A basic diagnostic headache diary (BDHD) is well accepted and useful in the diagnosis of headache. a multicentre European and Latin American study

Development of a Headache Diary and Assessment of Tension-Type Headache Diagnostic Criteria and Oral Behaviors, Joint Range of Motion, and Tenderness to Palpation: An Observational Study

Objective

The aim of this study was to design and use a headache diary in patients with frequent tension-type headaches (TTH). Another aim was to assess the relationship among oral behaviors, range of motion, and tenderness to palpation of the craniomandibular muscles.

Methods

Thirty-four patients participated in this prospective observational study for a 3-month period at the Adavall Clinic for Physiotherapy and Rehabilitation (Valladolid, Spain) in 2019. Oral behaviors were collected through the Oral Behavior Checklist in the Adavall-TTH diary. Range of motion was measured in the cervical region and in the temporomandibular joint. Tenderness to palpation was measured on 38 myofascial trigger points of the craniomandibular region.

Results

Oral behaviors were directly related to the pain intensity of TTH, the number of days, and the headache diagnostic criteria. Cervical range of motion was indirectly related to the intensity of TTH and the number of days of TTH (from r = -0.341 to r = -0.418, P < .05). Tenderness to palpation was associated with intensity and different diagnostic criteria of TTH in different craniomandibular muscles (from r = 0.342 to r = 0.400, P < .05).

Conclusion

We found associations between examination findings and TTH diagnostic criteria. The headache diary may be a useful tool in the diagnosis and management of TTH and for analyzing the relationship between oral activities and temporomandibular joint tenderness in TTH. Future research should test the validity and reliability of this diary.

Validation of a Digital Headache Calendar at a Tertiary Referral Center

BACKGROUND

Headache calendars are essential tools in monitoring changes in headache frequency and type. They are used in clinical practice for long-term monitoring, but their validation remains limited. The aim of this study was to validate the use of a digital calendar in monitoring single migraine and tension-type headache attacks.

METHODS

From July 2022 to February 2023, patients diagnosed with migraine and tension-type headache were enrolled. The validation of the digital calendar involved the comparison of self-reported single headache attacks in the digital calendar with the diagnostic headache diary based on the ICHD-3 criteria for migraine and tension-type headache. Sensitivity and specificity were calculated to assess reliability, and the level of agreement was calculated using kappa statistics.

RESULTS

This study included 30 patients (87% women) diagnosed with migraine and tension-type headache. The level of agreement in the classification of a single migraine attack revealed a sensitivity of 82% and a specificity of 78%, representing a substantial level of agreement (κ = 0.60). The classification of a single tension-type headache attack revealed a sensitivity of 84% and a specificity of 72%, with a moderate level of agreement (κ = 0.54).

CONCLUSIONS

The digital calendar proves effective in monitoring single headache attacks in patients with migraine and tension-type headache. In clinical practice, we recommend using the digital calendar as a monitoring tool for headache patients, as they can accurately identify true migraine and tension-type headache days.

Neuromodulation in Pediatric Migraine using Repetitive Neuromuscular Magnetic Stimulation: A Feasibility Study

Migraine has a relevant impact on pediatric health. Non-pharmacological modalities for its management are urgently needed. This study assessed the safety, feasibility, acceptance, and efficacy of repetitive neuromuscular magnetic stimulation (rNMS) in pediatric migraine. A total of 13 patients with migraine, ≥6 headache days during baseline, and ≥1 myofascial trigger point in the upper trapezius muscles (UTM) received six rNMS sessions within 3 weeks. Headache frequency, intensity, and medication intake were monitored using headache calendars; headache-related impairment and quality of life were measured using PedMIDAS and KINDL questionnaires. Muscular involvement was assessed using pressure pain thresholds (PPT). Adherence yielded 100%. In 82% of all rNMS sessions, no side effects occurred. All participants would recommend rNMS and would repeat it. Headache frequency, medication intake, and PedMIDAS scores decreased from baseline to follow-up (FU), trending towards statistical significance (p = 0.089; p = 0.081, p = 0.055). A total of 7 patients were classified as responders, with a ≥25% relative reduction in headache frequency. PPT above the UTM significantly increased from pre- to post-assessment, which sustained until FU (p = 0.015 and 0.026, respectively). rNMS was safe, feasible, well-accepted, and beneficial on the muscular level. The potential to reduce headache-related symptoms together with PPT changes of the targeted UTM may underscore the interplay of peripheral and central mechanisms conceptualized within the trigemino-cervical complex.

Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023)

Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.

Burden of migraine with acute medication overuse or psychiatric comorbidities and treatment with CGRP pathway-targeted monoclonal antibodies: A review

Migraine is a complex and often debilitating neurological disease that affects more than 1 billion people worldwide. It is characterized by moderate-to-intense, throbbing headache attacks that are worsened by activity and is associated with nausea, vomiting, and sensitivity to light and sound. Migraine, ranked the second leading cause of years lived with disability by the World Health Organization, can diminish patients' quality of life and bring significant personal and economic burden. Furthermore, migraine patients with a history of acute medication overuse (AMO) or psychiatric comorbidities, such as depression or anxiety, may experience even greater impairment and burden, and their migraine may be more difficult-to-treat. Appropriate treatment of migraine is essential to reduce this burden and improve patient outcomes, especially for those with AMO or psychiatric comorbidities. There are several available preventive treatment options for migraine, though many of these are not migraine-specific and may have limited efficacy and/or poor tolerability. The calcitonin gene-related peptide pathway plays a key role in the pathophysiology of migraine, and monoclonal antibodies that target the calcitonin gene-related peptide pathway have been developed as specific preventive treatments for migraine. Four of these monoclonal antibodies have been approved for the preventive treatment of migraine after demonstrating favorable safety and efficacy profiles. These treatments offer substantial benefits for migraine patients, including those with AMO or common psychiatric comorbidities, by reducing monthly headache days and migraine days, days of acute medication use, and disability measures, as well as improving quality of life.

Impact of COVID-19 Pandemic Lockdown on Migraine Patients in Latin America

The coronavirus (COVID-19) pandemic, confinement, fear, lifestyle changes, and worldwide health care impacted almost all diseases. Reports from countries outside Latin America revealed differences in migraine patients. In this study, we describe and compare the immediate changes in migraine symptoms associated with COVID-19 quarantine in patients from Argentina, Mexico, and Peru. An online survey was conducted from May to July 2020. The survey was answered by 243 migraine patients, with questions related to sociodemographic data, quarantine conditions, changes in working conditions, physical activity, coffee intake, healthcare access, acute migraine medication use, symptoms of anxiety, depression, and fear of COVID-19. The results show that 48.6% of migraine patients experienced worsened symptoms, 15.6% improved, and 35.8% remained unchanged. Worsening migraine symptoms were associated with staying at home during the lockdown. Intake of analgesics was associated with an increase in migraine symptoms of 18 times relative to those who did not increase their intake. Migraine symptoms improved when the number of sleep hours was increased, and we observed an improvement when patients decreased analgesic intake. The uncertainty about the end of the pandemic, the news, and social media are three items that contributed to the worsening of migraine symptoms in patients in the three investigated countries. Confinement during the first pandemic wave in Latin America harmed migraine patients who stayed home during the lockdown.

