Are the headache guidelines useful in therapeutic decisions for primary care physicians, general neurologists, and headache specialists?

The International Headache Society Classification of Headache Disorders has been widely accepted as the gold standard for classification of headache. Initially a research tool, this classification is now increasingly used in the daily practice of headache medicine. Accurate diagnosis is a prerequisite to planning a therapeutic approach. The three commentaries here discuss the use of this tool in the setting of primary care, general neurology, and subspecialty headache medicine. As the Section Editor, I hope these perspectives are helpful to the reader.

The long-term prognosis of tension-type headache

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

Risk of Lung Cancer and Leukemia from Exposure to Ionizing Radiation and Potential Confounders among Workers at the Portsmouth Naval Shipyard

Significantly elevated lung cancer deaths and statistically significantly positive linear trends between leukemia mortality and radiation exposure were reported in a previous analysis of Portsmouth Naval Shipyard workers. The purpose of this study was to conduct a modeling-based analysis that incorporates previously unanalyzed confounders in exploring the exposure-response relationship between cumulative external ionizing radiation exposure and mortality from these cancers among radiation-monitored workers in this cohort. The main analyses were carried out with Poisson regression fitted with maximum likelihood in linear excess relative risk models. Sensitivity analyses varying model components and using other regression models were conducted. The positive association between lung cancer risk and ionizing radiation observed previously was no longer present after adjusting for socioeconomic status (smoking surrogate) and welding fume and asbestos exposures. Excesses of leukemia were found to be positively, though not significantly, associated with external ionizing radiation, with or without including potential confounders. The estimated excess relative risk was 10.88% (95% CI -0.90%, 38.77%) per 10 mSv of radiation exposure, which was within the ranges of risk estimates in previous epidemiological studies (-4.1 to 19.0%). These results are limited by many factors and are subject to uncertainties of the exposure and confounder estimates.

The tension headache component of chronic daily headache

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

Posttraumatic headache

Posttraumatic headache (PTH) is divided into acute and chronic groups whose management and prognosis are clearly different. Although IHS criteria stipulate that PTH should have an onset within 2 weeks of the trauma, it has been observed that a headache linked to the trauma can start later. PTH can be clinically divided into the following groups: migraine-like headache, tension-type-like headache, cluster-like headache, cervicogenic-like headache, and others. Based on these clinical distinctions, therapy can be administered accordingly. However, the distinction is relative and numerous clinical features may be common to all. There seems to be a weak inverse relationship between the severity of the head trauma and the occurrence of a PTH, especially chronic. A holistic approach is not only useful but it is necessary for a therapeutic success. Early and aggressive treatment and empathy are essential to the patient's improvement. Prompt recognition and treatment of laceration, peripheral nociceptive sources such as cervical joint displacement, vascular factors, may diminish chronicity. Neuromodulation of pain with prophylactic agents is recommended early. Although it is less necessary for the acute PTH, it will be crucial for the chronic form and should be initiated no later than 2 months cut-off time between acute and chronic PTH. Recognition and treatment of psychiatric factors such as depression and anxiety will lessen the risk of chronicity. Analgesic rebound-withdrawal headache commonly is seen in chronic PTH. This must be corrected rapidly because it can protract the headache and render other inappropriate therapeutic measures inefficient.

Differences in mortality by radiation monitoring status in an expanded cohort of Portsmouth Naval Shipyard workers

Studies of leukemia and lung cancer mortality at the Portsmouth Naval Shipyard (PNS) have yielded conflicting results. In an expanded cohort of PNS workers employed between 1952 and 1992 and followed through 1996, the all-cause standardized mortality ratio (SMR) was 0.95 (95% confidence interval, 0.93-0.96). Employment duration SMRs were elevated with confidence intervals excluding 1.00 for lung cancer, esophageal cancer, and all cancers combined. Leukemia mortality was as expected overall, but standardized rate ratio analyses showed a significant positive linear trend with increasing external radiation dose. The role of solvent exposures could not be evaluated. Findings differed by radiation monitoring subcohort, with excess asbestosis deaths limited to radiation workers and several smoking-related causes of death higher among nonmonitored workers. At PNS, asbestos exposure and possibly smoking could be nonrandomly distributed with respect to radiation exposure, suggesting potential for confounding in internal analyses of an occupational cohort.

