An interdisciplinary integrated specialized one-stop outpatient clinic for idiopathic intracranial hypertension - an assessment of sick leave, presenteeism, and health care utilization

BACKGROUND

Management of idiopathic intracranial hypertension (IIH) is complex requiring contributions from multiple specialized disciplines. In practice, this creates considerable organizational and communicational challenges. To meet those challenges, we established an interdisciplinary integrated outpatient clinic for IIH with a central coordination and a one-stop- concept. Here, we aimed to evaluate effects of this concept on sick leave, presenteeism, and health care utilization.

METHODS

In a retrospective cohort study, we compared the one-stop era with integrated care (IC, 1-JUL-2021 to 31-DEC-2022) to a reference group receiving standard care (SC, 1-JUL-2018 to 31-DEC-2019) regarding economic outcome parameters assessed over 6 months. Multivariate binary logistic regression models were used to adjust for confounders.

RESULTS

Baseline characteristics of the IC group (n = 85) and SC group (n = 81) were comparable (female: 90.6% vs. 90.1%; mean age: 33.6 vs. 32.8 years, educational level: ≥9 years of education 60.0% vs. 59.3%; located in Vienna 75.3% vs. 76.5%). Compared to SC, the IC group showed significantly fewer days with sick leave or presenteeism (-5 days/month), fewer unscheduled contacts for IIH-specific problems (-2.3/month), and fewer physician or hospital contacts in general (-4.1 contacts/month). Subgroup analyses of patients with migration background and language barrier consistently indicated stronger effects of the IC concept in these groups.

CONCLUSIONS

Interdisciplinary integrated management significantly improves the burden of IIH in terms of sick leave, presenteeism and healthcare consultations - particularly in socioeconomically underprivileged patient groups.

Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache

BACKGROUND AND OBJECTIVES

Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects.

METHODS

We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS

A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%.

CONCLUSION

This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Reconceptualizing autonomic function testing in migraine: a systematic review and meta-analysis

BACKGROUND

Autonomic nervous system (ANS) testing has aided in our ability to evaluate autonomic dysfunction in migraine patients. We reviewed the literature in multiple databases which investigate ANS function in migraine patients and healthy subjects.

METHODS

This systematic review and meta-analysis examined the respective deep breathing, Valsalva manoeuvre, orthostatic and isometric challenge results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analyses of Observational Studies in Epidemiology (MOOSE) statements.

RESULTS

Seven articles met all inclusion criteria. Fixed-effects meta-analysis showed migraine patients (n = 424), collectively, had lower interictal autonomic test results compared with healthy controls (n = 268). In detail, this was true for the standardized mean difference (g) of deep breathing (g= -0.32; 95% confidence interval (CI) -0.48, -0.16), orthostatic challenge (g= -0.28; 95% CI -0.44, -0.13) and isometric challenge (g= -0.55; 95% CI -0.71, -0.39) and for the difference of means (MD) of the Valsalva ratio (MD = -0.17; 95% CI -0.23, -0.10).

CONCLUSIONS

Interictal ANS dysfunction can be identified in migraine patients when compared to healthy controls. These findings indicate the importance to evaluate ANS function in migraine patients - especially, as migraine-specific prophylactic therapies (such as anti-calcitonin gene-related peptide (CGRP) antibodies) may affect the function of the ANS.

The Vienna idiopathic intracranial hypertension database-An Austrian registry

BACKGROUND

Idiopathic intracranial hypertension (IIH) is becoming increasingly more prevalent bearing the risk of visual impairment and affecting the quality of life. Clinical presentation and outcome are heterogeneous. Large, well-characterized cohorts are scarce.

OBJECTIVE

To characterize the clinical spectrum, diagnostic findings, therapeutic management, and outcome of IIH.

METHODS

We identified patients with IIH according to modified Friedman criteria treated at our center between 2014 and 2021. The Vienna IIH database is described in detail.

RESULTS

Of 113 patients 89% were female (mean age 32.3 years). Median body mass index (BMI) was 31.8, with 85% overweight (BMI > 25) and 5% were classified as IIH without papilledema. Headache was present in 84% and showed migraine features in 43%. Median opening pressure in lumbar puncture was 31 cmH2O. Pharmacotherapy (predominantly acetazolamide) was established in 99%, 56% required at least 1 therapeutic lumbar puncture and 13% a surgical intervention. After a median 3.7 years follow-up, 57% had achieved significant weight loss, papilledema was present in 59% and headache in 76% (58% improved). Comparing initial presentation to follow-up, perimetry was abnormal in 67% vs. 50% (8% worsened, 24% improved) and transorbital sonography in 87% vs. 65% with a median optic nerve sheath diameter of 5.4 mm vs. 4.9 mm. Median peripapillary retinal nerve fiber layer thickness decreased from 199 µm to 99 µm and ganglion cell layer volume from 1.13 mm3 to 1.05 mm3.

CONCLUSION

The large representative Vienna IIH cohort characterizes IIH-related symptoms, diagnostic findings, treatment, and outcome emphasizing substantial long-term sequelae of IIH. Future analyses will aim to refine phenotyping and identify factors predicting outcome.

Impact of rater experience and referral question on detecting magnetic resonance imaging features of idiopathic intracranial hypertension

BACKGROUND AND PURPOSE

In idiopathic intracranial hypertension (IIH), magnetic resonance imaging (MRI) features are promising diagnostic markers, but the impact of rater experience and the specific referral question is unknown.

METHODS

From the Vienna Idiopathic Intracranial Hypertension database, patients were included with definitive IIH and routine cranial MRI performed during diagnostic work-up. Frequencies of partial empty sella (ES), optic nerve sheath distension (ONSD), optic nerve tortuosity (ONT), posterior globe flattening (PGF) and transverse sinus stenosis (TSS) were compared in three settings: (i) real-world rating, (ii) junior neuroradiologist without special IIH training and (iii) senior neuroradiologist with experience in IIH imaging (gold standard).

RESULTS

Magnetic resonance imaging scans of 84 IIH patients (88% female, mean age 33.5 years) were evaluated. By gold standard, ONSD was the most frequent (64.3%) followed by TSS (60.0%), ONT (46.4%), ES (44.4%) and PGF (23.8%). Compared to the gold standard, IIH features were described significantly less frequently in routine MRI reports (ONSD 28.6%, ONT 13.1%, PGF 4.8%, TSS 42.9%, p < 0.01 respectively) except for ES (42.9%, p = 0.9). A specific referral question regarding IIH increased detection rates in routine reports, but rates remained significantly lower than by gold standard. In contrast, a rating by a neuroradiologist without special training produced significantly higher frequencies of ONSD (81.0%, p < 0.01) and ONT (60.7%, p < 0.01) but not of ES (47.6%), PGF (29.8%) and TSS (68.1%).

CONCLUSIONS

Idiopathic intracranial hypertension MRI features are underestimated in routine MRI reports and partly overcalled by less experienced neuroradiologists, driven by features less well known or methodologically difficult. Reevaluation of MRI scans by an experienced rater (and to a lesser degree a specific referral question) improves diagnostic accuracy.

MRI features of idiopathic intracranial hypertension are not prognostic of visual and headache outcome

BACKGROUND

In idiopathic intracranial hypertension (IIH), certain MRI features are promising diagnostic markers, but whether these have prognostic value is currently unknown.