Response Predictors of Repetitive Neuromuscular Magnetic Stimulation in the Preventive Treatment of Episodic Migraine

Background

Repetitive neuromuscular magnetic stimulation (rNMS) of the trapezius muscles showed beneficial effects in preventing episodic migraine. However, clinical characteristics that predict a favorable response to rNMS are unknown. The objective of this analysis is to identify such predictors.

Methods

Thirty participants with a diagnosis of episodic migraine (mean age: 24.8 ± 4.0 years, 29 females), who were prospectively enrolled in two non-sham-controlled studies evaluating the effects of rNMS were analyzed. In these studies, the interventional stimulation of the bilateral trapezius muscles was applied in six sessions and distributed over two consecutive weeks. Baseline and follow-up assessments included the continuous documentation of a headache calendar over 30 days before and after the stimulation period, the Migraine Disability Assessment Score (MIDAS) questionnaire (before stimulation and 90 days after stimulation), and measurements of pain pressure thresholds (PPTs) above the trapezius muscles by algometry (before and after each stimulation session). Participants were classified as responders based on a ≥25% reduction in the variable of interest (headache frequency, headache intensity, days with analgesic intake, MIDAS score, left-sided PPTs, right-sided PPTs). Post-hoc univariate and multivariate binary logistic regression analyses were performed.

Results

Lower headache frequency (P = 0.016) and intensity at baseline (P = 0.015) and a migraine diagnosis without a concurrent tension-type headache component (P = 0.011) were significantly related to a ≥25% reduction in headache frequency. Higher headache frequency (P = 0.052) and intensity at baseline (P = 0.014) were significantly associated with a ≥25% reduction in monthly days with analgesic intake. Lower right-sided PPTs at baseline were significantly related to a ≥25% increase in right-sided PPTs (P = 0.0.015) and left-sided PPTs (P =0.030). Performance of rNMS with higher stimulation intensities was significantly associated with a ≥25% reduction in headache intensity (P = 0.046).

Conclusions

Clinical headache characteristics at baseline, the level of muscular hyperalgesia, and stimulation intensity may inform about how well an individual patient responds to rNMS. These factors may allow an early identification of patients that would most likely benefit from rNMS.

Mechanical sensitivity changes in pericranial muscles after local anesthesia and experimentally induced pain in the temporalis tendon: Implications for headache and facial pain

OBJECTIVES

To assess changes in mechanical sensitivity of the pericranial muscles in healthy individuals after a local anesthetic block of the temporalis tendon. In addition, to assess, if experimentally induced temporalis tendon pain, can lead to an increase in mechanical sensitivity of the pericranial muscles and reports of headache.

METHODS

40 healthy participants were recruited for this randomized, double-blinded, controlled experiment, and were randomly injected with mepivacaine and isotonic saline into the dominant-side temporalis tendon in two different sessions, and either nerve growth factor (n = 20) or isotonic saline (n = 20) in a third session. Mechanical sensitivity was assessed in the temporalis, masseter, and trapezius muscles as well as in the temporalis tendon, on the dominant side, before and 10 minutes after each injection, and in a fourth session two days after the third session. Pain drawings and headache diaries were kept for 30 days after the final session to register any developing pain or headache.

RESULTS

Mepivacaine injection into the temporalis tendon caused a significant decrease in mechanical sensitivity in the temporal tendon (-54.5%) and the masseter (-15.4%) muscle (P < 0.05) but not the temporalis (-12.1%) and trapezius muscles (-12.7%) (P > 0.05). Nerve growth factor injection into the temporalis tendon caused a significant increase in mechanical sensitivity in the tendon (+15.4%) and masseter muscle (+14.4%) (P < 0.05) but not the temporalis (+2.8%) or trapezius muscles (+3.1%) (P > 0.05). A significant increase was found for headache frequency in the first seven days (P < 0.05) after nerve growth factor injection compared to after isotonic saline injection, but not intensity (P > 0.05).

CONCLUSION

These findings suggest that the therapeutic effect of temporalis tendon anesthetic injections on facial pain and headaches are most likely not only due to a direct effect of the local anesthetic on the temporalis tendon but rather to a more generalized block of the nerves in the area. In addition, the temporal tendon may contribute to the pathophysiological processes of headache.

Role of Estrogens in Menstrual Migraine

Migraine is a major neurological disorder affecting one in nine adults worldwide with a significant impact on health care and socioeconomic systems. Migraine is more prevalent in women than in men, with 17% of all women meeting the diagnostic criteria for migraine. In women, the frequency of migraine attacks shows variations over the menstrual cycle and pregnancy, and the use of combined hormonal contraception (CHC) or hormone replacement therapy (HRT) can unveil or modify migraine disease. In the general population, 18–25% of female migraineurs display a menstrual association of their headache. Here we present an overview on the evidence supporting the role of reproductive hormones, in particular estrogens, in the pathophysiology of migraine. We also analyze the efficacy and safety of prescribing exogenous estrogens as a potential treatment for menstrual-related migraine. Finally, we point to controversial issues and future research areas in the field of reproductive hormones and migraine.

Repetitive transcranial magnetic stimulation as a prophylactic treatment in migraine

Background

Clinical applications of transcranial magnetic stimulation (TMS) have shown promising results in the treatment of headache disorders, with migraine being one of the most encountered.

Objective

To assess the role of low-frequency repetitive transcranial magnetic stimulation as a preventive treatment of migraine (with and without aura) and correlate the results with the serum level of the inflammatory biomarker (neurokinin A).

Methods

Forty patients, with age ranging from 15 to 55 years, diagnosed with migraine (30 migraine without aura and 10 with aura) and 20 apparently healthy individuals, who were age and sex matched with the patient group, were included in this study.

A low-frequency (1 Hz) rTMS protocol was applied for all patients for five consecutive days interictally. Assessment of pain intensity using visual analogue scale and frequency and duration of attacks as well as number of pills taken by patients as an abortive treatment according to the Basic Diagnostic Headache Diary for 4 weeks before and 4 weeks after TMS sessions was done. In addition, the Migraine Disability Assessment scale (MIDAS) was applied to assess the severity and degree of disability caused by migraine.

Measurement of neurokinin A serum level was done by using ELISA for all patients before and after TMS and for control group once.

Results

There was a significant reduction in pain intensity, frequency and duration of migraine attacks, migraine disability scores, and number of pills taken as abortive treatment for attacks after rTMS (P < 0.001). Also, serum level of neurokinin A in the patients was significantly reduced after rTMS (P < 0.001).

Conclusion

Low-frequency rTMS is an effective prophylactic treatment for migraine with and without aura.

Assessing migraine patients with multifocal pupillographic objective perimetry

Background

To establish the effects of stimulating intrinsically-photosensitive retinal ganglion cells (ipRGCs) on migraine severity, and to determine if migraine produces objectively-measured visual field defects.

Methods

A randomized, open labelled, crossover study tested migraineurs and normal controls using multifocal pupillographic objective perimetry (mfPOP) with 44 test-regions/eye. A slow blue protocol (BP) stimulated ipRGCs, and a fast yellow protocol (YP) stimulated luminance channels. Migraine diaries assessed migraine severity. Per-region responses were analyzed according to response amplitude and time-to-peak.

