Epidemiology of tension-type headache in Santiago, Chile: a prevalence study

Primary headache disorders in Latin America and the Caribbean: A meta-analysis of population-based studies

BACKGROUND

In this manuscript, we aim to systematically estimate the pooled prevalence and incidence of primary headaches and its subtypes (migraine, tension-type headache, and chronic headaches) in Latin America and the Caribbean, describing its epidemiological profile and associated factors.

METHODS

We systematically searched PubMed/MEDLINE, Scopus, and LILACS (From conception to March 2021), for populational studies reporting the epidemiology of primary headaches and their associated factors in Latin America and the Caribbean. The data extraction was conducted independently. We performed random-effect model meta-analysis of prevalence (overall primary headaches and by subtypes) and associated factors, assessed potential sources of heterogeneity, the risk of bias, publication bias, and the evidence certainty (GRADE methodology).

RESULTS

We included 32 populational studies (38 subpopulations, n = 63,813). The prevalence of primary headaches was 41.4% (95% CI 31.1-52.2%; n = 54,357), 15% for migraine (95% CI 12.0-18.3; n = 53,658 individuals), 20.6% for tension-type headache (95% CI 12.4-30.2; n = 25,840), and 6% for chronic headaches (95% CI 3.3-9.6; n = 21,720), with high between-study heterogeneity. No incidence data was found. Female sex, white ethnicity, high BMI, comorbid mental health disorders, and low-back pain were associated with higher prevalence of primary headaches. The prevalence was less in rural areas.

CONCLUSION

In Latin America and the Caribbean, primary headaches are highly prevalent affecting young females disproportionally. The prevalence of chronic headaches is higher than in other systematic global and regional estimations. The presence of comorbidities as modifiable risk factors should encourage their integration as targets for community-based preventive and therapeutic interventions.

PROTOCOL REGISTRATION NUMBER

CRD42018105116.

Tension-type headache

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

Aspirin for acute treatment of episodic tension-type headache in adults

BACKGROUND

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (two to 14 headache days per month), and chronic TTH (15 headache days per month or more). Aspirin is one of a number of analgesics suggested for acute treatment of episodic TTH.

OBJECTIVES

To assess the efficacy and safety of aspirin for acute treatment of episodic tension-type headache (TTH) in adults compared with placebo or any active comparator.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Oxford Pain Relief Database from inception to September 2016, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral aspirin for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. For various outcomes (predominantly those recommended by the International Headache Society (IHS)), we calculated the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT), one additional harmful outcome (NNH), or to prevent one event (NNTp) for oral aspirin compared to placebo or an active intervention.We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included five studies enrolling adults with frequent episodic TTH; 1812 participants took medication, of which 767 were included in comparisons of aspirin 1000 mg with placebo, and 405 in comparisons of aspirin 500 mg or 650 mg with placebo. Not all of these participants provided data for outcomes of interest in this review. Four studies specified using IHS diagnostic criteria; one predated commonly recognised criteria, but described comparable characteristics and excluded migraine. All participants treated headaches of at least moderate pain intensity.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged one study to be at high risk of bias due to small size.There were no data for aspirin at any dose for the IHS preferred outcome of being pain free at two hours, or for being pain free at any other time, and only one study provided data equivalent to having no or mild pain at two hours (very low quality evidence). Use of rescue medication was lower with aspirin 1000 mg than with placebo (2 studies, 397 participants); 14% of participants used rescue medication with aspirin 1000 mg compared with 31% with placebo (NNTp 6.0, 95% confidence interval (CI) 4.1 to 12) (low quality evidence). Two studies (397 participants) reported a Patient Global Evaluation at the end of the study; we combined the top two categories for both studies to determine the number of participants who were 'satisfied' with treatment. Aspirin 1000 mg produced more satisfied participants (55%) than did placebo (37%) (NNT 5.7, 95% CI 3.7 to 12) (very low quality evidence).Adverse events were not different between aspirin 1000 mg and placebo (RR 1.1, 95% CI 0.8 to 1.5), or aspirin 500 mg or 650 mg and placebo (RR 1.3, 95% CI 0.8 to 2.0) (low quality evidence). Studies reported no serious adverse events.The quality of the evidence using GRADE comparing aspirin doses between 500 mg and 1000 mg with placebo was low or very low. Evidence was downgraded because of the small number of studies and events, and because the most important measures of efficacy were not reported.There were insufficient data to compare aspirin with any active comparator (paracetamol alone, paracetamol plus codeine, peppermint oil, or metamizole) at any of the doses tested.

