Transformed migraine, analgesic rebound, and other chronic daily headaches

Preliminary External Validation Results of the Artificial Intelligence-Based Headache Diagnostic Model: A Multicenter Prospective Observational Study

The misdiagnosis of headache disorders is a serious issue, and AI-based headache model diagnoses with external validation are scarce. We previously developed an artificial intelligence (AI)-based headache diagnosis model using a database of 4000 patients' questionnaires in a headache-specializing clinic and herein performed external validation prospectively. The validation cohort of 59 headache patients was prospectively collected from August 2023 to February 2024 at our or collaborating multicenter institutions. The ground truth was specialists' diagnoses based on the initial questionnaire and at least a one-month headache diary after the initial consultation. The diagnostic performance of the AI model was evaluated. The mean age was 42.55 ± 12.74 years, and 51/59 (86.67%) of the patients were female. No missing values were reported. Of the 59 patients, 56 (89.83%) had migraines or medication-overuse headaches, and 3 (5.08%) had tension-type headaches. No one had trigeminal autonomic cephalalgias or other headaches. The models' overall accuracy and kappa for the ground truth were 94.92% and 0.65 (95%CI 0.21-1.00), respectively. The sensitivity, specificity, precision, and F values for migraines were 98.21%, 66.67%, 98.21%, and 98.21%, respectively. There was disagreement between the AI diagnosis and the ground truth by headache specialists in two patients. This is the first external validation of the AI headache diagnosis model. Further data collection and external validation are required to strengthen and improve its performance in real-world settings.

Questionnaire-Based Survey during COVID-19 Vaccination on the Prevalence of Elderly’s Migraine, Chronic Daily Headache, and Medication-Overuse Headache in One Japanese City—Itoigawa Hisui Study

Background: The prevalence of headache disorders, migraine, chronic daily headache (CDH), and medication-overuse headache (MOH) among the elderly in Japan has not been sufficiently investigated. We performed a questionnaire-based survey and revealed 3-month headache prevalence and headaches’ characteristics. Methods: The population aged over 64 was investigated in Itoigawa during their third coronavirus disease 2019 vaccination. Migraine, MOH was defined as The International Classification of Headache Disorders Third edition. CDH was defined as a headache occurring at least 15 days per month. K-means++ were used to perform clustering. Results: Among 2858 valid responses, headache disorders, migraine, CDH, and MOH prevalence was 11.97%, 0.91%, 1.57%, and 0.70%, respectively. Combined-analgesic and non-opioid analgesic were widely used. Only one migraineur used prophylactic medication. We performed k-means++ to group the 332 MOH patients into four clusters. Cluster 1 seemed to have tension-type headache-like headache characteristics, cluster 2 seemed to have MOH-like headache characteristics, cluster 3 seemed to have severe headaches with comorbidities such as dyslipidemia, stroke, and depression, and cluster 4 seemed to have migraine-like headache characteristics with photophobia and phonophobia. Conclusions: This is the largest prevalence survey in the Japanese elderly. Headache disorders are still the elderly’s burden. Clustering suggested that severe headaches associated with some comorbidities may be unique to the elderly.

Variability of Reported Headache Symptoms and Diagnosis of Migraine at 12 Months

Assignment of a diagnosis of migraine has been formalized in diagnostic criteria proposed by the International Headache Society. The objective of the present study is to determine the reproductibility of the formal diagnosis of migraine in a cohort of headache sufferers over a one-year period. The study was performed in a community cohort taking part in a long-term prospective health survey, the GAZEL study. Two thousand five hundred individuals reporting headache in the GAZEL cohort were sent two postal questionnaires concerning headache symptoms and features at 12-monthly intervals. Replies to the questions allowed a migraine diagnosis to be attributed retrospectively using an algorithm based on the IHS classification scheme. The response rate was 82% for the first questionnaire and 69% for both questionnaires. Of the 1733 subjects providing information at both time-points, the agreement rate for the diagnosis of strict migraine (IHS categories 1.1 or 1.2) was 77.7% (kappa = 0.48), with 62.2% of the patients with this diagnosis (IHS categories 1.1 or 1.2) at Month 0 retaining the same diagnosis at Month 12. When diagnostic criteria were widened to include IHS category 1.7 (migrainous disorder), the agreement rate of the diagnosis was similar at 77.6% (kappa = 0.52), but 82% of the patients with this diagnosis (IHS categories 1.1 or 1.2 or 1.7) at Month 0 now retained the same diagnosis at Month 12. In conclusion, the one-year reproducibility of reporting of migraine headache symptoms is only moderate, varies between symptoms, and leads to instability in the formal assignment of a migraine headache diagnosis and to diagnostic drift between headache types. This finding is compatible with the continuum model of headache, where headache attacks can vary along a severity continuum from episodic tension-type headaches to full-blown migraine attacks.

Chronic Daily Headaches in Children and Adolescents

The clinical characteristics of chronic daily headache were studied in 40 children and adolescents, as well as the associated factors responsible for maintenance of the continuous headache pattern. The study of the clinical headache characteristics, showed a female preponderance (75%), mean age of 11 years old at the first consultation, and onset of headache symptomatology at a mean age of 8.5 years old. The average time interval for the evolution of sporadic headache into chronic daily headache was 1.4 years, and psychosocial stressors were present, acutely or chronically, during the period of headache-frequency increase in 47% of the children. Headaches were classified as transformed migraine (65%), mixed pattern (17.5%) and chronic tension-type headache (17.5%). Sixty per cent of patients had mothers with migraine. Data regarding common analgesic use showed an average intake of 11.2 days/month.

