Chronic daily headaches

Prognostic Value of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Profiles in Predicting Outcomes of Occipital Nerve Stimulation for Refractory Chronic Migraine: A Retrospective Bias-Corrected Multivariable Analysis

BACKGROUND

Refractory chronic migraine (rCM) is characterized by debilitating headaches that do not respond adequately to conventional medical treatments, leaving patients severely disabled. In these rare cases, central cervical spinal cord stimulation or occipital nerve stimulation (ONS) may offer a potential therapeutic option. However, these techniques are not without risks, lack clear scientific evidence, and impose a significant economic burden. Therefore, it is crucial to identify parameters that can assist physicians in selecting appropriate candidates for implantation. This study aimed to investigate the role of psychological profiles in predicting outcomes for ONS in rCM patients.

METHODS

We conducted a retrospective analysis on rCM patients treated with ONS at a second-level neuromodulation university facility. These patients were refractory to conventional medical treatments, including onabotulinumtoxin-A injections (monoclonal antibodies targeting CGRP were not yet available). The NRS for migraine intensity, the number of monthly migraine attacks, and drug consumption were assessed at 6-month and 12-month follow-ups post-implant. Psychological profiles were evaluated prior to OCN using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). A multivariable logistic regression model was developed to predict ONS outcomes, incorporating MMPI-2 as a covariate. The model's accuracy and performance were assessed through non-parametric bootstrap, calibration, and discrimination analyses.

RESULTS

Twenty-three rCM patients were analysed. ONS was able to significantly reduce the pain intensity, the number of headache attacks per month, and drug consumption compared to pre-treatment levels at both 6- and 12-month follow-ups. The final multivariable logistic model at 12 months showed that the MMPI-2 Depression score was independently and negatively associated with favourable outcomes following ONS (optimism-adjusted OR 0.52, 95% CI 0.21-0.77, p = 0.03). The ROC curve indicated high model sensitivity (AUC: 0.96, 95% CI: 0.88-0.98), and the calibration plot revealed a good fit, with some improvement needed in mid-range predicted probabilities.

CONCLUSION

ONS significantly reduced pain intensity, headache frequency, and drug use at the 12-month follow-up compared to pre-treatment levels. The MMPI-2 Depression score was an independent predictor of ONS failure, highlighting the importance of comprehensive psychological assessments in patient selection for ONS.

Effects of chronic daily headache with subclinical depression on brain volume: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The relationship between chronic daily headache (CDH), depression symptoms, and brain volume remains unclear.

METHODS

To investigate the effects of CDH on brain volume and the impact of depressive symptoms (DSs) as well as the effects of demography and medication overuse, PubMed, Embase, and Web of Science databases were systematically searched using appropriate keyword strings to retrieve observational studies from inception to May 2023.

RESULTS

Two distinct comparisons were made in CDH patients: (1) those with DSs versus their pain-free counterparts and (2) those without DSs versus pain-free controls. The first comprised nine studies enrolling 225 CDH patients with DSs and 234 controls. Beck depression inventory, Hamilton depression scale, and Hospital anxiety/depression scale were used to assess DSs, revealing significantly more DSs in CDH patients with DSs compared to their controls (all p < 0.05). Besides, the second analysed four studies involving 117 CDH patients without DSs and 155 comparators. Compared to CDH patients without DSs, those with DSs had a smaller brain volume than controls (p = 0.03). Furthermore, CDH patients with DSs who did not overuse medications showed a smaller right cerebral cortical volume than overusers (p = 0.003). A significant inverse correlation between female prevalence and brain volume (p = 0.02) was revealed using regression analysis.

CONCLUSIONS

Pain-induced persistent depressive symptoms not only incur structural alterations but also encompass affective-motivational changes, involving medication use and gender-specific health concerns.

SIGNIFICANCE

This study highlighted the importance of an integrated CDH treatment, emphasizing psychological interventions for the affective-motivational component alongside pain management.

Transverse Sinus Stenosis as an Underdiagnosed Cause of Chronic Headache: A Case Report

Transverse sinus stenosis (TSS) is an abnormality in the cerebral venous system in which the narrowing of the transverse sinus of the brain leads to obstructed cerebral venous outflow. It is an infrequent, incidental radiological finding. However, it is not uncommon among patients with chronic headaches of unclear cause, particularly those that remain unexplained after initial evaluation or those that are refractory to medical treatment. Its diagnosis frequently eludes the initial workup, and a high degree of suspicion should be maintained since its identification can lead to potentially curative treatment. This report describes the case of a 36-year-old female with a history of chronic headache who was found to have TSS. This paper discusses its etiology, pathophysiology, clinical presentation, radiological findings, and management.