AUTHORS' CONCLUSIONS

A single dose of aspirin between 500 mg and 1000 mg provided some benefit in terms of less frequent use of rescue medication and more participants satisfied with treatment compared with placebo in adults with frequent episodic TTH who have an acute headache of moderate or severe intensity. There was no difference between a single dose of aspirin and placebo for the number of people experiencing adverse events. The amount and quality of the evidence was very limited and should be interpreted with caution.

Ketoprofen for episodic tension-type headache in adults

BACKGROUND

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache day per month), frequent episodic TTH (2 to 14 headache days per month), and chronic TTH (15 headache days a month or more). Ketoprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH.

OBJECTIVES

To assess the efficacy and safety of ketoprofen for treatment of episodic TTH in adults compared with placebo or any active comparator.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Oxford Pain Relief Database up to May 2016, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral ketoprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. We used the numbers of participants achieving each outcome to calculate the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT) or one additional harmful outcome (NNH) for oral ketoprofen compared to placebo or an active intervention for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included four studies, all of which enrolled adults with frequent episodic TTH. They all specified using the IHS diagnostic criteria and reported mean baseline pain of at least moderate intensity. While 1253 people with TTH participated in these studies, the numbers available for any analysis were lower than this because outcomes were inconsistently reported and because many participants received active comparators.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged one study to be at high risk of bias due to small size.Useful information was available only for ketoprofen 25 mg. For the IHS preferred outcome of being pain-free at two hours the NNT for ketoprofen 25 mg compared with placebo was 9.0 (95% confidence interval (CI) 4.8 to 72) in two studies (272 participants; low quality evidence). The NNT was 3.7 (95% CI 2.6 to 6.3) for pain-free or mild pain at two hours in two studies (272 participants; moderate quality evidence). Fewer people needed rescue medication with ketoprofen 25 mg than with placebo, with a number needed to treat to prevent one event (NNTp) of 6.2 (95% CI 4.3 to 11) in three studies (605 participants; moderate quality evidence). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than placebo (NNH 15, (95% CI 8.7 to 45)) in three studies (651 participants with 66 events; low quality evidence). Most events were of mild to moderate intensity.Ketoprofen 25 mg was not different from paracetamol 1000 mg in two studies with 276 participants for any efficacy outcomes (low to moderate quality evidence); the RR for pain-free at two hours was 1.3 (95% CI 0.9 to 2.0). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than with paracetamol (NNH 17, 95% CI 8.9 to 130)) in two studies (582 participants, 68 events; low quality evidence).Studies reported no serious adverse events.We judged the quality of the evidence comparing ketoprofen 25 mg with placebo or paracetamol 1000 mg as moderate to very low. Where evidence was downgraded it was because of the small number of studies and events.

AUTHORS' CONCLUSIONS

Ketoprofen 25 mg provided a small benefit compared with placebo in terms of being pain-free at two hours or having mild or no pain at two hours for people with frequent episodic TTH who have an acute headache of moderate or severe intensity. Its use was associated with more people experiencing adverse events. Ketoprofen 25 mg was not superior to paracetamol 1000 mg for any efficacy outcome.

