An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score

Use of a Pine Bark Extract and Antioxidant Vitamin Combination Product as Therapy for Migraine in Patients Refractory to Pharmacologic Medication

OBJECTIVE

To evaluate the potential benefit of a pine bark extract and antioxidant vitamin combination product in the treatment of migraine headache.

BACKGROUND

This was an uncontrolled preliminary study to investigate the potential of an antioxidant formulation as therapy for migraine headache.

METHODS

Twelve patients with a long-term history of migraine with and without aura who had failed to respond to multiple treatments with beta-blockers, antidepressants, anticonvulsants, and 5-hydroxytryptamine receptor agonists were selected for the study. They were treated with 10 capsules of an antioxidant formulation of 120 mg pine bark extract, 60 mg vitamin C, and 30 IU vitamin E in each capsule daily for 3 months. Following enrollment patients completed a migraine disability assessment (MIDAS) questionnaire to give a baseline measure of migraine impact on work, school, domestic, and social activities over the previous 3 months. Patients were then treated for 3 months with the antioxidant formulation while continuing to receive existing pharmacologic medications. A second MIDAS was given at the conclusion of the treatment period.

RESULTS

There was a significant mean improvement in MIDAS score of 50.6% for the 3-month treatment period compared with the 3 months prior to baseline (P < .005). The treatment was also associated with significant reductions in number of headache days and headache severity score. Mean number of headache days was reduced from 44.4 days at baseline (95% CI 28.9 to 59.8) to 26.0 days (95% CI 5.3 to 46.7; P < .005) after 3 months' therapy and mean headache severity was reduced from 7.5 of 10 (95% CI 6.7 to 8.4) to 5.5 (95% CI 4.1 to 7.0; P < .005).

CONCLUSION

These data suggest that the antioxidant therapy used in this study may be beneficial in the treatment of migraine possibly reducing headache frequency and severity. Further clinical investigation into the efficacy of antioxidant as therapy for chronic migraine is warranted.

Reliability, Validity, and Clinical Utility of the Migraine-ACT Questionnaire

BACKGROUND

The 4-item Migraine-ACT questionnaire is an assessment tool for use by primary care physicians to identify patients who require a change in their current acute migraine treatment. It has been shown to be easy to use, and to be reliable and accurate in its assessments.

OBJECTIVES

To further analyze the Migraine-ACT study database, providing additional information on the reliability, validity, and potential clinical utility of the questionnaire.

METHODS

Reliability was assessed by recording the distribution of Migraine-ACT scores recorded at baseline and 1 week later (test-retest reliability). Analyses of consistency of Migraine-ACT scores were conducted on the total sample of patients and for the separate centers, using Pearson and Spearman correlations. Validity was assessed by comparing the t-discrimination values for clinically relevant questions within domains of the original 27-item questionnaire. Reliability and validity were also assessed by constructing an "alternative" (Form B) Migraine-ACT questionnaire, derived from an analysis of the second-best items in each domain in the original study data. Clinical utility was assessed using Pearson pairwise correlations to compare Migraine-ACT scores with clinically defined criteria as analyzed by the SF-36 Quality of Life questionnaire, the Migraine Disability Assessment (MIDAS) questionnaire, and the Migraine Therapy Assessment (MTAQ) questionnaire.

RESULTS

The distribution of Migraine-ACT scores between the 2 completions of the questionnaire was consistent for the total sample (test-retest reliability, r= .81) and between the individual countries (r= .61 to .92). In this study, the validity (assessed as t-discrimination) of the Migraine-ACT "impact" and "global assessment of relief" questions were markedly higher than those of other endpoints used in migraine clinical studies. The Form B Migraine-ACT questionnaire was almost as reliable and accurate as the original Form A questionnaire. The distribution of Migraine-ACT scores was: 0 = 12.6%, 1 = 13.7%, 2 = 14.7%, 3 = 20.5%, and 4 = 38.4%. The change in Migraine-ACT score correlated with, and had a linear relationship with changes in SF-36, MIDAS, and MTAQ scores, and indicated that a Migraine-ACT score of <or=2 corresponded with a need to consider changing the patient's acute medication. About 40% of the migraine patients in the study scored <or=2 and may have had significant unmet treatment needs.

CONCLUSIONS

These data confirm the excellent reliability and validity of the Migraine-ACT questionnaire and provide further evidence for its utility in clinical practice.

Hormones, menstrual distress, and migraine across the phases of the menstrual cycle

OBJECTIVE

The primary objectives of the present study were to (1) contrast reproductive hormone levels and ratings of menstrual distress of female migraineurs with those of a control group in each menstrual cycle phase, (2) examine correlations between hormone levels and migraine frequency, severity, and migraine-related disability, and (3) examine correlations between menstrual distress and migraine frequency, severity, and migraine-related disability. A secondary objective was to evaluate the validity of a migraine disability measure modified to reflect 7-day recall.

BACKGROUND

Further controlled, prospective study is needed regarding the temporal relationships between reproductive hormones at each stage of the menstrual cycle and fluctuations in migraine activity across the cycle.

METHODS

Twenty-three women (17 with migraine, 6 control participants) completed laboratory hormone assays and measures of menstrual distress and disability at each phase of one menstrual cycle, and monitored their headache activity daily during the same cycle. Results.-The migraine group evidenced lower premenstrual luteinizing hormone and more menstrual distress symptoms at each phase of the menstrual cycle. Hormones were associated with migraine activity and disability within cycle phases, and across phases in a time-lagged manner. Menstrual distress was associated with ovulatory phase migraine activity and with migraine-related disability across the menstrual cycle. A retrospective 7-day migraine disability measure appeared to be a consistently valid index.

CONCLUSIONS

Both reproductive hormones and menstrually related distress appear to predict migraine activity and disability. These associations were evident not only for perimenstrual migraine, but also for migraine at each phase of the menstrual cycle.

The Contribution of Pain-Related Anxiety to Disability from Headache

Disability associated with headache cannot be fully accounted for by pain intensity and headache frequency. As such, a variety of cognitive and affective factors have been identified to help explain headache-related disability beyond that accounted for by pain levels. Pain-related anxiety, a multidimensional construct, also has been found to contribute to disability in headache sufferers. What is not known is whether pain-related anxiety is unique in contributing to disability beyond the role of headache-specific cognitive factors and emotional distress. The present study examines the influence of pain-related anxiety on disability, after controlling for pain, cognitive (self-efficacy and locus of control), and affective factors (emotional distress) in a sample of 96 primary headache sufferers. Pain, headache-related control beliefs, and emotional distress accounted for 32%, with locus of control related to health care professionals contributing unique variance. In the full model, with the addition of pain-related anxiety, only pain-related anxiety was a unique predictor of disability. These findings suggest that pain-related anxiety may have a unique and important role in contributing to disability in headache sufferers.

Validity, Reliability and Application of the Taiwan Version of the Migraine Disability Assessment Questionnaire

BACKGROUND/PURPOSE

The seven-item Migraine Disability Assessment (MIDAS) questionnaire is a simple and useful tool for evaluating migraine-related disability. The goals of this study were: (1) to test the reliability and validity of the Taiwan version of the MIDAS (MIDAS-T) questionnaire, and (2) to measure the impact of migraine among Taiwanese patients in a headache clinic.

METHODS

Consecutive migraine patients, aged 20-50 years, visiting the headache clinic at the Taipei Veterans General Hospital were invited to participate in the study. They completed the MIDAS-T and a form, which collected headache-related information including characteristics and impact on their lives. Of them, about 30 patients were randomly invited to repeat the MIDAS-T 3 weeks later.

RESULTS

A total of 281 migraine patients (M/F, 63/218; mean age, 35.27 +/- 8.21 years) participated in the study. Of them, 31 completed the MIDAS-T again 3 weeks later. MIDAS-T showed acceptable internal consistency (Cronbach alpha = 0.79), test-retest reliability (r = 0.67) and criterion validity (r = 0.37 for question A [headache frequency] and r = 0.34 for question B [headache intensity], p < 0.001). The mean score of migraine patients on MIDAS-T was 34.21 +/- 45.90, ranging from 0 to 265. MIDAS grade I (score 0-5) was found in 22% of patients, grade II (6-10) in 15%, grade III (11-20) in 17%, and grade IV (>or=21) in 46%.