Results

Thirty-eight migraineurs (42.0 ± 16.5 years, 23 females) and 24 normal controls (39.2 ± 15.2 years, 14 females) were tested. The proportion of subjects developing a migraine did not differ after either protocol, either during the 1st day (odds ratio 1.0; 95% confidence interval 0.2–4.4, p = 0.48) or during the first 3 days after testing (odds ratio 0.8; 95% confidence interval 0.3–2.1, p = 0.68). Migraine days/week did not increase following testing with either protocol in comparison to the baseline week (1.4 ± 1.6 pre-testing (mean ± SD), 1.3 ± 1.4 post-BP, and 1.3 ± 1.2 post-YP; p = 0.96), neither did other measures of severity. Migraine occurring up to 2 weeks before testing significantly lowered amplitudes, − 0.64 ± 0.14 dB (mean ± SE), while triptan use increased amplitudes by 0.45 ± 0.10 dB, both at p < 0.001.

Conclusions

Stimulating ipRGCs did not affect migraine occurrence or severity. Pupillary response characteristics were influenced by the occurrence of a recent migraine attack and a history of triptan use.

Alleviation of migraine symptoms by application of repetitive peripheral magnetic stimulation to myofascial trigger points of neck and shoulder muscles - A randomized trial

Migraine is a burdensome disease with an especially high prevalence in women between the age of 15 and 49 years. Non-pharmacological, non-invasive therapeutic methods to control symptoms are increasingly in demand to complement a multimodal intervention approach in migraine. Thirty-seven subjects (age: 25.0 ± 4.1 years; 36 females) diagnosed with high-frequency episodic migraine who presented at least one active myofascial trigger point (mTrP) in the trapezius muscles and at least one latent mTrP in the deltoid muscles bilaterally prospectively underwent six sessions of repetitive peripheral magnetic stimulation (rPMS) over two weeks. Patients were randomly assigned to receive rPMS applied to the mTrPs of the trapezius (n = 19) or deltoid muscles (n = 18). Whereas the trapezius muscle is supposed to be part of the trigemino-cervical complex (TCC) and, thus, involved in the pathophysiology of migraine, the deltoid muscle was not expected to interfere with the TCC and was therefore chosen as a control stimulation site. The headache calendar of the German Migraine and Headache Society (DMKG) as well as the Migraine Disability Assessment (MIDAS) questionnaire were used to evaluate stimulation-related effects. Frequency of headache days decreased significantly in both the trapezius and the deltoid group after six sessions of rPMS (trapezius group: p = 0.005; deltoid group: p = 0.003). The MIDAS score decreased significantly from 29 to 13 points (p = 0.0004) in the trapezius and from 31 to 15 points (p = 0.002) in the deltoid group. Thus, rPMS applied to mTrPs of neck and shoulder muscles offers a promising approach to alleviate headache frequency and symptom burden. Future clinical trials are needed to examine more profoundly these effects, preferably using a sham-controlled setting.

[Migraine burden and clinical inertia: what can we do?]

AIM

To study the compliance of neurologists and headache specialists to chronic headache and chronic migraine (CM) diagnosis and treatment guidelines.

MATERIAL AND METHODS

The survey included 634 neurologists from all regions of the Russian Federation. Mean age of respondents was 40.7±8.5 years, mean years of experience 14.2±7.8 years.

RESULTS

Most doctors work in outpatient or hospital settings (49% and 24%, respectively), 7% were headache specialists. Tension-type headache (TTH) was diagnosed in 30% and CM in 17% of patients while 44% of patients were presumed to have a mixed headache disorder (TTH+CM). Only 10% of physicians do not use instrumental diagnostic methods in chronic headache. This study has shown sufficient attention to comorbid conditions and frequent prescription of headache preventative treatment. Botox prescription data is equivocal: 35% of physicians recommend such treatment, 27% do not, while other doctors prescribe it for off-label indications.

CONCLUSION

To overcome clinical inertia, further education in chronic headaches and their optimal treatment is warranted.

Variables associated with use of symptomatic medication during a headache attack in individuals with tension-type headache: a European study

Background

Pharmacological treatment of patients with tension-type headache (TTH) includes symptomatic (acute) and prophylactic (preventive) medication. No previous study has investigated variables associated to symptomatic medication intake in TTH. Our aim was to assess the association of clinical, psychological and neurophysiological outcomes with the use and timing of the use of symptomatic medication in TTH.

Methods

A longitudinal observational study was conducted. One hundred and sixty-eight (n = 168) patients with TTH participated. Pain features of the headache (intensity, frequency, duration), burden of headache (Headache Disability Inventory), sleep quality (Pittsburgh Sleep Quality Index), anxiety/depression (Hospital Anxiety and Depression Scale), trait/state anxiety levels (State-Trait Anxiety Inventory), and bilateral pressure pain thresholds on the temporalis, C5-C6 joint, second metacarpal and tibialis anterior were assessed. Symptomatic medication intake was also collected for a 6-months follow-up period. Differences between patients using or not using symptomatic medication, depending on self-perceived effectiveness, and time (early during an attack, i.e., the first 5 min, or when headache attack is intense) when the symptomatic medication was taken were calculated.

Results

One hundred and thirty-six (n = 136, 80%) reported symptomatic medication intake for headache (73% NSAIDs). Sixteen (12%) reported no pain relief, 81 (59%) experienced moderate relief and 39 (29%) total pain relief. Fifty-eight (43%) took ‘early medication’ whereas 78 (57%) took ‘late medication’. Patients taking symptomatic medication in general showed lower headache frequency and lower depressive levels than those patients not taking medication. Symptomatic medication was more effective in patients with lower headache history, frequency, and duration, and lower emotional burden. No differences in pressure pain sensitivity were found depending on the self-perceived effectiveness of medication. Patients taking ‘late symptomatic’ medication exhibited more widespread pressure pain sensitivity than those taking ‘early medication’.

Conclusions

This study found that the effectiveness of symptomatic medication was associated with better headache parameters (history, frequency, or duration) and lower emotional burden. Further, consuming early symptomatic medication at the beginning of a headache attack (the first 5 min) could limit widespread pressure pain sensitivity.

Alterations in Surface Electromyography Are Associated with Subjective Masticatory Muscle Pain

Background

Tenderness of masseters and temporalis can be considered a relevant tool for diagnosis of myo-type craniofacial pain disorders, but a limit of pain score systems is that they are based on subjective pain perception. Surface electromyography (sEMG) is a noninvasive and reliable tool for recording muscle activity. Therefore, we investigated whether a correlation exists between tenderness on masseters and temporalis, assessed by subjective pain scale, and muscles activity, evaluated by sEMG, in patients with painful temporomandibular disorder (TMD) and concurrent tension-type headache (TTH).

Methods

A cross-sectional study on fifty adult volunteer patients with TMD and TTH, who underwent tenderness protocol according to Diagnostic Criteria for TMD (DC/TMD) guidelines, was conducted followed by sEMG recording of temporalis and masseters. Pearson's correlation was performed to investigate the correlation between muscular activity and subjective pain scores.

Results

An overall moderate correlation between muscle tenderness and sEMG values (y = 1 + 1.2 · x; r² = 0.62; p < 0.0001), particularly in the temporalis, was observed. Segregation of data occurred according to tenderness and sEMG values. At the highest pain score, the mean sEMG absolute value was higher at the temporalis than the masseters.

