Factors Associated With Medication-Overuse Headache in Patients Seeking Treatment for Primary Headache

Headache and psychological variables as predictors of disability in individuals with primary headache disorders

OBJECTIVE

To examine the relative contribution of headache symptoms and psychological factors to headache-related disability.

BACKGROUND

Both headache symptoms and comorbid psychological factors (psychiatric symptoms and transdiagnostic constructs) negatively impact functioning among individuals with migraine and tension-type headache, but few studies have explored their relative contribution to headache-related disability. We hypothesized that psychiatric symptoms and transdiagnostic variables would afford incremental contribution to disability beyond headache symptoms, and we investigated the moderating role of headache diagnosis on these relationships.

METHODS

This cross-sectional study examined data from a southern U.S. university online sample of 1818 young adults (mean [SD] age 19.0 [5.1] years; 74.6% female) who met the International Classification of Headache Disorders, third edition criteria for primary headache disorders (46.6% episodic migraine, 11.6% chronic migraine, 38.3% episodic tension-type headache, 3.5% chronic tension-type headache) and completed measures assessing psychological factors and headache-related disability. Headache, psychiatric symptoms, and transdiagnostic factors were examined in relation to headache-related disability, after controlling for sex. Moderation analyses examined the conditional effect of diagnosis on disability.

RESULTS

As predicted, both psychiatric and transdiagnostic symptoms accounted for unique variance in headache-related disability beyond headache symptoms (R2 changes of 2.7% and 2.3%, respectively). Significant three-way interactions revealed the relationship between psychiatric symptoms and disability (b = -3.16, p = 0.002), and between transdiagnostic variables and disability (b = -2.37, p = 0.034). Tests of simple slopes showed greater psychiatric symptoms and transdiagnostic variables were associated with higher levels of disability. However, the associations of these variables with disability were strongest among individuals with chronic tension-type headache (B = 3.93 for psychiatric symptoms and B = 4.62 for transdiagnostic symptoms, both p < 0.001).

CONCLUSION

Psychiatric and transdiagnostic factors contribute uniquely to headache-related functional impairment, which may be important for expanding targeted assessment and behavioral interventions.

The Primary Care Management of Headache: Synopsis of the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

INTRODUCTION

In June of 2020, the U.S. DVA and DoD approved a new joint clinical practice guideline for assessing and managing patients with headache. This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with headache.

METHODS

In October of 2018, the DVA/DoD Evidence-Based Practice Work Group convened a guideline development panel that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines.

RESULTS

The guideline panel developed key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 42 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system.

CONCLUSION

This synopsis summarizes the key features of the guideline in three areas: prevention, assessing and treating medication overuse headache, and nonpharmacologic and pharmacologic management of headache.

Effects of Different Therapeutic Exercise Modalities on Migraine or Tension-Type Headache: A Systematic Review and Meta-Analysis with a Replicability Analysis

The primary aim of this study was to review the effect of exercise in comparison with a non-active treatment on pain intensity, frequency of headache episodes, headache duration, quality of life, medication use, and psychological symptoms, in patients with migraine or tension-type headache (TTH). A systematic search was conducted in various electronic databases to identify all relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of exercise interventions in patients with primary headaches were selected. Methodological quality was evaluated using the Cochrane Risk of Bias Tool and PEDro scale and qualitative analysis was based on classifying the results into levels of evidence according to the GRADE. 19 studies (2776 participants; 85% female) were included. The meta-analysis showed statistically significant differences in pain intensity for aerobic training in patients with migraine (SMD = -0.65; 95% CI = -1.07 to -0.22, very low certainty evidence) and for strength training in patients with TTH (SMD = -0.84; 95% CI = -1.68 to- -0.01, very low certainty evidence). Statistically significant differences were also found in the medication use (SMD = -0.51; 95% CI = -0.85 to -0.17, low certainty evidence). Low transparency, replicability and high risk of bias were found. Aerobic training has a small to moderate clinical effect on pain intensity and medication use on migraine patients, with very low to low certainty of evidence. Strength training showed a moderate clinical effect with very low quality of evidence in patients with TTH. Exercise could be considered as clinically relevant for the management of patients with primary headaches, but the presence of low certainty of evidence and low transparency and replicability limited its clinical application. PERSPECTIVE: This article presents current evidence about exercise interventions in patients with primary headaches, including migraine and tension-type headache. Existing findings are reviewed, and relevant data are provided on the effectiveness of each exercise modality, as well as its certainty of evidence and clinical applicability.