CONCLUSION

This study supports the reliability and validity of MIDAS-T for use in Taiwanese patients. Almost half of the migraine patients were classified as having severe disability (grade IV).

Medication-overuse headache: Description, treatment, and relapse prevention

Medication-overuse headache (MOH) has increasingly become a focus within the field of headache. The biologic and physiopathologic origin for MOH likely resides in receptor physiology, but it also is probable that the initiation and sustaining dynamics of this pathologic condition involve several other factors. Not all patients with frequent headache eventually overuse their medications, but when it happens (the percentage is approximately 1%), the diagnosis of MOH is clinically important because patients rarely respond to preventive medications while overusing acute medications. Properly treating medication overuse and preventing relapse require recognition of the different factors that contribute to its development and perpetuation, including some behaviors and psychologic elements that are important in sustaining the overuse of medication. The problem regarding the diagnosis, the classification, and clinical aspects of MOH is reviewed in this article. The different therapeutic approaches, initial outcomes, and long-term durability of treatment also are discussed.

Evolution of Migraine After a 10-Year Follow-Up

OBJECTIVE

To assess the evolution of headaches in a workplace cohort over a 10-year period.

BACKGROUND

Migraine headaches are associated with significant handicap in everyday activities and poor quality of life. The prevalence of migraine shows a bell-shaped age distribution with a peak during the third and fourth decades. However, there is little longitudinal data available on the natural history of this condition. A prospective health survey undertaken in a large workplace cohort since 1989 provides an opportunity to assess the evolution of migraine and other headache syndromes over a 10-year period.

METHODS

A sample of 2500 subjects who reported regular headaches was chosen at random from those with headache identified in a cohort of 46,244 employees of the French national power company aged between 35 and 50 years in 1989 participating in a yearly health survey. In 1993, all subjects were sent a headache questionnaire to complete and return. In 2003, an identical questionnaire was sent to all subjects who had returned exploitable data in 1993. Headache diagnosis was assigned retrospectively using the International Headache Society (IHS) criteria to migraine (IHS categories 1.1 and 1.2), migrainous disorder (IHS category 1.7), or other episodic headaches.

RESULTS

Of 2500 subjects sampled, 2051 (82%) returned exploitable data for the first questionnaire in 1993. In 2003, 1250 (61%) of these provided a second data set. In 1993, 623 (30.4%) of subjects fulfilled diagnostic criteria for migraine. However, only 37% of these retained the diagnosis 10 years later. In contrast, the proportion of subjects with other forms of episodic headache rose from 23.7% to 31.6%. In 2003, 9.5% of the sample were headache-free. Retention or acquisition of a diagnosis of migraine was more common in women than in men, and age was associated with evolution to a less severe headache syndrome. In those subjects who continued to have headaches, frequency and severity were lower at the second assessment.

CONCLUSIONS

Only a minority of subjects diagnosed with migraine or migrainous disorder retain the diagnosis 10 years later, with most subjects evolving to a less disabling headache type.

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.

Burden of Illness and Satisfaction With Care Among Patients With Headache Seen in a Primary Care Setting

OBJECTIVE

To assess the current level of headache burden and the headache management needs at three diverse clinical sites.

BACKGROUND

Headache is a common disabling disorder that is costly for the patient and a management challenge for physicians. The determination of whether and how to intervene to improve headache management depends on both the burden of disease and the characteristics of patients that would likely be targeted.

METHODS

Patients from three healthcare organizations were identified by administrative records as having either migraine or tension-type headache and then mailed a survey that addressed demographics, headache type, headache-related disability, depression and anxiety, satisfaction with care, general health, worry about headache, problems with headache management, and healthcare utilization. Comparisons were made across sites and between patients with more and less severe headache-related impairments.

RESULTS

Of the 789 patients contacted, 385 (50%) returned a survey. While the socio-demographic characteristics of the patients were diverse, headache-related characteristics were similar. These patients have significant problems with headache management, disability, pain, worry, and dissatisfaction with care. Patients who described higher headache-related impairment experienced significantly greater problems in these areas, perceived themselves to be in worse general health, and had significantly greater use of medical services than those with lower headache severity.

CONCLUSIONS

Despite various elements of heterogeneity, we observed across the sites a consistent need for improvement in headache management. Future efforts should be directed at developing and evaluating methods for effectively improving headache management.

Disability is the major determinant of the severity of depressive symptoms in primary headaches but not in low back pain

Pain syndromes are often associated with depression. In a prospective study we analysed if determinants of depression differ among patients with different primary headaches and between headaches and non-headache pain. During a 2-year period between 1 February 2002 and 31 January 2004, 635 subjects (migraine n = 231; tension-type headache n = 176; cluster headache n = 11; patients with low back pain n = 103; and healthy subjects n = 114) seen by two neurologists filled in a questionnaire on pain characteristics, the MIDAS questionnaire and the Beck Depression Inventory. A multivariate general regression model was used to identify independent predictors of the severity of depressive symptoms. Pain was most frequent in chronic tension-type headache and most intense in the cluster subgroup (P < 0.001, Kruskal-Wallis ANOVA). In univariate tests gender, age, pain frequency, pain intensity and disability were all significantly associated with the severity of depressive symptoms. In the multivariate model disability was the most important independent determinant of the severity of depressive symptoms in the pooled headache group as well as in the migraine and tension-type headache subgroups. In contrast to patients with headache, pain frequency and pain intensity were the significant independent predictors of the severity of depressive symptoms in patients with low back pain. In a multivariate model, after controlling for other factors, determinants of the severity of depressive symptoms were different in headache and non-headache pain subjects, suggesting a different mechanism for developing depression in primary headaches and in other pain syndromes.

Outcome Measurement in Behavioral Headache Research: Headache Parameters and Psychosocial Outcomes

The experience of pain is complex and includes multiple dimensions or aspects, such as sensory and affective (among others). Headache includes not only pain, but also associated symptoms that can further diversify the relevant dimensions. Subjective ratings of head pain, sampled daily, have come to be regarded as the "gold standard" in behavioral headache research. Primary measures of headache include the attack frequency or headache days per month. Secondary measures of headache may include headache activity/index, headache duration, peak headache severity, and/or frequency of severe headaches per month. Secondary measures of disability and quality of life include Migraine Disability Assessment (MIDAS), Headache Impact Test (HIT), Headache Disability Inventory (HDI). Secondary nonheadache measures include medication consumption, psychiatric symptoms, stress and coping, treatment satisfaction and preference, side effects, and others. Researchers should include not only primary measures of headache, but also secondary measures, disability and quality of life, and nonheadache measures. All measures should be clearly defined and reported. A baseline period that is adequate for each measure needs inclusion and a minimum of 4 weeks is recommended for primary headache measures. Specific suggestions for future research directions are provided.

Depressive Symptoms and Insecure Attachment as Predictors of Disability in a Clinical Population of Patients With Episodic and Chronic Migraine

OBJECTIVES

To define predictors of migraine-related disability in patients with episodic and chronic migraine referred to a specialty migraine clinic, focusing on depressive symptoms and insecure attachment style that, because of their association with responses to pain and physical illness, might be predictive of greater migraine-related disability.

BACKGROUND

The Migraine Disability Assessment questionnaire (MIDAS) has proved to be a reliable and easy-to-use instrument to assess migraine-related disability. As clinicians are increasingly using MIDAS in their diagnostic and treatment decisions for patient care, an understanding of the factors influencing migraine-related disability is essential for a rationale use of such an instrument.

METHODS

Two-hundred patients suffering from episodic migraine without aura (EM), and chronic migraine (CM) with and without medication overuse, and referred to a specialty headache clinic were evaluated using the MIDAS, the Beck Depression Inventory (BDI), and the Attachment Style Questionnaire (ASQ). Diagnosis of episodic and chronic migraine was operationally defined according to the International Headache Society (IHS) and Silberstein-Lipton criteria.

RESULTS

Multiple regression analysis showed that, in the total sample, disability was higher in those patients with CM, more severe depressive symptoms, an insecure style of attachment (as reflected by a lower score on the ASQ confidence scale), and experiencing more severe headache pain intensity. In the subgroup of patients with episodic migraine, an insecure style of attachment emerged as the most significant predictor of disability (other significant predictors were female sex and number of headache days per month). In contrast, in the subgroup of patients with CM, the only significant predictor of the total MIDAS score was a greater severity of depressive symptoms.