Conclusions

Our study provides evidence that subjective pain perception can be objectively quantified at a magnitude proportional to pain severity. At greater tenderness scores, higher sEMG activity at the level of temporalis could help discriminate clinically prevalent TTH versus prevalent TMD. sEMG confirms to be an accurate tool to reliably objectify the subjective perception of pain. When combined with clinical evaluation and patients' symptoms, sEMG increases diagnostic sensitivity in the field of myo-type craniofacial pain disorders. This trial is registered with NCT02789085.

Prevalence and factors associated with the use of primary headache diagnostic criteria by chiropractors

Background

The diagnosis of primary headaches assists health care providers in their decision-making regarding patient treatment, co-management and further evaluation. Chiropractors are popular health care providers for those with primary headaches. The aim of this study is to examine the clinical management factors associated with chiropractors who report the use of primary headache diagnostic criteria.

Methods

A cross-sectional survey was distributed between August and November 2016 to a random sample of Australian chiropractors who are members of a practice-based research network (n = 1050) who had reported ‘often’ providing treatment for patients with headache disorders to report on practitioner approaches to headache diagnosis, management, outcome measures and multidisciplinary collaboration. Multiple logistic regression was conducted to assess the factors that are associated with chiropractors who report using International Classification of Headache Disorders (ICHD) primary headache diagnostic criteria.

Results

With a response rate of 36% (n = 381), the majority of chiropractor’s report utilising ICHD primary headache diagnostic criteria (84.6%). The factors associated with chiropractors who use ICHD primary headache diagnostic criteria resulting from the regression analysis include a belief that the use of ICHD primary headache criteria influences the management of patients with primary headaches (OR = 7.86; 95%CI: 3.15, 19.60); the use of soft tissue therapies to the neck/shoulders for tension headache management (OR = 4.33; 95%CI: 1.67, 11.19); a belief that primary headache diagnostic criteria are distinct for the diagnosis of primary headaches (OR = 3.64; 95%CI: 1.58, 8.39); the use of headache diaries (OR = 3.52; 95%CI: 1.41, 8.77); the use of ICHD criteria improves decision-making regarding primary headache patient referral/co-management (OR = 2.35; 95%CI: 1.01, 5.47); referral to investigate a headache red-flag (OR = 2.67; 95%CI: 1.02, 6.96) and not referring headache patients to assist headache prevention (OR = 0.16; 95%CI: 0.03, 0.80).

Conclusion

Four out of five chiropractors managing headache are engaged in the use of primary headache diagnostic criteria. This practice is likely to influence practitioner clinical decision-making around headache patient management including their co-management with other health care providers. These findings call for a closer assessment of headache characteristics of chiropractic patient populations and for further enquiry to explore the role of chiropractors within interdisciplinary primary headache management.

Neck pain and migraine: Association or cause?—A narrative review of the literature

This literature review deals with the question whether neck pain (NP) constitutes a symptom or a trigger of migraine. Firstly, a short survey about some techniques for measuring NP in association and relation with migraine is presented. Secondly, the arguments about NP as a symptom or a trigger of migraine are being reviewed and compared. The main questions are the following: Which tests can be used to distinguish NP as a trigger or a symptom of migraine? Is a therapy for NP an adequate method to treat migraine? Finally, the pros and cons of NP as a symptom or as a trigger will be reviewed, and possible treatment options will be suggested. This review found that no reliable and standardized tests exist to classify NP in relation to migraine. However, there is a comparability among these studies due to the common use of migraine definition in the “International Classification of Headache Disorders.” Regarding the quality and methods, different types of studies were analyzed, for example, retrospective, prospective, and cross-sectional studies. Nevertheless, none of these types are specifically suited to show a causality between NP and migraine. In order to do this, the authors would suggest using a randomized controlled study. Another adequate study design might be a population-based case–control crossover study and calculating the population attributable risk. Furthermore, the pathophysiology of NP in migraine patients should be investigated in more detail. Besides their questionable suitability for showing a connection between NP and migraine, some studies were additionally subject to a population and selection bias. To sum up, part of the authors in the reviewed literature generate the hypothesis that NP is more often a symptom than a trigger of migraine. However, due to methodological flaws, more studies are necessary to confirm this hypothesis.

Characterization and predictive mechanisms of experimentally induced tension-type headache

Objective

Studies have shown it is possible to elicit a tension-type headache episode in 15 to 30% of healthy individuals following a tooth-clenching or stress-inducing task. Despite this, no studies have attempted to understand why some healthy individuals develop a headache episode while others do not.

Methods

The present randomized, single-blind, controlled study recruited 60 healthy participants who participated in a 30-minute tooth-clenching task and 10 participants who participated in a control task. Before the tasks, participants had their pericranial tenderness and pain modulation profiles (wind-up ratio and conditioned pain modulation) assessed. Two hours later, pericranial tenderness and pressure pain thresholds were assessed as well as any developing temporomandibular disorders. Pain diaries were kept for 24 hours to register any developing pain or headache.

Results

Participants with a decrease in pericranial tenderness after the tooth-clenching task were less likely to develop headache when compared to participants without. Pain modulation profiles could not predict who developed headache and who did not. Finally, no difference was found between groups for developing temporomandibular disorders. No difference in frequency of participants who developed headache was found between the tooth-clenching and the control task.

Conclusions

In conclusion, it was shown that increased pericranial tenderness was not required to trigger an episode of tension-type headache in healthy participants. Furthermore, pain modulation profiles could not predict who developed headache and who did not. Finally, activation of descending inhibitory pathways, as assessed by decreases in pericranial tenderness, was protective against the development of headache. These findings provide new insights into the pathophysiology of experimentally-induced tension-type headache.

Manual therapy for chronic migraine: a pragmatic randomised controlled trial study protocol

Introduction

Chronic migraine is a largely refractory condition affecting between 1 and 2.2% of the overall population worldwide, with females more affected than males. There are also high health and socioeconomic costs associated both for the individual and society. The mainstay of chronic migraine management is pharmacological, but the options available have limited efficacy and there are often unwanted side effects. There is some evidence for manual therapy as a treatment option for migraine, but its effectiveness for chronic migraine is unknown. Therefore, we have designed a pragmatic randomised control trial to investigate whether adding manual therapy to the tertiary specialist treatment of chronic migraine improves patient-reported outcomes.

Methods

A pragmatic, randomised controlled trial in a hospital tertiary headache clinic. Participants will be randomised into one of two groups: treatment as usual or treatment as usual plus manual therapy. The primary outcome measure will be a change in the Headache Impact Test score. Secondary outcomes will also be measured over the 12-week study period including changes in headache frequency, migraine specific quality of life and reductions in relevant medicine consumption. The manual therapy group will have five treatment sessions each lasting 30 min. The recruitment target of 64 participants will allow power at 80% with p = 0.05 using minimal clinical difference for Headache Impact Test of 3.7 and includes provision for a 10% dropout rate. Recruitment will take place between August 2018 and February 2019. The results will form part of a doctoral study and be published in peer-reviewed journals and presented at national/international conferences.

Discussion

Current pharmacological approaches have limited effects in the management of chronic migraine and there is a requirement to improve treatment options and reduce the health and economic burden of the condition. Manual therapy has been shown to be effective in other chronic pain conditions as well as other primary headaches. This study will explore the effectiveness of manual therapy as an adjunctive approach to the management of chronic migraine.