Effectiveness of transcranial direct current stimulation (tDCS) as adjunctive treatment for chronic headache in adults with clinically stable systemic lupus erythematosus (SHADE): a randomised double-blind multiarm sham controlled clinical trial

BACKGROUND

Chronic headache is a 'silent' neuropsychiatric systemic lupus erythematosus symptom with heterogeneous prevalence, potentially reaching 54.4%. It may reduce quality of life by increasing the likelihood of depression and sleep disturbance. While pharmacotherapy remains the first-line treatment, the current management is still challenging and needs other non-invasive modalities. An effective, tolerable and disease-specific treatment modality including transcranial direct current stimulation (tDCS) is considered to reduce the frequency of chronic headaches, including in SLE. Until recently, there was no standard protocol for tDCS in treating headaches.

METHODS AND ANALYSIS

SHADE is a single-centre randomised double-blind multiarm sham-controlled trial for adults with clinically stable SLE, chronic headaches and without history of traumatic brain injury, brain infection, stroke or brain tumour. Random allocation is conducted to 88 subjects into 3 treatment groups (administration at primary motor, primary sensory and dorsolateral prefrontal cortex) and control group in 1:1:1:1 ratio. The primary endpoint is reduced number of headache days after adjunctive tDCS. The secondary endpoints are reduced headache intensity, increased quality of life, increased sleep quality, decreased depression and reduced analgesics use. The outcome is measured monthly until 3-month postintervention using headache diary, 36-Item Short Form Survey, Chronic Headache Quality of Life Questionnaire, Pittsburgh Sleep Quality Index and Mini International Neuropsychiatry Interview version 10 (MINI ICD 10). Intention-to-treat analysis will be performed to determine the best tDCS electrode placement.

ETHICS AND DISSEMINATION

Ethical approval had been obtained from the local Institutional Review Board of Faculty of Medicine Universitas Indonesia. Results will be published through scientific relevant peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05613582.

Personality in Chronic Headache: A Systematic Review with Meta-Analysis

Background

Chronic headache (CH) is a condition that includes different subtypes of headaches and that can impair different life domains. Personality traits can play a relevant role both in the development and in coping with this medical condition. The first aim of the present study is to realize a systematic review of the personality traits associated with CH compared to healthy controls; the second objective is to carry out a quantitative meta-analysis with the studies using the same instrument to assess personality traits.

Method

The literature search encompassed articles published from 1988 until December 2022 on the major databases in the field of health and social sciences: PubMed, Scopus, PsychInfo, and Web of Science.

Results

Thirteen studies were included in the systematic review, but only three studies were deeply explored in a meta-analysis since the only ones used a common instrument for personality assessment (Minnesota Multiphasic Personality Inventory). According to the meta-analysis, different subtypes of CH patients scored higher than healthy controls on Hypochondriasis and Hysteria Scales. The systematic review showed higher levels of depressive and anxious personality dimensions and pain catastrophizing in CH compared to healthy controls. Moreover, frequent-chronic forms and medication-overuse headache were the most symptomatic and frail categories showing higher levels of dysfunctional personality traits and psychopathological symptoms.

Conclusions

These results seem to confirm a "neurotic profile" in patients suffering from CH. The identification of the main personality traits involved in the onset and maintenance of headache disorders represents an important objective for developing psychological interventions.

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis

Background: Migraine surgery at 1 of 6 identified "trigger sites" of a target cranial sensory nerve has rapidly grown in popularity since 2000. This study summarizes the effect of migraine surgery on headache severity, headache frequency, and the migraine headache index score which is derived by multiplying migraine severity, frequency, and duration. Materials and Methods: This is a PRISMA-compliant systematic review of 5 databases searched from inception through May 2020 and is registered under the PROSPERO ID: CRD42020197085. Clinical trials treating headaches with surgery were included. Risk of bias was assessed in randomized controlled trials. Meta-analyses were performed on outcomes using a random effects model to determine the pooled mean change from baseline and when possible, to compare treatment to control. Results: 18 studies met criteria including 6 randomized controlled trials, 1 controlled clinical trial, and 11 uncontrolled clinical trials treated 1143 patients with pathologies including migraine, occipital migraine, frontal migraine, occipital nerve triggered headache, frontal headache, occipital neuralgia, and cervicogenic headache. Migraine surgery reduced headache frequency at 1 year postoperative by 13.0 days per month as compared to baseline (I2 = 0%), reduced headache severity at 8 weeks to 5 years postoperative by 4.16 points on a 0 to 10 scale as compared to baseline (I2 = 53%), and reduced migraine headache index at 1 to 5 years postoperative by 83.1 points as compared to baseline (I2 = 2%). These meta-analyses are limited by a small number of studies that could be analyzed, including studies with high risk of bias. Conclusion: Migraine surgery provided a clinically and statistically significant reduction in headache frequency, severity, and migraine headache index scores. Additional studies, including randomized controlled trials with low risk-of-bias should be performed to improve the precision of the outcome improvements.