Dysfunctional coping in headache: avoidance and endurance is not associated with chronic forms of headache

INTRODUCTION

About 4% of the population suffer from daily or near daily headache, which in most cases evolved from an episodic type of headache. The impact of psychological factors on this process is unknown. It seems reasonable to assume, that besides somatic and social conditions psychological factors like pain-related coping and cognition play an important role, as has been shown for other pain conditions.

METHODS

We performed a cross sectional study on pain coping behaviour in 211 patients with migraine and tension type headache. Pain-related cognition and coping was investigated using the Kiel Pain Inventory. Prevalence of depression, medication intake and headache characteristics were analysed in regard to chronicity of headache.

RESULTS

Overall pain intensity was high in the patient sample. The level of depression increased with headache frequency. Dysfunctional coping, characterized by fear and avoidance is frequently used by headache patients. As in low back pain, also endurance is highly prevalent. Other features known to be associated with chronic headache, like depression and medication overuse, could be confirmed.

DISCUSSION

Dysfunctional coping was seen with high prevalence in the entire patient sample (66%). Against our hypothesis, it was not confined to chronic forms of headache. In respect to our data, we discuss the role of avoidance and endurance coping in headache and its possible role in chronicity.

Chronic pain and depression in the quality of life of women with migraine--a controlled study

BACKGROUND

Migraine is comorbid to depression and widespread chronic pain (WCP), but the influence of these conditions on the health-related quality of life (HRQoL) of individuals with episodic (EM) and chronic migraine (CM) is poorly understood.

OBJECTIVE

To assess the prevalence of depressive symptoms and WCP in individuals with EM and CM, as well as to estimate the joint impact of these conditions on the HRQoL of these individuals.

METHODS

All women aged 18 to 65 years with a first diagnosis of EM or CM from September of 2006 to September of 2008 seen in an outpatient headache service were invited to participate. They were asked to attend a separate appointment in the service, and to bring another woman of similar age that also agreed to participate. Depressive symptoms were assessed using the Beck Depression Inventory. Questions about WCP followed the protocol of the American College of Rheumatology. HRQoL was assessed using the Short-Form 36 (SF-36). Multivariate analysis modeled HRQoL as a function of headache status, depressive symptoms, and pain, using quantile regression.

RESULTS

Sample consisted of 179 women, 53 in the EM group, 37 in the CM group and 89 in control group. Groups did not differ by demographics. Mean scores of SF-36 were 53.6 (standard deviation [SD] = 23.5) for EM, 44.2 (SD = 18.5) for CM and 61.8 (SD = 21.5) for controls. In multivariate analysis, SF-36 scores were predicted by a CM status (P = .02; -10.05 [95% CI -18.52; -1.58]) and by a Beck Depression Inventory score (P < .01; -1.27 [95% CI -1.55; -0.99]). The influence of WCP in the SF-36 scores approached significance (P = .08; -0.78 [95% CI -1.64; 0.88]). Age did not contribute to the model.

CONCLUSION

Women with migraine are at an increased chance of WCP, and the chance increases as a function of headache frequency. Both depressive symptoms and CM independently predict HRQoL status.

The paradoxical effects of analgesics and the development of chronic migraine

In a subgroup of individuals episodic migraine evolves into a stage where individuals have headaches on more days than not. Among the risk factors for chronification, excessive use of analgesic medications figure prominently and reviewing this topic is the scope of this article. The issue of causality is discussed and evidence suggesting that specific medications, at critical doses, are risk factors for chronic migraine (CM) is reviewed. The concept of critical dose of exposure for different classes is presented and biological plausibility and putative mechanisms are reviewed.

Medication use in patients with migraine and medication-overuse headache: the role of problem-solving and attitudes about pain medication

Excessive medication intake is a risk factor for the development of medication-overuse headache (MOH), a condition characterized by an increase of headache frequency to a daily or near-daily pattern. As yet, it is largely unknown why some patients overuse medication. In this study, we examined to what extent attitudes about pain medication, especially perceived need and concerns, and problem-solving are related to MOH. Patients with migraine (n=133) and MOH with a history of migraine (n=42) were recruited from a tertiary headache referral center and completed questionnaires measuring problem-solving and attitudes about pain medication. A problem-solving mode aimed at solving pain was associated with a higher need for and concerns about medication intake. Interestingly, in a model accounting for demographic factors and pain intensity, attempts to control pain, need for medication, and concerns about scrutiny by others because of medication intake all had a unique value in accounting for MOH. Results are discussed in terms of how repeated attempts to solve pain may trigger overuse of medication, even in the presence of clear negative consequences. Repeated attempts at solving pain may increase the need for analgesic medication, despite obvious costs. This mechanism might contribute to the problem of medication-overuse headache.

Frequent headaches in the preadolescent pediatric population

Objectives: To estimate the prevalence of chronic daily headaches (CDH) and of high-frequency episodic headaches (HFEH) in preadolescent children from the general population.

Background: Early-onset cases of neurologic diseases often reflect increased biologic predisposition, specific risk factors, or both.

Methods: Of 2,173 children identified as the target sample, consents were obtained from 1,870 (86.0%), and analyzable data were provided by 1,547 (71.2%). Parents and children were interviewed using a questionnaire consisting of 97 questions, with a validated headache module (10 questions). Crude and adjusted prevalences of HFEH (10–14 headache days per month) and CDH (15 or more headache days per month) were calculated.