The Prevalence of Migraine and Tension-Type Headaches Among Adolescents in Norway. The Nord-Trøndelag Health Study (Head-Hunt-Youth), A Large Population-Based Epidemiological Study

The aim of this study was to examine the prevalence of headache and primary headache disorders like migraine and tension-type headaches among adolescents, and to explore the differences in headache prevalence and frequency by gender and age. This cross-sectional study was conducted in Nord-Trøndelag county, Norway, during the years 1995-97. In total, 8984 (88%) out of 10 202 invited adolescents aged 12-19 years participated in the youth part of the Nord-Trøndelag Health Study [Helseundersøkelsen i Nord-Trøndelag (HUNT)]. The total study population in this study consisted of 8255 individuals after exclusion of invalid questionnaires and students outside the target range of 13-18 years of age. The students completed a comprehensive questionnaire, and one of the questions was whether the students had experienced any headaches during the last 12 months. In addition, 5847 of these students were also subject to an interview in which they were asked whether they had experienced recurring headaches during the last year and, if so, were they classified as migraine (MI), tension-type headache (TTH) or non-classifiable headache. In the total questionnaire-based population, 76.8% reported having had headaches during the last 12 months (69.4% boys and 84.2% girls). Among those who also were interviewed, 29.1% reported having recurrent headaches (21.0% boys and 36.5% girls). The overall 1-year prevalence of migraine was 7%, of tension-type headache 18%, and of non-classifiable headache 4.8%. Higher prevalence rates were found for girls in all age groups and for all headache categories. The overall frequency of recurrent headaches did not vary significantly with age, but girls had significantly more frequent headaches than boys. We concluded that headache in general, and recurrent primary headache disorders like migraine and tension-type headaches, are common somatic complaints among Norwegian adolescents, especially among girls.

Tension-Type Headache and Physical Activity: An Actigraphic Study

There have been some studies on the relationship between tension-type headache (TTH) and physical activity. However, most previous studies were not prospective and assessed physical activity by questionnaire. Therefore, this study was aimed to investigate the relationship between TTH intensity and physical activity prospectively utilizing computerized ecological momentary assessment and actigraphy Thirty-one TTH patients wore watch-type computers equipped with actigraphy inside for 1 week to record momentary headache intensity and physical activity. Multilevel modelling was used to investigate the effect of headache intensity on the simultaneous and subsequent activity level. There were significant negative associations between headache intensity and the simultaneous and subsequent activity level, and activity level was significantly reduced at headache exacerbations. These results provide objective and quantitative evidence suggesting that TTH negatively affects physical activity.

Epidemiological and Clinical Characteristics with Psychosocial Aspects of Tension-Type Headache in Turkish College Students

We investigated the prevalence and clinical characteristics of tension-type headache (TTH), psychosocial factors contributing to the onset and aggravation of headache and coping mechanisms of individuals in a young population in Turkey. The sample consisted of 2226 university students, aged 7 to 21 years old. A self-administered questionnaire inquiring about epidemiological and clinical features of headache was filled out by participants. TTH diagnosis was determined in accordance with the International Headache Society Criteria of 1988. The prevalence of TTH was 20.35% (25.54% for women and 14.25% for men). 43.7% of headache sufferers had one or more stressful life events before the onset of headache and stress was the most frequent aggravating factor of headache (52%). Resting (58.1%) was the most common coping style. In conclusion, TTH is not a rare condition in Turkish young people and psychosocial factors are always taken into consideration for diagnosis and treatment of TTH.

An Epidemiological Study of Headache in Florianopolis, Brazil

The aim of this study was to estimate the 1-year prevalence of headache, migraine, tension-type headache (TTH) and chronic daily headache (CDH), and the degree of association of migraine with some sociodemographic characteristics of the population of Florianopolis, Brazil. This is a cross-sectional, door-to-door, population-based study. In 300 randomly selected households, 625 subjects, aged 15–64 years, responded to a structured questionnaire. The 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4%. Migraine and CDH were significantly more prevalent in females than in males. Migraine was significantly associated with the following variables: low household income, low electricity consumption, and divorced or widowed marital status. We have shown high prevalences of migraine and CDH in Florianopolis, close to the higher rates of previous studies. There was a preponderance of migraine in females, divorced  or  widowed,  with  a  low  socioeconomic  level.

Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults

BACKGROUND

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (two to 14 headaches per month), and chronic TTH (15 headache days a month or more). Paracetamol (acetaminophen) is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH.

OBJECTIVES

To assess the efficacy and safety of paracetamol for the acute treatment of frequent episodic TTH in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (CRSO), MEDLINE, EMBASE, and the Oxford Pain Relief Database to October 2015, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral paracetamol for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. We used the numbers of participants achieving each outcome to calculate the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT) or one additional harmful outcome (NNH) for oral paracetamol compared to placebo or an active intervention for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables.

MAIN RESULTS

We included 23 studies, all of which enrolled adults with frequent episodic TTH. Twelve studies used the IHS diagnostic criteria or similar, six used the older classification of the Ad Hoc Committee, and five did not describe specific diagnostic criteria but generally excluded participants with migraines. Participants had moderate or severe pain at the start of treatment. While 8079 people with TTH participated in these studies, the numbers available for any analysis were lower than this because outcomes were inconsistently reported and because many participants received active comparators.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged five studies to be at high risk of bias for incomplete outcome reporting, and seven due to small size.For the IHS preferred outcome of being pain free at two hours the NNT for paracetamol 1000 mg compared with placebo was 22 (95% confidence interval (CI) 15 to 40) in eight studies (5890 participants; high quality evidence), with no significant difference from placebo at one hour. The NNT was 10 (7.9 to 14) for pain-free or mild pain at two hours in five studies (5238 participants; high quality evidence). The use of rescue medication was lower with paracetamol 1000 mg than with placebo, with an NNTp to prevent an event of 7.8 (6.0 to 11) in six studies (1856 participants; moderate quality evidence). On limited data, the efficacy of paracetamol 500 mg to 650 mg was not superior to placebo, and paracetamol 1000 mg was not different from either ketoprofen 25 mg or ibuprofen 400 mg (low quality evidence).Adverse events were not different between paracetamol 1000 mg and placebo (RR 1.1 (0.94 to 1.3); 5605 participants; 11 studies; high quality evidence). Studies reported no serious adverse events.The quality of the evidence using GRADE comparing paracetamol 1000 mg with placebo was moderate to high. Where evidence was downgraded it was because a minority of studies reported the outcome. For comparisons of paracetamol 500 mg to 650 mg with placebo, and of paracetamol 1000 mg with active comparators, we downgraded the evidence to low quality or very low quality because of the small number of studies and events.

AUTHORS' CONCLUSIONS

Paracetamol 1000 mg provided a small benefit in terms of being pain free at two hours for people with frequent episodic TTH who have an acute headache of moderate or severe intensity.

The Frequent Unusual Headache Syndromes: A Proposed Classification Based on Lifetime Prevalence

BACKGROUND

There is no agreement on a single cutoff point or prevalence for regarding a given disease as rare. The concept of what is a rare headache disorder is even less clear and the spectrum from a very frequent, frequent, occasional to rare headache syndrome is yet to be established.

OBJECTIVE

An attempt has been made to estimate the lifetime prevalence of each of the headache subtypes classified in the ICHD-II.

METHOD

Using the ICHD-II, 199 different headache subtypes were identified. The following classification was made according to the estimated lifetime prevalence of each headache disorder: very frequent (prevalence >10%); frequent (between 1 and 10%); occasional (between 0.07 and 1%); and unusual or rare (<0.07%).

RESULTS

One hundred and fifty-four of 199 (77%) were categorized as unusual headache disorders, 7/199 (4%) as very frequent, 9/199 (5%) as frequent, and 29/199 (15%) as occasional forms of headache disorder.

CONCLUSION

The unusual headache syndromes do not appear to be as infrequent in clinical practice as has been generally believed. About three-fourths of the classified headache disorders found in the ICHD-II can be considered as rare. This narrative review article may be regarded as an introduction to the concept of unusual headaches and a proposed classification of all headaches (at least those listed in the ICHD-II).