METHODS

We included patients from the Vienna-Idiopathic-Intracranial-Hypertension (VIIH) database with IIH according to Friedman criteria and cranial MRI performed at diagnosis. Presence of empty sella (ES), perioptic subarachnoid space distension (POSD) with or without optic nerve tortuosity (ONT), posterior globe flattening (PGF) and transverse sinus stenosis (TSS) was assessed and multivariable regression models regarding visual outcome (persistent visual impairment/visual worsening) and headache outcome (headache improvement/freedom of headache) were fitted.

RESULTS

We included 84 IIH patients (88.1% female, mean age 33.5 years, median body mass index 33.7). At baseline, visual impairment was present in 70.2% and headache in 84.5% (54.8% chronic). Persistent visual impairment occurred in 58.3%, visual worsening in 13.1%, headache improvement was achieved in 83.8%, freedom of headache in 26.2%. At least one MRI feature was found in 78.6% and 60.0% had ≥3 features with POSD most frequent (64.3%) followed by TSS (60.0%), ONT (46.4%), ES (44.0%) and PGF (23.8%). In multivariable models, there was no association of any single MRI feature or their number with visual impairment, visual worsening, headache improvement or freedom. Visual impairment at baseline predicted persistent visual impairment (odds ratio 6.3, p<0.001), but not visual worsening. Chronic headache at baseline was significantly associated with lower likelihood of headache freedom (odds ratio 0.48, p=0.013), but not with headache improvement.

CONCLUSIONS

MRI features of IIH are neither prognostic of visual nor headache outcome.

Treatment with GLP-1 receptor agonists is associated with significant weight loss and favorable headache outcomes in idiopathic intracranial hypertension

BACKGROUND

In idiopathic intracranial hypertension (IIH), sustained weight loss is the main pillar in modifying disease course, whereby glucagon-like peptide-1 receptor agonists (GLP-1-RAs) could present an attractive treatment option.

METHODS

In this open-label, single-center, case-control pilot study, patients with IIH (pwIIH) and a body mass index (BMI) of ≥ 30 kg/m² were offered to receive a GLP-1-RA (semaglutide, liraglutide) in addition to the usual care weight management (UCWM). Patients electing for UCWM only served as a control group matched for age-, sex- and BMI (1:2 ratio). The primary endpoint was the percentage weight loss at six months (M6) compared to baseline. Secondary endpoints included the rate of patients with a weight loss of ≥ 10%, monthly headache days (MHD), the rate of patients with a ≥ 30% and ≥ 50% reduction in MHD, visual outcome parameters, and adverse events (AEs).

RESULTS

We included 39 pwIIH (mean age 33.6 years [SD 8.0], 92.3% female, median BMI 36.3 kg/m² [IQR 31.4-38.3]), with 13 patients being treated with GLP-1-RAs. At M6, mean weight loss was significantly higher in the GLP-1-RA group (-12.0% [3.3] vs. -2.8% [4.7]; p < 0.001). Accordingly, weight loss of ≥ 10% was more common in this group (69.2% vs. 4.0%; p < 0.001). Median reduction in MHD was significantly higher in the GLP-1-RA group (-4 [-10.5, 0.5] vs. 0 [-3, 1]; p = 0.02), and the 50% responder rate was 76.9% vs. 40.0% (p = 0.04). Visual outcome parameters did not change significantly from baseline to M6. Median reduction in acetazolamide dosage was significantly higher in the GLP-1-RA group (-16.5% [-50, 0] vs. 0% [-25, 50]; p = 0.04). AEs were mild or moderate and attributed to gastrointestinal symptoms in 9/13 patients. None of the AEs led to premature treatment discontinuation.

CONCLUSIONS

This open-label, single-center pilot study suggests that GLP-1-RAs are an effective and safe treatment option for achieving significant weight loss with a favorable effect on headache, leading to reduced acetazolamide dosage in pwIIH.

Idiopathic intracranial hypertension presenting with migraine phenotype is associated with unfavorable headache outcomes

OBJECTIVE

To assess the prognostic impact of migraine headache in idiopathic intracranial hypertension (IIH).

BACKGROUND

Migraine headache is common in IIH, but it is unclear whether it has prognostic relevance.

METHODS

We investigated patients with IIH from the Vienna-IIH-database and differentiated migraine (IIH-MIG) from non-migraine headache (IIH-nonMIG) and without headache (IIH-noHA). Using multivariable models, we analyzed the impact of IIH-MIG on headache and visual outcomes 12 months after diagnosis.

RESULTS

Among 97 patients (89% female, mean [SD] age 32.9 [11.1] years, median body mass index 32.0 kg/m2 , median cerebrospinal fluid opening pressure 310 mm), 46% were assigned to IIH-MIG, 37% to IIH-nonMIG (11% tension-type, 26% unclassifiable), and 17% to IIH-noHA. Overall, headache improvement was achieved in 77% and freedom of headache in 28%. The IIH-MIG group showed significantly lower rates for headache improvement (67% vs. 89% in IIH-nonMIG, p = 0.019) and freedom of headache (11% vs. 33% in IIH-nonMIG and 63% in IIH-noHA, p = 0.015). These differences persisted when only analyzing patients with resolved papilledema at follow-up. In contrast, visual worsening was significantly less common in IIH-MIG (9% vs. 28% in IIH-nonMIG and 31% in IIH-noHA, p = 0.045). In multivariable models, IIH-MIG was associated with a significantly lower likelihood of achieving headache improvement (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.40-0.78, p < 0.001) and freedom of headache (OR 0.29, 95% CI 0.12-0.46, p < 0.001), but also a lower risk for visual worsening (OR 0.26, 95% CI 0.04-0.82, p < 0.001).

CONCLUSIONS

In IIH, migraine headache is associated with unfavorable outcomes for headache, even when papilledema has resolved, and possibly favorable visual outcome.

The role of avoiding known triggers, embracing protectors, and adhering to healthy lifestyle recommendations in migraine prophylaxis: Insights from a prospective cohort of 1125 people with episodic migraine

OBJECTIVES/BACKGROUND

Until recently, guidelines for migraine prevention recommended avoiding known migraine headache triggers. Adhering to healthy lifestyle behaviors is also recommended. In a recent cohort study many triggers were found to decrease the probability of migraine attacks in some individuals. The extent to which people with migraine adhere to healthy lifestyle recommendations is unknown. We set out to determine if known migraine trigger factors and daily adherence to healthy lifestyle recommendations are associated with decreased probability of migraine attacks in some individuals.

METHODS

This was an observational longitudinal cohort study of individuals with episodic migraine who registered to track their headache symptoms and daily exposure to trigger factors prospectively using a migraine-headache electronic diary during 90 days. We assessed whether triggers increased or decreased migraine attack risk in each individual. In addition, we calculated the proportion of days in which the individual adhered to lifestyle recommendations.

RESULTS

We analyzed a total of 1125 individuals contributing 14,080 migraine attacks. Out of 47 triggers, 24 were more often associated with decreased rather than with increased migraine attack risk. Most pronouncedly this was true for caffeine, alcohol, and chocolate; happiness; relaxedness; sleep factors (longer duration, higher quality, and waking up refreshed); and physical activity. People who were more compliant with healthy behaviors, especially keeping good hydration and regular meals, were significantly older and had been diagnosed with migraine disease for a longer period, compared to those who were less compliant. Overall, exercising ≥3 times a week was the least followed recommendation.