Nerve blocks for occipital headaches: A systematic review and meta-analysis

Migraine surgeons have identified six "trigger sites" where cranial nerve compression may trigger a migraine. This study investigates the change in headache severity and frequency following nerve block of the occipital trigger site. This PRISMA-compliant systematic review of five databases searched from database inception through May 2020 is registered under the PROSPERO ID: CRD42020199369. Only randomized controlled trials utilizing injection treatments for headaches with pain or tenderness in the occipital scalp were included. Pain severity was scored from 0 to 10. Headache frequency was reported as days per week. Included were 12 RCTs treating 586 patients of mean ages ranging from 33.7 to 55.8 years. Meta-analyses of pain severity comparing nerve blocks to baseline showed statistically significant reductions of 2.88 points at 5 to 20 min, 3.74 points at 1 to 6 weeks, and 1.07 points at 12 to 24 weeks. Meta-analyses of pain severity of nerve blocks compared with treatment groups of neurolysis, pulsed radiofrequency, and botulinum toxin type A showed similar headache pain severity at 1 to 2 weeks, and inferior improvements compared with the treatment groups after 2 weeks. Meta-analyses of headache frequency showed statistically significant reductions at 1 to 6-week follow-ups as compared with baseline and at 1 to 6 weeks as compared with inactive control injections. The severity and frequency of occipital headaches are reduced following occipital nerve blocks. This improvement is used to predict the success of migraine surgery. Future research should investigate spinous process injections with longer follow-up.

Prevalence and characteristics of new-onset pain in COVID-19 survivours, a controlled study

BACKGROUND

We assessed whether COVID-19 is associated with de novo pain and de novo chronic pain (CP).

METHODS

This controlled cross-sectional study was based on phone interviews of patients discharged from hospital after COVID-19 compared to the control group composed of individuals hospitalized during the same period due to non-COVID-19 causes. Patients were classified as having previous CP based on the ICD-11/IASP criteria, de novo pain (i.e. any new type of pain, irrespective of the pain status before hospital stay), and de novo CP (i.e. persistent or recurring de novo pain, lasting more than 3 months) after COVID-19. We assessed pain prevalence and its characteristics, including headache profile, pain location, intensity, interference, and its relationship with fatigue, and persistent anosmia. Forty-six COVID-19 and 73 control patients were included. Both groups had similar sociodemographic characteristics and past medical history.

RESULTS

Length of in-hospital-stay and ICU admission rates were significantly higher amongst COVID-19 survivours, while mechanical ventilation requirement was similar between groups. Pre-hospitalisation pain was lower in COVID-19 compared to control group (10.9% vs. 42.5%; p = 0.001). However, the COVID-19 group had a significantly higher prevalence of de novo pain (65.2% vs. 11.0%, p = 0.001), as well as more de novo headache (39.1%) compared to controls (2.7%, p = 0.001). New-onset CP was 19.6% in COVID-19 patients and 1.4% (p = 0.002) in controls. These differences remained significant (p = 0.001) even after analysing exclusively (COVID: n = 40; controls: n = 34) patients who did not report previous pain before the hospital stay. No statistically significant differences were found for mean new-onset pain intensity and interference with daily activities between both groups. COVID-19 pain was more frequently located in the head/neck and lower limbs (p < 0.05). New-onset fatigue was more common in COVID-19 survivours necessitating inpatient hospital care (66.8%) compared to controls (2.5%, p = 0.001). COVID-19 patients who reported anosmia had more new-onset pain (83.3%) compared to those who did not (48.0%, p = 0.024).

CONCLUSION

COVID-19 was associated with a significantly higher prevalence of de novo CP, chronic daily headache, and new-onset pain in general, which was associated with persistent anosmia.

SIGNIFICANCE

There exists de novo pain in a substantial number of COVID-19 survivours, and some develop chronic pain. New-onset pain after the infection was more common in patients who reported anosmia after hospital discharge.