Update of chronic tension-type headache

Tension-type headache (TTH) is the most common type of primary headaches, and its chronic form, chronic tension-type headache (CTTH), is affecting 0.5 to 4.8 % of the worldwide population. Although the mechanism underlying CTTH remains unclear, the role of central versus peripheral mechanisms has always been discussed while explaining the pathogenesis of CTTH. There is always a debate on differential diagnosis between CTTH and chronic migraine without aura which are regarded as different aspects of chronic daily headache spectrum because of many similarities and fuzzy boundaries. Compared with pharmacological treatments, non-pharmacological treatments have been popular as alternative interventions for CTTH in recent years. This review summaries the update knowledge on CTTH and discusses the most interested questions regarding pathogenesis and therapeutic strategies of CTTH.

Ibuprofen for acute treatment of episodic tension-type headache in adults

BACKGROUND

Tension-type headache (TTH) affects about one person in five worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (1 to 14 headaches per month), and chronic TTH (15 headaches a month or more). Ibuprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH.

OBJECTIVES

To assess the efficacy and safety of oral ibuprofen for treatment of acute episodic TTH in adults.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and our own in-house database to January 2015. We sought unpublished studies by asking personal contacts and searching on-line clinical trial registers and manufacturers' websites.

SELECTION CRITERIA

We included randomised, placebo-controlled studies (parallel-group or cross-over) using oral ibuprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, and extracted data. Numbers of participants achieving each outcome were used to calculate risk ratio (RR) and number needed to treat for an additional beneficial outcome (NNT) or number needed to treat for an additional harmful outcome (NNH) of oral ibuprofen compared to placebo for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).

MAIN RESULTS

We included 12 studies, all of which enrolled adult participants with frequent episodic TTH. Nine used the IHS diagnostic criteria, but two used the older classification of the Ad Hoc Committee, and one did not describe diagnostic criteria but excluded participants with migraines. While 3094 people with TTH participated in these studies, the numbers available for any form of analysis were lower than this; placebo was taken by 733, standard ibuprofen 200 mg by 127, standard ibuprofen 400 mg by 892, and fast-acting ibuprofen 400 mg by 230. Participants had moderate or severe pain at the start of treatment. Other participants were either in studies not reporting outcomes we could analyse, or were given one of several active comparators in single studies.For the IHS-preferred outcome of being pain free at 2 hours the NNT for ibuprofen 400 mg (all formulations) compared with placebo was 14 (95% confidence interval (CI), 8.4 to 47) in four studies, with no significant difference from placebo at 1 hour (moderate quality evidence). The NNT was 5.9 (4.2 to 9.5) for the global evaluation of 'very good' or 'excellent' in three studies (moderate quality evidence). No study reported the number of participants experiencing no worse than mild pain at 1 or 2 hours. The use of rescue medication was lower with ibuprofen 400 mg than with placebo, with the number needed to treat to prevent one event (NNTp) of 8.9 (5.6 to 21) in two studies (low quality evidence).Adverse events were not different between ibuprofen 400 mg and placebo; RR 1.1 (0.64 to 1.7) (high-quality evidence). No serious adverse events were reported.

AUTHORS' CONCLUSIONS

Ibuprofen 400 mg provides an important benefit in terms of being pain free at 2 hours for a small number of people with frequent episodic tension-type headache who have an acute headache with moderate or severe initial pain. There is no information about the lesser benefit of no worse than mild pain at 2 hours.