Topiramate for migraine prevention: a randomized controlled trial

CONTEXT

Small open-label and controlled trials suggest that the antiepileptic drug topiramate is effective for migraine prevention.

OBJECTIVE

To assess the efficacy and safety of topiramate for migraine prevention in a large controlled trial.

DESIGN, SETTING, AND PATIENTS

A 26-week, randomized, double-blind, placebo-controlled study was conducted during outpatient treatment at 52 North American clinical centers. Patients were aged 12 to 65 years and had a 6-month history of migraine (International Headache Society criteria) and 3 to 12 migraines a month but no more than 15 headache days a month during a 28-day prospective baseline phase.

INTERVENTIONS

After a washout period, patients meeting entry criteria were randomized to topiramate (50, 100, or 200 mg/d) or placebo. Topiramate was titrated by 25 mg/wk for 8 weeks to the assigned or maximum tolerated dose, whichever was less. Patients continued receiving that dose for 18 weeks.

MAIN OUTCOME MEASURES

The primary efficacy measure was change from baseline in mean monthly migraine frequency. Secondary efficacy measures included responder rate (proportion of patients with > or =50% reduction in monthly migraine frequency), reductions in mean number of monthly migraine days, severity, duration, and days a month requiring rescue medication, and adverse events. The month of onset of preventive treatment action was assessed.

RESULTS

Of 483 patients randomized, 468 provided at least 1 postbaseline efficacy assessment and comprised the intent-to-treat population. Mean monthly migraine frequency decreased significantly for patients receiving topiramate at 100 mg/d (-2.1, P =.008) and topiramate at 200 mg/d (-2.4, P<.001) vs placebo (-1.1). Statistically significant reductions (P<.05) occurred within the first month with topiramate at 100 and 200 mg/d. The responder rate was significantly greater with topiramate at 50 mg/d (39%, P =.01), 100 mg/d (49%, P<.001), and 200 mg/d (47%, P<.001) vs placebo (23%). Reductions in migraine days were significant for the 100-mg/d (P =.003) and 200-mg/d (P<.001) topiramate groups. Rescue medication use was reduced in the 100-mg/d (P =.01) and 200-mg/d (P =.005) topiramate groups. Adverse events resulting in discontinuation in the topiramate groups included paresthesia, fatigue, and nausea.

CONCLUSION

Topiramate showed significant efficacy in migraine prevention within the first month of treatment, an effect maintained for the duration of the double-blind phase.

Chronic Daily Headache

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

Antidepressants in the treatment of migraine headache

Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. These cause significant side effects in some patients. The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.

A study to determine the accuracy of a computerized algorithm for interpretation of EEGs

The main use of computerized EEG has been in sleep studies. A comprehensive system of interpreting routine EEGs by computers has not yet been developed and is technically difficult. We have tried to incorporate computers in the analysis and interpretation of EEGs by using information obtained from visual analysis of EEG in the present work. The purpose of this study was to determine the accuracy of such an algorithm. An electroencephalographer visually analyzed routine EEGs and the data was entered into an EEG Worksheet. The electroencephalographer then interpreted the data and a report was dictated and transcribed. Data from the EEG Worksheet was entered into a computer for interpretation, clinical correlation, and report preparation. Results indicate that the algorithm used with the EEG Worksheet can correctly interpret and clinically correlate visually-analyzed EEG data entered into a computer and reduce time for EEG report generation.

Safety and efficacy of PNU-142633, a selective 5-HT1D agonist, in patients with acute migraine

In this randomized, double-blind, placebo-controlled, parallel-group study, patients received a single 50-mg oral dose of a 5-HT(1D) agonist, PNU-142633 (n = 34), or matching placebo (n = 35) during an acute migraine attack. No statistically significant treatment effects were observed at 1 and 2 h after dosing, even after stratifying by baseline headache intensity. At 1 and 2 h post-dose, 8.8% and 29.4% of the PNU-142633 group, respectively, and 8.6% and 40.0% of the placebo group, respectively, experienced headache relief; 2.9% and 8.8% of the PNU-142633 group and 0% and 5.7% of the placebo group were free of headache pain. Adverse events associated with PNU-142633 treatment included chest pain (two patients) and QTc prolongation (three patients). Results from this study suggest that anti-migraine efficacy is not mediated solely through the 5-HT(1D) receptor subtype, although this receptor may contribute, at least in part, to the adverse cardiovascular effects observed with 5-HT agonist medications.

