Transformed or evolutive migraine

Childhood chronic daily headache: a biopsychosocial perspective

The aim of our observational study was to highlight some clinical observations on chronic daily headache (CDH) in children and adolescents. Data on patients < or =18 years aged presenting with CDH to the Pediatric Headache Clinic at the Royal University Hospital, Saskatoon, Canada, were collected prospectively and sequentially from February 2004 to July 2006. Standardized data sheets and definitions were used. Follow-up information on the 70 participants (22 males, 48 females) was current to February 2007. Fifty-four participants (77%) had had recurrent headaches before transformation to CDH. Comorbid chronic migraine and chronic tension-type headache was the most frequent subtype of CDH (37 participants; 53%). Anxiety and mood disorders were diagnosed in 17 and 15 children respectively. Stressors that precipitated or contributed to the maintenance of CDH were judged important in 44 (63%). The possibility of a somatoform disorder was considered in five children, a factitious disorder in one, and malingering in another. We suggest that CDH be viewed from a biopsychosocial rather than a narrow biomedical perspective and the classification improved to enhance clinical utility.

Neurovascular pains: implications of migraine for the oral and maxillofacial surgeon

Epidemiologic studies have shown that migraine headaches are a common finding in the general population, often associated with a high degree of disability. Additionally, migraine has a reported comorbidity with other medical conditions, most notably with chronic pains, such as temporomandibular disorders. The pathophysiologic mechanisms involved with migraine are suggestive of an increased and prolonged hyperexcitability to stimuli, especially within the trigeminal distribution. Because migraine is mediated by branches of the trigeminal nerve it has the potential to mimic other types of pains, such as toothache or sinusitis. It is therefore recommended that oral and maxillofacial surgeons be familiar with the diagnostic criteria for migraine headaches to identify and appropriately treat such individuals who present to their clinics.

Chronic daily headache in French children and adolescents

To characterize the clinical profile, comorbidity and aggravating factors, and outcomes, a consecutive series of 34 French children and adolescents with chronic daily headache was studied. Of 206 referred over an inclusive interval of 2 years for the evaluation of headaches, 34 merited a diagnosis of chronic daily headache, which was defined as persistent or daily headaches of at least 3 months in duration. The overwhelming majority were female (61.8%), with a mean age at diagnosis of 10.5+/-3.1 years (range, 2.9-14.8 years). According to the Silberstein-Lipton criteria, transformed migraine was the etiology in 61.8%, whereas according to the second edition of the International Classification of Headache Disorders, chronic migraine accounted for 50% of cases. Stressors were recognized in 82%. Analgesic abuse was evident in 52.9%. Of the 29 for whom follow-up information was available, headaches resolved or greatly improved in 93.1%. Children and adolescents with chronic daily headache are thus a small subset of children with headache seen in general ambulatory practice. They tend to be girls in the midteen years experiencing a transformed migraine complicated by analgesic abuse, suggesting potential preventability. Simple measures, which can include reassurance and analgesia education, can be expected to result in improvement and eventual resolution of headache symptoms.

Predictors of response to botulinum toxin type A (BoNTA) in chronic daily headache

OBJECTIVE

To evaluate predictors of response to botulinum toxin type A (BoNTA; BOTOX, Allergan Inc., Irvine, CA, USA) in patients with chronic daily headache (CDH).

BACKGROUND

Chronic migraine (CM) and chronic tension-type headache (CTTH) form the majority of CDH disorders. Controlled trials indicate that BoNTAis effective in reducing the frequency of headache and number of headache days in patients with CDH disorders. A recent migraine study found that patients with imploding or ocular types of headaches were responders to BoNTA, whereas those with exploding headaches were not. To date, there are no data on factors that might predict response to BoNTA in patients with CDH.

METHODS

A total of 71 patients with CM and 11 patients with CTTH were treated with 100 units BoNTA. Every patient received at least 2 sets of injections at intervals of 12-15 weeks; fixed sites, fixed dose, and "follow-the-pain" approaches were used for the injections. A detailed medical history was taken for each patient in addition to recording Migraine Disability Assessment Scale (MIDAS) scores at baseline and every 3 months after each set of injections. Headache frequency was assessed throughout the study from baseline to weeks 24-27. Patients recorded the frequency, severity, and duration of headaches in Headache Diaries. Patients were divided into responders (> or = 50% reduction in both headache frequency and MIDAS scores compared with baseline) and nonresponders (< 50% reduction in either of the above variables). Variables analyzed for predictors of response include headache that is predominantly unilateral or bilateral in location, presence of cutaneous allodynia (scalp allodynia), and presence of pericranial muscle tenderness (also referred to as muscle allodynia). Chi-square analysis was used for parallel-group comparisons (proportion of CM responders vs proportion of CM nonresponders and proportion of CTTH responders vs proportion of CTTH nonresponders).

RESULTS

In the CM group, 76.1% (54 /71) of patients were responders to BoNTA, of which 68.5% (37/54) had headache that was predominantly unilateral in location and the remaining 31.5% (17/54) had headache that was predominantly bilateral in location (both P < .01 vs CM nonresponders). Of the 23.9% (17/71) CM nonresponders, 76.5% (13/17) reported predominantly bilateral headache and in the remaining 23.5% (4/17) the headache was unilateral. In the CM responders group, 81.5% (44/54) had clinically detectable scalp allodynia, while pericranial muscle tenderness was present in 61.1% (33/54) (both P < .01 vs CM nonresponders). The presence of scalp allodynia and pericranial muscle tenderness in the CM nonresponders was 11.8% (2/17) and 17.6% (3/17), respectively. In the CTTH group where all patients (100%, 11/11) had bilateral headache, 36.4% (4/11) of patients were responders to BoNTA. All of those CTTH responders (100%, 4/4) had pericranial muscle tenderness (P < .05 vs CTTH nonresponders). None of the CTTH nonresponders had pericranial muscle tenderness. No clinically significant serious adverse events (AEs) were reported. Mild AEs, eg, injection-site pain that persisted for 1-9 days, were reported in 11 patients. One patient had transient brow ptosis.

CONCLUSIONS

A greater percentage of patients with CM responded to BoNTA than patients with CTTH. Headaches that were predominantly unilateral in location, presence of scalp allodynia, and pericranial muscle tenderness appear to be predictors of response to BoNTA in CM, whereas in CTTH, pericranial muscle tenderness may be a predictor of response.