Headache and migraine: a leading cause of absenteeism

Migraine and tension-type headache, the two dominant primary headache disorders, are among the most common causes of lost work time. The population impact of both disorders is similar, but the demographics and individual impact differ. Approximately 18% of females and 6% of males have migraine in the general population. Prevalence is highest around age 40, when individuals are at the peak of their work abilities. Headaches cause substantial individual impact on work productivity and employer and societal burden from direct medical costs, lost work time, and underemployment, and, in more severe persistent headache, unemployment. The lost work time costs greatly exceed medical care costs. Chronic daily headache (15 or more headache days per month) represents a widely accepted stage of pain progression that occurs in 2-4% of the population. Treatment of headaches can be acute or preventive. The goals of acute treatment are timely alleviation of pain and associated symptoms without recurrence, the restoring of ability to function, minimizing the use of back-up and rescue medications with minimal adverse events, and providing the best cost-effective management. Migraine-preventive medications are used to decrease future attack frequency, severity, and duration, improving responsiveness to acute treatments, and improving overall function and decreasing disability. Preventing analgesic overuse that leads to chronic daily headache is another goal of using preventive treatment. Preventive medications should be considered in migraine patients reporting either 3-6 or more headache days per month, depending on how headaches impair function.

The PACE study: past-year prevalence of tension-type headache and its subtypes in Parma's adult general population

The mean global prevalence of tension-type headache (TTH) in adult is 42 %. To date, there have been no Italian studies on TTH prevalence in the adult general population. Therefore, we conducted a cross-sectional study, called PACE, aimed at detecting the prevalence of primary headaches in the city of Parma's adult general population. 904 subjects representative of Parma's adult general population were interviewed face to face by a physician of our Headache Centre. Crude past-year prevalence for definite TTH was 19.4 % (95 % CI 16.8-21.9; 18.4 %, 95 % CI 14.6-22.3 in men, and 20.1 %, 95 % CI 16.6-23.6 in women), namely, 9.0 % (95 % CI 7.1-10.8) for infrequent TTH, 9.8 % (95 % CI 7.9-11.8) for frequent TTH, and 0.6 % (95 % CI 0.1-1) for chronic TTH. Crude prevalence for probable TTH was 2.3 % (95 % CI 1.3-3.3; 2 %, 95 % CI 0.6-3.4 in men, and 2.6 %, 95 % CI 1.2-3.9 in women). Our results indicate a TTH prevalence (19.4 %) at the lower limit of data ranges for Western countries, and prevalence rates for infrequent forms (9 %) do not appear different from those of frequent forms (9.8 %).

Chronic daily headache in Korea: prevalence, clinical characteristics, medical consultation and management

Background and Purpose

Chronic daily headache (CDH) is a commonly reported reason for visiting hospital neurology departments, but its prevalence, clinical characteristics, and management have not been well documented in Korea. The objective of this study was to characterize the 1-year prevalence, clinical characteristics, medical consultations, and treatment for CDH in Korea.

Methods

The Korean Headache Survey (KHS) is a nationwide descriptive survey of 1507 Korean adults aged between 19 and 69 years. The KHS investigated headache characteristics, sociodemographics, and headache-related disability using a structured interview. We used the KHS data for this study.

Results

The 1-year prevalence of CDH was 1.8% (95% confidence interval, 1.1-2.5%), and 25.7% of the subjects with CDH met the criteria for medication overuse. Two-thirds (66.7%) of CDH subjects were classified as having chronic migraine, and approximately half of the CDH subjects (48.1%) reported that their headaches either substantially or severely affected their quality of life. Less than half (40.7%) of the subjects with CDH reported having consulted a doctor for their headaches and 40.7% had not received treatment for their headaches during the previous year.

Conclusions

The prevalence of CDH was 1.8% and medication overuse was associated with one-quarter of CDH cases in Korea. Many subjects with CDH do not seek medical consultation and do not receive appropriate treatment for their headaches.

Prevalence of Tension-Type Headache in Individuals Aged between 18-65 Years in the Eastern Parts of Turkey

OBJECTIVE

Although tension-type headache (TTHA) is one of the most frequently encountered diseases in the general population, relatively few studies have been conducted on this health condition. The published data are limited on the frequency of TTHA in Turkey, and no studies to date have been initiated on the prevalence of TTHA in the city of Erzurum or the Eastern Anatolian Region.