Higher frequency of medication overuse headache in patients attended by neurologists in Lima, Peru

BackgroundThe type of medical care received (self-medication and/or medical care provided by a general practitioner or a neurologist) may be associated with differences in the frequency of medication overuse headaches.MethodThis cross-sectional analytical study included 222 records of patients with chronic daily headaches seen at the National Institute of Neurological Sciences Outpatient Unit in Lima, Peru. A pre-designed questionnaire was used to assess and categorize patients with frequent and chronic headaches.ResultsNinety-four patients (42.34% of those with chronic daily headaches) met the criteria for medication overuse headache. Of these, 19 (28%) self-medicated, 22 (36%) consulted with the general practitioner, and the highest proportion of subjects, 53 (58%), consulted with a neurologist. On bivariate analysis, subjects who had received care from a general practitioner and self-medicated were 38% and 51% less likely to have MOH than the subjects whoreceived medical care from the neurologist (p=0.012; 95% CI 0.42-0.90 and p=0.001; 95% CI 0.32-0.74). On multivariate analysis adjusting by sociodemographic and clinical factors, the association remained significant in regards to self-medication, but became marginal (p=0.055) in regard to being seen by a general practitioner.ConclusionIn this study, the frequency of the headache due to overuse of medication was higher in patients attending a neurologist than those attending a general practitioner or self-medicated. This cross-sectional design cannot assess whether this reflects more severe cases looking for specialized care or more medication overuse headaches as a result of inappropriate management.

Fear, Avoidance, and Disability in Headache Disorders

PURPOSE OF REVIEW

The purpose of this review is to summarize the role of avoidance behavior in headache-related disability and overview relevant clinical implications.

RECENT FINDINGS

Avoidance occupies a central role in contemporary psychological perspectives on headache disorders and other chronic pain conditions. Several cognitive constructs of relevance to headache are influenced and maintained by avoidance behavior. A growing body of literature attests to the notion that avoidance of headache triggers, of stimuli that exacerbate headache, and of broader life domains can negatively affect headache progression, disability/quality of life, and comorbid psychiatric symptoms. Interventions targeting avoidance behavior, such as therapeutic exposure to headache triggers, mindfulness, and acceptance and commitment therapy (ACT), hold promise for headache disorders but need to be tested in larger trials. Researchers and clinicians are encouraged to attend to functional impairment as a critically important treatment outcome. Comprehensive understanding of headache disorders necessitates attention not merely to diagnostic symptoms and their reduction, but to patterns of avoidance behavior that inadvertently exacerbate headache and contribute to functional impairment.

Practical approach to a patient with chronic pain of uncertain etiology in primary care

Chronic pain of uncertain etiology often presents a challenge to both patients and their health care providers. It is a complex condition influenced by structural and physiological changes in the peripheral and central nervous systems, and it directly influences, and is modulated by, psychological well-being and personality style, mood, sleep, activity level and social circumstances. Consequently, in order to effectively treat the pain, all of these need to be evaluated and addressed. An effective management strategy takes a multidisciplinary biopsychosocial approach, with review of all current medications and identification and careful withdrawal of those that may actually be contributing to ongoing pain. The management approach is primarily nonpharmacological, with carefully considered addition of medication, beginning with pain-modulating treatments, if necessary. In this article, we present a primary care approach to the assessment and management of a patient with chronic pain where the cause cannot be identified.

High Achievement Motivation is Not Related to Increased Use of Acute Headache Medication in Migraine: A Cross-sectional Observational Cohort Study

OBJECTIVE

To determine if migraine patients with high achievement motivation have an increased use of acute headache medication.

BACKGROUND

It has been hypothesized that high achievement-motivated migraine patients have an increased use of acute headache medication to be able to perform at work and during daily life, putting them at risk for medication overuse headache (MOH).

METHODS

The Achievement Motivation Inventory and use of acute headache medication were assessed in 117 migraine patients (60 episodic, 57 chronic) at their first appointment at our tertiary headache center.

RESULTS

Patients with low vs high achievement motivation were not significantly different in acute headache medication days per month (10.8 ± 6.9 vs 10.9 ± 7.8, P = .98), in acute headache medication use in the absence of headache (to prevent occurrence of headache later that day: 51.8% vs 48.2%, P = .38), in having a diagnosis of MOH (37.9 vs 23.7%, P = .12), or in reduction of acute headache medication days at 3 and 6 months follow-up (both P > .20).

CONCLUSIONS

High achievement motivation in migraine patients was not associated with increased acute headache medication use or more frequent diagnosis of MOH.