CONCLUSION

Many triggers behaved as protectors in a non-negligible proportion of individuals with episodic migraine, challenging the recommendation of avoiding known triggers. Low adherence to healthy lifestyle recommendations demonstrates an opportunity to increase awareness among people with migraine.

Monoclonal Antibodies against Calcitonin Gene-Related Peptide for Migraine Prophylaxis: A Systematic Review of Real-World Data

OBJECTIVE

To perform a systematic review of real-world outcomes for anti-CGRP-mAbs.

METHODS

Following the PRISMA guidelines, we searched PubMed for real-world data of erenumab, galcanezumab, fremanezumab, or eptinezumab in patients with migraines.

RESULTS

We identified 134 publications (89 retrospective), comprising 10 pharmaco-epidemiologic and 83 clinic-based studies, 38 case reports, and 3 other articles. None of the clinic-based studies provided follow-up data over more than one year in more than 200 patients. Findings suggest that there are reductions in health insurance claims and days with sick-leave as well as better treatment adherence with anti-CGRP-mAbs. Effectiveness, reported in 77 clinic-based studies, was comparable to randomized controlled trials. A treatment pause was associated with an increase in migraine frequency, and switching to another antibody resulted in a better response in some of the patients. Adverse events and safety issues were addressed in 86 papers, including 24 single case reports.

CONCLUSION

Real-world data on anti-CGRP-mAbs are limited by retrospective data collection, small patient numbers, and short follow-up periods. The majority of papers seem to support good effectiveness and tolerability of anti-CGRP-mAbs in the real-world setting. There is an unmet need for large prospective real-world studies providing long-term follow-ups of patients treated with anti-CGRP-mAbs.

The prevalence of primary headache disorders in children and adolescents in Zambia: a schools-based study

BACKGROUND

The Global Campaign against Headache collects data from children (6-11 years) and adolescents (12-17) to inform health and education policies and contribute to the Global Burden of Disease (GBD) study. This survey in Zambia, part of this global enquiry, was the second from sub-Saharan Africa (SSA).

METHODS

Following the generic protocol, this was a schools-based cross-sectional survey. We used the child and adolescent versions of the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, self-completed by pupils within classes, in a total of nine schools in Lusaka (urban) and Copperbelt (semi-rural). These two of Zambia's ten provinces were selected to represent the country's urban/rural divide. Headache diagnostic questions were based on ICHD-3 except for undifferentiated headache (UdH).

RESULTS

Of 2,759 potential participants, 2,089 (615 children [29.4%], 1,474 adolescents [70.6%]) completed questionnaires (participating proportion 75.7%). Children were therefore under-represented (mean age 13.1 ± 2.8 years), while gender distribution (1,128 [54.0%] male, 961 [46.0%] female) was close to expectation. Observed lifetime prevalence of headache was 97.5%. Gender- and age-adjusted 1-year prevalence estimates were 85.8% for all headache, 53.2% for migraine (definite 17.5%, probable 35.7%), 12.1% for tension-type headache (TTH), 14.8% for UdH, 3.3% for all headache on ≥ 15 days/month and 0.9% for probable medication-overuse headache. Headache durations were short: only 28.6% of participants with any headache, and only 10.5% of those diagnosed as probable migraine, reported usual durations of > 2 h (the threshold for definite migraine). Of the latter, 36.6% reported < 1 h, the duration criterion for UdH. There were weak associations of migraine (definite + probable) with female gender, and of TTH and headache on ≥ 15 days/month with adolescence. Headache yesterday was reported by 22.2% of the sample, 25.5% of those with headache.

CONCLUSIONS

Headache disorders among young people are prevalent in Zambia. Among them, migraine is the most common, with UdH also highly prevalent. In this study there were diagnostic uncertainties, which rested to a large extent on the distinction between migraine and UdH among the many participants reporting headache of < 2 h' duration. Similar uncertainties occurred in the first study in SSA, in Ethiopia. Because of these, we conclude only that migraine affects at least 17.5% of these age groups in Zambia, which is still a large proportion, adult prevalence in an earlier study being 22.9%. Supplementary estimates of attributed burden are needed to inform public-health and educational policies in Zambia.

Avoid or seek light - a randomized crossover fMRI study investigating opposing treatment strategies for photophobia in migraine

Background

Photophobia, the aberrantly increased sensitivity to light, is a common symptom in migraine patients and light discomfort is frequently found as a trigger for migraine attacks. In behavioral studies, planned exposure to light was found to reduce headache in migraine patients with photophobia, potentially by increasing habituation to this migraine trigger. Here, we aimed to elucidate neurophysiological mechanisms of light exposure versus light deprivation in migraine patients using functional magnetic resonance imaging (fMRI).

Methods

Ten migraine patients (9 female, age = 28.70 ± 8.18 years) and 11 healthy controls (9 female, age = 23.73 ± 2.24 years) spent one hour on 7 consecutive days exposed to flashing light (Flash) or darkness (Dark) using a crossover design with a wash-out period of 3 months. Study participants kept a diary including items on interictal and ictal photophobia, presence and severity of headache 7 days before, during and 7 days after the interventions. One week before and one day after both interventions, fMRI using flickering light in a block design was applied. Functional activation was analyzed at whole-brain level and habituation of the visual cortex (V1) was modeled with the initial amplitude estimate and the corrected habituation slope.

Results

Mean interictal photophobia decreased after both interventions, but differences relative to the baseline did not survive correction for multiple comparisons. At baseline, flickering light induced activation in V1 was higher in the patients compared to the controls, but activation normalized after the Flash and the Dark interventions. V1 habituation indices correlated with headache frequency, headache severity and ictal photophobia. In the Flash condition, the individual change of headache frequency relative to the baseline corresponded almost perfectly to the change of the habituation slope compared to the baseline.

Conclusions

On average, light exposure did not lead to symptom relief, potentially due to the short duration of the intervention and the high variability of the patients’ responses to the intervention. However, the strong relationship between visual cortex habituation and headache symptoms and its modulation by light exposure might shed light on the neurophysiological basis of exposure treatment effects.

Trial registration

NCT05369910 (05/06/2022, retrospectively registered).

Triptans and vascular comorbidity in persons over fifty: Findings from a nationwide insurance database – A cohort study

Objective

To gather information about prescription of triptans and to evaluate whether vascular comorbidity differs in users and nonusers of triptans over the age of 50 years.

Background

Beyond the age of 50 years, migraine is still common—yet the incidence of vascular disorders increases. Triptans, medications for treating migraine attacks, are vasoconstrictive drugs and contraindicated in persons with vascular disorders.

Methods

Based on a nationwide insurance database from 2011, we compared the prescription of vascular drugs (identified by Anatomical Therapeutic Chemical codes), vascular diagnoses and hospitalizations, between triptan users greater than 50 years and a matched control group.

Results

Of the 3,116,000 persons over 50 years, 13,833 (0.44%) had at least one triptan prescription; 11,202 (81%) were women. Thirty percent of the triptan users (13,833/47,336 persons) were over 50 years. Of those over 50 years, 6832 (49.4%) had at least one vascular drug and 870 (6.3%) had at least one inpatient vascular diagnosis; 15.7% (2166 of 13,833 users) overused triptans. We compared triptan‐users to 41,400 nonusers, using a 1:3 match. In triptan‐users, prescriptions of cardiac therapies and beta blockers were significantly more common (odds ratio [OR] = 1.35, 95% confidence interval [CI] = 1.24–1.47 and OR = 1.19, 95% CI = 1.14–1.25, respectively); whereas prescriptions of calcium channel blockers and renin/angiotensin inhibitors were significantly less common (OR = 0.82, 95% CI = 0.76–0.88 and OR = 0.75, 95% CI = 0.72–0.79, respectively). The prescriptions of antihypertensive, diuretic, and antilipidemic drugs as well as platelet inhibitors and direct thrombin inhibitors did not differ in users and nonusers. Triptan users had significantly more hospital stays (OR = 1.39, 95% CI = 1.33–1.45); however, the number of days spent in the hospital and more importantly the frequency of inpatient vascular diagnoses did not differ statistically significantly between the two groups.