Chronic daily headache in the posttrauma syndrome: relation to extent of head injury

OBJECTIVE

To evaluate the occurrence of continued intermittent headache and chronic daily headache in patients with head injury and the relationship between severity of the headache problem and intensity of the head injury.

BACKGROUND

In the majority of patients with posttraumatic headache, the condition is self-limited, but a minority of patients may develop persistent headaches. The features of posttraumatic headache may vary, but the most distressing type is the chronic daily headache. This study evaluates occurrence of chronic daily headache in relation to the intensity of head injury.

METHODS

All patients with head injury who were seen by the senior author (J.R.C.) in the Southern Illinois University Medical School (SIUMS) Neurology Clinic between 1980 and 1991 were identified from the SIUMS headache registry. Data on headache status before and after head injury was obtained, and patients with more than one headache per week before head injury were excluded. Each patient's headache status at the time of the clinic visit was classified as chronic daily headache (headache occurring at least 5 of 7 days for 6 months), intermittent migraine, or no headache. Head injury severity was graded by duration of loss of consciousness or amnesia as minimal (less than 5 minutes), mild (5 to 60 minutes), moderate (1 to 24 hours), or severe (more than 24 hours).

RESULTS

There was an inverse relation between extent of head injury and occurrence of chronic daily headache. For minimal head injury (n = 54), 80% had chronic daily headache, and 11% had no headache, while for moderate/severe head injury (n = 23), only 27% had chronic daily headache, and 68% had no headache (P<.001, chi2).

CONCLUSION

This study suggests that the risk of developing posttraumatic chronic daily headache is greater for less severe head injury compared with moderate/severe head injury. The reason for this relation is unclear.

Treatment of migraine with BMS180048: response at 2 hours. North American BMS180048 Study Group

BMS180048 is a 5HT agonist that was well-tolerated in early phase II trials. This study utilized a double-blind, parallel-group dose ranging format, comparing BMS180048 in doses of 25, 50, or 75 mg to placebo in effectiveness of treatment of a single migraine headache. To assess tolerability of BMS180048, patients received a test dose of the medication they would receive for a headache in the clinic under observation. If no significant side effects occurred, patients were allowed to treat a headache. Headaches were moderate or severe in intensity before treatment, and response at 2 hours was tabulated. Reduction to mild or no headache was the criteria for successful response. Response rates at 2 hours were as follows: placebo--19 of 53 subjects (35.8%); 25 mg--21 of 53 subjects (40.3%); 50 mg--34 of 53 subjects (64.2%); 75 mg--35 of 55 subjects (63.6%) The improvement for subjects treated with 50 or 75 mg of BMS180048 when compared to placebo was highly significant (P < .01). Nausea, photophobia, and phonophobia improved 35% to 50% for BMS180048-treated subjects and 20% to 24% in the placebo group. The improvement in these symptoms in comparison to placebo was statistically significant only for nausea in those treated with 75 mg of BMS180048 (P = .02). Side effects were mild for the most part, and no serious adverse events occurred. The study suggests BMS180048 is effective in acute symptomatic therapy of migraine.

Onset of neurologic deficits after treatment with dihydroergotamine in a patient with sagittal sinus thrombosis

A woman with a 7-year history of intermittent migraine had 3 months of gradually worsening headaches. Initial neurologic examination including fundus examination was normal, and initial head computerized tomographic (CT) scan and magnetic resonance imaging (MRI) were thought to be normal. The patient was given dihydroergotamine (DHE-45), 1.0 mg, intravenously for relief of headache. Five hours later, she complained of severe diffuse headache and nausea. Neurologic examination showed left arm weakness and sensory loss, blurring of the left optic disc, and bilateral Babinski signs. Cerebral arteriography demonstrated thrombosis of the sagittal sinus, which in retrospect was present on the initial contrast CT scan and MRI scan. The patient's deficits worsened, and she eventually died 20 days later as a result of cerebral infarctions and increased intracranial pressure, despite attempts at selective thrombolysis of the sagittal sinus. DHE has potent venoconstrictive effects. We suspect that DHE helped precipitate neurologic deterioration in this patient with sagittal sinus thrombosis.