Trial registration

The trial has received a favourable opinion from the UK Health Research Authority (IRAS 228901) and is registered at ClinicalTrials.gov.number NCT03395457. Registered 1st March 2018.

The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey

BACKGROUND

Headache management is common within chiropractic clinical settings; however, little is yet known about how this provider group manage headache sufferers. The aim of this study is to report on the prevalence of headache patients found within routine chiropractic practice and to assess how chiropractors approach key aspects of headache management applicable to primary care settings.

METHODS

A 31-item cross-sectional survey was distributed to a national sample of chiropractors (n = 1050) to report on practitioner approach to headache diagnosis, interdisciplinary collaboration, treatment and outcome assessment of headache patients who present with recurrent headache disorders.

RESULTS

The survey attracted a response rate of 36% (n = 381). One in five new patients present to chiropractors with a chief complaint of headache. The majority of chiropractors provide headache diagnosis for common primary (84.6%) and secondary (90.4%) headaches using formal headache classification criteria. Interdisciplinary referral for headache management was most often with CAM providers followed by GPs. Advice on headache triggers, stress management, spinal manipulation, soft tissue therapies and prescriptive neck exercises were the most common therapeutic approaches to headache management.

CONCLUSION

Headache patients make up a substantial proportion of chiropractic caseload. The majority of chiropractors managing headache engage in headache diagnosis and interdisciplinary patient management. More research information is needed to understand the headache types and level of headache chronicity and disability common to chiropractic patient populations to further assess the healthcare needs of this patient population.

Paediatric migraine: evidence-based management and future directions

Migraine is prevalent in children and adolescents and constitutes an important cause of disability in this population. Early, effective treatment of paediatric migraine is likely to result in improved outcomes. Findings from the past few years suggest that a biopsychosocial approach that uses interdisciplinary multimodal care is most effective for treatment of migraine in the paediatric population. Key elements of this management include effective and timely acute pharmacological interventions (such as NSAIDs and/or triptans), education of patients regarding self-management techniques, and psychological interventions such as biofeedback, relaxation and cognitive-behavioural therapy. The efficacy of current pharmacological or nutraceutical interventions for migraine prevention in children and adolescents is unclear, although reported placebo response patterns suggest that the effect of pill-taking behaviour is positive. As such, clinicians can consider adding a preventive intervention that involves a daily pill-taking behaviour to evidence-based non-pharmacological first-line preventive interventions (such as cognitive-behavioural therapy). More rigorous research is needed to delineate the role of pharmacological and nutraceutical interventions, the mechanisms of the clinically relevant placebo response, and interventions that enhance this response for migraine prevention in this population. Given the prevalence of migraine, cost-effective and efficacious strategies are needed for the large-scale delivery of interdisciplinary multimodal paediatric migraine care.

Variables associated with sleep quality in chronic tension-type headache: A cross-sectional and longitudinal design

OBJECTIVE

To investigate variables associated at baseline (cross-sectional design) and at one year (longitudinal design) with the quality of sleep in chronic tension-type headache (CTTH).

METHODS

One hundred and eighty (n = 180) and 135 individuals with CTTH participated in the cross-sectional and longitudinal design respectively. Clinical features were collected with a 4-weeks headache diary at baseline and one-year follow-up. Sleep quality was assessed at baseline and 1-year follow-up with the Pittsburgh Sleep Quality Index. Anxiety and depression (Hospital Anxiety and Depression Scale-HADS), burden of headache (Headache Disability Inventory-HDI), quality of life (SF-36 questionnaire), and pressure pain thresholds (PPTs) at trigeminal, extra-trigeminal and widespread area were assessed at baseline. Hierarchical regression analyses were conducted to determine the associations between variables at baseline and 1-year follow-up with sleep quality.

RESULTS

At baseline positive correlations between sleep quality and headache intensity, headache frequency, headache duration, emotional and physical burden of headache and depression were observed. The regression analyses found that depression and emotional burden of headache explained 27.5% of the variance in sleep quality at baseline (r2 = .262; F = 23.72 P < .001). At one-year, sleep quality was significantly associated with baseline burden of headache, depression, widespread PPTs, vitality and mental health domains. Regression analyses revealed that vitality, PPT over the second metacarpal and PPT over the neck explained 30.0% of the variance of sleep quality at one-year (r2 = .269, F = 9.71, P < .001).

CONCLUSIONS

It seems that sleep quality exhibits a complex interaction in individuals with CTTH since depression and the emotional burden were associated with sleep quality at baseline, but vitality and PPTs over extra-trigeminal areas were associated with the quality of sleep at one-year.

The burden of headache is associated to pain interference, depression and headache duration in chronic tension type headache: a 1-year longitudinal study

Background

To investigate variables associated at one year (longitudinal design) with the physical or emotional component of burden in chronic tension type headache (CTTH).

Methods

One hundred and thirty (n = 130) individuals with CTTH participated in this longitudinal study. Clinical features were collected with a 4-weeks headache diary at baseline and 1-year follow-up. The burden of headache was assessed at baseline and one -year follow-up with the Headache Disability Inventory (HDI), physical (HDI-P) or emotional (HDI-E) component. Sleep quality (Pittsburgh Sleep Quality Index), anxiety and depression (Hospital Anxiety and Depression Scale-HADS), and quality of life (SF-36) were also assessed at baseline. Hierarchical regression analyses were conducted to determine the associations between the baseline variables and the headache burden at 1-year. Simple mediation models were also applied to determine the potential mediation effect of any intermediary variable.

Results

Regression analyses revealed that baseline pain interference and depression explained 32% of the variance in the emotional burden of headache, whereas baseline emotional burden of the headache, pain interference, and headache duration explained 51% of the variance in the physical burden of headache (P < .01) at 1-year. The mediation models observed that the effect of baseline pain interference on emotional burden of headache at 1-year was mediated through baseline depression, whereas the effect of baseline pain interference on the physical burden of headache at 1-year was mediated through baseline emotional burden of headache (both P < .05).

Conclusions

The current study found a longitudinal interaction between pain interference and depression with the burden of headache in individuals with CTTH.

Onabotulinumtoxin A for the management of chronic migraine in current clinical practice: results of a survey of sixty-three Italian headache centers

BACKGROUND

Chronic migraine is a complex clinical condition often undertreated. Onabotulinumtoxin A (OBT-A) was approved in Italy in 2013 for symptom relief in patients with chronic migraine who have failed, or do not tolerate, oral prophylactic treatments. However, the impact of OBT-A in clinical practice remains to be defined.

METHODS

To investigate the current management of chronic migraine with OBT-A in clinical practice, a web-based survey was conducted among clinicians working in third-level headache centers across Italy. A 26-item questionnaire was designed and developed by a group of 10 Italian headache specialists to address the following issues: treatment paradigm and OBT-A injection intervals, frequency of treatment and retreatment, definition of responders/non-responders, satisfaction with treatment potential impact of early treatment with OBT-A. Ninety-six headache centers were selected and contacted via e-mail. The online survey was anonymous and carried out using a secure website.

