Chronic daily headache in a patient with nasopharyngeal carcinoma

Chronic daily headache (CDH) among nasopharyngeal carcinoma (NPC) patients is a multidisciplinary challenge. Although imaging studies are recommended to identify skull-base invasion, intracranial metastasis or skull-base osteoradionecrosis, a headache diary is also a practical approach. A 42-year-old woman had been bothered with CDH since she was diagnosed with T3N1M0 stage III NPC 2 years earlier. Although the imaging studies did not show any abnormality, the attending doctor informed her that there remained the possibility of an intracranial or skull-base lesion. She was regularly taking painkillers. Eventually, when her headache diary was examined, the diagnosis of chronic migraine superimposed on medication overuse headache was made according to the ICHD-IIR. The CDH abated after 1 week of outpatient detoxification. The following half year was uneventful. In reporting this case, we suggest that it would be of interest to a number of disciplines including otorhinolaryngologists, oncologists and radio-oncologists. By avoiding medication overuse in similar patients, we hope to improve the quality of life of these individuals.

Anxiety disorders and migraine intractability and progression

Comorbid psychopathology has been implicated as a risk factor for the chronification and progression of migraine. Although past research has focused principally on depression and migraine, recent research consistently has confirmed that a disproportionate number of migraineurs suffer from one or more comorbid anxiety disorders. Moreover, this research has implicated anxiety disorders as factors potentially associated with migraine intractability and progression; growing evidence suggests that anxiety disorders may be even more prognostically significant than depression. This article summarizes these recent developments, considers mechanisms underlying this comorbidity, discusses strategies for assessing and managing comorbid anxiety, and notes directions for future clinical and empiric work.

Hemicrania continua evolving from cluster headache responsive to valproic acid

Hemicrania continua (HC) is a rare type of primary headache characterized by a prompt and enduring response to indomethacin. We describe a patient who suffered from cluster headache evolving into ipsilateral HC, who does not tolerate a long-term indomethacin therapy. The case was complex in terms of diagnosis, associated comorbidity, and choice of treatment; after several trials with different therapeutic regimens, we started the patient on a therapy with valproic acid and obtained an improvement of her HC.

Neuropathic orofacial pain in children and adolescents

The field of orofacial pain is broad and includes pain conditions affecting the head, face, neck, and intraoral structures. Much has been written about orofacial pain, specifically chronic pain conditions affecting adults. Little is known, however, about the presentation of orofacial pain in pediatric patients. The objective of this paper was to increase awareness and provide information regarding neuropathic orofacial pain in children and adolescents, as pediatric dentists may be asked to participate in the treatment of these patients. Moreover, an accurate history and examination can lead to on early diagnosis of the pain condition, thus avoiding unnecessary or inappropriate dental procedures.

Predictors of abdominal pain in schoolchildren: a 4-year population-based prospective study

BACKGROUND

Chronic abdominal pain (CAP) is common among schoolchildren, but risk factors for its onset are still largely unknown.

AIMS

To determine the frequency of onset of CAP in schoolchildren and investigate risk factors for its development.

METHODS

1411 schoolchildren aged 11-14 years were recruited from schools in North West England. Information was collected on recent pain symptoms and potential risk factors for developing CAP. Participants were followed up 1 and 4 years later and new episodes of CAP were identified.

RESULTS

22% reported new-onset abdominal pain at 1-year follow-up which persisted at 4-year follow-up (CAP). CAP was almost three times higher in girls than boys (34% vs 13%; chi(2): 26.0; p<0.001). In girls, reporting headache at baseline was the only predictive factor for CAP onset: those reporting headaches experienced a doubling in the risk of symptom onset (relative risk: 2.1; 95% confidence interval: 0.95 to 4.7). In contrast, in boys, development of CAP was independently predicted by daytime tiredness (3.0; 1.2 to 7.6), lack of school enjoyment (2.0; 0.95 to 4.2), adverse psychosocial exposures (2.3; 1.2 to 4.5) and taller stature (1.9; 0.8 to 4.5).

CONCLUSION

Our results suggest that over 20% of adolescent schoolchildren experience new-onset non-self-limiting abdominal pain over a 1-year period. Future abdominal pain is predicted by previous somatic symptom reporting in girls and both somatic symptom reporting and psychosocial factors in boys. These risk factors indicate a possible mechanism for understanding the development of CAP, and might have important implications for both primary and secondary preventive strategies.

Carotidynia: a new case for an old controversy

Whereas International Headache society (IHS) criteria of carotidynia were defined in 1988, its validity as a distinct nosological entity has recently been questioned, leading this entity to be removed from the second IHS classification in 2004. We report the case of a 30-year-old woman who developed a pain located at the left carotid bulb, associated with typical findings on ultrasonography and MRI. We discuss new criteria and denomination of this clinical entity.