Transnasal butorphanol in the treatment of acute migraine

We studied transnasal butorphanol (Stadol NS) for pain relief during acute migraine in a multicenter, randomized, double-blind, placebo controlled trial using ambulatory patients at 10 geographically diverse headache centers. Patients were volunteer adults diagnosed with migraine with or without aura by International Headache Society criteria. One hundred fifty-seven patients completed the study. We treated the pain of one headache in each patient with either transnasal butorphanol (n = 107) or transnasal placebo (n = 50). Pain relief, pain intensity, nausea, vomiting, and effect on function were measured periodically. Adverse experiences were documented. Global assessments were made at follow-up. With butorphanol, migraine pain was reduced from moderate, severe, or incapacitating to slight or absent for 35 patients (33%) within 30 minutes, for 50 patients (47%) within 1 hour, and for 76 (71%) within 6 hours, compared to 2 (4%), 8 (16%) and 15 (30%) respectively for placebo. Side effects were prominent, though confounded by the migraine. The most common side effects, compared to placebo, were dizziness (58% vs 4%), nausea and/or vomiting (38% vs 18%), and drowsiness (29% vs 0%). We conclude that transnasal butorphanol is a useful analgesic for the pain of acute migraine. Its prominent side effects and low self reinforcement rate may limit its usefulness in some patients, while increasing its appropriateness for others.

Antiplatelet therapy in the treatment of cerebrovascular disease

Aspirin and the new agent ticlopidine have been the most thoroughly evaluated of the platelet-antiaggregating drugs used for the prevention of stroke and other vascular events. Numerous trials have shown aspirin to be effective in reducing the risk of myocardial infarction (MI), recurrent transient ischemic attacks, stroke, and vascular death in men at high risk for these events. Primary prevention trials have shown that aspirin reduces the risk of MI in healthy men over 50 years of age but does not reduce the risk of stroke. Two large, multicenter trials have shown that ticlopidine is effective in reducing the risk of fatal and nonfatal stroke in both men and women. Ticlopidine may also be effective in reducing the risk of recurrent stroke in patients who have had a completed thromboembolic stroke.

Headache to worry about

The headache to worry about is one that is unique or different from headaches which the patient has suffered in the past. The association with the headache of meningismus or of focal neurologic symptoms of oculoparesis, other cranial nerve palsies, hemiparesis, or loss of consciousness are particularly worrisome, especially if onset is recent and acute. Headaches related to arteritis or vasculitis usually have a slower subacute course but may also produce focal neurologic deficits. For subjects over 50 years old, temporal arteritis is always a consideration and any new type of headache requires testing of the sedimentation rate to rule out this treatable but potentially devastating problem.

Headache as a risk factor in atherosclerosis-related diseases

A group of 350 migraineurs (87 male, 263 female) and 300 controls without migraine (104 male, 196 female) were questioned about occurrence, in parents, of the atherosclerosis-related diseases (ASRD) of diabetes mellitus (DM), hypertension (HBP), myocardial infarction (MI), and stroke as well as about recurrent severe headache (RSHA). Occurrence of DM, HBP, MI and stroke was compared for mothers and fathers of migraine vs. those of control subjects and no significant differences were found. The mothers and fathers were pooled and resegregated by presence or absence of RSHA and then occurrence of DM, HBP, MI and stroke again compared. For mothers there was increased occurrence of stroke and DM in the RSHA group but the differences were not significant. For RSHA fathers there was increased incidence of MI (p less than .10) and HBP (p less than .01). Aggregate occurrence of all ASRD was evaluated for RSHA vs. no-RSHA parents. ASRD occurred more frequently in the RSHA than in the no-RSHA parents (p less than .05). Breakdown by age showed that this occurred at all ages in men (p less than .05) but in women the difference was significant only under age 60 (p less than .05). This study suggests that RSHA, which is primarily migraine, may be a risk factor or a marker for occurrence of ASRD.