CONCLUSIONS

Our findings demonstrate the relevance of attachment style, an enduring psychological trait not evaluated in previous studies, in influencing the disability level in patients with migraine and confirm the role of comorbid depressive symptoms in modulating the impact of migraine on every day functioning.

Fibromyalgia and headache: an epidemiological study supporting migraine as part of the fibromyalgia syndrome

Fibromyalgia is defined by widespread body pain, tenderness to palpation of tender point areas, and constitutional symptoms. The literature reports headache in about half of fibromyalgia patients. The current epidemiological study was designed to determine the prevalence and characteristics of headache in fibromyalgia patients. Treatment-seeking fibromyalgia patients were evaluated with measures for fibromyalgia, chronic headache, quality of life, and psychological distress. Multivariate analysis of variance (MANOVA) and t-tests were used to identify significant differences, as appropriate. A total of 100 fibromyalgia patients were screened (24 fibromyalgia without headache and 76 fibromyalgia with headache). International Headache Society diagnoses included: migraine alone (n = 15 with aura, n = 17 without aura), tension-type alone (n = 18), combined migraine and tension-type (n = 16), post-traumatic (n = 4), and probable analgesic overuse headache (n = 6). Fibromyalgia tender point scores and counts and most measures of pain severity, sleep disruption, or psychological distress were not significantly different between fibromyalgia patients with and without headache. As expected, the fibromyalgia patients with headache scored higher on the Headache Impact Test (HIT-6) (62.1 +/- 0.9 vs 48.3 +/- 1.6, p < 0.001). HIT-6 scores were >60 in 80% of fibromyalgia plus headache patients, representing severe impact from headache, and 56-58 in 4%, representing substantial impact. In summary, chronic headache was endorsed by 76% of treatment-seeking fibromyalgia patients, with 84% reporting substantial or severe impact from their headaches. Migraine was diagnosed in 63% of fibromyalgia plus headache patients, with probable analgesic overuse headache in only 8%. General measures of pain, pain-related disability, sleep quality, and psychological distress were similar in fibromyalgia patients with and without headache. Therefore, fibromyalgia patients with headache do not appear to represent a significantly different subgroup compared to fibromyalgia patients without headache. The high prevalence and significant impact associated with chronic headache in fibromyalgia patients, however, warrants inclusion of a headache assessment as part of the routine evaluation of fibromyalgia patients.

An assessment of the burden of migraine using the willingness to pay model

Willingness to pay methods measure treatment preferences and also measure the burden of illness in economic terms. We used a contingent valuation method to measure migraine sufferers' willingness to pay (WTP) for acute medication for their most severe headache attacks, based on various profiles of treatment benefits and the characteristics of the migraine sufferer. Subjects were identified from a population-based database of migraine sufferers, previously recruited by random digit dialing. Telephone interviews (n = 1428) were used to gather demographic and headache characteristics. Subjects who met the International Headache Society criteria for migraine with or without aura and satisfied the other inclusion criteria based on telephone interview (n = 312) were invited to participate in a mailed questionnaire study. The questionnaire was mailed to the 310 subjects who agreed to participate and 201 (65%) surveys were returned. The survey included questions on the demographics, the migraine characteristics, and the psychological disposition of the respondents. WTP for an acute migraine treatment with 14 different hypothetical treatment profiles was explored. Responders and non-responders to the survey were generally similar. The newly designed WTP questionnaire had high internal consistency (Cronbach's alpha 0.90) and test-retest reliability (Spearman's correlation coefficients 0.71-0.77). Study subjects were willing to pay a median price of US 5 dollars for a migraine treatment that provided complete relief in 30 min and worked 100% of the time, with no side-effects and no headache recurrence. Median WTP decreased as treatment attributes deviated from this ideal. For example, WTP declined to a median of US 1 dollar for complete relief in 2 h and to US 0.25 dollars for complete relief in 4 h. All of the medication attributes powerfully influenced WTP. Several variables predicted WTP including current payment for medication, MIDAS (Grade III), and those with headaches of long duration. Subjects who employed a greater number of coping skills were less willing to pay. Patient demographics and migraine severity predict WTP, but treatment attributes were also important. As treatment improves, WTP for migraine medications is likely to increase.

Use of the headache impact test (HIT-6) in general practice: relationship with quality of life and severity

To assess the global impact of episodic headaches in patients consulting general practitioners (GPs) using the Headache Impact Test (HIT-6) questionnaire, and to compare this with measures of headache severity and quality of life. A total of 2802 patients consulting 349 GPs participated to this cross-sectional study. Data were collected on headache severity using the Migraine Severity (MIGSEV) scale, headache impact with the HIT-6 and quality of life with the Qualité de Vie et Migraine (QVM) questionnaire. Diagnosis was assigned retrospectively according to the International Headache Society criteria. The association between the HIT-6 scale and the other scales was determined from a Pearson's chi-square test, an analysis of variance and Spearman correlation coefficients. Patients (2537) provided exploitable data. Six percent of the sample had little impact, 14% moderate, 14% substantial and 66% severe impact. The HIT-6 scores were significantly different between diagnostic groups, being highest in the migraine group. The HIT-6 score were well correlated with headache severity and QVM score. The HIT-6 scale correlates, across different diagnostic groups of headache, with both headache severity and with quality of life.

Assessment and management of disability in chronic daily headache

The problem of chronic daily headache is ubiquitous and affects up to 5% of the world's population. In most cases, it is associated with the overuse of symptomatic medications in patients with a history of migraine or tension-type headaches, indicating an urgent need for intensive public and professional education. In a minority, it develops de novo from episodic migraine without excessive drug intake. The condition is likely to have a biologic (rather than psychologic) basis. The degree with which it negatively impacts patients and their family is reviewed. Current treatment regimes are described, but it is noted that those currently employed are seldom adequate in the long term, possibly because of the unavailability of nonpharmacologic treatments to most people or because of the low frequency of use of preventative pharmacologic and lifestyle measures.

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.

Prevalence and impact of migraine and probable migraine in a health plan

BACKGROUND

A large number of headache sufferers with features of migraine fail to meet criteria for strict migraine (SM; migraine with or without aura) but do meet criteria for probable migraine (PM).

OBJECTIVES

To estimate the prevalence of PM, to compare the epidemiologic profiles of SM and PM, and to assess the disability and impact on the health-related quality of life (HRQoL) of these patients.

METHODS

Computer-assisted telephone interviews in a sample recruited from a mixed model health maintenance organization were used. SM, PM, and control subjects were identified. Also assessed were demographic features, disability, HRQoL, and depression.

RESULTS

The 1-year prevalence for SM was 14.7% (19.2% in women and 6.6% in men); for PM, it was 14.6% (15.9% in women, 12.6% in men). Most subjects with PM (82%) did not meet the associated symptom criteria for migraine. HRQoL was reduced in the PM, SM, and all migraine (AM; SM and PM pooled together) groups compared with controls. The proportion of subjects with high disability was elevated in PM (13%), SM (31%), and AM (22%) groups vs controls (3.7%; p < 0.0001).

CONCLUSIONS

Within a health plan, probable migraine is a prevalent form of migraine, with symptom and epidemiologic profiles that overlap with strict migraine. Although strict migraine prevalence was consistent with previous studies, a probable migraine prevalence higher than previously reported was found, perhaps reflecting a difference between health plan and population samples.

The medical care utilization and costs associated with migraine headache

OBJECTIVE

To describe the medical care use and costs associated with migraine.

DESIGN

Retrospective case-control design in which migraine case status was ascertained via validated telephone interview and linked with comprehensive claims data. Unadjusted and adjusted use and cost differences by migraine status were evaluated using exponential score tests and generalized estimating equations.

SETTING AND PATIENTS

We interviewed 8,579 individuals to identify migraine cases (N = 1,265) and a random sample of nonmigraine controls (N = 1,178) among eligible health plan enrollees aged 18 to 55.

MEASURES

Survey responses were used to categorize individuals meeting the International Headache Society's diagnostic criteria for migraine with or without aura as migraine cases and to collect information on comorbid psychiatric symptoms. Claims data were used to compile annual medical and pharmaceutical use and costs, presence of migraine diagnosis, and other diagnosed comorbidities.