Results: The prevalence of CDH was 1.68% (girls 2.09%, boys 1.33%). The overall prevalence of HFEH was 2.52% (girls 2.8%, boys 2.3%). After adjusting for gender, age, parental history of headaches, income, and school of origin, the prevalence of CDH was higher in girls than in boys (2.2% vs 1.1%, p < 0.01) and in nonwhite vs white children (2.2% vs 1.2%, p < 0.01). Similar differences were seen for HFEH (girls 3.1%, boys 2.0%, p < 0.01), (nonwhite 3.1%, white 1.9%, p < 0.01). Income significantly contributed to the model.

Conclusion: High-frequency episodic headaches and chronic daily headaches are common in the preadolescent pediatric population. Health care providers and educators should be aware of the magnitude of the problem to properly identify and treat children with headaches.

Optimizing prophylactic treatment of migraine: Subtypes and patient matching

Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.

Behavioral dependence in patients with medication overuse headache: a cross-sectional study in consulting patients using the DSM-IV criteria

OBJECTIVE

The aim of this study was to assess behavioral dependence on migraine abortive drugs in medication-overuse headache (MOH) patients and identify the predisposing factors.

BACKGROUND

It is common occurrence that MOH patients relapse after medication withdrawal. Behavioral determinants of medication overuse should therefore be identified in MOH patients.

METHODS

This was a cross-sectional, multicenter study that included 247 MOH patients (according to International Classification of Headache Disorders, 2nd edition criteria) consulting in French headache specialty centers. Face-to-face interviews were conducted by senior neurologists using a structured questionnaire including the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for the evaluation of dependence, Hospital Anxiety and Depression Scale for the evaluation of anxiety and depression, and 6-item short-form Headache Impact Test scale for the determination of functional impact.

RESULTS

Most MOH patients had pre-existing primary migraine (87.4%) and current migraine-type headaches (83.0%). Treatments overused included triptans (45.8%), opioid analgesics alone or in combination (43.3% of patients), and analgesics (27.9%). Nonmigraine abortive substances (tobacco, caffeine, sedatives/anxiolytics) were overused by 13.8% of patients. Two-thirds of MOH patients (66.8%) were considered dependent on acute treatments of headaches according to the DSM-IV criteria. Most dependent MOH patients had migraine as pre-existing primary headache (85.7%) and current migraine-type headaches (87.9%), and most of them overused opioid analgesics. More dependent than nondependent MOH patients were dependent on psychoactive substances (17.6% vs 6.1%). Multivariate logistic analysis indicated that risk factors of dependence on acute treatments of headaches pertained both to the underlying disease (history of migraine, unilateral headaches) and to drug addiction (opioid overuse, previous withdrawal). Affective symptoms did not appear among the predictive factors of dependence.

CONCLUSION

In some cases, MOH thus appears to belong to the spectrum of addictive behaviors. In clinical practice, behavioral management of MOH should be undertaken besides pharmacological management.

Chronic daily headache: stress and impact on the quality of life

OBJECTIVE: To evaluate the stress presence and its influence in the quality of life of patients with chronic daily headache (CDH). METHOD: A hundred patients with at least 18 years old, with primary headache with duration greater than 4 hours a day, and frequency of 15 or more days monthly for at least three months were studied. Lipp's Inventory of Stress Symptoms and the Medical Outcomes Study Short Form (SF-36) were used. RESULTS: Stress was observed in 90% of the patients; nearly half of them was in the phase almost exhaustion. Patients with stress when compared with the ones with no stress presented significantly lower scores in all the domains of SF-36; except in physical functioning. The resistance phase presented scores significantly higher than almost exhaustion; except for bodily pain. CONCLUSION: The majority of the patients presented stress with significant reduction in their quality of life. Consequently, the stress could be related with both the development and the maintenance of CDH.

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.

Pain and traumatic brain injury

For the patient who has sustained traumatic brain injury (TBI), understanding the problem and listening to and believing the patient are prerequisites to treating pain. Because the information provided may be limited, communication skills problematic, and consistency variable, the challenge of treating individuals with TBI and pain can be daunting. Most painful conditions after TBI involve the musculoskeletal system; however, in conditions that are neurologically based, a careful and well-organized neurologic examination can be helpful to direct one's attention toward ordering the appropriate tests and treatments. The primary focus for helping patients with pain involves not only understanding the problem and assisting with symptom relief but also providing the opportunity to improve their functioning, physically and cognitively.

Medication-overuse headache in children: is initial preventive therapy necessary?

Chronic daily headaches can be a difficult problem in children as well as adults. Over half of the cases of chronic daily headaches in adults are thought to be due to medication-overuse headache, and treatment consists of discontinuation of these analgesics. Since many patients are also treated with preventive agents at the time of analgesic withdrawal, it is difficult to determine whether discontinuation alone is the most effective treatment. A retrospective study was performed to evaluate the outcomes of 43 children (ages 6-17 years) with medication-overuse headache 1 month after withdrawal of analgesics: 20 children received daily doses of a preventive medication, and 23 received no preventive medication. Headache reduction was assessed 1 month later. There was no difference in the percentage, with 90% or greater headache reduction at 1 month between children treated by withdrawal of analgesic drugs only and those receiving preventive medications (57% vs 50%, respectively). There was no influence of age, gender, use of triptans as rescue agents, or caffeine use on outcomes. A previous duration of headaches over 2 years was negatively correlated with overall outcome. We advise discontinuation of analgesics in all children with medication-overuse headache, without the necessity for starting daily preventive agents concurrently. Should headaches persist after 1 month, such agents can be added. (J Child Neurol 2006;21:45-48).

Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches

BACKGROUND

Headache is a common medical problem. In view of recent discoveries about the role of serotonin in pain mechanisms, selective serotonin re-uptake inhibitors (SSRIs) have been evaluated for the prevention of migraine and tension-type headaches (TTH).

OBJECTIVES

To evaluate the efficacy and tolerability of SSRIs for preventing migraine and TTH.

SEARCH STRATEGY

We searched MEDLINE (1966-2004), EMBASE (1994-2003), the Cochrane Central Register of Controlled Trials (Issue 4, 2003), and reference lists of retrieved articles. Headache Quarterly was hand searched from 1990 to 2003.

SELECTION CRITERIA

We included randomised controlled trials comparing SSRIs with any type of control intervention in patients of either sex, over 18 years of age, with migraine or TTH.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data (headache frequency, index, severity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement; cost-effectiveness; and adverse events) and assessed the methodological quality of trials.

MAIN RESULTS

Thirteen studies utilizing five SSRIs met the inclusion criteria (636 participants). Most of the included studies had methodological and/or reporting shortcomings; follow up rarely extended beyond 3 months. After 2 months SSRIs did not significantly lower headache index scores in patients with migraine when compared to placebo (SMD -0.14; 95% CI -0.57 to 0.30). Patients with chronic TTH treated with an SSRI had a significantly higher analgesic intake of 5 more doses per month when compared to patients treated with a tricyclic antidepressant (WMD 4.98; 95% CI 1.12 to 8.84). Tricyclics also significantly reduced headache duration by 1.26 hours per day (WMD 1.26; 95% CI 0.06 to 2.45) and marginally reduced headache indexes (SMD 0.42; 95% CI 0.00 to 0.85) when compared to SSRIs in patients with chronic TTH. When the data on adverse events were considered without regard to headache diagnostic subgroups, there were no significant differences between SSRIs and placebo for withdrawals due to adverse events (Peto OR 1.02; 95% CI 0.31 to 3.34). For minor adverse events, SSRIs were generally more tolerable than tricyclics (OR 0.34; 95% CI 0.13 to 0.92). However, there were no differences in the number of patients withdrawing due to any reason in the SSRI and tricyclic groups (OR 1.01; 95% CI 0.56 to 1.80).

AUTHORS' CONCLUSIONS

Over 2 months of treatment, SSRIs are no more efficacious than placebo in patients with migraine. In patients with chronic TTH, SSRIs are less efficacious than tricyclic antidepressants. In comparison with SSRIs, the burden of adverse events in patients receiving tricyclics was greater. These results are based on short-term trials and may not generalise to longer-term treatment.

New developments in the pharmacotherapy of tension-type headaches

The first International Headache Society classification defined tension-type headaches (TTHs) by itemising those characteristics of migraines TTHs did not possess [1]. As a result, TTHs, both episodic and chronic, remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate TTHs; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of TTHs in lieu of its more glamorous neighbour, migraine. As a result, there are few well-designed studies on the pharmacotherapy of TTHs. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the NSAIDs. New research is now emerging that points to the potential utility of botulinum toxin type A, NMDA-receptor antagonists including Mg(2+) and nitric oxide synthase inhibitors. More scientifically rigorous clinical studies are needed.

[How children aged 7 to 11 explain their headache]

The aim of the present study was to observe the ability of children aged 7 to 11 in describing their headache during anamnesis. For this purpose, two evaluations of 94 children were performed in individual assessments, done by the same Pediatrician, within a six to eight week interval, without the presence of adults. The characteristics of headache in these children could be properly evaluated during the interviews. There were no remarkable conflicting information between the two interviews. Although the headache of the child is usually described by the accompanying adult during the consultation, childhood headache should really be informed by the patient. In this group of young children (7 to 11 years old), information could be obtained without difficulty since we allowed the child enough time and the use of his (her) own words.

Chronic daily headache

Chronic daily headache (CDH) represents one of the most challenging medical conditions that a health care provider is called on to treat. This article outlines the scope of this misunderstood condition,updates the reader on the revised diagnostic criteria for chronic daily headache, and gives practical insight into diagnosis and treatment. Four specific subtypes of CDH are covered: chronic tension-type headache, chronic migraine, new daily persistent headache, and hemicrania continua. Through better recognition and treatment of this all too common condition, this segment of our population can be better helped to lead quality lives.

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.

Morbidity and Medication Preferences of Individuals With Headache Presenting to a Community Pharmacy

OBJECTIVE

To assess the degree of debilitation and the treatment views of individuals with headache presenting to a community pharmacy.

BACKGROUND

Migraine and chronic daily headache are common poorly managed illnesses. Pharmacists recommend an over-the-counter "headache product" to customers more than 53 000 times daily, thus they are well positioned to help those with headache.

DESIGN

Pilot project of 22 self-administered surveys of individuals presenting to a community pharmacy with a complaint of headache.

RESULTS

Thirteen persons had Migraine Disability Assessment scores of grade III or grade IV. Of the sample population, a substantial minority (41%) did not believe their headaches could be effectively managed with over-the-counter medications, 72% did not feel over-the-counter agents were safer than prescription products, 96% did not indicate that over-the-counter drugs were more effective than prescription drugs, and 50% disagreed that a physician's evaluation was not necessary. Only half of the population was satisfied with their current therapy, and individuals overwhelmingly (91%) wished they could prevent their headaches.