Conclusion

In persons over 50 years of age, a prescription of triptans is common. Vascular comorbidity is comparable in users and nonusers of triptans showing that triptans are prescribed despite vascular comorbidity and suggesting that triptan use does not increase vascular risk in patients with migraine over the age of 50 years. Nevertheless, regular evaluation for contraindications against triptans and for vascular risk factors is recommended in this age group.

The burden attributable to headache disorders in children and adolescents in Lithuania: estimates from a national schools-based study

Background

We recently showed headache to be common in children (aged 7–11 years) and adolescents (aged 12–17) in Lithuania. Here we provide evidence from the same study of the headache-attributable burden.

Methods

Following the generic protocol for Lifting The Burden’s global schools-based study, this cross-sectional survey administered self-completed structured questionnaires to pupils within classes in 24 nationally representative schools selected from seven regions of the country. Headache diagnostic questions were based on ICHD-3 beta criteria but for the inclusion of undifferentiated headache (UdH; defined as mild headache with usual duration < 1 h). Burden enquiry was conducted in multiple domains.

Results

Questionnaires were completed by 2505 pupils (1382 children, 1123 adolescents; participating proportion 67.4%), of whom 1858 reported headache in the preceding year, with mean frequency (±SD) of 3.7 ± 4.5 days/4 weeks and mean duration of 1.6 ± 1.9 h. Mean proportion of time in ictal state, estimated from these, was 0.9% (migraine 1.5%, probable medication-overuse headache [pMOH] 10.9%). Mean intensity on a scale of 1–3 was 1.6 ± 0.6 (mild-to-moderate). Symptomatic medication was consumed on 1.5 ± 2.8 days/4 weeks. Lost school time was 0.5 ± 1.5 days/4 weeks (migraine 0.7 ± 1.5, pMOH 5.0 ± 7.8) based on recall, but about 50% higher for migraine according to actual absences recorded in association with reported headache on the preceding day. More days were reported with limited activity (overall 1.2 ± 2.4, migraine 1.5 ± 2.2, pMOH 8.4 ± 8.5) than lost from school. One in 30 parents (3.3%) missed work at least once in 4 weeks because of their son’s or daughter’s headache. Emotional impact and quality-of-life scores generally reflected other measures of burden, with pMOH causing greatest detriments, followed by migraine and tension-type headache, and UdH least. Burdens were greater in adolescents than children as UdH differentiated into adult headache types.

Conclusions

Headache in children and adolescents in Lithuania is mostly associated with modest symptom burden. However, the consequential burdens, in particular lost school days, are far from negligible for migraine (which is prevalent) and very heavy for pMOH (which, while uncommon in children, becomes four-fold more prevalent in adolescents). These findings are of importance to both health and educational policies in Lithuania.

Early use of acute medication for preventing migraine attacks: Results from a diary-based cohort study

Background:

Treating migraine attacks early may improve outcome. The aim of this analysis was to investigate whether certain premonitory symptoms could be indicators for taking acute medication.

Methods:

We analyzed 3-month diary data recorded by 271 patients with episodic migraine and looked at all migraine-free intervals. For investigating the interaction between acute medication and neck discomfort associated with sensitivity to lights, noises, or odors, we used a marginal structural model and a Cox regression analysis adjusted for moderate or severe headache.

Results:

The patients (mean age 43 ± 15.4 years, 88% women) recorded a total of 20,219 diary days without migraine. In the marginal structural model analysis, the risk for occurrence of a migraine attack on the subsequent day was reduced when acute medication was used in the presence of neck discomfort associated with sensitivity to lights (hazard ratio 0.4; 95% confidence interval 0.2–0.7), noises (0.4; 0.3–0.7), or odors (0.2; 0.1–0.4). The marginal structural model showed lower risk of migraine attacks than the Cox regression analysis adjusted for moderate or severe headache in the majority of the cases.

Conclusion:

Migraine attacks may be prevented when acute medication is used in the presence of neck discomfort associated with sensitivity to lights, noises, or odors. The results of this study may stimulate further prospective trials.

Medication overuse headache in 787 patients admitted for inpatient treatment over a period of 32 years

BACKGROUND

Definitions of medication overuse headache have changed over time.

OBJECTIVE

To evaluate the clinical characteristics of medication overuse headache patients admitted for inpatient withdrawal therapy over a period of 32 years.

METHODS

We included all patients with medication overuse headache treated from 1 January 1984 to 31 December 2015. We obtained all data from the medical reports and defined three periods, P1 (1984-1993), P2 (1994-2003), and P3 (2004-2015). The p-value adjusted for multiple comparisons was set to 0.005.

RESULTS

Within 32 years, a total of 787 patients accounted for 904 admissions for MOH. From P1 to P3, the proportion of patients with preexisting migraine increased from 44.3% to 53.3% (chi² = 9.0, p = 0.01) and that with preexisting tension-type headache decreased from 47.9% to 34.6% (chi² = 9.3, p < 0.01). The median time since onset of headache and medication overuse headache decreased from 20 to 15 years (p < 0.001) and from 3 to 2 years (p < 0.001). The median cumulative number of single doses decreased from 120 to 90 per month (p = 0.002). Overuse of triptans, non-opioid analgesics, and opioids increased, whereas overuse of ergotamines decreased over time (p < 0.001 for all tests). The use of prophylactic medication before admission increased from 8.3% to 29.9% (chi² = 89.5, p < 0.001).

CONCLUSION

This retrospective study in a large number of patients with medication overuse headache admitted for inpatient withdrawal therapy over a period of 32 years shows a trend towards changes in the preexisting headache type, a decrease in the time since onset of headache and medication overuse headache, a decrease in the number of drug doses used per month, changes in the type of drugs overused, and an increase in, but still low rate, of prophylactic medication prior to admission.

Use and overuse of triptans in Austria - a survey based on nationwide healthcare claims data

Background

To evaluate triptan use and overuse as well as prescription patterns in Austria based on a nationwide healthcare database because data on triptan use and overuse in Austria is missing.

Methods

We included all persons insured with one of 19 Austrian social security institutions in 2007. Inclusion criteria comprised an age of 18–99 years, known sex, and receipt of insurance benefits. We defined triptan use as ≥1 package of a triptan dispensed in 2007 and triptan overuse as ≥30 defined daily doses dispensed in at least one quarter.

Results

Out of 8.295 million inhabitants in Austria, 7,426,412 persons (89.5%) were insured with a social insurance carrier and 5,918,487 persons of those insured (79.7%) fulfilled the inclusion criteria. Among the latter 33,062 persons (0,56%) were triptan users and 1970 (0.033%) were triptan overusers. The estimated proportion of persons with migraine using a triptan was less than 6%. Among users 5.9% were overusers of whom 55% overused triptans in ≥2 quarters of 2007. The median number of days of sick-leave was higher in triptan users than in non-users: due to any reason of sick-leave 12 vs. 10, p < 0.001, due to migraine 3 vs. 2, p < 0.001. The proportion of hospital admissions did not differ between triptan users and non-users.