Visualization of brain iron by mid-field MR

Brain iron was visualized on a mid-field (0.5 T) scanner using a spin-echo pulse sequence. Methemoglobin was hyperintense on T1- and T2-weighted images. Deoxyhemoglobin, hemosiderin, and ferritin were seen as decreased intensity on T2-weighted images. The spin-echo pulse sequences were improved for identification of deoxyhemoglobin, hemosiderin, and ferritin by prolonging the TR to 3000 msec and the TE to 80-120 msec. Phase-encoding artifacts at the level of the sylvian fissures caused increased noise, obscuring the brain iron in the lentiform nuclei with the TE of 120 msec. This artifact was substantially reduced or eliminated by lowering the TE to 80 msec, changing the phase-encoding gradient to the Y axis, or using additional pulsing in the slice and read gradients. Use of either the improved spin-echo or gradient-echo pulse sequences on a mid-field MR scanner provides improved evaluation of brain iron.

Placebo effect and clinical trials in migraine therapy

Migraine is a cyclical condition in which the cycles may occur or remit in an unpredictable fashion. The goal of prophylactic antimigraine therapy is to induce remission of an active cycle of migraine or to inhibit occurrence of individual headaches until the cycle remits for other reasons. The placebo effect probably takes advantage of these cycles. The placebo effect is significant and quite potent. The placebo effect may be divided into (1) the initial effect and (2) the continuing effect which is seen following a stabilization period. The initial placebo effect is dramatic with 62% of 188 subjects improving by 75% after 4 weeks of placebo. The continuing effect is demonstrated by occurrence of 75% further improvement in 28% of 282 subjects in 7 studies in which comparison of results after 4-12 weeks was made with a placebo stabilization period. The placebo effect is a very potent one and must be taken into account in designing and carrying out studies of migraine therapy.

Modulation of spinal synaptic transmission by beta-melanocyte stimulating hormone (beta-MSH)

Synaptic modulation refers to altered excitability of a synapse by a substance that does not produce a spike potential at the synapse. Available evidence points to the conclusion that beta-melanocyte stimulating hormone (beta-MSH) modulates synaptic transmission through monosynaptic pathways in the cat spinal cord. Earlier evidence is reviewed, and new data are presented. In the first experiments populations of cells contributing to a knee jerk were studied using the Lloyd preparation, and MSH was found to increase the monosynaptic reflex. With intracellular single unit recording techniques, beta-MSH was found to facilitate recovery from synaptic transmission. With extracellular single unit recording techniques and iontophoretic methods for drug application, beta-MSH has been found to increase the probability of generation of single spike potentials by alpha-motoneurons in response to orthodromic stimulation. Administration of beta-MSH did not cause spontaneous discharge of alpha-motoneurons. The physiological and pharmacological importance of synaptic modulation is discussed.

"Numb, clumsy hands" and high cervical spondylosis

Thirteen patients with cervical spondylosis and high compressive myelopathy between C-3 and C-5 presented with a distinctive clinical syndrome of "numb, clumsy hands" and stereoanesthesia of the hands. Loss of position and vibration sense was much more severe in the hands than in the legs. Relative sparing of primary sensory modalities and motor and bladder functions were other features. Most patients were incorrectly diagnosed at first and cervical myelography was the critical diagnostic test. Pathology was confirmed surgically or at autopsy. Early recognition and treatment resulted in lessened disability. The syndrome is a distinctive and unusual manifestation of high cervical myelopathy, and it has seldom been reported associated with cervical spondylosis.

Headache syndromes suggested by statistical analysis of headache symptoms

Statistical study of the correlation between 49 variables concerning characteristics of headache and of headache patients was carried out on 1,198 sequential patients complaining of severe or disabling headaches and attending a headache clinic. Factor analysis was the statistical method employed, 17 factors accounting for 64% of total variation emerged. The most prominent factor contained descriptors of neurological dysfunction associated with headache. Another factor contained variables of nausea and vomiting, only associated with inability to work. Other factors, contained separately, the following variables: (a) Time of headache, (b) time of week of headache, (c) unilateral nature of headache, (d) visual phenomena associated with headache. Relation of these findings to headache taxonomy is discussed.