RESULTS

Interview-ascertained migraine cases used more outpatient visits (9.1 vs 6.8; P < .01), were more likely to be seen in the emergency department (20.7% vs 17.6%; P < .05), and were admitted to the hospital more (4.5% vs 2.8%; P < .05) compared to nonmigraine controls. Cases incurred significantly higher medical care costs ($2,761 vs $2,064; P < .01). Multivariable model results indicate that much of this increase in costs is due to the presence of major depressive symptoms as well as other diagnosed comorbidities that are more common among those with migraine.

CONCLUSIONS

By combining validated telephone survey information to identify migraine cases and controls with comprehensive claims data, we found migraine cases incur higher medical care costs compared to controls. These increased costs are associated with the presence of psychiatric symptoms and other comorbidities.

Pharmacy and medical claims data identified migraine sufferers with high specificity but modest sensitivity

OBJECTIVE

Claims data are often used to identify and monitor individuals with particular conditions, but many health conditions are not easily recognizable from claims data alone. Patient characteristics routinely available in claims data were used to develop model-based claims signatures to identify migraineurs.

STUDY DESIGN AND SETTING

A validated telephone interview was administered to 23,299 continuously enrolled managed care members aged 18-55 to identify 1,265 migraineurs and 1,178 controls. Responses were linked to medical and prescription claims. Claims variables were evaluated for sensitivity, specificity, and positive and negative predictive value in predicting migraine status. Regression models for predicting migraine status were developed.

RESULTS

Regression-based claims signature models were successful in case-finding, as indicated by fairly sizable odds ratios (OR). In the full model (including demographic, medical, pharmacy, and comorbidity claims variables), a claim for a migraine drug, gender, and a claims-based headache diagnosis were strongly associated with migraine case status (OR=3.9, 3.2, and 3.0, respectively).

CONCLUSION

Using either medical or pharmacy claims provided highly specific and moderately sensitive case-findings. Strategies that combined medical and pharmacy information improved sensitivity and may increase the usefulness of claims for identifying migraine and improving the quality of migraine care.

Validity and Reliability of the Turkish Migraine Disability Assessment (MIDAS) Questionnaire

OBJECTIVES

The aim of this study is to assess the comprehensibility, internal consistency, patient-physician reliability, test-retest reliability, and validity of Turkish version of Migraine Disability Assessment (MIDAS) questionnaire in patients with headache.

BACKGROUND

MIDAS questionnaire has been developed by Stewart et al and shown to be reliable and valid to determine the degree of disability caused by migraine.

DESIGN AND METHODS

This study was designed as a national multicenter study to demonstrate the reliability and validity of Turkish version of MIDAS questionnaire. Patients applying to 17 Neurology Clinics in Turkey were evaluated at the baseline (visit 1), week 4 (visit 2), and week 12 (visit 3) visits in terms of disease severity and comprehensibility, internal consistency, test-retest reliability, and validity of MIDAS. Since the severity of the disease has been found to change significantly at visit 2 compared to visit 1, test-retest reliability was assessed using the MIDAS scores of a subgroup of patients whose disease severity remained unchanged (up to +/-3 days difference in the number of days with headache between visits 1 and 2).

RESULTS

A total of 306 patients (86.2% female, mean age: 35.0 +/- 9.8 years) were enrolled into the study. A total of 65.7%, 77.5%, 82.0% of patients reported that "they had fully understood the MIDAS questionnaire" in visits 1, 2, and 3, respectively. A highly positive correlation was found between physician and patient and the applied total MIDAS scores in all three visits (Spearman correlation coefficients were R= 0.87, 0.83, and 0.90, respectively, P <.001). Internal consistency of MIDAS was assessed using Cronbach's alpha and was found at acceptable (>0.7) or excellent (>0.8) levels in both patient and physician applied MIDAS scores, respectively. Total MIDAS score showed good test-retest reliability (R= 0.68). Both the number of days with headache and the total MIDAS scores were positively correlated at all visits with correlation coefficients between 0.47 and 0.63. There was also a moderate degree of correlation (R= 0.54) between the total MIDAS score at week 12 and the number of days with headache at visit 2 + visit 3, which quantify headache-related disability over a 3-month period similar to MIDAS questionnaire.

CONCLUSION

These findings demonstrated that the Turkish translation is equivalent to the English version of MIDAS in terms of internal consistency, test-retest reliability, and validity. Physicians can reliably use the Turkish translation of the MIDAS questionnaire in defining the severity of illness and its treatment strategy when applied as a self-administered report by migraine patients themselves.

Primary headaches in an outpatient neurology headache clinic in East Hungary

The majority of patients with primary headache do not seek medical help. In the present study we analyse the characteristics of those patients with primary headaches who consulted a single headache outpatient service in East Hungary. All consecutive patients with primary headaches referred to the headache center between February 2002 and April 2003 were asked to fill in a questionnaire on headache characteristics and the migraine disability score (MIDAS) form. A total of 327 patients had some form of primary headache: 42% migraine, 31% tension-type headache, 1% cluster headache and 26% had combination headache. Of the patients 95% were younger than 60 years of age. Only 16% of the patients were male. Chronic daily headache was found in 41% of patients. Although headache was the least severe in tension-type headache, reported disability occurred on much more days in this group than in migraine patients. The majority of patients with primary headache were in the active age group. Patients with tension-type headache need more attention, as disability is more severe in this patient group than generally assumed. More attention to the headaches of men and the elderly could improve the quality of life in these groups of the Hungarian population.

Identifying patients who require a change in their current acute migraine treatment: the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire

BACKGROUND

Currently available measures of the efficacy of acute migraine medications are not frequently used in primary care. They may be too burdensome and complicated for routine use.

OBJECTIVES

To design and test a new, easy to use, 4-item assessment tool, the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire for use by clinicians, to quickly evaluate how a recently prescribed acute medication is working, and to identify patients who require a change of their current acute treatment.

METHODS

A 27-item Migraine-ACT questionnaire was developed by an international advisory board of headache specialists. Questions were formulated in four domains: headache impact, global assessment of relief, consistency of response and emotional response. All these are clinically important measures of migraine severity and treatment outcome. All questions were dichotomous and answered by yes or no. Patients (n = 185) attending secondary care headache clinics who were diagnosed with migraine according to International Headache Society criteria entered a multinational, prospective, observational study to investigate the test-retest reliability and construct validity of the 27-item Migraine-ACT. Patients completed the Migraine-ACT on two occasions, separated by a 1-week interval, and test-retest reliability was assessed by Pearson product moment and Spearman rank measures. Construct validity was assessed by correlating patients' answers to the 27-item Migraine-ACT with those to other questionnaires (individual domains and total scores) conceptually related to it; the Short-Form 36 quality of life questionnaire (SF-36), the Migraine Disability Assessment (MIDAS) questionnaire and the Migraine Therapy Assessment Questionnaire (MTAQ). Discriminatory t-tests were used to identify the four Migraine-ACT questions (one in each domain) which discriminated best between the domains of the SF36, MIDAS, and MTAQ. These four items constituted the final 4-item Migraine-ACT.

RESULTS

The test-retest reliability of the 27 Migraine-ACT questions ranged from good to excellent, and correlation coefficients were highly significant for all items. The consistency of reporting the yes and no answers was also excellent. Correlations of Migraine-ACT items with SF-36 and MIDAS items and SF-36, MIDAS and MTAQ total scores indicated that the following were the most discriminating items, in the respective four domains, and constitute the final Migraine-ACT questionnaire: Consistency of response: Does your migraine medication work consistently, in the majority of your attacks? Global assessment of relief: Does the headache pain disappear within 2 h?

IMPACT

Are you able to function normally within 2 h? Emotional response: Are you comfortable enough with your medication to be able to plan your daily activities? The 4-item Migraine-ACT was shown to be highly reliable (Spearman/Pearson measure r = 0.82). The individual questions, and the total 4-item Migraine-ACT score, showed good correlation with items of the SF-36, MIDAS and MTAQ questionnaires, particularly with the total MTAQ and SF-36 scores.

CONCLUSIONS

The 4-item Migraine-ACT questionnaire is an assessment tool for use by primary care physicians to identify patients who require a change in their current acute migraine treatment. It is brief and simple to complete and score, and has demonstrated reliability, accuracy and simplicity. Migraine-ACT can therefore be recommended for everyday clinical use by clinicians.