DHE in the pharmacotherapy of migraine: potential for a larger role

Despite a large array of currently marketed, frequently effective drugs for the acute treatment of migraine headache, comprising various classes and formulations, predictably reliable treatment for most headache types is often lacking. Dihydroergotamine mesylate (DHE) is a comparatively safe and effective therapy for migraine headache that could potentially be used for a broader range of headache types than occurs at present. The features of DHE supporting this assertion include (1) effectiveness in terminating severe, long-lasting headaches, (2) rapid onset of action, (3) very low rates of headache recurrence, (4) minimal risk of medication-overuse headache, and (5) in the nasal spray formulation, suitability for outpatients (especially patients who are very nauseated or vomiting, potentially obviating the need for an office or hospital visit for acute care). Conditions or circumstances for which there are data supporting the expanded use of DHE include menstrual migraine, migraine with central sensitization and cutaneous allodynia, medication-overuse headache, migraine recurrence, and status migrainosus. The introduction of the intranasal formulation of DHE provides both pharmacologic and patient-convenience advantages for use in migraine therapy. This article reviews the rationale for the use of DHE in these common, often difficult-to-treat migraine forms.

Evidence-based understanding of medication-overuse headache: clinical implications

This article discusses the problem of medication-overuse headache from a variety of perspectives, based on the best available evidence. This presentation clarifies the definition of the disorder, distinguishing it from alternative terminology, and describes its epidemiology, natural history, and clinical course. Antimigraine medications are believed to differ in their relative liability to contribute to the development of medication-overuse headache. Patients most at risk of developing medication-overuse headache need to be identified so that appropriate preventive measures can be initiated.

Efficacy and safety of topiramate for the treatment of chronic migraine: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of topiramate (100 mg/day) compared with placebo for the treatment of chronic migraine.

METHODS

This was a randomized, placebo-controlled, parallel-group, multicenter study consisting of 16 weeks of double-blind treatment. Subjects aged 18 to 65 years with 15 or more headache days per month, at least half of which were migraine/migrainous headaches, were randomized 1:1 to either topiramate 100 mg/day or placebo. An initial dose of topiramate 25 mg/day (or placebo) was titrated upward in weekly increments of 25 mg/day to a maximum of 100 mg/day (or to the maximum tolerated dose). Concomitant preventive migraine treatment was not allowed, and acute headache medication use was not to exceed 4 days per week during the double-blind maintenance period. The primary efficacy endpoint was the change from baseline in the mean monthly number of migraine/migrainous days; the change in the mean monthly number of migraine days also was analyzed. A fixed sequence approach (ie, gatekeeper approach) using analysis of covariance was used to analyze the efficacy endpoints. Assessments of safety and tolerability included physical and neurologic examinations, clinical laboratory parameters, and spontaneous reports of clinical adverse events.

RESULTS

The intent-to-treat population included 306 (topiramate, n = 153; placebo, n = 153) of 328 randomized subjects who provided at least 1 efficacy assessment; 55.8% of the topiramate group and 55.2% on placebo were trial completers. The mean final topiramate maintenance dose was 86.0 mg/day. The mean duration of therapy was 91.7 days for the topiramate group and 90.6 days for the placebo group. Topiramate treatment resulted in a statistically significant mean reduction of migraine/migrainous headache days (topiramate -6.4 vs placebo -4.7, P= .010) and migraine headache days relative to baseline (topiramate -5.6 vs placebo -4.1, P= .032). Treatment-emergent adverse events occurred in 132 (82.5%) and 113 (70.2%) of topiramate-treated and placebo-treated subjects, respectively, and were generally of mild or moderate severity. Most commonly reported adverse events in the topiramate group were paresthesia (n = 46, 28.8%), upper respiratory tract infection (n = 22, 13.8%), and fatigue (n = 19, 11.9%). The most common adverse events in the placebo group were upper respiratory tract infection (n = 20, 12.4%), fatigue (n = 16, 9.9%), and nausea (n = 13, 8.1%). Discontinuations due to adverse events occurred in 18 (10.9%) topiramate subjects and 10 (6.1%) placebo subjects. There were no serious adverse events or deaths.

CONCLUSIONS

Topiramate treatment at daily doses of approximately 100 mg resulted in statistically significant improvements compared with placebo in mean monthly migraine/migrainous and migraine headache days. Topiramate is safe and generally well tolerated in this group of subjects with chronic migraine, a burdensome condition with important unmet treatment needs. Safety and tolerability of topiramate were consistent with experience in previous clinical trials involving the drug.

The Convergence Hypothesis

The Convergence Hypothesis postulates a single pathophysiological mechanism to explain the clinical spectrum of primary headaches seen in patients with migraine. The history and the scientific underpinnings of the Convergence Hypothesis are presented. Extrapolations from the Convergence Hypothesis are used to explore the evolution of episodic to chronic migraine and the development of common migraine co-morbidities as a consequence of frequent migraine. A patient staging system is presented to illustrate this transformation process in migraine patients.

Mood state and quality of sleep in cancer pain patients: a comparison to chronic daily headache

Cancer pain is commonly believed to be a unique type of pain and dissimilar to noncancer pain; however, only limited research efforts have been directed at examining this belief. The aim of this study was to explore whether patients with chronic daily headache (CDH) and patients with chronic cancer pain (CCP) present with different pain, mood, and sleep quality profiles. Forty-seven patients diagnosed with CDH were matched by age and gender with 47 patients with CCP. The research instruments included the Brief Pain Inventory-Chinese version, the Profile of Mood States Short Form, and the Pittsburgh Sleep Quality Index-Taiwan Form (PSQI-T). Results revealed that there was no difference in pain intensity between the patients with CDH and those with CCP; however, the CCP group reported significantly higher mean levels of pain interference with daily life than did the CDH group. These two groups did not differ on the Total Mood Disturbance score; however, the CCP group reported significantly lower mean levels of vigor than did the CDH group. Moreover, there was no difference on the PSQI-T total score between these two groups; however, the CDH group reported higher mean scores of sleep disturbance, higher mean scores of use of sleep medications, lower mean scores of sleep efficiency, and lower mean scores of daytime dysfunction than did the CCP group. Despite some differences between these two groups, pain, mood, and sleep quality profiles in these two types of pain groups are similar.