Conclusion

The rate of triptan use is low in Austria but triptan users are at risk for triptan overuse. In triptan users more days of sick-leave and the same proportion of hospital admissions as in the older non-users suggest poorer health.

Undifferentiated headache: broadening the approach to headache in children and adolescents, with supporting evidence from a nationwide school-based cross-sectional survey in Turkey

BACKGROUND

Headache is a leading disabler in adults worldwide. In children and adolescents, the same may be true but the evidence is much poorer. It is notable that published epidemiological studies of these age groups have largely ignored headaches not fulfilling any specific set of ICHD criteria, although such headaches appear to be common. A new approach to these is needed: here we introduce, and investigate, a diagnostic category termed "undifferentiated headache" (UdH), defined in young people as recurrent mild-intensity headache of < 1 h's duration.

METHODS

We conducted a nationwide cross-sectional survey in 31 schools in six regions of Turkey selected by mixed convenience-based and purposive modified cluster-sampling. A validated, standardised self-completed structured questionnaire was administered by a physician-investigator to entire classes of pupils aged 6-17 years.

RESULTS

Of the identified sample of 7889 pupils, 7088 (89.8%) participated. The 1-year prevalence of UdH was 29.2%, of migraine (definite and probable) 26.7%, and of tension-type headache (TTH) (definite and probable) 12.9%. UdH differed with respect to almost all headache features and associated symptoms from both migraine and TTH. Burden of headache and use of acute medication were lower in UdH than in migraine and TTH. Headache yesterday was less common in UdH than migraine (OR 0.32; 95% CI 0.28-0.37) and TTH (OR 0.64; 95% CI 0.56-0.77). Quality of life (QoL) was better in UdH (33.6 ± 5.2) than in migraine (30.3 ± 5.6; p < 0.001) and TTH (32.4 ± 5.3; p < 0.001), but worse than in pupils without headache (35.7 ± 4.7; p < 0.001).

CONCLUSIONS

This large nationwide study in Turkey of pupils aged 6-17 years has shown that many children and adolescents have a headache type that does not conform to existing accepted diagnostic criteria. This new diagnostic category of presumably still-evolving headache (undifferentiated headache) is common. UdH differs in almost all measurable respects from both migraine and TTH. Although characterised by mild headaches lasting < 1 h, UdH is associated with significant adverse impact on QoL. Longitudinal cohort studies are needed to evaluate the prognosis of UdH but, meanwhile, recognition of UdH and its distinction from migraine and TTH has implications for epidemiological studies, public-health policy and routine clinical practice.

Psychiatric comorbidities and photophobia in patients with migraine

BACKGROUND

Based on recent findings and our own impressions we took a closer look at the relationship between (inter)ictal photophobia and psychometric variables in migraine patients with photophobia.

FINDINGS

For this study we included 29 (27 female) migraine patients and 31 (18 female) controls with a mean age of 31.6 ± 12.5 years and 24.0 ± 4.1 years, respectively. All participants filled out the Depression Anxiety Stress Scale (DASS). Interictal photophobia in patients was significantly higher than photophobia in controls (p = .001). Patients showed statistically significantly higher levels of depressive symptoms (p < .001), anxiety symptoms (p < .001) and stress (p < .001) than controls. Among all participants, (interictal) photophobia correlated positively with age (rho = .318, p = .013) as well as with the levels of depressive symptoms (rho = .459, p < .001), anxiety symptoms (rho = .346, p = .008) and stress (rho = .368, p = .005), but not with gender. In the patients, ictal photophobia correlated positively with age (rho = .473, p = .01) and interictal photophobia (rho = .423, p = .022). Linear regression analysis revealed only a trend towards statistical significance for (interictal) photophobia as a predictor for the level of depressive symptoms (rho = .457, p = 0.056) in the whole sample.

CONCLUSIONS

Considering higher levels of photophobia in depression and the comorbidity of migraine and depression, it might be possible that depression contributes to interictal photophobia in patients with migraine. The same may be true for anxiety and stress. Both are also related to migraine and their possible impact on photophobia in migraine may be explained by pupillary dysfunction.

Tics in TACs: A Step into an Avalanche? Systematic Literature Review and Conclusions

BACKGROUND

Trigeminal autonomic cephalalgias (TACs) comprise cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. In some cases, trigeminal neuralgia (TN, "tic douloureux") or TN-like pain may co-occur with TACs.

AIM

This article will review the co-occurrence and overlap of TACs and tics in order to contribute to a better understanding of the issue and an improved management of the patients.

METHODS

For performing a systematic literature review Pubmed was searched using a total of ten terms. The articles identified were screened for further articles of relevance.

SUMMARY

TACs are related to tics in various ways. TN or TN-like paroxysms may co-occur with CH, PH, and HC, labeled as cluster-tic syndrome, PH-tic syndrome, and HC-tic syndrome. Such co-occurrence was not only found in the primary TACs but also in secondary headaches resembling TACs. The initial onset of TAC and tic may be simultaneous or separated by months or years. In acute attacks, tic and TAC may occur concurrently or much more often independently of each other. The term "cluster-tic syndrome" was also used in patients with a single type of pain in a twilight zone between TACs and TN fulfilling none of the relevant diagnostic criteria. Short-lasting neuralgiform headache attacks overlap with TN in terms of clinical features, imaging findings, and therapy.

Field testing of ICHD-3 beta criteria of periictal headaches in patients with focal epilepsy - a prospective diary study

Background To date we are lacking prospective data for field testing of ICHD-3 beta criteria for periictal headache (PIH). Methods Patients with focal epilepsy diagnosed by means of prolonged video-EEG monitoring completed a paper-pencil diary for three months and recorded seizures and headaches on a daily basis. According to ICHD-3 beta, we classified PIH, defined as headache present on a day with at least one seizure, as "7.6 headache related to epileptic seizure", "7.6.1 hemicrania epileptica" or "7.6.2 postictal headache". In addition, we compared the ICHD-3 beta diagnoses to the diagnoses according to ICHD-2. Results Thirty two patients completed the diary. Data analysis included 2,668 patient days, 300 seizures and 37 episodes of PIH. Two of these episodes (5.4%) were classified as headache related to seizure, three (8.1%) fulfilled both the criteria of headache related to seizure and hemicrania epileptica and four (10.8%) were postictal headaches. Twenty eight episodes (75.7%) did not fulfil any of the ICHD-3 beta criteria of seizure-related headaches, mostly because headache onset was before seizure onset. Applying ICHD-2 criteria allowed only one single episode of PIH to be classified as postictal headache. Discussion Our study is the first to present prospective field testing data of the ICHD-3 beta criteria for three types of seizure-related headaches. The majority of PIH episodes do not fulfil any of these criteria. One quarter can be classified according to ICHD-3 beta, whereas purely clinical diagnosis of PIH is markedly restricted in ICHD-2 because of mandatory electroencephalographic evidence.

Similar impact of multiple sclerosis and migraine on sexual function in women : Is the multiple sclerosis impact scale questionnaire useful?

Background

Sexuality is an integral part of overall health but the impact of neurological diseases on sexual function still receives too little attention.