Impact of Headache on Quality of Life in a General Population Survey in France (GRIM2000 Study)

OBJECTIVES

The objectives of this study were to determine the impact of headache on health-related quality of life in a nationwide sample of the French general population using a disease-specific measure, the Qualité de Vie et Migraine (QVM), to compare quality of life in subjects reporting different headache to types, and to evaluate the relationship between quality of life and severity, frequency, associated disability, and treatment responsiveness of headaches.

METHODS

The QVM questionnaire was included within a large epidemiological survey of 1486 headache sufferers. Diagnosis was assigned retrospectively using an algorithm based on the International Headache Society classification. Headache severity was assessed with the MIGSEV scale and disability with the MIDAS scale.

RESULTS

The mean global QVM score in the sample was 80.2. Quality of life was poorer in subjects with chronic daily headache (QVM score: 66.2) than in those with migraine (QVM score: 76.7), while those with other forms of episodic headache had the best quality of life (QVM score: 91.7). Quality-of-life scores were correlated with frequency, severity, disability, and treatment resistance of headaches (P <.001).

CONCLUSION

The QVM scale is a sensitive tool to measure health-related quality of life in headache sufferers in the general population.

Use and misuse of triptans in France: data from the GRIM2000 population survey

The extent and nature of triptan use for headache relief has been evaluated in a large epidemiological survey in the French general population. Over 25 000 individuals were screened for headache and for triptan use. Of this sample, 290 triptan users were identified from whom extensive data on headache characteristics and healthcare resource consumption were obtained. The use of triptans is relatively infrequent, 0.2% in the general population, with only 7.5% of migraine sufferers using these drugs. The majority of triptan users were female (80%) and presented headache characteristics typical of migraine (80%). The remaining 20% of subjects were thus using triptans for headache types in which the utility of these drugs has not been demonstrated. Among migraineurs, triptan consumers reported more frequent and severe headaches than non-consumers, and reported a higher incidence of nausea and vomiting. The principal determinant of triptan prescription was consultation with a general practitioner (GP), which may itself have been triggered by the severity of the headaches. GPs, rather than specialists, are the primary prescribers of triptans in France.

The Medical Management of Migraine

Migraine is a common, chronic neurologic disorder that affects 11% of the adult population in Western countries. In this article, we review the current approaches to the pharmacologic treatment of migraine. Once migraine is diagnosed, and illness severity has been assessed, clinicians and patients should work together to develop a treatment plan based on the patient needs and preferences. The goals of the treatment plan usually include reducing attack frequency, intensity, and duration; minimizing headache-related disability; improving health-related quality of life; and avoiding headache escalation and medication misuse. Medical treatments for migraine can be divided into preventive drugs, which are taken on a daily basis regardless of whether headache is present, and acute drugs taken to treat individual attacks as they arise. Acute treatments are further divided into nonspecific and migraine-specific treatments. The US Headache Consortium Guidelines recommend stratified care based on the level of disability to help physicians individualize treatment. Simple analgesics are appropriate as first-line acute treatments for less disabled patients; if simple analgesics are unsuccessful, treatment is escalated. For those with high disability levels, migraine-specific acute therapies, such as the triptans, are recommended as the initial treatment, with preventive drugs in selected patients. A variety of behavioral interventions are helpful. The clinicians have in their armamentariums an ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.

Economic impact of migraine and other episodic headaches in France: data from the GRIM2000 study

BACKGROUND

Migraine is a prevalent and incapacitating condition that affects individuals in the prime of their productive life, thus generating an economic burden for both society and healthcare systems. The direct annual healthcare costs of migraine in France were assessed over 10 years ago, and the current study updates these figures.

OBJECTIVE

The objective of this study was to determine the economic cost (primarily direct costs) of migraine and other episodic headache in France based on a general population survey of headache, the GRIM2000 (Groupe de Researche Interdisciplinaire sur la Migraine).

DESIGN

From a representative general population sample of 10,585 individuals aged > or = 15 years in France in 1999, 1486 individuals experiencing headaches were identified and interviewed regarding healthcare resource consumption in the previous 6 months. By applying unit costs to the resource data, costings (in 1999 values) were determined for physician consultations, hospitalisation, medication use and diagnostic/laboratory tests, and evaluated from a healthcare system perspective. Information on absenteeism and lost productivity was derived from the Migraine Disability Assessment Score (MIDAS) questionnaire.

RESULTS

The prevalence of migraine (including migrainous disorder) was determined to be 17%. Total annual direct healthcare costs were estimated to be Euros 128 per individual with migraine in 1999, corresponding to Euros 1044 million when extrapolated to all individuals experiencing migraine and aged > or = 15 years. Around two-thirds of this cost accrued to the social security system (Euros 698 million; Euros 85 per individual). The total annual direct cost of other forms of episodic headache was much lower at Euros 28 per individual (social security cost Euros 18); with a prevalence of 9.2%, the annual national direct cost for other forms of episodic headache totalled Euros 124 million. The principal cost element was physician consultations. However, it was found that many individuals had never consulted a physician for their headaches, and self-medication contributed substantially to the medication costs (the second greatest cost factor for migraine). The cost per individual rose steeply with increasing severity of headache.

CONCLUSIONS

The direct healthcare costs of migraine do not seem to have risen significantly over the past decade. A small minority of individuals with more severe headaches consume most of the healthcare resources devoted to migraine, while most individuals generate relatively low direct costs. The total annual direct costs in France for migraine are almost 10-fold higher than those of other episodic headache.

The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity

This study estimates the 1-year prevalence of migraine in adults in England in relation to the major demographic variables of age, gender and ethnicity, and describes some of its features, including aspects of consequential disability. A telephone survey was conducted of a random sample (n = 4007) of the population aged 16-65 years of mainland England using a previously validated diagnostic interview. The response rate was 76.5%. Overall, 7.6% of males and 18.3% of females reported migraine with or without aura within the last year meeting diagnostic criteria closely approximate to those of the International Headache Society. Prevalence of migraine varied with age, rising through early adult life and declining in the late 40s and early 50s. Prevalence was higher in Caucasians than in other races. Attack rates were > or = 1/month in most migraineurs, and most experienced interference with daily activities in > or = 50% of their attacks. On average, an estimated 5.7 working days were lost per year for every working or student migraineur, although the most disabled 10% accounted for 85% of the total. Results were in keeping with those from surveys in other countries. If these findings in mainland England are projected to the entire UK population, we estimate that 5.85 million people aged 16-65 years experience 190 000 migraine attacks every day and lose 25 million days from work or school each year because of them. Migraine is an important public health problem in the UK, associated with very substantial costs.

Burden of migraine in Brazil: estimate of cost of migraine to the public health system and an analytical study of the cost-effectiveness of a stratified model of care

BACKGROUND

The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies.

PURPOSE

To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine.

METHODS

An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels-primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication. We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P x N x C + P x Cp + P x Cat x AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year. Results.-The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%.

CONCLUSION

Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.

Headache management program improves outcome for chronic headache

OBJECTIVE

To determine the feasibility of developing a headache management program and to assess the outcomes of patients referred to the program for treatment of chronic headache.

BACKGROUND

Effective headache treatment requires that the patient receives the correct headache diagnosis; that appropriate acute and, if indicated, preventive medications be prescribed; and that the patient receives adequate education, including headache self-management skills.

DESIGN/METHODS

A headache management program was established at a northern California staff-model health maintenance organization. Fifty-four patients were enrolled in the program and followed for 6 months. Patients participated in a structured program of group and individual sessions with the program manager. Data collection at baseline and 6 months included the Migraine Disability Assessment (MIDAS), the Short Form-36 Health Survey (SF-36), a patient satisfaction survey, and 2 additional short surveys--one that assessed patient worries about their headaches and another that queried patients on their problems with headache management.

RESULTS

All enrolled patients participated in the initial group visit; 74% had at least one additional visit. All but one patient suffered from more than one headache type. Sixty-one percent of patients suffered from migraine headache and 98% from tension-type headache. At baseline, patients were severely disabled, with a mean MIDAS score of 41. At 6 months, MIDAS scores decreased an average of 21.2 points (P <.005). Patients reported 14.5 fewer days with headache over the preceding 3 months (P <.0001) and experienced clinically significant improvements in 6 of the SF-36 subscales. Patients were significantly more satisfied with their headache care (P <.0001), reported less problems with their headache management (P <.0001), and were less worried about their headaches (P <.01). During the intervention, emergency department visits for headache decreased (P <.02).