Chronic Daily Headache in Hereditary Hemochromatosis Treated by Venesection

Coincidence or causality between iron overload and headaches (e.g., daily headache, migraine, and cluster headache) is still under discussion. Herein we report a patient suffering from hereditary hemochromatosis (homozygous C282Y mutation; OMIM: 235220, Locus 6p21.3) and daily headache fulfilling the IHSD-2 criteria of chronic migraine. Three treatments by venesection improved the headache substantially in frequency, intensity, and duration of attacks. We suggest treatment by venesection for iron depletion in patients suffering from hemochromatois and headache.

Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes

OBJECTIVES

To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS).

METHODS

A critical overview of the literature and incorporation of the author's own views.

RESULTS

The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms.

CONCLUSIONS

CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.

Sleep and headache disorders: clinical recommendations for headache management

Clinical practice points were drawn from a review of sleep and headache disorders published in the regular issue of Headache (released in tandem with this supplement). The recommendations include: (1) Sleep as well as psychiatric disorders tend to become prevalent in more complex and severe headache patterns and regulation of sleep and mood may favorably impact headache threshold; (2) Specific headache patterns, irrespective of headache diagnosis, are suggestive of a potential sleep disorder (eg, "awakening" or morning headache, chronic daily headache); (3) Sleep disorders most implicated with headache include obstructive sleep apnea, primary insomnia, and circadian phase abnormalities, and treatment of such sleep disorders may improve or resolve headache; (4) Inexpensive screening tools (eg, sleep history interview, headache/sleep diary, validated questionnaires, prediction equations) aid identification of patients warranting polysomnography; and (5) Pharmacologic and behavioral therapies are effective in the regulation of sleep and are compatible with usual headache care.

Improvement of Chronic Headache After Treatment of Unruptured Intracranial Aneurysms

OBJECTIVE

The objective of this study is to determine the incidence, character, and outcome of headache in patients with unruptured intracranial aneurysms who had been treated to avoid the risk of rupture.

BACKGROUND

There are a variety of clinical manifestations associated with unruptured intracranial aneurysms. Among them, chronic headache is the most common presenting and/or accompanying symptom.

METHODS

Among the 137 patients with unruptured aneurysms who had been treated, we collected 81 patients excluding 30 on the basis of inclusion criteria. Twenty-six patients were lost to follow-up. We collected data by medical record review and a telephone survey. Included in the information collected was the analysis of presenting symptom, location and size of each aneurysm, location, quality, intensity and duration of headaches, associated symptoms, triggering and alleviating factors, and precipitating events.

RESULTS

Forty-nine patients (60.5%) of 81 had chronic headaches before the diagnosis of unruptured intracranial aneurysm. Forty-four patients (89.8%) answered that their headaches were improved slightly (12 patients) or markedly (32 patients) (P <.05). The clinical pattern of the headache worsened in only 1 patient and did not change in 4 patients. When the surgical group (40 patients) and the coil embolization group (41 patients) were compared, there was no significant difference observed in outcome (P >.05).

CONCLUSION

Either by employing the technique of clipping or by coil embolization, treatment of unruptured intracranial aneurysms resulted in relief of headaches in majority of patients who had headaches pre-operatively.

Managing the “difficult” headache patient

This article reviews the challenges in managing the more complicated headache patient. These patients often have chronic daily headache or high-frequency disabling migraine. Some patients have problems adhering to treatment regimens, which may reduce treatment efficacy and in some patients lead to medication misuse and overuse. Medication overuse may transform headache to daily and reduce the effectiveness of acute and preventive therapies. There is an elevated risk of mood and anxiety disorders in migraine, with even greater risk in chronic migraine. Personality disorders may further compromise treatment efforts. Current research is reviewed on these issues and clinical suggestions are provided for more effective management of these challenging patients.

Effect of valproic acid on withdrawal therapy in patients with overuse of chronic daily headache medications

Discontinuation of medication is the treatment of choice for patients with chronic daily headache (CDH) who overuse their medications. This treatment may be difficult due to increased headache severity observed in patients immediately after withdrawal. We retrospectively evaluated the efficacy of valproic acid therapy in 66 patients with overuse of CDH medication during withdrawal therapy. Patients were all withdrawn from medications and valproic acid started at 250 mg or 500 mg daily. Forty-two (63.6%) patients had decreased headache severity, including 27.3% objective responses in the first week. At the last visit in the 12th week, 50 patients were headache-free and only one patient had persistent headache. Fifteen patients withdrew from therapy due to side effects and lost to follow-up within this timeframe. Thus, low dose valproic acid appears to be safe and effective in the management of withdrawal therapy.