RESULTS

Overall, 64 of the 96 centers (66.7%) completed the questionnaire. Most centers (98.4%) had been using OBT-A for >1 year. OBT-A was administered according to the PREEMPT paradigm in most centers (88.9%). While during the first year of prophylaxis with OBT-A most clinicians (93.6%) repeated OBT-A treatment every 3 months, as recommended, in the following years interval duration was variable. Response to OBT-A was defined as a ≥ 50% reduction in the headache days by 58.7% of the clinicians, and as a ≥ 30% reduction by 25.4% of them. Almost 60% of the clinicians considered OBT-A as a long-lasting therapy, while for one-third of them treatment could be discontinued in patients showing a benefit for ≥6 months. According to 80% of the clinicians, early administration of OBT-A after the onset of chronic migraine was associated with better outcomes, and 47.6% felt that OBT-A should be recommended as a first-line option.

CONCLUSIONS

This survey indicates that in third-level headache centers in Italy OBT-A is used in good compliance with current recommendations. There is agreement about the definition of response as a reduction in headache days by 30% to 50%. Additional effort is required to define response to OBT-A and to establish optimal treatment duration.

The association of headache frequency with pain interference and the burden of disease is mediated by depression and sleep quality, but not anxiety, in chronic tension type headache

BACKGROUND

A better understanding of potential relationship between mood disorders, sleep quality, pain, and headache frequency may assist clinicians in determining optimal therapeutic programs. The aim of the current study was to analyze the effects of sleep quality, anxiety, depression on potential relationships between headache intensity, burden of headache, and headache frequency in chronic tension type headache (CTTH).

METHODS

One hundred and ninety-three individuals with CTTH participated. Headache features were collected with a 4-weeks headache diary. The Hospital Anxiety and Depression Scale was used for assessing anxiety and depression. Headache Disability Inventory evaluated the burden of headache. Pain interference was determined with the bodily pain domain (SF-36 questionnaire). Sleep quality was assessed with Pittsburgh Sleep Quality Index. Path analyses with maximum likelihood estimations were conducted to determine the direct and indirect effects of depression, anxiety, and sleep quality on the frequency of headaches.

RESULT

Two paths were observed: the first with depression and the second with sleep quality as mediators. Direct effects were noted from sleep quality, emotional burden of disease and pain interference on depression, and from depression to headache frequency. The first path showed indirect effects of depression from emotional burden and from sleep quality to headache frequency (first model R 2 = 0.12). Direct effects from the second path were from depression and pain interference on sleep quality and from sleep quality on headache frequency. Sleep quality indirectly mediated the effects of depression, emotional burden and pain interference on headache frequency (second model R 2 = 0.18).

CONCLUSIONS

Depression and sleep quality, but not anxiety, mediated the relationship between headache frequency and the emotional burden of disease and pain interference in CTTH.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Efficacy of strength training on tension-type headache: A randomised controlled study

Background Strength training has shown effects in reducing neck pain. As neck pain is highly prevalent in tension-type headache (TTH), it is relevant to examine the effect of strength training of the shoulder muscles on TTH patients. Aim To examine the effect of strength training of the shoulder/neck muscles on TTH frequency and duration. Methods Sixty patients with TTH were randomised into strength training or a control group. The strength training group trained ten weeks with elastic resistance bands. The control group performed ergonomic and posture correction. Efficacy was evaluated at follow-up after 19-22 weeks. Results Twenty-three patients completed strength training and 21 completed ergonomic and posture correction (per-protocol). No between-group effect was detected, but within groups numerical reductions were noted in both groups from baseline to follow-up. Frequency of TTH in the strength training group decreased by 11% ( P = 0.041) and duration decreased by10% ( P = 0.036), while the ergonomic and posture correction group showed a significant reduction in frequency of 24% ( P = 0.0033) and a decrease in duration of 27% ( P = 0.041). Conclusion No significant difference between the groups was found and the within-group effects did not reach clinical significance. Combining all the elements into a multifaceted intervention could prove more useful and should be further explored in future studies. Clinical trials registration number NCT02984826.

Tension-Type Headache - The Normal and Most Prevalent Headache

PREMISE

Tension-type headache (TTH) is the most prevalent form of primary headache in the general population but paradoxically the least studied headache.

PROBLEM

In this article, the epidemiology and diagnostic challenges of TTH are presented and discussed. The typical features and differential diagnosis of TTH are highlighted and the situations more likely to raise doubts are discussed.

POTENTIAL SOLUTION

A structured approach to the patient and a better comprehension of the very frequent coexistence of migraine and medication overuse headache in the clinical population are emphasized. According to the IHS classification, several diagnoses should be applied but still some clinicians prefer to apply a single combined diagnosis in the severely affected patients, namely chronic migraine. Such uneven practice may complicate the diagnostic comparability and the entire management of TTH. The present treatment strategies for TTH are summarized and hopefully an increased awareness of TTH can translate into better quality of care and a more specific diagnosis and treatment for the numerous TTH sufferers.

Relationship of active trigger points with related disability and anxiety in people with tension-type headache

To investigate the differences in the presence of trigger points (TrPs) and their association with headache-related disability and mood disorders in people with frequent episodic tension-type headache (TTH) (FETTH) and chronic TTH (CTTH). One hundred twenty-two individuals with TTH participated. Clinical features of headache (i.e., intensity, duration, and frequency) were recorded on a headache diary. Headache-related disability was assessed with the Headache Disability Inventory, trait and state anxiety levels with State-Trait Anxiety Inventory, and depression with the Hospital Anxiety and Depression Scale. TrPs were bilaterally explored in the temporalis, masseter, suboccipital, upper trapezius, splenius capitis, and sternocleidomastoid muscles. Sixty-two (51%) patients were classified as FETTH, whereas 60 (49%) were classified as CTTH. Individuals with CTTH showed higher burden of headache and depression than FETTH (P < 0.001). Subjects with FETTH showed similar number of TrPs (total number: 5.9 ± 3.1, active TrPs: 4.7 ± 2.5, and latent TrPs: 1.2 ± 1.9) than those with CTTH (total number: 5.7 ± 3.2, active TrPs: 4.2 ± 3.0, and latent TrPs: 1.5 ± 1.8). The number of active TrPs was significantly associated with the burden of headache (r = 0.189; P = 0.037) and trait anxiety (r = 0.273; P = 0.005): the higher the number of active TrPs, the greater the physical burden of headache or the more the trait anxiety level. No association with the depression was observed. The presence of active TrPs in head and neck/shoulder muscles was similar between individuals with FETTH and CTTH and associated with the physical burden of headache and trait anxiety levels independently of the subgroup of TTH.

Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache

Objective

To investigate the association between trigger points (TrPs) and widespread pressure pain sensitivity in people with tension-type headache (TTH) and to determine if this association is different between frequent episodic (FETTH) or chronic (CTTH) headache.

Design

A cross-sectional study.

Methods

One hundred and fifty-seven individuals (29% male) with TTH participated. Clinical features of headache, i.e., intensity, duration, and frequency, were recorded in a headache diary. Active and latent TrPs were bilaterally explored in the temporalis, masseter, suboccipital, upper trapezius, sternocleidomastoid, and splenius capitis muscles. Pressure pain thresholds (PPT) were assessed over the trigeminal area (i.e., temporalis muscle), extra-trigeminal (i.e., C5/C6 zygapophyseal joint), and two distant pain-free points (i.e., second metacarpal and tibialis anterior muscle).