CONCLUSIONS

A headache management program was successfully established. Patients referred to the program experienced significant improvement in headache-related disability and functional health status and reported greater satisfaction with care. Even so, these results were obtained at one site and in a small sample that was not randomized. We currently are conducting a randomized controlled trial to better evaluate the clinical and financial impact of a headache management program for patients with chronic headache.

Use of the Migraine Disability Assessment Questionnaire in children and adolescents with headache: an Italian pilot study

OBJECTIVES

To determine the suitability of the Migraine Disability Assessment (MIDAS) Questionnaire for assessing disability in children and adolescents with headache and to obtain preliminary information about disability in different primary headaches.

BACKGROUND

During the last decade, researchers have begun to employ standardized methodologies to investigate the global impact of primary headaches. Disease-specific instruments have been developed to measure headache-related disability. The MIDAS Questionnaire, which is the most extensively studied of these instruments, was designed to assess the overall impact of headaches over the 3 months before compilation. The MIDAS Questionnaire is an optimal tool to assess headache-related disability in adults.

METHODS

Ninety-five patients aged 7 to 17 years with tension-type headache, migraine, or both completed the validated Italian form of the MIDAS questionnaire on 2 occasions. Test-retest reliability was assessed by the Spearman rank correlation test. The Cronbach alpha assessed internal consistency. The patients answered questions about the adequacy of the questionnaire.

RESULTS

The Cronbach alpha was.8. Correlation coefficients were generally high for the overall MIDAS score and for the items investigating disability in school and in family/leisure activities; they were lower for the items about housework. Most patients thought that the MIDAS Questionnaire was useful (98.9%) and that it captured the impact of their headaches (58.9%); 41% thought that questions about disability in housework were useless, 44.2% suggested adding questions regarding inability to do homework. All primary headaches had a considerable impact on daily activities, but patients with migraine tended to have lower headache frequencies and lower total disability time; those with tension-type headache suffered more days in which activities, although performed, were substantially impaired.

CONCLUSIONS

The MIDAS Questionnaire is useful for assessing disability in children and adolescents with different primary headaches. Minimal changes in the phrasing and content of the items would be sufficient to render the MIDAS specific for the younger population with headache.

Migraine headache disability and health-related quality-of-life: a population-based case-control study from England

The aims of this study were: (i) to compare health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) in a population sample of migraine headache sufferers and controls without migraine; (ii) to assess the relationship of HRQoL and work-related disability attributed to headache in a population sample. The study was conducted in two phases. First, a population-based, telephone interview survey of 5769 residents of greater London, England was conducted to identify individuals with migraine headache (cases) and controls without migraine. In the second stage, in-person interviews were conducted in a matched sample of 200 migraine cases and 200 controls selected from survey respondents. At the beginning of the in-person interview, participants were asked to complete the SF-36. In addition, a work-related disability score based on the telephone interview was defined as the number of lost work days or days when usual activity was reduced by 50% or more over the previous year. The disability score was trichotomized as mild (n = 98), moderate (n = 49), and severe disability (n = 49). Compared with controls, individuals with migraine headache scored significantly lower in eight of the nine domains of the SF-36 as well as in the overall Physical Component Summary (PCS) score and Mental Component Summary (MCS) score. Further, among migraine sufferers, each of the disability groups scored significantly lower in seven of the nine domains and in the summary scales. Scores showed greater reductions in HRQoL for the moderate and severe disability groups vs. the mild disability group in five of nine scales and in the Total Physical Summary score. We conclude that, in a population-based sample of migraine headache sufferers, individuals with migraine headache have lower HRQoL scores compared with controls. Moreover, among individuals with migraine headache, work-related disability is associated with lower HRQoL scores. Specifically, individuals classified with moderate to severe work-related disability had lower HRQoL scores than those classified with low disability.

Assessing the severity of migraine: development of the MIGSEV scale

OBJECTIVES

To identify items that serve to assess the severity of migraine with a high level of clinical and psychometric relevance and to combine these into a unitary severity scale.

BACKGROUND

Severity of migraine is an important determinant of patient quality of life and of health care resource utilization. Despite this, no validated method exists for measuring migraine severity.

METHODS

After selection from the medical literature items of potential relevance to the severity of migraine, consensus meetings led to a choice of items which subsequently were refined further on the basis of patient interviews. The psychometric properties of those items then were assessed in a survey involving 287 migraineurs. The methods used to test reliability and validity included test-retest, calculation of Cronbach alpha coefficient, analysis of factorial structure using principal components analysis, a comparison of the agreement between doctors' and patients' assessments, and correlation with a validated quality-of-life questionnaire. The most pertinent items revealed by the factorial analysis were combined in a unitary scale.

RESULTS

Seven items reflecting severity were identified by expert consensus. These were intensity of pain, tolerability, disability in daily activities, presence of nausea or vomiting, resistance to treatment, duration of attacks, and frequency of attacks. Principal components analysis identified 3 dimensions accounting for 65% of the overall variance related to intensity of attacks, resistance to treatment, and frequency of attacks. The internal consistency and the reproducibility of the items appeared quite satisfactory, and variations in these items were correlated with quality-of-life scores. The 4 items related to intensity of attacks were combined into a single scale with 3 response modalities.

CONCLUSIONS

The 3 dimensions identified by this investigation appeared medically relevant and to have good psychometric properties. The items on the intensity dimension can be used to generate a simple scale for assessing migraine attack severity.

Factors associated with burden of primary headache in a specialty clinic

OBJECTIVE

To examine factors associated with social, occupational, and psychological burden of common primary headache (migraine and tension-type headache).

BACKGROUND

The personal and social burden of primary headache is high. Health, occupational, social, and psychological factors contributing to burden in people with disabling headache have not been fully unravelled.

METHODS

One hundred eighty consecutive patients with either migraine or tension-type headache attending a specialty headache outpatient clinic for the first time were evaluated over a 9-month period. Headache subtype was operationally defined according to International Headache Society criteria. Headache frequency, duration, and severity were recorded. Occupational and social disability were quantified using the Migraine Disability Assessment questionnaire. Psychological burden was quantified using the 28-item General Health Questionnaire, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Premorbid vulnerability to life stress was quantified using the neuroticism subscale of the Eysenck Personality Inventory.

RESULTS

Patients with frequent (chronic) headache scored higher on the Migraine Disability Assessment questionnaire and had higher Beck Depression Inventory and General Health Questionnaire depression scores than those with less frequent (episodic) headache. Frequency of headache, but not pain severity, duration, or diagnosis, predicted both Migraine Disability Assessment total disability and General Health Questionnaire/Beck Depression Inventory depression. Neuroticism was predictive of depression but not disability. Patients with chronic migraine had the highest depression and disability scores.

CONCLUSION

The number of days per month with headache is a key determinant of headache-related burden in those attending specialty clinics. Frequent (chronic) headache is associated with significantly higher psychopathology scores and general social impairment, but the direction of this relationship is not clear. Those with migraine and chronicity are the most impaired.

Rapid and sensitive paradigm for screening patients with headache in primary care settings

OBJECTIVE

To determine the sensitivity and specificity of a brief headache screening paradigm for primary care clinicians.

BACKGROUND

Migraine and drug rebound headache are disabling primary headache disorders. Both are underdiagnosed and undertreated. A method for rapid screening of migraine, drug rebound headache, and other daily headache syndromes would be useful. The Brief Headache Screen uses 3 questions-the frequency of severe (disabling) headache, other (mild) headache, and use of symptomatic medication-to generate diagnoses.

METHODS

The Brief Headache Screen was evaluated in an emergency department, a family practice department, and a referral headache clinic. Diagnoses from the Brief Headache Screen were compared to diagnoses of trained researchers and headache specialists.

