distinguished by level of severity rather than unique constellations of symptoms. A population-based telephone interview was carried out among 10,169 subjects aged 12-29 to estimate the prevalence of serious headaches and better characterize symptoms that accompany headache attacks. In an analysis of frequency of occurrence, pain and duration of recent (within 4 weeks prior to interview) headache attacks, the data revealed that common symptoms (such as forehead pain and pain in the back of the head, neck and shoulders) were reported frequently, but headaches with these symptoms were generally characterized by low levels of pain and short duration. Although not an original study objective, the data were analyzed to determine whether distinct symptom constellations could be identified or whether symptoms overlapped between headache types. Symptoms of migraine were frequently experienced concomitant with tension-type symptoms; the resultant headaches were usually characterized as moderate in intensity. In contrast, symptoms usually associated with migraine in the absence of concomitant tension-type symptoms were infrequently experienced, but resulted in headaches causing the greatest disability. The data provide some support for the severity model of headache.

Use of headache rating scales: a multiaxial approach

The basic principles of the rating scale procedure have been outlined, including the Likert scale, the Guilford criteria for item definitions, and the Guttman and Rasch criteria for item combinations. With these criteria, headache rates among the core symptoms of anxiety and depression. Next, we have discussed one of the prevailing scales for headache, the Waters Headache Questionnaire (WHQ), with a multiaxial approach. The WHQ thus contains a severity axis, a diagnostic axis, and a personality axis. Previous studies on the validity of the WHQ, including factor analysis, have shown that migraine and muscular headaches are not mutually exclusive categories. Studies to validate a two-dimensional diagnostic system of migraine and non-migraine headache by Rasch models are discussed. In the field of personality it was suggested, when using questionnaires like the WHQ, to focus on the concepts of acquiescence and dissimulation. Supplemental axes such as "severity of psychosocial stressors" and "social functioning" or "quality of life" should be considered in future research.

Clinical diagnosis and computer analysis of headache symptoms

The headache histories obtained from clinical interviews of 600 patients were analysed by computer to see whether patients could be separated systematically into clinical categories and to see whether sets of symptoms commonly reported together differed in distribution among the categories. The computer classification procedure assigned 537 patients to the same category as their clinical diagnosis, the majority of discrepancies between clinical and computer classifications involving common migraine, tension-vascular and tension headache. Cluster headache emerged as a clearly-definable syndrome, and neurological symptoms during headache were most prevalent in the classical migraine group. However, the classical migraine, common migraine, tension-vascular and tension headache categories differed in terms of the number, rather than the nature, of common migraine features. Whether the two extremes of this migraine-tension headache spectrum are different disorders can be determined only by studies of their pathophysiology.

So-called "tension headache"--the response to a 5-HT uptake inhibitor: femoxetine

Sixteen patients with a headache resembling the so-called "tension headache" and a clear response to doxepin (demonstrated in a previous work) were given femoxetine, 400 mg p.d., and placebo in a cross-over, double-blind fashion. Only single blindness was kept in the last third of the study. Placebo and femoxetine tablets were each given for four weeks. Whereas there was a daily or practically daily occurring headache untreated, placebo was associated with a headache frequency of 92%. The corresponding figures for doxepin and femoxetine were 27% and 41%, respectively. Femoxetine led to transitory nausea and gastrointestinal discomfort, but in contrast to doxepin, no weight gain and only slight, if any, sedation. Most patients preferred femoxetine to doxepin. Femoxetine, an antidepressant phenylpiperidine derivative with predominant serotonin re-uptake inhibition (little effect on noradrenaline), thus seems to counteract so-called "tension headache".