Results

Eighty (51%) patients were classified as FETTH, whereas 77 (49%) were classified as CTTH. No differences in the number of either active or latent TrPs (all p > 0.171) or widespread pressure pain sensitivity (all p > 0.351) were observed between FETTH and CTTH groups. The number of active and latent TrPs was significantly and negatively associated with PPTs: The higher the number of active or latent TrPs, the lower the widespread PPT, and the more generalized sensitization. This association was stronger within the FETTH group than the CTTH group.

Conclusions

This study found that the number of TrPs in head and neck/shoulder muscles was associated with widespread pressure hypersensitivity independently of the frequency of headache.

The added value of an electronic monitoring and alerting system in the management of medication-overuse headache: A controlled multicentre study

Background

Medication-overuse headache (MOH) is a chronic disabling condition associated with a high rate of relapse.

Methods

We evaluated whether the adoption of electronic-assisted monitoring, advice and communication would improve the outcome over a follow-up of 6 months in a controlled, multicentre, multinational study conducted in six headache centres located in Europe and Latin America. A total of 663 MOH subjects were enrolled and divided into two groups: the Comoestas group was monitored with an electronic diary associated with an alert system and a facilitated communication option, and the Classic group with a paper headache diary.

Results

We observed a significantly higher percentage of overuse-free subjects in the Comoestas group compared with the Classic group: 73.1 vs 64.1% (odds ratio 1.45, 95% confidence interval 1.07–2.09, p = 0.046). The Comoestas group performed better also regarding the number of days/month with intake of acute drugs and the level of disability [Migraine Disability Assessment Score: Comoestas group – 42.5 ± 53.6 (35.5–49.3) and Classic group – 27.5 ± 56.1 (20.6–34.3) ( p < 0.003)].

Conclusion

The adoption of the electronic tool improved the outcome of patients suffering from MOH after withdrawal from overused drugs. Information and communication technology represents a valid aid for optimizing the management of chronic conditions at risk of worsening or of relapsing.

Trial registration

The trial was registered at ClinicalTrials.gov (no. NCT02435056).

Specific strength training compared with interdisciplinary counseling for girls with tension-type headache: a randomized controlled trial

BACKGROUND

Childhood tension-type headache (TTH) is a prevalent and debilitating condition for the child and family. Low-cost nonpharmacological treatments are usually the first choice of professionals and parents. This study examined the outcomes of specific strength training for girls with TTH.

METHODS

Forty-nine girls aged 9-18 years with TTH were randomized to patient education programs with 10 weeks of strength training and compared with those who were counseled by a nurse and physical therapist. Primary outcomes were headache frequency, intensity, and duration; secondary outcomes were neck-shoulder muscle strength, aerobic power, and pericranial tenderness, measured at baseline, after 10 weeks intervention, and at 12 weeks follow-up. Health-related quality of life (HRQOL) questionnaires were assessed at baseline and after 24 months.

RESULTS

For both groups, headache frequency decreased significantly, P=0.001, as did duration, P=0.022, with no significant between-group differences. The odds of having headache on a random day decreased over the 22 weeks by 0.65 (0.50-0.84) (odds ratio [95% confidence interval]). For both groups, neck extension strength decreased significantly with a decrease in cervicothoracic extension/flexion ratio to 1.7, indicating a positive change in muscle balance. In the training group, shoulder strength increased $10% in 5/20 girls and predicted [Formula: see text] increased $15% for 4/20 girls. In the training group, 50% of girls with a headache reduction of $30% had an increase in [Formula: see text] >5%. For the counseling group, this was the case for 29%. A 24-month follow-up on HRQOL for the pooled sample revealed statistically significant improvements. Fifty-five percent of the girls reported little to none disability.

CONCLUSION

The results indicate that both physical health and HRQOL can be influenced significantly by physical exercise and nurse counseling. More research is needed to examine the relationship between physical exercise, [Formula: see text], and TTH in girls. Thus, empowering patient education to promote maximum possible outcomes for all children needs more attention.

Cognitive behavioural treatment for the chronic post-traumatic headache patient: a randomized controlled trial

BACKGROUND

Chronic post-traumatic headache (CPTH) after mild head injury can be difficult to manage. Research is scarce and successful interventions are lacking.To evaluate the effect of a group-based Cognitive Behavioural Therapy (CBT) intervention in relation to headache, pain perception, psychological symptoms and quality of life in patients with CPTH.

METHODS

Ninety patients with CPTH according to ICHD-2 criteria were enrolled from the Danish Headache Center into a randomized, controlled trial. Patients were randomly assigned to either a waiting list group or to a nine-week CBT group intervention. At baseline and after 26 weeks all patients completed the Rivermead Post Concussion Symptoms Questionnaire, SF-36, SCL-90-R and a headache diary.

RESULTS

The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms. The waiting-list group experienced no change in headache but, opposed to the treatment group, a significant decrease in somatic and cognitive symptoms indicating a spontaneous remission over time.

CONCLUSIONS

Our primarily negative findings confirm that management of patients with CPTH still remains a considerable challenge. Psychological group therapy with CBT might be effective in an earlier stage of CPTH and in less severely affected patients but our findings strongly underline the need for randomized controlled studies to test the efficacy of psychological therapy.

Methodological issues in studying trigger factors and premonitory features of migraine

OBJECTIVE

In this review, we focus on migraine as a chronic disorder with episodic attacks (CDEA). We aim to review methodological approaches to studying trigger factors and premonitory features that often precede a migraine attack.

BACKGROUND

Migraine attacks are sometimes initiated by trigger factors, exposures which increase the probability of an attack. They are heralded by premonitory features, symptoms which warn of an impending attack.

DESIGN/METHODS

We review candidate predictors of migraine attack and discuss the methodological issues and approaches to studying attack prediction and suggest that electronic diaries may be the method of choice.

CONCLUSION

Establishing the relationship between antecedent events and headaches is a formidable challenge. Successfully addressing this challenge should provide insights into disease mechanisms and lead to new strategies for treatment. In the second paper in this series, we review the available literature on trigger factors and premonitory features.

Feasibility of a brief intervention for medication-overuse headache in primary care--a pilot study

Background

Medication-overuse headache (MOH) is a common problem in primary care. Brief intervention (BI) has successfully been used for detoxification from overuse of alcohol and drugs. The aim of this pilot study was to develop and test methodology, acceptability and logistics for a BI for MOH in primary care.

Findings

Observational feasibility study of an intervention in a Norwegian general practice population.

Six general practitioners (GPs) were recruited. A screening questionnaire for MOH was sent to all 18–50 year old patients on these GPs` list. GPs were taught BI, which was applied to MOH patients as follows: Severity of dependence scale (SDS) scores were collected and individual feedback was given of the relationship between the SDS, medication overuse and headache. Finally, advice to reduce medication was given. Patients were invited to a headache interview three months after the BI. Main outcomes were feedback from GPs/patients about the feasibility and logistics of the study design, screening/recruitment process, BI and headache interviews. Efficacy and patient-related outcomes were not focused. The patients reported a high degree of acceptability of the methodology. The GPs reported the BI to be feasible to implement within a busy practice and to represent a new and improved instrument for communication with MOH patients. The BI requires further testing in a randomised controlled trial (RCT) in order to provide evidence of efficacy.

Conclusion

This feasibility study will be used to improve the BI for MOH and the design of a cluster-RCT.