Integrative East-West Medicine Intervention for Chronic Daily Headache: A Case Report and Care Perspective

Chronic daily headache is a group of headache syndromes including most commonly chronic migraine and chronic tension-type headache, which often overlap, are complicated by medication overuse and are disabling, costly, and variable responsive to western pharmacotherapeutic interventions. There is growing research and awareness of integrative health approaches and therapies to address patients with chronic headache, yet limited examples of how to deliver this approach. This article reviews a commonly seen challenging case of a patient with overlapping chronic migraine and chronic tension-type headache complicated by medication overuse managed with an integrative east-west medicine intervention. This included person-centered biopsychosocial history taking, traditional Chinese medicine informed acupuncture, trigger point injections, and contributing factors modifications. A narrative review of the literature is presented to demonstrate an evidence-informed rationale for incorporating nonpharmacologic approaches to effectively help reduce the symptom burden of this patient population.

The Effect of Propofol on Chronic Headaches in Patients Undergoing Endoscopy

Objective

This study determined acute and long-term effects of propofol administration in patients with severe headaches undergoing endoscopic procedures.

Background

Approximately 13% of the US population is affected by migraines or severe headaches. The effect of propofol on headaches more than a few days after the intervention has not been explored.

Methods

We employed a nonrandomized, prospective observational study that recruited patients with chronic headaches who received propofol from an outpatient endoscopy center for either upper or lower endoscopies. Patients completed the six-item Headache Impact Test (HIT-6) questionnaire prior to the procedure and 30 days after endoscopy. Additionally, the patients' response to propofol two days after endoscopy was assessed via phone.

Results

The age of the participants (n=31) ranged from 20 to 70 years. The mean HIT-6 composite scores were significantly lower (p < 0.05) 30 days after propofol administration when compared to baseline scores. Upon stratification, 23 patients indicated an improved condition, 7 a worsened outcome, and 1 showed no change. Furthermore, mean scores were significantly lower (p < 0.05) in three HIT-6 questions pertaining to the severity of pain, daily activity, and frequency of lying down. Finally, the mean pain score obtained was significantly lower (p < 0.05) two days after procedure.

Conclusions

The results of this suggest that propofol administration should be considered in treating chronic headaches. Double-blind studies are necessary to confirm these results.

Conceptualizing a subtype of patients with chronic pain: The necessity of obtaining a history of sexual abuse

Lifetime history of sexual abuse is estimated to range between 15% and 25% in the general female population. Cross-sectional studies have shown that sexual assault survivors frequently report chronic musculoskeletal pain and functional somatic syndromes. Treating chronic pain with opioids went from being largely discouraged to being included in standards of care and titrating doses until patients self-report adequate control has become common practice, with 8% to 30% of patients with chronic noncancer pain receiving opioids. In this clinical review, we will discuss the association between survivors of sexual assault and chronic pain/functional somatic syndromes. We will further review evidence-based treatment strategies for this "pain-prone phenotype."

A Review of Select Centralized Pain Syndromes: Relationship With Childhood Sexual Abuse, Opiate Prescribing, and Treatment Implications for the Primary Care Physician

Pain can be broadly divided into 3 classes, including nociceptive or inflammatory pain (protective), neuropathic (pathological, occurring after damage to the nervous system), or centralized (pathological, due to abnormal function but with no damage or inflammation to the nervous system). The latter has been posited to occur when descending analgesic pathways are attenuated and/or glutamatergic transmission is facilitated. Additionally, this "pain prone phenotype" can be associated with early life trauma and a suboptimal response to opiates. This article will review the relationships between centralized pain syndromes (ie, fibromyalgia, chronic low back pain), childhood sexual abuse, and opiate misuse. Finally, treatment implications, potentially effecting primary care physicians, will be discussed.

Headache and facial pain: differential diagnosis and treatment

Headaches affect 90% of the population sometime during their life. Most are benign and fleeting, some are serious and life-threatening, and others require ongoing medical consultation and treatment. A careful history and physical is necessary to establish a differential diagnosis and to guide the choice of testing to make an accurate diagnosis. The most common types of headaches are discussed in this review. They are divided into primary and secondary headache disorders as classified by the International Headache Society. Primary headache disorders include migraine without and with aura, cluster and tension-type headaches. Secondary headaches are those that occur as a result of some other disorder and include brain tumors, rhinosinusitis, diseases of intracranial and extracranial vasculature, and temporomandibular joint disease.