CONCLUSIONS

The majority of individuals with headache presenting to a community pharmacy had high levels of morbidity and were in need of education regarding the proper role of over-the-counter medications, the advantages of prescription agents, and the benefits of a physician's referral. These preliminary results indicate that community pharmacies are potentially important locations for identification, education, and referral of individuals with headache.

Chronic daily headaches: clinical profile in Indian patients

Chronic daily headache (CDH) remains a relatively unexplored entity in India. Misconceptions are common, unnecessary investigations often done and inappropriate therapy prescribed. Analgesic overuse is seldom recognized. The present report appears to be the first of its kind from India. CDH has been defined as headaches occurring more than 15 days per month for more than 3 months (secondary causes excluded). Over 2 years (1998-1999) 849 cases (49.6% of all primary headaches) were seen. More than 1 year's follow-up data were available in 205 subjects (M 34; F 171). The distribution of these was as follows: (i), chronic tension-type headache (CTH), 33 (16.1%); (ii), chronic/transformed migraine (TM), 169 (82.4%); (iii), new persistent CDH, 3 (1.5%). There were 169 cases of TM (M : F 1 : 4.7; age 26-58 years). History of past episodic migraine was present in all. Transformation had been gradual (89.4%) or acute (10.6%). Possible factors in transformation included psychological stress (44.4%), analgesic overuse (28.4%), ergot overuse (4.1%). HRT seemed to be implicated in three female subjects. Analgesic overuse was limited between intake of 600 and 2400 mg of aspirin equivalent per day (mean 735 mg). Ergot overuse varied between 1 and 3 mg/day of ergotamine for > or = 3 days/week. With medical therapy approximately 70% TM and 40% CTH patients noted significant improvement. About 80% of these relapsed on therapy withdrawal. CDH in India is not uncommon. Analgesic/ergot overuse needs to be recognized early. The average dose of analgesic implicated in CDH seems much less compared with that reported in the West.

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.

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.

American Headache Society members' assessment of headache diagnostic criteria

OBJECTIVE

We assessed the views of physicians interested in headache as to the diagnosis of the most commonly occurring and currently controversial headaches.

BACKGROUND

The International Headache Society (IHS) classification system has received wide professional endorsement and considerable empirical support, but in the United States, their adoption by clinicians may be proceeding more slowly. Questions remain, including what diagnostic criteria for migraine and tension-type headache clinicians may continue to favor over those outlined by the IHS, to what extent is the "transformed migraine" diagnosis used in clinical practice, and how is analgesic rebound headache diagnosed with regard to the various quantitative measures of analgesic use.

METHODS

Members of the American Headache Society rated the importance of IHS and non-IHS diagnostic criteria for migraine and tension-type headache and for analgesic rebound headache. Respondents also described their use of the proposed transformed migraine diagnosis.

RESULTS

Two-thirds (67.3%) of the respondents reported use of the IHS criteria or the IHS criteria in conjunction with clinical judgment. For migraine and tension-type headache, IHS criteria were rated with high importance, but some respondents reported using additional non-IHS diagnostic criteria and de-emphasizing certain IHS criteria. For chronic headache, almost two-thirds (63%) of respondents reported using the transformed migraine diagnosis. For analgesic rebound headache, respondents preferred to make the diagnosis based on medication consumption that is lower than amounts stipulated in the IHS classification system.

CONCLUSIONS

There remains a number of physicians interested in headache who do not use the IHS classification system, who modify the IHS criteria in practice, and who use the "transformed migraine" diagnosis for patients with chronic daily headache.

Cognitive-behavioral issues in the treatment and management of chronic daily headache

Chronic daily headache is a heterogeneous group of daily or near-daily headaches that afflicts close to 5% of the general population and accounts for close to 35% to 40% of patients at headache centers. First-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of headaches. However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. Cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, improving headache-related disability, affective distress, and quality of life, and reducing overreliance on medication. For cognitive-behavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance.

Fatigue in chronic migraine patients

Fatigue is a common symptom frequently reported in many disorders including headaches, but little is known about its nature. The objective was to determine the prevalence of fatigue in chronic migraine (CM) patients, to define its subtypes and its relationship with other conditions comorbid with CM. Sixty-three CM patients were analysed. The Fatigue Severity Scale (FSS), the Chalder fatigue scale and the CDC diagnostic criteria for chronic fatigue syndrome (CFS) were used. Fifty-three (84.1%) patients had FSS scores greater than 27. Forty-two (66.7%) patients met the CDC criteria for CFS. Thirty-two patients (50.8%) met the modified CDC criteria (without headache). Beck depression scores correlated with FSS, mental and physical fatigue scores. Trait anxiety scores also correlated with fatigue scales. Women had higher FSS scores than men, P < 0.05. Physical fatigue was associated with fibromyalgia, P < 0.05. Fatigue as a symptom and CFS as a disorder are both common in CM patients. Therapeutic interventions include a graded aerobic exercise program, cognitive behavioural therapy and antidepressants. Identification of fatigue and its subtypes in headache disorders and recognition of headaches in CFS patients has implications for the pathophysiology, diagnosis and treatment of these disorders.

What is the evolutionary advantage of migraine?