RESULTS

Three hundred ninety-nine patients were screened and interviewed. The criterion of episodic severe (disabling) headache correctly identified migraine in 136 (93%) of 146 patients with episodic migraine and 154 (78%) of 197 patients with chronic migraine, with a specificity for any migraine (episodic or chronic) of 32 (63%) of 51. The inclusion of episodic or daily severe headache identified migraine in 100% of patients with chronic migraine. Only 6 (1.7%) of 343 patients with migraine were not identified by severe (disabling) headache. The combination of severe and mild headache frequency was sensitive to daily headache syndromes in 218 (94%) of 232 patients with a specificity of 87 (54%) of 162. Medication overuse was correctly identified in 146 (86%) of 169 patients with a specificity of 22 (79%) of 28.

CONCLUSIONS

The frequency of severe (disabling) and mild headaches and use of symptomatic medications, rapidly and sensitively screens for migraine, daily headache syndromes, and medication overuse. The use of this paradigm in primary care settings may improve the recognition of these important headache syndromes.

Reliability and validity of the Japanese Migraine Disability Assessment (MIDAS) Questionnaire

OBJECTIVE

This study was designed to assess the test-retest reliability, internal consistency, and validity of a Japanese translation of the Migraine Disability Assessment (MIDAS) Questionnaire in a sample of Japanese patients with headache.

BACKGROUND

Previous studies have demonstrated that the English-language version of the MIDAS Questionnaire is a reliable and valid instrument for the assessment of migraine-related disability. Any translations of the MIDAS Questionnaire must also be assessed for reliability and validity.

METHODS

Study participants were recruited from the patient population attending either the Neurology Department of Kitasato University or an affiliated clinic. Participants were eligible for study entry if they had 6 or more primary headaches per year. For reliability testing, participants completed the MIDAS Questionnaire on 2 occasions, exactly 2 weeks apart. To assess validity, patients were also invited to participate in a 90-day daily diary study. Composite measures from the 90-day diaries were compared to equivalent MIDAS measures (ie, 5 questions on headache-related disability and 1 question each on average pain intensity and headache frequency in the last 3 months) and to the total MIDAS score obtained from a third MIDAS Questionnaire completed at the end of this 90-day period.

RESULTS

One hundred one patients between the ages of 21 and 77 years were recruited (81 women and 20 men). Ninety-nine patients (80 women and 19 men) participated in the diary study. At baseline, 46.5% of patients were MIDAS grade I or II (minimal, mild, or infrequent disability), 22.2% were MIDAS grade III (moderate disability), and 31.3% were MIDAS grade IV (severe disability). Test-retest Spearman correlations for the 5 disability questions and the questions on average pain intensity and headache frequency ranged from 0.59 to 0.80 (P<.0001). The test-retest Spearman correlation coefficient for the total MIDAS score was 0.83 (P<.0001). The degree to which individual MIDAS questions correlated with the diary-based measures ranged from 0.36 to 0.88. The correlation between the total MIDAS score and the equivalent diary-based measure was 0.66. In general, the mean and median values for the MIDAS items and total MIDAS score were similar to the means and medians for the diary-based measures. However, the mean MIDAS scores for the number of days on which headache was experienced and the number of missed workdays were significantly different compared to the diary-based estimates for these items (P<.05). In addition, the mean MIDAS score for the number of days of missed housework was significantly higher than the corresponding diary-based estimate (P<.01).

CONCLUSIONS

The results from this study show that the Japanese translation of the MIDAS Questionnaire is comparable with the English-language version in terms of reliability and validity.

Assessment of migraine disability using the migraine disability assessment (MIDAS) questionnaire: a comparison of chronic migraine with episodic migraine

BACKGROUND

Chronic migraine is the most common type of chronic daily headache seen in headache tertiary care centers. Most patients with chronic migraine report their ability to function and feeling of well-being as severely impaired.

OBJECTIVE

To measure the headache-related disability of patients with chronic migraine using the Migraine Disability Assessment (MIDAS) Questionnaire, comparing it with that obtained in a control group of patients with episodic migraine.

METHODS

The clinical records of 703 patients with chronic daily headache treated in a headache specialty clinic were reviewed to identify 182 with chronic migraine who were evaluated using the MIDAS at their initial visit. Our control group consisted of 86 patients with episodic migraine.

RESULTS

Of the 182 patients with chronic migraine, 127 (69.8%) were overusing acute-care medication. Patients were predominantly women (72.5%), with a mean age of 38.3 years. The group with episodic migraine consisted of 59 women (68.6%), with a mean age of 36.1 years. No statistically significant demographic differences were observed between the two groups. The group with chronic migraine had more total headache days over 3 months (66.7 versus 15.5, P<.001), missed more days of work or school (5.3 versus 2.3, P =.0007), had more reduced effectiveness days at work or school (11.9 versus 4.6, P =.0001), missed more days of housework (16.5 versus 3.3, P<.0001), and missed more days of family, social, or leisure activities (7.0 versus 5.5, P =.03). The group with chronic migraine was more likely to be in MIDAS grade IV (64.3% versus 43.2%, P =.001), reflecting the great likelihood of severe disability in this group. The average total MIDAS score was 34.9 in the group with chronic migraine versus 19.3 in the group with episodic migraine (P<.001).

CONCLUSION

In subspecialty centers, patients with chronic migraine demonstrate remarkable impairment of their daily activities and are severely burdened by their headache syndrome, reflected by their high MIDAS scores. The chronicity and pervasiveness of migraine thus is associated with increased functional impairment as well as increase in headache frequency.

Chronic daily headaches in children

Chronic daily headache (CDH) or highly frequent headaches are being recognised as an increasing problem. In adults it is estimated that up to 4% of the population has CDH, however, this number appears to be lower in children. The actual prevalence of CDH in children, however, has not been determined. The simplest definition of CDH is > 15 headache days per month. In the international headache society (IHS) criteria, only chronic tension-type headaches and chronic cluster headaches are recognised as CDH. Criteria for CDH have been suggested for adults that mirror the IHS criteria. In children, the majority of CDH appear to be migraine related. The next revision of the IHS criteria has been proposed to include chronic migraine as one of the CDH. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Treatment and management involves a multi-tiered approach, which includes abortive therapy when the headache becomes more severe. With the precaution of avoiding overuse of analgesic medication, prophylactic therapy is used to help reduce the characteristics of the headache as well as the frequency and mild behavioural therapy.

Migraine disability assessment (MIDAS) score: relation to headache frequency, pain intensity, and headache symptoms

OBJECTIVE

To determine the extent to which variation in the Migraine Disability Assessment (MIDAS) score is associated with headache frequency, pain intensity, headache symptoms, gender, and employment status.

BACKGROUND

The MIDAS questionnaire is a 7-item questionnaire (with 5 scored items) designed to measure headache-related disability, to improve physician-patient communication, and to identify patients with high treatment needs.

METHODS

Data from 3 population-based studies (total sample, n = 397) conducted in the United States and the United Kingdom were used to evaluate the relationship between headache features (attack frequency, pain intensity, pain quality, and associated symptoms) and MIDAS score. Data on headache features were collected by telephone using a standardized interview. The MIDAS questionnaire was completed shortly after the telephone interview. General linear models were used to determine the extent to which population variation in the MIDAS score was explained by headache features.

RESULTS

Using linear regression, variables for all headache features (ie, headache frequency, pain intensity, pain quality, and associated symptoms) and demographic characteristics explained only 22% of the variation in MIDAS scores. Almost all (19.9%) the explained variance was accounted for by average pain intensity (12.0%), number of headache days (6.1%), and exacerbation of pain with movement (1.8%). When pain intensity and headache frequency were included in the model, no statistically significant differences in MIDAS scores were observed by gender or employment status. Although explaining only 2.1% of the variance, age was significantly associated with MIDAS scores, with those under 25 years demonstrating higher MIDAS scores than other age groups. No other variables (ie, frequency of occurrence of associated symptoms and other measures of quality of pain) were associated with MIDAS scores.

CONCLUSIONS

Challenges to the utility of the MIDAS as a measure include whether headache-related disability is largely a function of other routine headache features and whether MIDAS is inherently biased based on work status and gender. While the MIDAS score was associated with headache frequency and average pain score, these two headache features explain only a modest proportion of the variation in MIDAS scores. Additionally, gender and work status were not related to MIDAS scores. These findings suggest that the MIDAS score captures information about disability that is not inherent to other headache features and is independent of gender and work status.