The Prophylactic Treatment of Chronic Daily Headache

Chronic daily headache (CDH), a heterogeneous group of headache disorders occurring on at least 15 days per month, affects up to 4% to 5% of the general population. CDH disorders include transformed (or chronic) migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. Patients with CDH have greater disability and lower quality of life than episodic migraine patients and often overuse headache pain medications. To date, only topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and botulinum toxin type A (BoNTA) have been evaluated as prophylactic treatment of CDH in randomized, double-blind, placebo-controlled, or active comparator-controlled trials. The evidence supporting the use of BoNTA as prophylaxis of CDH is composed of larger and longer trials, as over 1000 patients were evaluated for up to 11 months duration. Compared with placebo BoNTA has significantly reduced the frequency of headache episodes, a recommended efficacy measure for headache trials and has been demonstrated to be safe and very well tolerated with few discontinuations due to adverse events. Side effects are generally transient, mild to moderate, and nonsystemic. The results of clinical trials using traditional oral pharmacotherapy, while supportive of their use as prophylactic treatment of CDH, are limited by several factors, including small numbers of patients, the choice of efficacy measures, and short treatment periods. The use of oral agents was associated with systemic side effects, which may limit their effectiveness as prophylactic treatment of CDH.

When migraine progresses: transformed or chronic migraine

Migraine may be conceptualized, not just as an episodic disorder, but as a chronic recurrent and sometimes chronic progressive disorder. Transformed migraine, often referred to as chronic migraine is the result of migraine progression. This article will review the clinical features of transformed migraine, highlighting that its phenotype varies according to stage. Early in the process of transformation, attacks with migraine features are very common. As the disease evolves, most attacks lack the migraine features. The risk factors for migraine progression and the mechanisms for progression will be discussed. This review concludes with the prospects for treating transformed migraine and avoiding migraine progression.

Field testing alternative criteria for chronic migraine

The criteria for chronic migraine (CM), as proposed by the Second Edition of the International Classification of Headache Disorders (ICHD-2) is very restrictive, excluding most patients that evolve from episodic migraine. In this study we empirically tested three recent proposals for revised criteria for CM. We included individuals with transformed migraine (TM) with or without medication overuse, according to the criteria proposed by Silberstein and Lipton. All individuals had headache calendars for at least three consecutive months. We assessed the proportion of subjects that fulfilled ICHD-2 criteria for CM or probable chronic migraine with probable medication overuse (CM+). We also tested three proposals for making the CM criteria more inclusive. In proposal 1, CM/CM + would require at least 15 days of migraine or probable migraine per month. Proposal 2 suggests that CM/CM + would be classified in those with >or= 15 days of headache per month, where at least 50% of these days are migraine or probable migraine. Proposal 3 suggests that CM/CM + would be classified in those with chronic daily headache and at least 8 days of migraine or probable migraine per month. Among TM sufferers, 399 (62.5%) had TM with medication overuse, and just 10.2% were classified as CM+ 158 (37.5%) had TM without medication overuse; just nine (5.6%) met current ICHD-2 criteria for CM. Using the alternative criteria, proposal 1 included 48.7% of patients with TM without medication overuse; proposal 2 captured 88%, and proposal 3 classified 94.9% of these patients. For TM with medication overuse, the proportions for proposals 1-3 were, respectively, 37%, 81% and 91%. The differences were statistically significant, favouring proposal 3. Consistently, criteria for CM and CM+ should be revised to require at least 8 days of migraine or probable migraine per month, in individuals with 15 or more days of headache per month.

Tension-type headache

Tension-type headache, the most common type of primary headache disorder, is reclassified in the second International Headache Society classification with clear diagnostic criteria. Chronic tension-type headache (CTTH) differs from episodic form in frequency, lack of response to most treatment strategies, more medication overuse, and more loss of quality of life. New concepts in the pathophysiology of CTTH emphasize the possible role of central nociceptive pathway sensitization in addition to peripheral myogenic factors. Mechanisms of central sensitization, even though poorly understood, may involve nitric oxide system and N-methyl-D-aspartate receptors. Future treatment modalities are likely to be based on such mechanisms. Using MRI and voxel-based morphometry, structural abnormalities have been found in patients with CTTH for the first time. Pain processing areas such as dorsal rostral and ventral pons, anterior cingulate cortex, anterior and posterior insular cortex, right posterior temporal lobe, orbitofrontal cortex, para hippocampus bilaterally, and the right cerebellum were found to have decreased gray matter in patients with CTTH compared with control subjects and patients with medication overuse headache. Amitriptyline remains the most effective preventive treatment so far. The role of botulinum toxin is not fully defined.

[Abuse pattern of analgesics in chronic daily headache: a study in the general population]

BACKGROUND AND OBJECTIVE

The abuse pattern of analgesics is not well known in persons with "chronic daily headache and analgesic abuse" (CHA) in the general population. The objective of this study was to know the type of analgesics used by pharmacological group and the active ingredient in subjects with CHA in a large sample of the general population.

PATIENTS AND METHODS

A questionnaire was distributed that investigated the frequency of headache and analgesic consumption among persons over 14 years (9,984 inhabitants) of the semiurban population of Santoña (Cantabria). A total of 4,855 subjects filled out the questionnaire. Although the CHA criteria require headache > or = 15 days a month, those individuals (n = 332) that report subjective consumption of analgesics for headache > or = 10 days in this period filled out a headache diary for one month. A total of 72 individuals fulfilled CHA criteria (1.48% of the general population). The varieties of CHA were classified according to the Silberstein et al criteria.

RESULTS

The greatest consumption corresponded to the simple analgesic group with 34.7% of all the subjects followed by those of combined analgesics and ergotaminics consumed by 27.8% and 22.2% respectively. A total of 12.5% took opioids alone or associated and triptans were in the fifth place. The latter were consumed by 2.8% of all the subjects. The active ingredients used most were: paracetamol (54%), caffeine (49%), ergotic derivatives (38%) and propyphenazone (35%). The subjects detected consumed a mean of 2.5 active ingredients simultaneously. The mean units consumed in their different presentation by the subjects with CHA was 50 units/month.

CONCLUSIONS

This study shows that CHA is a significant health care problem. In our setting, 85% of the persons with CHA of the population used analgesics and/or ergotics. These medications were given without prescription so that their obtention should be regulated in the pharmacy offices.

A randomized, controlled trial of acupuncture for chronic daily headache

BACKGROUND

Approximately 4% of adults experience headaches nearly every day. Nonpharmacologic interventions for frequent headaches may be appropriate because medical management alone is often ineffective.