Susceptibility to migraine is determined by genetic factors and is therefore subject to the forces of natural selection. Migraine is a common and ancient disorder whose prevalence may be increasing, suggesting that a migraine-prone nervous system may be associated with reproductive or survival advantages. Five evolutionary explanations are reviewed that might account for the persistence of migraine: (i). migraine as a defence mechanism; (ii). migraine as a result of conflict with other organisms; (iii). migraine as result of novel environmental factors; (iv). migraine as a trade-off between genetic harms and benefits; and (v). migraine as a design constraint. An evolutionary perspective on migraine allows the generation of important hypotheses about the disorder and suggests rewarding possibilities for further research.

Pharmacotherapy of tension-type headaches

The first International Headache Society classification defined tension-type headaches by itemizing characteristics of migraines that tension-type headaches did not possess. As a result, tension-type headaches (episodic and chronic) remain the most nonspecific of all the commonly observed primary headaches. Until recently, there has been little impetus on the part of the pharmaceutical industry to investigate tension-type headaches; many of the potentially useful drugs are now generic and unprofitable. In addition, few investigators have pursued the study of tension-type headache because of its more glamorous neighbor, migraine. As a result, there are few well-designed studies on the pharmacotherapy of tension-type headaches. The few studies that exist support the use of age-old standard drug classes, the tricyclic antidepressants and the nonsteroidal anti-inflammatory drugs. New research is emerging that points to the potential use of botulinum toxin and nitric synthase inhibitors. More scientifically rigorous clinical studies are needed.

Prophylaxis of migraine, transformed migraine, and cluster headache with topiramate

OBJECTIVE

To assess the efficacy and tolerability of topiramate for prophylaxis of migraine and cluster headache via a retrospective chart analysis.

BACKGROUND

Topiramate has multiple mechanisms of action that could potentially contribute to migraine prophylaxis. We conducted a retrospective chart review to assess the efficacy of topiramate as add-on therapy in patients with transformed migraine or cluster headache, and as first-line therapy in patients with episodic migraine.

METHODS

Patients diagnosed with transformed migraine, episodic migraine, or cluster headache, who received topiramate either as add-on therapy or monotherapy were selected via retrospective chart review. Patients had begun topiramate therapy at 25 mg/day for the first week and increased their dosage by 25 mg/week to a maximum of 200 mg/day. Topiramate was used as add-on therapy for patients with transformed migraine and cluster headache, and as a first-line monotherapy in patients with episodic migraine who had no previous prophylactic therapy. The outcome parameters examined included a mean 28-day migraine frequency, migraine severity, number of headache days/month, number of abortive medication tablets/month, patient global evaluation, and the MIDAS scale.

RESULTS

One hundred seventy-eight patients (transformed migraine: n = 96; episodic migraine: n = 70; and cluster headache: n = 12) were included in the retrospective analysis. The mean dose of topiramate for all patients was 87.5 mg/day. For patients with transformed migraine, mean migraine frequency decreased from 6.3/28 days to 3.7 (P = 0.005). Mean severity decreased from 7.1 to 3.8 on a 10-point scale, with 10 representing the most severe pain (P = 0.003). The mean number of headache days/month decreased from 22.1 to 9.6 (P = 0.001), and the mean number of abortive medication tablets decreased from 28.7/month to 10.6 (P = 0.001). Patient global evaluation indicated substantial or moderate improvement in 53% of patients with transformed migraine who used topiramate as add-on therapy. Mean MIDAS scale values decreased from 90.2 to 24.9 (P< 0.0001). The 70 episodic migraine patients who were administered topiramate as first-line therapy exhibited a decrease in mean migraine frequency (5.8/28 days to 1.9, P = 0.001), while mean migraine severity decreased from 8.1 to 2.0 (P = 0.003). Sixty-one percent of patients reported marked improvement. Nine of the 12 cluster headache patients exhibited substantial or moderate improvement in symptoms, whereas three had no improvement. The most common adverse effects were paresthesias (12%), cognitive effects (11%), and dizziness (6%). Eight patients discontinued topiramate due to adverse effects; cognitive effects were the most common reason. No patient discontinued topiramate treatment due to lack of efficacy. Twelve percent of patients lost more than 5 lbs during treatment (a range of 5-120 lbs).

CONCLUSION

For both patients with transformed migraine (add-on therapy) and patients with episodic migraine (first-line monotherapy), topiramate yielded significant reductions in migraine frequency, migraine severity, number of headache days/month, and use of abortive medications. Topiramate also appears to be well tolerated and useful in the adjunctive treatment of cluster headache. Prospective double-blind, placebo-controlled trials will be required to confirm our results.

Health resource utilization of the emergency department headache "repeater"

OBJECTIVE

To document the health resource utilization of patients who repeatedly use emergency department services for headache care.

BACKGROUND

Patients with headache who frequently use emergency department services may differ from patients with more typical, episodic migraine. Previous studies of health resource utilization have often failed to distinguish the high utilizer as a specific subset of the migraine population.

DESIGN

Retrospective review of urgent care/emergency department charts, clinic charts, and pharmacy rosters.

PATIENTS AND METHODS

Patients who made three or more visits for headache to an urgent care/emergency department (UC/ED) facility for headache over a 6-month study period were identified and designated as "repeaters" for this study. Pharmacy profiles and appointment histories of 52 of the 54 repeaters whose records were available were reviewed for the 12 months prior to the study period.