Prevalence and description of chronic daily headache in the general population in France

The objective of this study was to describe the epidemiology, clinical presentation and consequences of chronic daily headache (CDH) in France. A representative nation-wide sample of the general population was identified using a stratified sampling method. Ten thousand five hundred and eight-five subjects were screened in face-to-face interviews, and data collected using a standard questionnaire. An overall point prevalence of CDH in the general population of 2.98% was observed. Two-thirds of these subjects presented migraine-like features. Severity, functional impact and healthcare consumption were higher than in subjects reporting episodic migraine in the same sample. Of the subjects, 28.2% reported the most severe migraine disability assessment scores (Grades 3 and 4), compared to 12% of episodic migraineurs. A qualité de vie et migraine score of 68.4 was observed, indicating severely attenuated quality of life. Only 6.6% of subjects were taking prophylactic treatment, whilst 88% were using non-specific acute headache treatments. The frequency of physician consultations and laboratory examinations was significantly higher than in individuals with episodic headache. CDH is thus a relatively prevalent condition in the general French population, associated with an important burden of suffering and with considerable expenditure in the health service. Management of this condition is generally inappropriate.

Patterns of health care utilization for migraine in England and in the United States

OBJECTIVE

To assess patterns of medical consultation, diagnosis, and medication use in representative samples of adults with migraine in England and the United States.

METHODS

Validated computer-assisted telephone interviews were conducted in the United Kingdom (n = 4,007) and the United States (n = 4,376). Individuals who reported six or more headaches per year meeting the criteria for migraine were interviewed.

RESULTS

Patients with migraine in the United Kingdom were more likely to have consulted a doctor for headache at least once in their lifetime (86% vs 69%, p < 0.0001), but also were more likely to have lapsed from medical care (37% vs 21%, p < 0.001). In the United States, patients with migraine who had consulted made more office visits for headache and were more likely to see a specialist. In the United States, but not in the United Kingdom, women with migraine were more likely than men to consult doctors for headache. Patients with migraine in the United Kingdom were more likely to receive a medical diagnosis of migraine (UK 67%, US 56%; p < 0.05). Patterns of medication use were similar in both countries, with most people treating with over-the-counter (OTC) medications. Substantial disability occurred in a high proportion of those who never consulted (UK 60%, US 68%), never received a correct medical diagnosis (UK 64%, US 77%), and treated only with OTC medication (UK 72%, US 70%).

CONCLUSION

Medically unrecognized migraine remains an important health problem both in the United States and the United Kingdom. Furthermore, there may be barriers to consultation for men in the United States that do not operate in the United Kingdom.

Differing central amine receptor sensitivity in different migraine subtypes? A neuroendocrine study using buspirone

Despite the importance of the 5HT1A receptor in regulating central serotonergic tone, there is a dearth of research examining its role in migraine. In this study, we examined the hypothesis that there would be altered neuroendocrine responses to a 5HT1A agonist challenge in different migraine subtypes. Prolactin (PRL) responses to the 5HT1A receptor agonist drug buspirone were compared in 30 female subjects with migraine (ten migraine with aura, MA; ten migraine without aura, MO and ten chronic/transformed migraine, CM), and ten healthy controls matched for age, gender and menstrual status. None of the subjects were taking psychotropic medication or migraine prophylactic treatment and those with formal psychiatric disorder were excluded. Endocrine responses were determined by measuring differences between baseline PRL and maximum increases post-buspirone (deltaPRL). There was no difference in baseline PRL between groups. MA subjects did not differ in their PRL responses to buspirone compared to healthy controls. The MO group had a four-fold increase in mean deltaPRL responses compared to healthy controls. Mean deltaPRL was also increased in the CM group compared to controls, but the difference was less exaggerated. This study indicates that there is supersensitive central amine receptor function in MO and CM, but not in MA. These findings support the hypothesis that central 5HT function differs among the migraine subtypes. The results also suggest that migrainous 'transformation' may be associated with adaptive changes in central 5HT receptor sensitivity. The relative contribution of 'state' and 'trait' receptor function to these findings as well as the possible role of dopamine receptors is discussed.

Analysis of the patients attending a specialist UK headache clinic over a 3-year period

OBJECTIVE

This study analyzed the profile of patients who attended a specialist UK headache clinic over a 3-year period.

METHODS

An audit was conducted of the clinical records of patients attending the specialist headache clinic at King's College, London, between January 1997 and January 2000. Data were collected for diagnoses given, current medications taken, medications prescribed and recommended, and investigations conducted. Results were calculated as numbers and proportions of patients for the 3-year period and for the 3 separate 12-month periods.

RESULTS

A total of 458 patients were included in the audit. Most patients were diagnosed as having chronic daily headache (CDH, 60%) or migraine (33%). Prior to the clinic visit, most patients with CDH and migraine treated their headaches with analgesics, and there was little use of prophylactic medication. In the clinic, 74% of patients with CDH and 85% of migraineurs were prescribed prophylactic medication, and 81% of migraineurs were given triptans for acute treatment. Diagnostic testing was performed in 12% of the patients, and all results were normal or negative.

CONCLUSIONS

CDH and migraine were the most common headache types encountered in this UK secondary-care clinic. Review of treatment patterns used prior to the initial clinic evaluation suggests that management of CDH and migraine in UK primary care is suboptimal, and educational initiatives are needed to improve headache management.

Need for care and perceptions of MIDAS among headache sufferers study

INTRODUCTION

Patients with migraine have varying medical care needs. To effectively stratify patients to appropriate care, physicians should consider the frequency and intensity of attacks, and their overall impact on ability to function. The Migraine Disability Assessment Scale (MIDAS) measures headache-related disability. The MIDAS Perceptions Study investigated whether MIDAS scores reflect headache severity and the need for medical care, and assessed whether the MIDAS questionnaire is meaningful and relevant to patients, and easy to use.

DESIGN

The Perceptions Study was conducted as a follow-up to a baseline telephone interview. Upon completion of the baseline survey, 471 individuals were invited to participate in the Perceptions Study and 420 participated: 168 patients with migraine headaches and 253 with non-migraine headaches. Patients with migraine or non-migraine headaches completed the MIDAS questionnaire and the Center of Epidemiologic Studies of Depression (CES-D) questionnaire, and were then interviewed by telephone within 48 hours of receiving the questionnaires.

RESULTS

Headache frequency and pain intensity increased significantly with increasing MIDAS grade (p < 0.0001). A pattern of decreasing quality-of-life scores on the physical and mental subscales of the Short Form-12 was also seen with increasing MIDAS grade. Scores on the CES-D scale increased significantly with increasing MIDAS grade (p < 0.0001), indicating a greater likelihood of depression and more severe depression with higher grades. There were significant associations between increasing MIDAS grade and an increasing proportion of individuals who had consulted a doctor within the past year, lower use of over-the-counter medication, and greater use of prescription medications (p < 0.0001 for all three variables). Satisfaction with current therapy decreased significantly with increasing MIDAS grade, mirroring the frequency with which individuals achieved complete relief from headache. The MIDAS questionnaire was rated as easy to use by the vast majority of respondents, and ratings of its perceived value increased significantly as MIDAS grade increased.

CONCLUSIONS

A low MIDAS score generally seems to indicate a low need for care, while individuals in MIDAS grades III and IV appear to have significant unmet medical care needs. The MIDAS questionnaire had increasingly perceived relevance as MIDAS grade increased, helped the majority of those in MIDAS grades III and IV to understand the impact of their headaches, and encouraged those with the greatest disability to seek medical care. The MIDAS questionnaire may facilitate communication between doctors and patients, and help physicians to identify those receiving inadequate medical care.

Determinants of migraine-specific quality of life

This paper reports an analysis of two randomized controlled trials of rizatriptan, in which the 24-h Migraine Quality of Life QuestionnaireCopyright was used to assess migraine-specific quality of life in patients receiving acute treatment. The objective of the analysis was to determine which clinical effects of a migraine medication, as measured by traditional clinical trial endpoints, contribute to a better short-term health-related quality of life. The results demonstrate that patients who experience complete pain relief and are able to function at their normal ability within 2 h and experience no headache recurrence have the highest migraine-specific quality of life scores. Patients who were satisfied with medication at 2 h had higher migraine-specific quality of life scores than those who were not satisfied. In conclusion, migraine therapy that provides rapid, complete, and sustained pain relief, with restoration of functional ability, has the most beneficial impact on short-term health-related quality of life for migraineurs.