OBJECTIVE

To assess the efficacy of acupuncture as an adjunct to medical management for chronic daily headache (CDH).

METHODS

We conducted a randomized, controlled trial of 74 patients with CDH that compared medical management provided by neurologists to medical management plus 10 acupuncture treatments. Primary outcome measures were daily pain severity and headache-related quality of life (QoL).

RESULTS

Patients who received only medical management did not demonstrate improvement in any of the standardized measures. Daily pain severity scores trended downward but did not differ between treatment groups (P= .60). Relative to medical management only, medical management plus acupuncture was associated with an improvement of 3.0 points (95% CI, 1.0 to 4.9) on the Headache Impact Test and an increase of 8 or more points on the role limitations due to physical problems, social functioning, and general mental health domains of the Short Form 36 Health Survey. Patients who received acupuncture were 3.7 times more likely (CI, 1.7 to 8.1) to report less suffering from headaches at 6 weeks (absolute risk reduction 46%; number needed to treat 2).

CONCLUSION

Headache-specialty medical management alone was not associated with improved clinical outcomes among our study population. Supplementing medical management with acupuncture, however, resulted in improvements in health-related QoL and the perception by patients that they suffered less from headaches.

Do children and adolescents have chronic daily headaches? Yes!

Chronic daily headaches in children and adolescents appear to have been increasing throughout the past few decades. The diagnosis, classification, treatment, and long-term prognosis continue to be poorly understood. Recent epidemiologic studies and updated classifications have been done in this area, but further work is needed to help these children.

Does medication overuse headache represent a behavior of dependence?

Medication overuse is relatively common in patients with frequent headache. To explore the prevalence of patients who meet the criteria for substance dependence in Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV), and to identify variables of substance dependence among patients with chronic daily headache, we recruited consecutive patients with chronic daily headache at a headache clinic from November 1999 to June 2004. Each patient completed a headache intake form, a dependence questionnaire modified from DSM-IV, and the Hospital Anxiety and Depression Scale (HADS). The presence of probable medication overuse headache (pMOH) was defined on the basis of the International Classification of Headache Disorders, 2nd edition, 2004. A total of 1,861 patients with chronic daily headache (1,369 women, 492 men; mean age, 49.6+/-15.4 years) were recruited. Almost half (895/1,861, 48%) met criteria of pMOH, and 606 of these patients (606/895, 68%) met three of five DSM-IV substance dependence criteria. In contrast, only 191 of 968 patients without pMOH (20%) met the DSM-IV criteria (OR=8.6, [7.0-10.6], chi-square test, P<0.001). Patients who fulfilled DSM-IV criteria of dependence had higher numbers of physician appointments in the past year. Multivariate logistic regression analyses revealed that migraine headache, frequent physician consultation, intensity of headache, and presence of a higher anxiety score were significant independent variables for substance dependence. Among patients with chronic daily headache, pMOH was associated with behaviors of substance dependence.

[Migraine with psychiatric co-morbidity]

Investigation of migraine co-morbidity has confirmed a strong association between depression, anxiety disorders (particularly panic and phobia) and migraine. However, research into the possible mechanisms underlying these associations remains limited. The literature also indicates that migrainers are at reduced risk of suffering from anxiety, mood disorders and substance-related disorders compared with medication overuse headache sufferers. Patients suffering from medication overuse headache sometimes exhibit addictive behavior for acute migraine drugs. Finally, migrainers show increased non-specific neurotic suffering.

Disability pattern in chronic migraine with medication overuse: a comparison with migraine without aura

OBJECTIVES

To assess headache-related disability in chronic migraine with medication overuse (CMO), as defined by Silberstein and Lipton (1996, 2001) in comparison to that caused by migraine without aura, investigating similarities and differences in disability patterns in these two conditions.

BACKGROUND

It is well known that migraine has a marked impact on daily activities. Less information is available on the functional consequences of chronic migraine.

METHODS

This was a prospective study on 247 patients with CMO and 264 with migraine without aura. All completed the validated Italian version of the Migraine Disability Assessment questionnaire (MIDAS). The MIDAS total score and scores of each question (investigating total or partial inability to perform different daily activities) were evaluated, and compared in the two groups using the Mann-Whitney rank sum test. We also evaluated the number of missed days (question 1) and days with significantly reduced effectiveness at work (question 2) and in nonwork activities (questions 3, 4, and 5), using descriptive statistics.

RESULTS

MIDAS total score in the CMO group was rather high (mean 84.1, median 70) and significantly higher than in the migraine group (mean 23.4, median 19). CMO patients also reported higher scores than migraine patients in MIDAS questions investigating disability in different domains, the differences being highly significant for questions 3, 4, and 5. In both CMO and migraine the number of days with total or significant disability in nonwork activities was higher than the number of days with total or significant disability in work activities, and days spent at work with significantly reduced effectiveness were more than work days missed.

CONCLUSIONS

Our findings show that CMO has a profound effect on patients' daily functioning. They suggest that differences between CMO and migraine are mainly quantitative, while the two groups are similar in terms of disability pattern. These results are consistent with the fact that CMO may be an evolution of episodic migraine, characterized by increase in headache frequency and more evident disability in performing different daily duties.

Botulinum toxin type A for the prophylactic treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

To identify a treatment-responsive population for botulinum toxin type A (BoNTA) and to evaluate the safety and efficacy of 3 different doses of BoNTA as prophylactic treatment of chronic daily headache (CDH).

PATIENTS AND METHODS

A randomized, double-blind, placebo-controlled study of BoNTA in patients with CDH was conducted from July 6, 2001, through November 7, 2003, at 28 North American study centers. Eligible patients were injected with BoNTA at 225 U, 150 U, 75 U, or placebo and returned for additional masked treatments at day 90 and day 180. Patients were assessed every 30 days for 9 months. The primary efficacy end point was the mean change from baseline in the frequency of headache-free days at day 180 for the placebo nonresponder group.

RESULTS

For this study, 702 patients were enrolled and randomized. The primary efficacy end point was not met. Mean improvements from baseline at day 180 of 6.0, 7.9, 7.9, and 8.0 headache-free days per month were observed in the placebo nonresponder group treated with BoNTA at 225 U, 150 U, 75 U, or placebo, respectively (P=.44). An a priori-defined analysis of headache frequency revealed that BoNTA at 225 U or 150 U had significantly greater least squares mean changes from baseline than placebo at day 240 (-8.4, -8.6, and -6.4, respectively; P=.03 analysis of covariance). Only 27 of 702 patients (3.8%) withdrew from the study because of adverse events, which generally were transient and mild to moderate.