Fibrous myopathy as a complication of repeated intramuscular injections for chronic headache

Two cases of fibrous myopathy associated with repeated, long-term intramuscular injections for treatment of chronic temporomandibular joint pain and chronic headache, respectively, are described. Both patients developed severe, function-limiting contractures in upper and lower extremity muscles used as injection sites. In one of the cases, the contractures were painful. Electrophysiological testing, magnetic resonance imaging and muscle biopsy results were all consistent with myopathy and replacement of skeletal muscle with noncontractile fibrous tissue. These cases are presented to increase awareness of fibrous myopathy and to promote surveillance for this serious potential complication of long-term intramuscular injections in chronic headache and other pain patients.

Factors associated with depression in patients referred to headache specialists

OBJECTIVE

To evaluate the relationship between selected demographic characteristics and clinical features in patients with headache and depression.

METHODS

We studied demographic and clinical data collected at the time of consultation for 712 new patients with headache referred to five headache specialty clinics in Canada. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The Beck Depression Inventory (BDI-II) was used to identify the presence of depression. Multivariable logistic regression analysis was employed to evaluate associations between age, gender, employment status, marital status, diagnosis, headache days per month, medication overuse, headache impact (HIT-6), and headache disability (MIDAS) and the presence of depression as measured by the BDI-II.

RESULTS

Among the sample of patients with headache, 27% (n = 189) had moderate to severe depression. Factors independently associated with depression included age less than 50 years, being unemployed, being on disability pension or welfare, being widowed, separated, or divorced, a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder, and showing severe headache impact as measured by the HIT-6, or severe disability as measured by the MIDAS.

CONCLUSIONS

In patients with headache referred for specialist consultation, depression is strongly associated with being on disability or welfare, unemployment, age under 50 years, showing severe headache impact on the Headache Impact Test-6, and receiving a diagnosis of transformed migraine. The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics.

Psychiatric comorbidity of migraine

Migraine affects nearly 12% of the adult population in the United States and causes significant lost productivity and decrements in health-related quality of life. The burden of migraine and the challenge in managing it are increased by the comorbid psychiatric conditions that occur in association with it. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder. In large scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Migraine is also comorbid with generalized anxiety disorder (Odds Ratio [OR] 3.5 to 5.3), panic disorder (OR 3.7), and bipolar disorder (OR 2.9 to 7.3). A diagnosis of migraine should lead to a heightened level of diagnostic suspicion for these comorbid psychiatric disorders. Similarly, a diagnosis of one of these psychiatric disorders should increase vigilance for migraine. Treatment plans for migraine should be mindful of the comorbid conditions.

An approach to children with chronic daily headache

Chronic daily headache is a condition that affects 2 to 4% of adolescent females and 0.8 to 2% of adolescent males. It is manifested by severe intermittent headaches, as well as a chronic baseline headache. Chronic daily headache is diagnosed when headaches occur for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, and with no underlying pathology. The headaches last for more than 4 hours a day. Patients with chronic daily headache will frequently have sleep disturbance, pain at other sites, dizziness, worsening anxiety and mood, and school absence. Successful approaches to treatment include education, use of preventative medication, avoidance of analgesics, and helping the children work their way back into a functional daily routine.

Coexistence of TACS and Trigeminal Neuralgia: Pathophysiological Conjectures

BACKGROUND

Trigeminal autonomic cephalgias (TACs) and trigeminal neuralgia are short-lasting unilateral primary headaches whose study is providing insights into craniofacial pain mechanisms. We report on 2 patients in whom trigeminal neuralgia coexists with the TACs paroxysmal hemicrania and SUNCT.

CONCLUSION

Coexistence of trigeminal neuralgia with various TAC forms suggests a pathophysiological relationship between these short-lasting unilateral headaches.

Headache disability in orofacial pain patients

OBJECTIVE

To retrospectively examine the reported history of and the disability caused by headaches in patients presenting for evaluation and treatment of orofacial pain.

BACKGROUND

More than 81% of patients with the chief complaint of pain in the orofacial region concomitantly report pain in other body locations. Among the comorbidities frequently reported with orofacial pain are a variety of different headaches types, including migraines, tension type headaches, and chronic daily headaches. The extent of the disability caused by those headache complaints in a large patient population is unknown.

METHODS

The Migraine Disability Assessment (MIDAS) is administered to all patients as a part of the initial assessment at the Orofacial Pain Center. This investigation is retrospectively examined the reported history of and the disability caused by headaches in patients who presented for evaluation and treatment of orofacial pain in the Orofacial Pain Center, National Naval Medical Center, Bethesda, MD, between the dates of 1 September 2003 and 1 December 2004.