Aim

The aim of this case control study was to compare frequencies and characteristics of sexual dysfunction in women with stable relapsing-remitting multiple sclerosis (MS) and migraine.

Methods

Sexually active women aged 18–50 years were recruited at the MS and headache outpatient clinics of a university hospital and asked to complete questionnaires on sexual function using the multiple sclerosis intimacy and sexuality questionnaire (MSISQ-19) adapted for patients with migraine, depression using the Beck depression inventory (BDI-II) and quality of life using the short form-36 questionnaire (SF-36).

Results

At least one symptom of sexual dysfunction was “almost always” or “always” present in 35.7 % of 42 patients with MS and in 22.6 % of 30 patients with migraine (p = 0.3). The MSISQ-19 total score did not differ between the two groups (31.6 ± 10.8 vs. 28.2 ± 11.6, respectively, p = 0.2). Sexual dysfunction was categorized as primary, secondary and tertiary in 66.7 %, 40 % and 33.3 % of MS patients and in 57.1 % (p = 0.7), 71.4 % (p = 0.2) and 71.4 % (p = 0.1) of migraine patients, respectively. Depressive symptoms were more common in women with sexual dysfunction than in those without both in MS (p = 0.001) and migraine (p = 0.006). The SF-36 showed decreasing quality of life with increasing MSISQ-19 sum scores (mental subscale p < 0.001 and physical subscale p = 0.04).

Conclusions

Sexual dysfunction is a major problem both in women with MS and in women with migraine and is strongly associated with comorbid depression and impaired quality of life. Thus, categorizing sexuality as done by MSISQ-19 is limited by its complex biopsychosocial interactions.

Clinical Features of Migraine: A Cross-Sectional Study in Patients Aged Three to Sixty-Nine

We investigated 260 consecutive patients classified as migraine cases aged 3-69 at two tertiary headache centres, one for children and adolescents and the other for adults to evaluate the relationship between age and clinical features of migraine cross-sectionally. We only included subjects with definite migraine without or with aura and we excluded subjects with coexisting tension-type headache, medication overuse and/or other clinically relevant disorders. The percentage of males decreased markedly from childhood to adulthood and this affected the evalution of age-related changes in male patients, as only large differences reached the level of statistical significance. In females, the headache duration and the prevalence of unilateral, pulsating pain, photophobia and phonophobia increased, whereas the prevalence of aggravation by physical activity decreased with age. In conclusion, this cross-sectional, clinic-based study on a strictly defined sample of 260 consecutive patients with definite migraine covering a wide range of age from the very young to the old suggests marked age-related differences of the clinical features of migraine in females and failed to demonstrate similar differences in males due to the small number of adult male migraineurs.

Familial Hemiplegic Migraine: Follow-up Findings of Diffusion-Weighted Magnetic Resonance Imaging (MRI), Perfusion-MRI and [99mTc] HMPAO-SPECT in a Patient with Prolonged Hemiplegic Aura

Familial hemiplegic migraine (FHM) is a rare inherited autosomal dominant disorder. Migraine aura may last up to several weeks and then resolve without sequel. We report a 21-year-old male with FHM since the age of 3 years. Diffusion-weighted magnetic resonance imaging (DWI), perfusion-MR imaging (P-MRI) and [99mTc] hexamethyl-propyleneamine-oxime-single photon emission tomography (HMPAO-SPECT) were performed on day 2, when he was somnolent with right-sided hemiplegia, on day 9 when a mild hemiparesis was still present and on day 24 after recovery. The right central region showed normal findings in DWI, whereas P-MRI and SPECT revealed hyperperfusion on day 2, less marked on day 9, and normal findings on day 24. In conclusion, this case report indicates for the first time, by means of SPECT, P-MRI and DWI studies, that even extremely long-lasting migraine aura is not associated with cerebral ischaemia. Therefore, it supports the revised International Headache Society criteria where the term ‘persistent’ aura is proposed.

Facial pain in a Neurological Tertiary Care Centre — Evaluation of the International Classification of Headache Disorders

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.

Prospective Analysis of Factors Related to Migraine Attacks: The PAMINA Study

Migraine is related to numerous factors such as hormones, stress or nutrition, but information about their actual importance is limited. Therefore, we analysed prospectively a wide spectrum of factors related to headache in migraineurs. We examined 327 migraineurs recruited via newspapers who kept a comprehensive diary for 3 months. Statistical analysis comprising 28 325 patient days and 116 dichotomous variables was based on the interval between two successive headache attacks. We calculated univariate Cox regression analyses and included covariables with a P-value of <0.05 in two stepwise multivariate Cox regression analyses, the first accounting for a correlation of the event times within a subject, the second stratified by the number of headache-free intervals. We performed similar analyses for the occurrence of migraine attacks and for the persistence of headache and migraine. Menstruation had the most prominent effect, increasing the hazard of occurrence or persistence of headache and migraine by up to 96%. All other factors changed the hazard by <35%. The two days before menstruation and muscle tension in the neck, psychic tension, tiredness, noise and odours on days before headache onset increased the hazard of headache or migraine, whereas days off, a divorced marriage, relaxation after stress, and consumption of beer decreased the hazard. In addition, three meteorological factors increased and two others decreased the hazard. In conclusion, menstruation is most important in increasing the risk of occurrence and persistence of headache and migraine. Other factors increase the risk less markedly or decrease the risk.

Towards improved migraine management: Determining potential trigger factors in individual patients

Background

Certain chronic diseases such as migraine result in episodic, debilitating attacks for which neither cause nor timing is well understood. Historically, possible triggers were identified through analysis of aggregated data from populations of patients. However, triggers common in populations may not be wholly responsible for an individual’s attacks. To explore this hypothesis we developed a method to identify individual ‘potential trigger’ profiles and analysed the degree of inter-individual variation.

Methods

We applied N = 1 statistical analysis to a 326-migraine-patient database from a study in which patients used paper-based diaries for 90 days to track 33 factors (potential triggers or premonitory symptoms) associated with their migraine attacks. For each patient, univariate associations between factors and migraine events were analysed using Cox proportional hazards models.

Results

We generated individual factor-attack association profiles for 87% of the patients. The average number of factors associated with attacks was four per patient: Factor profiles were highly individual and were unique in 85% of patients with at least one identified association.

Conclusion

Accurate identification of individual factor-attack profiles is a prerequisite for testing which are true triggers and for development of trigger avoidance or desensitisation strategies. Our methodology represents a necessary development toward this goal.

Impact of depression and anxiety on burden and management of episodic and chronic headaches - a cross-sectional multicentre study in eight Austrian headache centres

BACKGROUND

Recurrent and especially chronic headaches are associated with psychiatric comorbidities such as depression and anxiety. Only few studies examined the impact of depression and anxiety on episodic (EH) and chronic headache (CH), and data for Austria are missing at all. Therefore, the aim of the present study was to assess the impact of depression and anxiety on burden and management of EH and CH in patients from eight Austrian headache centres.

METHODS

We included 392 patients (84.1 % female, mean age 40.4 ± 14.0 years) who completed the Eurolight questionnaire. The treating physician recorded details about ever-before prophylactic medications. We used Hospital Anxiety and Depression Scale to assess depression and anxiety and compared patients with anxiety and/or depression to those without.