CONCLUSIONS

Although the primary efficacy end point was not met, all groups responded to treatment. The 225 U and 150 U groups experienced a greater decrease in headache frequency than the placebo group at day 240. The placebo response was higher than expected. BoNTA was safe and well tolerated. Further study of BoNTA prophylactic treatment of CDH appears warranted.

Migraine during pregnancy: options for therapy

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.

Management of chronic daily headache: challenges in clinical practice

Chronic daily headache (CHD) refers to a category of headache disorders that are characterized by headaches occurring on more than 15 days per month. This category is subdivided into long- and short-duration (>4 or <4 hours) CDH disorders based on the duration of individual headache attacks. Examples of long-duration CDH include transformed migraine (TM), chronic migraine (CM), new daily persistent headache (NDPH), acute medication overuse headache, and hemicrania continua (HC). The goal of this review is to enable clinicians to accurately diagnose and effectively manage patients with long-duration CDH. Patients with CDH often require an aggressive and comprehensive treatment approach that includes a combination of acute and preventive medications, as well as nondrug therapies.

Chronic migraine and medication-overuse headache through the ages

We set out to review early descriptions of chronic migraine and medication-overuse headache. The International Headache Society (IHS) recently gave criteria for chronic migraine and medication-overuse headache. Chronic migraine was absent from the 1988 IHS criteria. Peters and Horton described ergotamine-overuse headache in 1951. In the 1980s it was more fully appreciated that overuse of other acute headache medications could increase headache frequency. We reviewed published English-language papers and book chapters. Willis (1672), Oppenheim (1900), Collier (1922), Balyeat (1933), and von Storch (1937) all described chronic migraine. Lennox (1934), O'Sullivan (1936), Silfverskiold (1947), Graham (1955), Friedman (1955), and Lippman (1955) wrote about ergotamine-overuse headache. Graham (1955), Friedman (1955), Lippman (1955), and Horton and Peters (1963) outlined withdrawal protocols. Chronic migraine has been mentioned in the literature for centuries, while medication-overuse headache has been written about for decades. Graham, Friedman, and Lippman deserve credit for separately reporting the first ergotamine withdrawal programmes.

The level of recognition of physical symptoms in patients with a major depression episode in the outpatient psychiatric practice in Puerto Rico: an observational study

BACKGROUND

This study was designed to evaluate the psychiatrists' level of recognition of somatic symptoms associated to a major depressive episode (MDE) (DSM-IV-TR criteria) and the impact of those somatic symptoms on the treatment effectiveness.

METHODS

This non-interventional study was conducted in 25 medical offices in Puerto Rico from February to December 2003. It had 2 visits separated by 8 weeks. The level of recognition was determined by: the correlation between the physician clinical evaluation and their patients' self-evaluations through different validated instruments using kappa statistics. Chi-square test was used to evaluate the impact of somatic symptoms on treatment antidepressants' effectiveness.

RESULTS

All the 145 recruited patients reported the presence of at least one somatic symptom associated with their current MDE. In the two visits covered by the study, a fair agreement between the psychiatrists' and the patients' reports was noted for headache, abdominal pain and upper limb pains (0.4003 <or= kappa >or= 0.6594). For other painful symptoms and painless somatic symptoms, the Kappa values obtained were non-significant. Slight but significant reductions in depression and painful symptoms severity were observed after 8 weeks of treatment. A proportional relationship between the pain and depression severity was observed (p < 0.0001).

CONCLUSION

The study results show that somatic symptoms: are very common in depressed Puerto Rican patients; are significant under-reported by psychiatrists; and have a significant impact on the antidepressant effectiveness.

The Classification of Chronic Daily Headache in Adolescents—A Comparison Between the Second Edition of the International Classification of Headache Disorders and Alternative Diagnostic Criteria

OBJECTIVES

To compare the second edition of the International Classification of Headache Disorders (ICHD-2) and the Silberstein-Lipton (S-L) criteria in the classification of adolescents with chronic daily headache (CDH).

METHODS

We reviewed the clinical records and the headache diaries of 170 adolescents (13 to 17 years) seen between 1998 and 2003 at a headache center. Relevant information was transferred to a standardized form that included operational criteria for the ICHD-2. CDH subtypes were classified according the criteria proposed by S-L into transformed migraine (TM) with (TM+) and without medication overuse (TM-), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC).

RESULTS

From the 69 patients with TM- according the S-L criteria, most (71%) could be classified as chronic migraine (CM), while a minority of patients required a combination of diagnosis, mainly migraine and CTTH (14.4%). Of the patients with TM+, just 39.6% met the criteria for probable CM (PCM) with probable medication overuse (PMO). If instead of 15 migraine days per month, we considered 15 or more days of migraine or probable migraine, 84% of the subjects with TM- and 68.7% of those with TM+ could be classified. Of the 27 subjects classified as NDPH without medication overuse according to the S-L system, the majority (51.2%) were also classified as NDPH according the ICHD-2. Interestingly, three (11.1% of the subjects with NDPH without medication overuse) were classified as CM in the ICHD-2 because these patients had an abrupt onset of 15 or more days of migraine per month. All patients with NDPH with medication overuse according to the S-L criteria required a combination of diagnoses in the ICHD-2. All subjects with CTTH received a single diagnosis in both classification systems.

CONCLUSIONS

(i) Among adolescents with TM, the majority (58.1%) could be classified as CM, according to the ICHD-2. These results were driven by TM without medication overuse. (ii) If the ICHD-2 criteria for CM are revised to require 15 days of migraine or probable migraine, the proportion of patients with TM- who meet the criteria for CM increases from 71% to 84%; for TM+, the proportion with probable chronic migraine and PMO increases from 30% to 68%. (iii) About half of the patients with NDPH according to the S-L criteria have too many migraine features to meet ICHD-2 criteria for NDPH.