RESULTS

In the present study 261 (61.3%) patients reported a headache complaint and 100 (38%) fulfilled the criteria for migraine with or without aura. MIDAS scores were reported by 55.3% of 426 patients with the mean score of 23.68. There were no significant differences in MIDAS scores in relation to the presence or absence of an intracapsular disorder. Patients with masticatory and/or cervical myalgia demonstrated significantly higher MIDAS scores when compared to patients without myalgia.

CONCLUSIONS

These findings clearly demonstrate the necessity for evaluation of headache and related disability in orofacial pain patients.

The prevalence and spectrum of sleep problems in women with transformed migraine

OBJECTIVES

It is our clinical observation that patients with transformed migraine (TM) almost invariably report nonrestorative sleep. In this study we sought first to validate that clinical observation, then to describe the prevalence and spectrum of factors that might contribute to nonrestorative sleep in a TM population.

BACKGROUND

Although headaches have been linked with sleep problems for over a century, there is little information about the spectrum or prevalence of specific sleep problems associated with TM in adults.

METHODS

We conducted a detailed sleep interview on 147 consecutive women with TM. Subjective sleep quality was assessed by asking patients to describe their state upon awakening as "refreshed" or "tired."

RESULTS

None of the 147 patients reported awakening "refreshed," and 83.7% stated that they awakened "tired." Sleep complaints were prevalent and varied in this population.

CONCLUSIONS

Although the relationship between pain and sleep is complex and ill understood, we found a very high prevalence of nonrestorative sleep and a similarly high prevalence of modifiable poor sleep habits in patients with TM. Since behavioral approaches have been found effective in improving sleep quality in patients with poor sleep hygiene, we propose that studies be undertaken to assess the impact of such treatment on TM.

Headache and mood disorders

The aim of the study was to estimate the occurrence of mood, anxiety and disability disorders in 300 patients affected by chronic daily headache and MOH, who were observed for a 16–month period in our centre. We monitored the patients on an interview basis, concerning the anamnestic data collection related to the pre–morbid period, information given by relatives regarding the patient’s behaviour during the day, attitudes towards others, maintenance of previous interests and enjoyments, and modifications of the biological rhythm. Several tests were conducted, underlining a significant correlation between headache and mood disorders, impairment of working activity, social and family life. The study shows that patients affected by chronic daily headache and MOH present high levels of anxiety, a depressive symptomatology associated with alexithymia. Moreover, it has been discovered that anxiety and depression facilitate the onset of headache, while patients suffering from pain persistence were more vulnerable to psychiatric problems. In consideration of these results, more exhaustive evaluations relating to the psychopathological aspects in patients affected by headache are necessary.

What is the impact, prevalence, disability, and quality of life of pediatric headache?

Pediatric headache is a common health problem in children, with a significant headache reported in more than 75% by the age of 15 years. Pediatric migraine occurs in up to 10.6% of children between the ages of 5 and 15 years and in up to 28% of adolescents between the ages of 15 and 19 years. Given this high frequency, the impact of this disease on the lives of these children and their parents can be quite significant. This impact can be assessed with disease-specific disability and impairment as well as disease non-specific effects on quality of life. The goal of evaluation should be recognition of this impact, whereas the goal of management should be effective treatment that minimizes the impact of this disorder in the short term and for the life of the patient.

Pediatric SUNCT Syndrome

This report describes a 5-year-old male with sudden unilateral headache attacks (2-50 seconds) accompanied by conjunctival injection, lacrimation, and nasal congestion. The episodes occurred without a precipitating factor, never during sleep. Brain imaging was normal. The attacks resolved spontaneously within 5 months. This headache syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) was previously described in two other children aged 10 and 11.

Balance disorders in headache patients: evaluation by computerized static stabilometry

OBJECTIVES

The aim of the study was to investigate the occurrence of equilibrium disturbances in headache patients, during the interictal period, by computerized static stabilometry.

MATERIALS AND METHODS

Sixty-seven patients were studied: 35 with migraine without aura (MwoA), 12 with tension-type headache (TTH) in the episodic form (ETTH) + MwoA, and 20 with only TTH [10 ETTH + 10 chronic (CTTH)]. The stabilometric parameters considered were: statokinesigram length (L) and surface (S) in open (EO) and closed (EC) eyes conditions with/without occlusal bite, EC with head retroflexion (ECR), and optokinetic stimulation (OKN).

RESULTS

The alteration of at least one of the stabilometric parameters was observed in 45 patients (67.2%): 21 MwoA, 8 ETTH + MwoA, and 16 TTH (8 ETTH + 8 CTTH).

CONCLUSION

In TTH patients (ETTH, CTTH, ETTH + MwoA), the stabilometric findings show a proprioceptive alteration induced by cervicofacial muscle contraction, which was peripheral in origin. In MwoA patients the alterations appear under OKN and support a control impairment in involuntary oculomotility of central origin.