RESULTS

Depression and anxiety were more common in CH than in EH (64 % vs. 41 %, p < 0.0001). Presence compared to absence of depression and anxiety increased the prevalence of poor or very poor quality of life from 0.7 % to 13.1 % in EH and from 3.6 % to 40.3 % in CH (p = 0.001; p < 0.0001). Depression and anxiety had a statistically significant impact on employment status and on variables related to the burden of headache such as reduced earnings, being less successful in career, or feeling less understood. Neither in EH nor in CH health care use and the ever-before use of prophylactic medication was correlated with anxiety and/or depression.

CONCLUSION

Depression and anxiety have a significant impact on quality of life and increase the burden in patients with EH and CH. Improved multidimensional treatment approaches are necessary to decrease disability on the personal, social and occupational level in these patients.

Prevalence, management and burden of episodic and chronic headaches--a cross-sectional multicentre study in eight Austrian headache centres

Background

Episodic and chronic headaches (EH, CH) are highly prevalent disorders. Severely affected patients are usually referred to headache centres. In Austria, at least one headache centre is available in seven of nine states, but detailed multicentre data are missing. Therefore we studied prevalence rates, use of medication and health care services, impact of headaches, and comorbid depression and anxiety.

Methods

We included consecutive patients from eight Austrian outpatient headache centres. The patients filled-in the Eurolight questionnaire. In addition, the treating neurologist completed a questionnaire on clinical diagnoses and ever-before prophylactic medications.

Results

Of 598 patients screened, 441 questionnaires were analysed (79 % female, mean age 41.1 years). According to the Eurolight algorithm, 56.4 % of the patients had EH, 38.3 % had CH and 5.2 % did not give their headache frequency. The prevalence rates of migraine, tension-type headache, and probable medication overuse headache (pMOH) were 48.5 %, 6.3 % and 15.9 %, respectively. The concordance between clinical and Eurolight diagnoses was good for EH and moderate for CH. During the preceding month, acute medication was used by 90.9 % of the patients and prophylactic medication by 34 %. Ever-before use of five standard prophylactic drugs was recorded in 52.3 %. The proportion of patients with current pharmacoprophylaxis did not differ in EH and CH, whereas ever-before use was more common in CH (62.5 % was 45,3 %, p = 0.02). Patients with CH significantly more often consulted general practitioners and emergency departments, had a lower quality of life and more often signs of depression and anxiety.

Conclusion

This study provides comprehensive data from eight Austrian headache centres for the first time. We found a substantial number of patients with CH including pMOH and its association with more common utilization of health care facilities and greater burden. The low use of prophylactic medication requires further examination.

The global burden of headache in children and adolescents - developing a questionnaire and methodology for a global study

Background

Burden of headache has been assessed in adults in countries worldwide, and is high, but data for children and adolescents are sparse. The objectives of this study were o develop a questionnaire and methodology for the global estimation of burden of headache in children and adolescents, to test these in use and to present preliminary data.

Methods

We designed structured questionnaires for mediated-group self-administration in schools by children aged 6-11 years and adolescents aged 12-17 years. In two pilot studies, we offered the questionnaires to pupils in Vienna and Istanbul. We performed face-to-face interviews in a randomly selected subsample of 199 pupils to validate the headache diagnostic questions.

Results

Data were collected from 1,202 pupils (mean 13.9 ± 2.4 years; 621 female, 581 male). The participation rate was 81.1% in Istanbul, 67.2% in Vienna. The questionnaire proved acceptable: ≤5% of participants disagreed partially or totally with its length, comprehensibility or simplicity. The sensitivity, specificity, positive and negative predictive values ranged between 0.71 and 0.76 for migraine and between 0.61 and 0.85 for tension-type headache (TTH). Cronbach’s alpha was 0.83. The 1-year prevalence of headache was 89.3%, of migraine 39.3% and of TTH 37.9%. The prevalence of headache on ≥15 days/month was 4.5%. One fifth (20.7%) of pupils with headache lost ≥1 day of school during the preceding 4 weeks and nearly half (48.8%) reported ≥1 day when they could not do activities they had wanted to. The vast majority of pupils with headache experienced difficulties in coping with headache and in concentrating during headache. Quality of life was poorer in pupils with headache than in those without.

Conclusion

These pilot studies demonstrate the usefulness of the questionnaires and feasibility of the methodology for assessing the global burden of headache in children and adolescents, and predict substantial impact of headache in these age groups.

The lesser occipital nerve visualized by high-resolution sonography—normal and initial suspect findings

Background

The lesser occipital nerve (LON) supplies the lateral part of the occiput and is—together with the greater occipital nerve (GON)—involved in headache pathogenesis. While the GON was described in high-resolution ultrasound (HRUS), the same does not apply to the LON. We aimed at characterizing the LON in HRUS, and present cases of suspect findings in the course of the LON identified by HRUS.

Methods

The LON was examined bilaterally in eight anatomical specimens with HRUS ( n = 16). HRUS-guided ink marking and consecutive dissection was performed. Further, measurements of the LON diameter were performed in 10 healthy volunteers ( n = 20), and patient charts were reviewed to identify patients who were considered to have possible pathology of the LON.

Results

The LON was identified correctly in all cadavers on both sides and all volunteers except for one side ( n = 19). The average diameter was 1.08 ± 0.30 mm. Four patients with pain within the LON territory and presumed peripheral origin of headache (defined as resolution of headache after diagnostic HRUS-guided selective blockade) were identified, and three of these showed interference of the LON with lymph nodes or an accessory muscle belly.

Discussion

We confirm the possibility of visualization of the LON using HRUS. HRUS may be a helpful adjunct tool in the assessment of patients with atypical headache.

Do nocturnal headaches matter? A prospective diary study on subjective sleep parameters in snorers and their bed partners

BACKGROUND

The objective of this study was to assess the influence of nocturnal headaches (NH) on subjective sleep parameters prospectively in habitual snorers and their bed partners.

METHODS

We recruited habitual snorers and their bed partners via newspaper articles. The participants completed a semistructured interview, filled in questionnaires about quality of sleep (PSQI), daytime sleepiness (ESS), depression (SDS) and anxiety (SAS) and they kept a 90-day headache and sleep diary.

RESULTS

Seventy-six snorers (25 female) and 41 bed partners (31 female) completed the study recording a total of 6690 and 3497 diary days, respectively. NH were recorded on 222 (3.3%) and 79 (2.2%) days in 32 (42%) snorers and 17 (41%) bed partners, respectively. Snorers with NH showed significantly higher PSQI (5 ± 3 vs. 4 ± 2, p = 0.004), SAS (38 ± 11 vs. 31 ± 10, p = 0.011) and SDS scores (39 ± 12 vs. 34 ± 10, p = 0.048) than snorers without NH. For bed partners with NH we found a significant female predominance (sex ratio f:m = 16:1 vs. 12:12, p = 0.005) and significantly higher SAS scores (38 ± 6 vs. 33 ± 8, p = 0.030) compared with bed partners without NH. The subjective quality of sleep in habitual snorers (p < 0.001) as well as their bed partners (p = 0.017) was negatively influenced by NH, but not total sleep time.

DISCUSSION

NH occurred in around 40% of snorers and their bed partners at least once during the 90-day observation period. Our results confirmed a negative impact on the subjective quality of sleep in both groups.

Morningness: protective factor for sleep-related and emotional problems in childhood and adolescence?