Future Directions in Behavioral Headache Research: Applications for an Evolving Health Care Environment

Three decades of research has produced effective behavioral treatments for migraine and tension-type headache, yet the full fruition of this research has not been realized. Further development and dissemination of behavioral treatments is needed to impact the large numbers of those with headache who potentially could benefit from these interventions. At the same time, an evolving health care environment challenges researchers and providers to employ greater efficiency and innovation in managing all chronic disorders. Hopefully, the recently published clinical trials guidelines for behavioral headache research will serve as a catalyst for production of quality empiricism that, in turn, will generate enhanced behavioral strategies and will optimize health care resource utilization. This article describes 10 areas of critical needs and research priorities for behavioral headache research, including: replication and extension of seminal studies using improved methodology; analysis of barriers to implementation of behavioral treatments; development of referral and treatment algorithms; behavioral compliance facilitation with medical interventions; development of a headache self-management model; integration of behavioral intervention within traditional medical practice; identification and management of comorbid psychopathology among headache patients; prevention of disease progression; analysis of behavioral therapeutic mechanisms, and development of innovative treatment formats and applications of information technologies.

Levetiracetam in the preventive treatmentof transformed migraine: A prospective, open-label, pilot study

BACKGROUND

Most preventive agents used for transformed migraine (TM)have not been studied specifically for the treatment of this syndrome. Open-label trials have demonstrated the effectiveness of levetiracetam in the treatment of refractory headaches.

OBJECTIVE

The aim of this study was to assess the effectiveness and tolerabilityof levetiracetam in the preventive treatment of refractory TM.

METHODS

This prospective, open-label, pilot study was conducted at TheNew England Center for Headache, Stamford, Connecticut. We included patients aged ≥ 18 years with refractory TM according to the criteria proposed by Silberstein et al. All participants had failed on at least 1 but not more than 3 preventive drugs. Other preventive drugs were allowed if they had been received at a stable dose for > 30 days. The dosage of the levetiracetam tablets ranged from 1000 to 3000 mg/d in 2 divided doses. The treatment phase lasted 3 months. The primary end point was headache frequency (expressed as the number of headache days per month), and the secondary end point was the frequency of moderate or severe headache (d/mo). Other end points were headache score, Migraine Disability Assessment (MIDAS) Questionnaire score, and Headache Impact Test (HIT-6) score. Statistical analyses were performed in the intent-to-treat (ITT) population (patients who received at least 1 dose of study medication) using data subjected to the last-observation-carried-forward algorithm. We also conducted per-protocol (PP) analyses in patients who completed the study.

RESULTS

The ITT population consisted of 36 patients (26 women, 10 men;mean [SD] age, 46.5 [17.4] years). The mean headache frequency at baseline was 24.9 d/mo, and a significant reduction in headache frequency was obtained at l, 2, and 3 months of treatment (19.4, 18.4, and 16.2 d/mo, respectively; all, P < 0.001 Reproduction in whole or part is not permitted. vs baseline). At baseline, the mean number of moderate or severe headache days was 16.8 d/mo compared with 13.2, 11.9, and 9.7 d/mo at 1, 2, and 3 months, respectively (P=NS, <0.01, and <0.01, respectively). The mean MIDAS score was significantly reduced at 3 months compared with baseline (40.8 vs 62.8 d/mo; P = 0.01). The mean HIT-6 score was 59.4 at 3 months versus 63.4 at baseline (P < 0.01). In the PP population, the mean (SD) headache frequency was reduced from 26.1 (4.1) d/mo at baseline to 14.3 (4.8) d/mo at the end of the study (P < 0.001). The mean (SD) headache score was reduced from 51.3 (17.1) at baseline to 34.0 (22.0) at 3 months (P < 0.016).

CONCLUSION

The results of this study in patients with TM support the role of levetiracetam in the preventive treatment of refractory TM.

Botulinum Toxin Type A for the Prophylaxis of Chronic Daily Headache: Subgroup Analysis of Patients Not Receiving Other Prophylactic Medications: A Randomized Double‐Blind, Placebo‐Controlled Study

OBJECTIVE

To assess the efficacy and safety of botulinum toxin type A (BoNT-A; BOTOX, Allergan, Inc., Irvine, CA) for the prophylaxis of headaches in patients with chronic daily headache (CDH) without the confounding factor of concurrent prophylactic medications.

BACKGROUND

Several open-label studies and an 11-month, randomized, double-blind, placebo-controlled study suggest that BoNT-A may be an effective therapy for the prophylaxis of headaches in patients with CDH.

DESIGN AND METHODS

This was a subgroup analysis of an 11-month, randomized double-blind, placebo-controlled study of BoNT-A for the treatment of adult patients with 16 or more headache days per 30-day periods conducted at 13 North American study centers. All patients had a history of migraine or probable migraine. This analysis involved data for patients who were not receiving concomitant prophylactic headache medication and who constituted 64% of the full study population. Following a 30-day screening period and a 30-day single-blind, placebo injection, eligible patients were injected with BoNT-A or placebo and assessed every 30 days for 9 months The following efficacy measures were analyzed per 30-day periods: change from baseline in number of headache-free days; change from baseline in headache frequency; proportion of patients with at least 30% or at least 50% decrease from baseline in headache frequency; and change from baseline in mean headache severity. Acute medication use was assessed, and adverse events were recorded at each study visit.

RESULTS

Of the 355 patients randomized in the study, 228 (64%) were not taking prophylactic medication and were included in this analysis (117 received BoNT-A, 111 received placebo injections). Mean age was 42.4+/-10.90 years; the mean frequency of headaches per 30 days at baseline was 14.1 for the BoNT-A group and 12.9 for the placebo group (P=.205). After two injection sessions, the maximum change in the mean frequency of headaches per 30 days was -7.8 in the BoNT-A group compared with only -4.5 in the placebo group (P=.032), a statistically significant between-group difference of 3.3 headaches. The between-group difference favoring BoNT-A treatment continued to improve to 4.2 headaches after a third injection session (P=.023). In addition, BoNT-A treatment at least halved the frequency of baseline headaches in over 50% of patients after three injection sessions compared to baseline. Statistically significant differences between BoNT-A and placebo were evident for the change from baseline in headache frequency and headache severity for most time points from day 180 through day 270. Only 5 patients (4 patients receiving BoNT-A treatment; 1 patient receiving placebo) discontinued the study due to adverse events and most treatment-related events were transient and mild to moderate in severity.

CONCLUSIONS

BoNT-A is an effective and well-tolerated prophylactic treatment in migraine patients with CDH who are not using other prophylactic medications.