RESULTS

Over the 6-month study period, 518 patients visited the UC/ED 1004 times for primary headache complaints. Fifty-four (10%) repeaters made 502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months prior to the study period, 52 of these repeaters made 1832 visits to the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated 12-month cost for all visits was $183,760. Pharmacy rosters showed use of narcotics in 41 of the 52 patients (annual mean +/- SD, 613 +/- 670 tablets), benzodiazepines in 30 patients (500 +/- 486 tablets), and butalbital products in 27 patients (395 +/- 590 tablets). Mean daily use of all symptomatic medications combined was 3.9 +/- 3.2 doses/day.

CONCLUSION

Health resource utilization of emergency department headache repeaters is predominantly headache-related acute care. Associated medication overuse is frequently present. Efforts to improve care for patients with headache will benefit from distinguishing the high utilizer as a subset of the migraine population.

Do butalbital-containing products have a role in the management of migraine?

STUDY OBJECTIVE

To evaluate the role of butalbital-containing products in the management of migraine.

METHODS

Qualitative systematic search using MEDLINE (January 1966-November 2001), review of the United States Headache Consortium's evidence-based guidelines for migraine treatment, and review of other pertinent literature.

RESULTS

Over 28 million people suffer with migraine, yet this illness is less than optimally diagnosed and managed. Between 14% and 36% of diagnosed migraineurs are prescribed butalbital-containing products, often as initial therapy. However, the only identified controlled trial of these drugs for migraine treatment showed that butalbital-containing products were inferior to butorphanol. The consortium's guidelines specifically discourage administration of butalbital-containing products for migraine. In addition, other published literature highlights the frequent adverse consequences of butalbital-containing products for migraineurs, such as poor migraine control, disability, drug-induced headaches, and withdrawal symptoms.

CONCLUSION

Although butalbital-containing products commonly are prescribed for migraine, no evidence in the literature demonstrates their benefit over other agents or placebo. Drugs with proven migraine efficacy, as listed in the consortium's evidence-based guidelines, should be prescribed instead.

Chronic daily headache prophylaxis with tizanidine: a double-blind, placebo-controlled, multicenter outcome study

OBJECTIVE

To assess the efficacy of tizanidine hydrochloride versus placebo as adjunctive prophylactic therapy for chronic daily headache (chronic migraine, migrainous headache, or tension-type headache).

BACKGROUND

Tizanidine is an alpha2-adrenergic agonist that inhibits the release of norepinephrine at both the spinal cord and brain, with antinociceptive effects that are independent of the endogenous opioid system. Previous open-label studies have suggested the drug may be effective for treatment of chronic daily headache.

METHODS

Two hundred patients completed a 4-week, single-blind, placebo baseline period, with 134 fulfilling selection criteria and then randomized to tizanidine or placebo. Ninety-two patients completed at least 8 weeks of treatment (tizanidine, n = 45; placebo, n = 47), and 85 patients completed 12 weeks of treatment (tizanidine, n = 44; placebo, n = 41). Most patients (77%) met the diagnostic criteria for migraine of the International Headache Society; 23% had either chronic migrainous headache or chronic tension-type headache. Tizanidine was slowly titrated over 4 weeks to 24 mg or the maximum dose tolerated (mean, 18 mg; SD, 6.4; median, 20.0; range, 2 to 24), divided equally over three dose intervals per day. Overall headache index ([headache days x average intensity x duration in hours]/28 days) was the primary end point.

RESULTS

Tizanidine was shown to be superior to placebo in reducing the overall headache index (P =.0025), as well as mean headache days per week (P =.0193), severe headache days per week (P =.0211), average headache intensity (P =.0108), peak headache intensity (P =.0020), and mean headache duration (P =.0127). The mean percentage improvement during the last 4 weeks of treatment with tizanidine versus placebo was 54% versus 19% for the headache index (P =.0144), 55% versus 21% for severe headache days (P =.0331), 35% versus 19% for headache duration (P =.0142), 35% versus 20% for peak headache intensity (P =.0106), 33% versus 20% for average headache intensity (P =.0281), and 30% versus 22% for total headache days (P =.0593). Patients receiving tizanidine also scored higher ratings of overall headache improvement on a visual analog scale (P =.0069). There was no statistically significant difference in outcome for patients with chronic migraine versus those with only migrainous or tension-type headache. Adverse effects reported by more than 10% of the patients included somnolence (47%), dizziness (24%), dry mouth (23%), and asthenia (19%). Dropouts due to adverse events did not differ significantly between tizanidine and placebo.

CONCLUSIONS

The results support tizanidine as an effective prophylactic adjunct for chronic daily headache, including migraine, migrainous headache, and tension-type headache. These results also suggest the possible importance of an alpha2-adrenergic mechanism underlying the pathophysiology of this spectrum of headache disorders.

Overview of tension-type headache

Tension-type headache (TTH) is the most prevalent form of headache. Although it is not the most severe form of headache, it has a significant impact on society. In spite of this, little is known about its pathophysiology. Current International Headache Society classification has been called into question, and new classification approaches have been suggested. With reference to chronic TTH, the issue of analgesic rebound may confound the diagnosis. Transformed migraine and new persistent daily headaches are clarified and differentiated from chronic TTHs (CTTHs). The best documented abnormality found in TTHs is the presence of pericranial tenderness. It is generally believed that pain is initiated by a peripheral mechanism, most likely increased input from the myofascial nociceptors. In CTTH, there may be an impaired supraspinal modulation of the incoming stimuli. Whether there is an overlap in the continuum between TTH and migraine is controversial. Abortive and prophylactic treatments are discussed and wellness and adjunct therapy are also emphasized. Lastly, special attention is paid to the doctor-patient relationship in patients with difficult headaches.