Trial registration

ClinicalTrials.gov: NCT01078012 (Initially registered as controlled efficacy trial but changed to observational study).

A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study

INTRODUCTION

The management of medication-overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. In this study we defined and tested a consensus protocol for the management of MOH on a large population of patients distributed in different countries.

SUBJECTS AND METHODS

The protocol was based on evidence from the literature and on consolidated expertise of the members of the consensus group. The study was conducted according to a multicentric interventional design with the enrolment of 376 MOH subjects in four centres from Europe and two centres in Latin America. The majority of patients were treated according to an outpatient detoxification programme. The post-detoxification follow-up lasted six months.

RESULTS

At the final evaluation, two-thirds of the subjects were no longer overusers and in 46.5% of subjects headache had reverted back to an episodic pattern of headache. When comparing the subjects who underwent out-patient detoxification vs those treated with in-patient detoxification, both regimens proved effective, although the drop-out rate was higher in the out-patient approach.

CONCLUSIONS

The present findings support the effectiveness and usability of the proposed consensus protocol in different countries with different health care modalities.

Chronic post-traumatic headache after mild head injury: a descriptive study

BACKGROUND

The aetiology behind chronic post-traumatic headache (CPTH) after mild head injury is unclear and management is complicated. In order to optimize treatment strategies we aimed to characterize a CPTH population.

METHODS

Ninety patients with CPTH and 45 patients with chronic primary headaches were enrolled from the Danish Headache Center. All patients were interviewed about demographic and headache data. They completed the Harvard Trauma Questionnaire (HTQ), Rivermead Post Concussion Symptoms Questionnaire, SF-36 and a headache diary.

RESULTS

The CPTH group experienced more cognitive ( P < 0.001) and somatic symptoms ( P = 0.048) and rated their self-perceived health as more affected in terms of physical function ( P = 0.036), physical role function ( P = 0.012) and social function ( P = 0.012) than the control group. Surprisingly, 31% of the CPTH group had a score equal to or above the cut-off score for having post-traumatic stress disorder (PTSD) according to the HTQ. In terms of demographics and headache, the groups were comparable except the CPTH group were more often without affiliation to the labour market ( P < 0.001).

CONCLUSIONS

The loss of work capacity and high levels of disability for the CPTH patients suggests directions for further research into what important factors are embedded in the patients' PTSD symptoms and might explain their prolonged illness.

Headache in children: Effectiveness of multidisciplinary treatment in a tertiary paediatric headache clinic

Aim

The aim of this article is to evaluate the effectiveness of a specific multidisciplinary treatment programme for children with headache and to describe the concept and settings of the Children’s Headache Clinic in Denmark.

Method

All new patients were included and evaluations were conducted after six and 12 months. Pharmacological and non-pharmacological treatments were offered by a team of specialists (physicians, headache nurses, a physiotherapist and a psychologist).

Patients

The subjects comprised 169 children (mean age 11.7 (range 4–17), 91 females, 78 males), 39% of whom suffered from chronic headache (≥15 days/month). All children were diagnosed according to the International Classification of Headache Disorders, second edition; 20% had migraine, 34% tension-type headache, 27% mixed headache, 4% medication-overuse headache, and 15% were diagnosed with other types of headaches.

Results

Fifty per cent of the children had an improvement in headache frequency above 50% at six months. By the use of repeated measurement analysis, we found a significant decrease in headache frequency in all of the six headache groups, whereas the increase in quality of life (PedsQL™ 4.0) was significant for the group as a whole.

Conclusion

Though preliminary, the results show a good outcome for multidisciplinary treatment programmes for children who suffer from frequent or chronic headache.

Study protocol: brief intervention for medication overuse headache--a double-blinded cluster randomised parallel controlled trial in primary care

Background

Chronic headache (headache ≥ 15 days/month for at least 3 months) affects 2–5% of the general population. Medication overuse contributes to the problem. Medication-overuse headache (MOH) can be identified by using the Severity of Dependence Scale (SDS). A “brief intervention” scheme (BI) has previously been used for detoxification from drug and alcohol overuse in other settings. Short, unstructured, individualised simple information may also be enough to detoxify a large portion of those with MOH. We have adapted the structured (BI) scheme to be used for MOH in primary care.

Methods/Design

A double-blinded cluster randomised parallel controlled trial (RCT) of BI vs. business as usual. Intervention will be performed in primary care by GPs trained in BI. Patients with MOH will be identified through a simple screening questionnaire sent to patients on the GPs lists. The BI method involves an approach for identifying patients with high likelihood of MOH using simple questions about headache frequency and the SDS score. Feedback is given to the individual patient on his/her score and consequences this might have regarding the individual risk of medication overuse contributing to their headache. Finally, advice is given regarding measures to be taken, how the patient should proceed and the possible gains for the patient. The participating patients complete a headache diary and receive a clinical interview and neurological examination by a GP experienced in headache diagnostics three months after the intervention. Primary outcomes are number of headache days and number of medication days per month at 3 months. Secondary outcomes include proportions with 25 and 50% improvement at 3 months and maintenance of improvement and quality of life after 12 months.

Discussion

There is a need for evidence-based and cost-effective strategies for treatment of MOH but so far no consensus has been reached regarding an optimal medication withdrawal method. To our knowledge this is the first RCT of structured non-pharmacological MOH treatment in primary care. Results may hold the potential of offering an instrument for treating MOH patients in the general population by GPs.

Trial registration

ClinicalTrials.gov identifier: NCT01314768

Migraine diagnosis: screening items, instruments, and scales

Migraine is a common and disabling disorder with a 1-year prevalence of 4.5-6% in men and 14.5-18% in women. The diagnosis of migraine is usually made according to the second edition of the International Classification of Headache Disorders (ICHD-2) criteria; however, not all physicians are familiar with the diagnostic criteria. Underdiagnosis remains a major issue in general practice, resulting in inadequate treatment. Several instruments are designed to improve the diagnosis of migraine, to identify the comorbid psychological disturbances, to measure the burden and disability, and to access any reduction in quality of life (QoL) that occurs due to migraine attacks with good reliability and validity. Furthermore, the disability and QoL measured by certain instruments serve as surrogate targets when treating migraines. In this review, we examine the instruments that are in common use in daily practice and current research on migraines, focusing on the purpose of each instrument, clinical applications, pitfalls in interpretation, and, if any, minimally clinically important difference(s) (MCID). In general, a structured intake form and a headache diary are recommended in approaching patients with headache. In addition, ID-Migraine, a three-item screening test, has been validated in primary care settings as a way to improve the rapid diagnosis of migraine. The Visual Aura Rating Scale (VARS) is helpful for the diagnosis of migraine with aura. In addition, migraine is commonly associated with psychiatric comorbidities, which can be assessed by the Beck Depression Inventory (BDI), 9-item Patient Health Questionnaire (PHQ-9), and Hospital Anxiety and Depression Scale (HADS). To evaluate the impact of migraines, disability can be assessed using the Migraine Disability Assessment Questionnaire (MIDAS). Reduction in QoL can be evaluated using the Migraine-Specific Quality of Life Survey (MSQ 2.1), European Quality of Life-Five Dimensions (EQ-5D), or Short-Form 36 (SF-36). Despite all these instruments, proper selection and interpretation of each instrument remain crucial.