Botulinum Toxin Type A (BOTOX ® ) for the Prophylactic Treatment of Chronic Daily Headache: A Randomized, Double‐Blind, Placebo‐Controlled Trial

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of botulinum toxin type A (BoNT-A; BOTOX, Allergan, Inc.) for the prophylactic treatment of chronic daily headache (CDH).

BACKGROUND

Several open-label and small controlled trials suggest that BoNT-A may be effective in the prophylactic treatment of headache.

DESIGN AND METHODS

This was an 11-month, randomized double-blind, placebo-controlled study of BoNT-A for the treatment of patients aged 18 to 65 years old with 16 or more headache days per 30 days conducted at 13 North American study centers. Following a 30-day screening period and a 30-day, single-blind, placebo-response period to identify placebo responders, eligible patients from both the placebo responder and placebo nonresponder groups were injected with BoNT-A or placebo every 90 days and assessed every 30 days for 9 months, a period encompassing three treatment cycles. The primary efficacy measure was the change from baseline in the frequency of headache-free days in a 30-day period for the placebo nonresponder group at day 180, the chosen efficacy time point. The secondary efficacy measure was the proportion of patients with a decrease from baseline of 50% or more in the frequency of headache days per 30-day period for the placebo nonresponder group at day 180. The change from baseline in the frequency of headaches (per 30-day period), the proportion of patients with a decrease from baseline of 50% or greater in the frequency of headaches per 30-day period, acute medication use, and adverse events were also assessed.

RESULTS

Of 571 patients assessed over the baseline period, 355 (mean age, 43.5 years; 300/355 [84.5%] female) were enrolled and randomized. At the end of the placebo run-in period, 279 patients (79%) were classified as placebo nonresponders and 76 patients (21%) as placebo responders. Subsequently, patients were randomized within each group to receive either BoNT-A or placebo. In the placebo nonresponder stratum, the mean number of headache-free days at baseline was 5.8 (+/-4.7) for BoNT-A- versus 5.5 (+/-4.7) for placebo-treated patients. At day 180, placebo nonresponders treated with BoNT-A had an improved mean change from baseline of 6.7 headache-free days per 30-day period compared to a mean change from baseline of 5.2 headache-free days for placebo-treated patients. The between-group difference of 1.5 headache-free days favored BoNT-A treatment, although the difference between the groups was not statistically significant. However, a statistically significant difference was observed at day 180 endpoint for the secondary efficacy measure. A significantly higher percentage of BoNT-A patients had a decrease from baseline of 50% or greater in the frequency of headache days per 30-day period at day 180 (32.7% vs. 15.0%, P=.027). Also, the mean change from baseline in the frequency of headaches per 30-day period at day 180 was -6.1 for BoNT-A patients vs. -3.1 for the placebo patients (P=.013). Only 4 of 173 BoNT-A patients (2.3%) discontinued the study due to adverse events. The majority of treatment-related adverse events were transient and mild to moderate in severity.

CONCLUSIONS

BoNT-A treatment resulted in patients having, on average, approximately seven more (1 week) headache-free days compared to baseline. Although at the primary time point (day 180) the BoNT-A treatment resulted in a 1.5 between-group difference compared to placebo, this difference was not statistically significant. The treatment met secondary efficacy outcome measures, including the percentage of patients experiencing a 50% or more decrease in the frequency of headache days, in addition to statistically significant reductions in headache frequency. BoNT-A was also well tolerated in patients with CDH.

Migraine: Epidemiology, Impact, and Risk Factors for Progression

Migraine is a chronic and sometimes progressive disorder characterized by recurrent episodes of headache and associated symptoms. This article reviews the epidemiology of and the risk factors for migraine described in population studies, and discusses the burden of disease and the socioeconomic costs of migraine. In the years prior to puberty, migraine is more common among boys than girls. By the onset of puberty, migraine is more prevalent in girls, and by the late teens, females are about twice as likely to suffer from migraine as males. The prevalence of migraine peaks in both sexes during the most productive years of adulthood (age 25 to 55 years) and, in the United States, the prevalence is higher in individuals of lower socioeconomic status. Direct costs of migraine include the cost of migraine medications and health care expenses. Indirect costs associated with migraine include reduced productivity due to absenteeism and reduced performance while at work. Recent evidence suggests that a subgroup of migraine patients may have a clinically progressive disorder. Future epidemiologic studies should focus on identifying patients who are at higher risk for progression and on assessing the impact of intervention strategies on disease progression.

Low Income and Education Levels May Cause Medication Overuse and Chronicity in Migraine Patients

BACKGROUND

Frequent analgesic drug intake, especially in migraine patients, may induce the risk of medication overuse headache (MOH). The various conditions that may affect the development and the features of MOH have not been determined yet.

AIM

To compare MOH patients with migraine as pre-existing headache and episodic migraine patients according to socioeconomic and educational variables.

METHODS

Forty-six MOH patients with migraine as pre-existing headache and 61 migraine patients were included into study. The headache characteristics, socioeconomic and educational variables of MOH and migraine groups and subgroups divided according to the education (low/high education subgroups), and income (low/high income subgroups) levels were evaluated.

RESULTS

We found that mean duration of education was shorter in MOH patients than migraine patients. There was a negative correlation between duration of education and duration of MOH. The mean duration of MOH was longer and rate of low-income level was higher in patients with low-education level. The duration of education was lower in MOH patients with low income. The frequency of migraine attacks and low-income rate was also higher in low-educated migraine patients. The duration of education was shorter in migraine patients with low income.

CONCLUSION

We report that migraineurs with low socioeconomic status may have risk of developing MOH. A better identification of patients at risk of drug-associated headache may contribute to improved health in a group of patients with MOH.

Disability in chronic migraine patients with medication overuse: treatment effects at 1-year follow-up

OBJECTIVE

To determine (1) the clinical course of a sample of chronic migraine patients with drug overuse 6 and 12 months following in-patient treatment and (2) whether functional impairment, assessed by the Migraine Disability Assessment (MIDAS) questionnaire, improved upon treatment.

BACKGROUND

Patients with chronic migraine and medication overuse are particularly difficult to treat (prophylactic medications that otherwise are effective become ineffective; discontinuation of the offending medication can lead to withdrawal headache; physical and emotional dependence can be present, as well as increased psychological involvement; initial treatment gains can be difficult to maintain).

METHODS

Of the 106 patients meeting criteria for chronic migraine with medication overuse, 84 went on to complete a structured in-patient treatment, consisting of medication withdrawal and then prophylactic treatment.