Prolonged recovery from rebound headaches

OBJECTIVE

To document that some patients with rebound headache require prolonged complete avoidance of the pain relief medications which might cause the daily or almost daily headaches in order to achieve a goal of 6 consecutive headache-free days.

BACKGROUND

Most articles on rebound headache imply that the patient improves after stopping the offending agents, but they fail to state the pattern of recovery, the time required for recovery, or the specific end point achieved.

DESIGN

Selected from the histories of approximately 1000 patients with suspected rebound headache who have been seen in a university headache referral clinic are the records of four patients who kept careful headache diaries, followed the treatment protocol (with minimal noncompliance by two patients), and required more than 6 months to achieve our goal of 6 consecutive headache-free days.

CONCLUSIONS

Hopefully, other physicians treating patients with suspected rebound headache will benefit from this report and will be able to better manage their patients.

Behavioral and nonpharmacologic treatments of headache

Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache.

Treatment of chronic headache with antidepressants: a meta-analysis

BACKGROUND

Although antidepressants are often used for preventing chronic headache, their effectiveness is uncertain.

METHODS

We performed a meta-analysis of English-language, randomized placebo-controlled trials of antidepressants as prophylaxis for chronic headache.

RESULTS

Thirty-eight trials were included. Because some compared more than one drug with placebo, 44 study arms were combined using a random effects model. Twenty-five studies focused on migraines, 12 on tension headaches, and 1 on both. Nineteen used tricyclic antidepressants, 18 serotonin antagonists, and 7 selective serotonin reuptake inhibitors. Patients receiving antidepressants were twice as likely to report headache improvement (rate ratio [RR]: 2.0; 95% confidence interval [CI]: 1.6 to 2.4). Because 31% (95% CI: 23% to 40%) more treated patients improved than those receiving placebo, clinicians would need to treat 3.2 patients for 1 patient to improve. The average amount of improvement (standardized mean difference) was 0.94 (95% CI: 0.65 to 1.2), an effect considered large. Treated patients also consumed less analgesic medication (standardized mean difference, -0.7; 95% CI: -0.5 to -0.94). There were no differences in outcomes among the three classes of agents studied or by the type of headache (migraine vs. tension), quality score, length of treatment, or percentage of patients lost to follow-up. Assessment of depression across studies was insufficient to determine if the effects were independent of depression.

CONCLUSION

Antidepressants are effective in preventing chronic headaches. Whether this is independent of depression and whether there are differences in efficacy by class of agent needs further study.

Diagnosis and management of headache

Migraine and tension headaches are among the most common diagnoses in women's health. Secondary causes of headache such as brain tumor, subarachnoid hemorrhage, and meningitis are uncommon but must not be missed. A careful history and physical examination, use of diagnostic criteria, and certain facts about the serious causes of headache are the keys to diagnosis and treatment. Neuroimaging should be limited to patients displaying signs or symptoms of a secondary headache cause. Menstrual migraine can be managed similarly to nonmenstrual migraine.

Retro-orbital tumour--an uncommon cause of headache in pregnancy

Retro-orbital tumour was the cause of headache and neuropathic facial pain in a 31-year-old pregnant woman. The diagnosis had been overlooked as a result of a long history of migraine. There was exacerbation of the pain throughout the pregnancy, particularly in the third trimester. Pharmacological agents commonly used to manage neuropathic pain states were relatively contraindicated due to potential adverse effects on the fetus. Cognisant of such limitations imposed by pregnancy, we used multimodal therapy in an attempt to control the pain. This included morphine, paracetamol, amitriptyline, ketamine and psychological support. The management challenges are described.

Childhood Migraine Headache Syndromes

The treatment of migraine headache in children depends on the following: a) defining the underlying cause; b) the frequency of the attacks; and c) the severity of the disability produced by the pain. Any medication taken to relieve pain is most effective if taken at maximum dose at the onset of the headache. The dose should be the maximum recommended by weight or age. Triptans are also more effective if used early. Over-the-counter (OTC) analgesics are often effective in relieving pediatric headache and should be tried before prescription drug therapy is attempted. The more frequent a child's headaches are, the greater the danger that repeated doses of pain medications, including those purchased OTC, will lead to a chronic headache syndrome as the medication is reduced. Recurrent severe headaches, occurring more than once a week and resulting in interruption of normal activities or poor concentration, need to be treated with prophylactic medications taken daily so that the number of headaches can be reduced. Amitriptyline, propanolol, and periactin are the most frequently used drugs to block headaches, but valproate, verapamil, or other calcium channel blockers and other antidepressants are also useful. Biofeedback, relaxation, or cognitive therapies can also reduce headache frequency in children with both migraine and tension headaches. Headaches that are intractable to oral medication for the acute relief of pain may respond more rapidly to an efficiently absorbed drug administered by nasal spray or subcutaneously. The initial dose of an injectable drug should be given in a situation where a physician is immediately available. Recurrent headaches that have occurred over more than 6 months and that are associated with a normal neurologic examination are almost never caused by an intracranial lesion. Routine CT and MRI scans or an electroencephalogram (EEG) are generally unnecessary for these patients because these scans are rarely of value in these patients unless there is a history of another neurologic disorder or the headaches are focal, relentless, and worsening over time.

A practical approach to migraine headache

Headache is a common problem in primary care practice. Migraine accounts for the vast majority of patients seeking treatment for their headaches. The ability to simplify the evaluation and treatment of these patients translates into patient's relief and increased productivity.