The relationship between morningness/eveningness, sleep, and psychological problems is well documented in adults as well as in adolescents. However, research on the circadian orientation and its concomitants in younger children is scarce. The authors investigated the distribution of morningness/eveningness and its connection to sleeping and psychological problems in 91 children and 151 adolescents in Austria. The authors found that morning (M) types had less sleep-related and psychological problems than intermediate (I) and evening (E) types, respectively. Among children, M-types suffered less from daytime sleepiness (females: χ(2)((2)) = 8.1, p = .017; males: χ(2)((2)) = 14.8, p = .001). Among adolescents, M-types showed fewer sleep-wake problems (females: χ(2)((2)) = 17.5, p < .001; males: χ(2)((2)) = 19.8, p < .001), and female M-types showed less externalizing (χ(2)((2)) = 8.7, p = .013) as well as internalizing problem behavior (χ(2)((2)) = 9.0, p = .011). In conclusion, these findings indicate that morningness may act as a protective factor against the development of sleep-related problems in childhood and sleep-related and psychological problems in adolescence, especially in females.

Morning headaches in snorers and their bed partners: a prospective diary study

BACKGROUND

The prevalence and characteristics of morning headaches (MH) in habitual snorers are not well known, with only one retrospective study reporting MH in 23.5% of snorers. The role of MH in bed partners of snorers has not yet been examined. Therefore, the objective of this study was to assess MH prospectively in habitual snorers and their bed partners.

METHODS

We recruited habitual snorers and their bed partners via newspaper articles. The participants completed a semistructured interview, filled in questionnaires about sleep quality, daytime sleepiness, depression and anxiety and kept a 90-day headache and sleep diary.

RESULTS

We included a total of 102 snorers and 63 bed partners. Seventy-six snorers (25 female) and 41 bed partners (31 female) completed the study, recording a total of 6690 and 3497 diary days, respectively. MH was present on at least 1 day in 57% of the snorers and in 61% of the bed partners and recorded on 7.2% and 3.6% of the diary days, respectively. Independent predictors of MH in snorers were pre-study headache frequency (p < 0.001), anxiety disorder (p < 0.001), waking up because of pain (p = 0.002) and waking up too early (p < 0.001); and independent predictors in bed partners were migraine (p = 0.02), difficulties breathing during sleep (p < 0.001), waking up because of pain (p = 0.01) and waking up too early (p < 0.001). The analysis of couples only (n = 41) revealed pre-study headache frequency (p < 0.001), waking up too early (p < 0.001) and nocturnal confusion (p < 0.001) as independent predictors of MH in snorers, and migraine (p = 0.02), difficulties breathing during sleep (p < 0.001), waking up because of pain (p = 0.01) and waking up too early (p < 0.001) as independent predictors in bed partners.

DISCUSSION

MH shows a 90-day prevalence of around 60% in habitual snorers as well as in their bed partners. Predictors of MH are related to sleep, headache and psychiatric comorbidity.

Increased RLS prevalence in children and adolescents with migraine: a case-control study

BACKGROUND

Previous studies have reported an increased frequency of restless legs syndrome (RLS) in adult migraine patients. Until now, the frequency of RLS in pediatric patients has not been investigated. We set out to assess the frequency of RLS in children and adolescents with migraine compared to headache-free controls.

METHODS

We investigated 111 consecutive patients with a sole diagnosis of migraine with or without aura presenting to the Headache Unit at the Department of Child and Adolescent Psychiatry and 73 headache-free controls for the presence of RLS using a semistructured interview. In addition, we assessed the level of daytime sleepiness by means of the Epworth sleepiness scale (ESS). A second group of headache-free controls was screened for the presence of RLS using an online questionnaire.

RESULTS

The frequency of RLS in migraine patients was significantly higher than in controls (22% vs. 5% (p < 0.001) and 8% (p < 0.001)).

DISCUSSION

This is the first study suggesting an association between RLS and migraine in the pediatric population. Future studies are needed to determine the extent of sleep disruption in children and adolescents with migraine and comorbid RLS.

Facial pain, scotomas and hemihypaesthesia as presenting symptoms of type A aortic dissection in a patient with migraine with aura

We report the case of a 31-year-old man with a history of migraine with aura who was admitted to our emergency department because of a sudden onset of severe bilateral facial pain radiating bilaterally into the medial cervical region after defecation. The pain was accompanied by scotomas in the right visual field and hypaesthesia in both upper limbs. Imaging of the aorta and supra-aortic vessels revealed a type A aortic dissection. Subsequently, the patient received an aortic valve replacement and an aortic tube graft. After the surgery he experienced recurring visual disturbances with a sudden onset mimicking his migraine aura. Due to a new onset of atrial fibrillation, he was put on oral anticoagulants. At follow-up after 10 months he still reported episodic and mostly isolated visual auras with a gradual onset.

Association analysis of STX1A gene variants in common forms of migraine

OBJECTIVES

To examine the association of genetic variants in the syntaxin 1A gene (STX1A) with common forms of migraine, and perform a combined analysis of the data from the current study and previously published reports.

METHODS

We investigated the parent-to-offspring transmission of rs6951030, rs4363087 and rs2293489 in 191 family trios, each with a proband with childhood-onset migraine, and performed a case-control analysis between the probands and 223 unrelated controls. In addition, we performed a combined data analysis with an overall sample of 567 migraine patients and 720 unrelated controls and performed a migraine-specific gene-network analysis.

RESULTS

The transmission disequilibrium test revealed significant transmission distortion of rs4363087 in migraine overall (OR = 1.56, p = 0.006; p = 0.01 after correction for multiple testing) and migraine without aura (OR = 1.58, p = 0.01; corrected p = 0.04). Two-marker haplotype analysis revealed transmission distortion of A-G (rs6951030-rs4363087; OR = 1.47, p = 0.01) and A-C (rs4363087-rs2293489; OR = 0.66, p = 0.01). Combined analysis showed significant association of rs941298 with migraine overall (OR = 1.28, p = 0.004) and migraine without aura (OR = 1.3, p = 0.008). Network analysis identified 24 genes relating STX1A to other migraine candidate genes, including KCNK18 (TRESK channel) involved in the cytoplasmatic calcium signalling together with syntaxin 1A.

CONCLUSION

Our results provide support for the hypothesis that STX1A represents a susceptibility gene for migraine.

Characteristics of acute posttraumatic headache following mild head injury

BACKGROUND

To examine the prevalence and characteristics of acute posttraumatic headache (APTH) attributed to mild head injury within a prospective, observational study design.

METHODS

We recruited 100 patients with acute mild head injury as defined in the International Classification of Headache Disorders, 2nd Edition (ICHD-2) presenting to the department of trauma surgery at the Medical University of Vienna. Patients underwent a detailed telephone interview between days 7 and 10 and between days 90 and 100 after the injury.

RESULTS

The prevalence of APTH was 66%. APTH had occurred within 24 hours after the trauma in 78% and lasted for a median of 3.0 days. Headache was unilateral in 45%. Aggravation by physical activity, nausea and photo-/phonophobia was present in 49%, 42% and 55%, respectively. The prevalence of APTH was related to conditions of chronic pain (excluding headache), pre-existing episodic headache, number of posttraumatic symptoms, anxiety and depression. At follow-up at 90-100 days, posttraumatic headache had abated in all patients.

CONCLUSIONS

APTH attributed to mild head injury is a common but self-limiting condition frequently showing migrainous features. Participants with chronic pain other than headache, pre-existing headache and affective disorders are at higher risk of developing APTH. None of the patients developed chronic posttraumatic headache.