RESULTS

As a group, the patients were improved at both 6- and 12-month follow-up, with respect to two headache parameters (frequency and medication use) and three measures of functional impact extracted from the MIDAS questionnaire (Total Score, Headache Frequency, and Headache Intensity).

CONCLUSION

Chronic migraine accompanied with medication overuse led to the considerable disability prior to treatment. However, notable improvement occurred coincident with the treatment. This suggests that successful treatment has more wide-ranging positive benefits beyond mere symptom reduction. To our knowledge, this is the first investigation where the MIDAS questionnaire has been used prospectively as an outcome measure in patients with chronic migraine and medication overuse to assess disability subsequent to a semi-standardized treatment program.

Chronic daily headaches in pediatric neurology practice

Using a comprehensive computerized database for a single general pediatric neurology ambulatory practice, the clinical profile, together with the precipitating features and outcomes, in a consecutive series of children with chronic daily headache was ascertained. Chronic daily headache was defined as persistent or daily headaches of at least 3 months' duration. Children with persistent headaches owing to a serious medical condition were specifically excluded from analysis. Of 1669 children (24% of total seen) referred over an 11-year inclusive interval for the evaluation of headaches, 50 (3%) merited a diagnosis of chronic daily headache. The overwhelming majority were female (45/50; 90%), with a mean age at diagnosis of 12.9 years (range 7-16 years). Transformed migraine was determined to be the etiology in the majority (35/50; 70%), with a minority attributable either to postconcussion syndrome (7/50; 14%) or new daily persistent headaches (6/50; 12%). Analgesic abuse was evident in a majority (26/50; 52%). Treatment consisted predominantly of migraine and analgesic education, with a majority of children (42/50; 84%) also receiving daily prophylaxis. Four fifths (41/50; 82%) returned for at least one follow-up. Of these, 56% (23/41) were improved, 32% (13/41) unchanged, and 12% (5/41) worse. Eventually, almost half (20/41) experienced complete resolution of their headache symptoms, with a mean time to resolution of 8 months (range 2-48 months). Children with chronic daily headache are thus a small subset of children with headache seen in general ambulatory practice. They tend to be females in the midteen years experiencing a transformed migraine complicated by analgesic abuse, suggesting potential preventability. Simple measures, which can include the use of prophylactic agents, can be expected to result in improvement and eventual resolution of headache symptoms.

Depression and migraine

The objective of this study was to evaluate both the presence and intensity of depressive symptoms in patients with episodic migraine (EM) and transformed migraine (TM) or chronic migraine, comparing them with a control group. Beck Depression Inventory (BDI) was used for this purpose. The median of BDI score of the control group was significantly lower than the EM and TM groups (p<0.0005). Either the EM or the TM did not show any significant difference in relation to the median of BDI scores (p=0.12). The TM group showed a higher frequency of severe depression when analyzed qualitatively by dependence analysis. Symptoms of severe depression by means of qualitative analysis may strengthen a co-morbidity between depression and transformed migraine. This association might be considered rather a factor of TM perpetuation than a risk factor for the transformation of EM into TM.

Challenging or difficult headache patients

This article addresses interesting and enigmatic presentations of headache from a diagnostic and treatment perspective. The emphasis is on migraineurs and other headache patients who represent a significant burden for the primary care provider. In particular, the author focuses on undiagnosed migraine, menstrual migraine, migraine in pregnancy, intractable migraine and status migrainosus,transformed migraine, hemiplegic migraine, basilar migraine, "triptan syndrome," sudden onset of severe headache, post-traumatic headache, and headache in elderly patients.

Drug-induced headache

Medication overuse headache is a common complex disorder with physical and psychologic elements. Treatment may be difficult but often is accomplished in an outpatient setting. Some patients require inpatient treatments. An option for some is day treatment with i.v medication in an infusion center over several consecutive days. The two most common classes of drugs that acutely induce headache are NO donors, typified by NTG, and PDE inhibitors, typified by sildenafil. NO donors cause a biphasic headache in migraineurs and PDE inhibitors a monophasic one.

Chronic Daily Headache: Correlation Between the 2004 and the 1988 International Headache Society Diagnostic Criteria

BACKGROUND

In a previous study, we compared the 1988 International Headache Society (IHS) criteria and the Silberstein-Lipton criteria (S-L) in a subspeciality clinic sample of 638 patients with chronic daily headache (CDH) assessed both clinically and with headache diaries. Both systems allowed for the classification of most patients with CDH. The 1988 IHS classification required multiple diagnoses and was more complex to apply.

OBJECTIVES

The aim of this study was to revisit the same database, now comparing the prior classification systems with the new 2004 IHS classification. In contrast with the 1st edition, the 2nd edition includes criteria for chronic migraine (CM), new daily persistent headache (NDPH), and hemicrania continua (HC).

METHODS

We reviewed the clinical records and the headache diaries of 638 patients seen between 1980 and 2001 at a headache center. All patients had primary CDH according to the S-L criteria.

RESULTS

Using the S-L criteria as a reference, of the 158 patients with transformed migraine (TM) without medication overuse, just 9 (5.6%) met 2004 IHS criteria for CM. Most of the subjects were classified using combinations of migraine and CTTH diagnoses, much like the 1988 IHS classification. Similarly, using the new IHS system, just 41/399 (10.2%) subjects with TM with medication overuse were classified as probable CM with probable medication overuse. Most patients with NDPH without overuse were easily classified using the 2004 criteria (95.8%). Regarding NDPH with medication overuse, the diagnostic groups were much like results for the 1st edition. All patients with chronic tension-type headache (CTTH) and hemicrania continua (HC) according to the S-L system were easily classified using the 2004 IHS criteria.

CONCLUSIONS

We conclude that the 2004 IHS criteria facilitate the classification of NDPH without medication overuse and HC. For subjects with TM according to the S-L system, the new IHS criteria are complex to use and require multiple diagnoses. Very few patients with TM in the S-L system could be classified with a single diagnosis in the 2004 IHS classification. In fact, CM was so rare that it would be virtually impossible to conduct clinical trials of this entity using the 2004 IHS criteria. Clinical trials of this entity should therefore be conducted using the S-L criteria. Finally, we propose that in the 3rd edition of the IHS classification, the diagnosis of NDPH be revised so as not to exclude migraine features.