MATERIALS AND METHODS

The study was conducted using in-depth interviews from 1972 individuals from city of Erzurum. TTHA was queried in patients with a history of headache, according to the International Classification of Headache Disorders diagnostic criteria, and the frequency of TTHA was investigated.

RESULTS

A total of 1972 patients were enrolled in this study. The frequency reached a peak between the ages of 40-49 years (35%), and it significantly declined after the age of 49. During an examination (palpation), cranial muscle sensitivity was detected in 33% of the patients.

CONCLUSION

The frequency of TTHA has been identified as 22.3% in patients between the ages of 18-65. The frequency of tension type headache in the city of Erzurum was lower than that in the general population of Turkey.

Epidemiology and cultural differences in tension-type headache

Tension-type headache (TTH) is the most prevalent headache worldwide Stovner et al. (Cephalalgia 27:193-210, 2007••); Robbins and Lipton (Semin Neurol 30:107-19, 2010••); Jensen and Stovner (Lancet Neurol 7:354-361, 2008). Despite being the most prevalent primary headache type, there is still a relative lack of epidemiologic data when compared to that for migraine Robbins and Lipton (Semin Neurol 30:107-19, 2010••). Out of the available data, it is apparent that there are wide variations and differences in tension-type headache epidemiology across different cultures Stovner et al. (Cephalalgia 27:193-210, 2007••). This review will focus on reviewing and comparing the epidemiology of episodic and chronic TTH in adult populations across varying continental regions. This will include prevalence, cultural variations and differences in study methodologies, common precipitants and prognosis. Possible explanations for such widely varying prevalence rates among different cultures and regions will also be discussed.

Evaluation of diagnostic and prognostic value of clinical characteristics of migraine and tension type headache included in the diagnostic criteria for children and adolescents in International Classification of Headache Disorders--second edition

Data about the sensitivity and the specificity of the items included in the diagnostic criteria for migraine and tension type headache (TTH) in children is limited and sometimes controversial.

AIM

To evaluate the diagnostic value of characteristics of migraine and TTH included in the diagnostic criteria of ICHD-II and according to results to suggest additional criteria for diagnostic differentiation of primary paediatric headache.

PATIENTS AND METHODS

The investigation consisted of an epidemiological school-based study (1029 pupils completed the study and 412 had chronic or recurrent headache) and a clinical study conducted in Paediatric Neurology Ward and outpatient clinic (203 patients with chronic or recurrent headache). Inclusion criterion was at least two episodes of headache during the last year. Exclusion criteria were: headache occurring only during acute infections; withdrawal of informed consent. ICHD - II was used to classify headache. The diagnostic value of characteristics of migraine and TTH was measured using sensitivity, specificity, odds ratio and area under receiver operating characteristic curve (AUC).

RESULTS

Regarding the AUC, the best diagnostic items for migraine are: moderate or severe intensity or only severe intensity, pain aggravation by physical activity, pulsating quality, respectively, for TTH - no photophobia, no nausea, no aggravation by physical activity, mild or moderate intensity and non-pulsating quality. The most significant symptom for increasing the migraine risk was pulsating pain and the most significant items for TTH risk were no photophobia, bilateral location and no nausea. Family history of migraine also increased migraine risk and could be either included in the diagnostic criteria for migraine or recommended as additional item in differentiating migraine and TTH with overlapping diagnostic criteria. According to AUC, we could recommend changing the content of the item of intensity for migraine as only severe intensity.

Interictal pain in primary headache syndromes

Primary headache disorders are generally characterized by the pain, time course, and associated symptoms of their attacks, but often are accompanied by milder interictal pain. Patients with chronic migraine, chronic tension-type headache, hemicrania continua, and new daily-persistent headache have constant pain more often than not. Patients with trigeminal autonomic cephalalgias such as cluster headache commonly have interictal pain as well, usually much milder and unilateral to the side of attacks. Even those with rare headache types, including hypnic headache and trigeminal neuralgia, commonly have interictal pain. This review describes the incidence of interictal pain in primary headache disorders and suggests the significance and biological meanings of this pain.

Current and emerging treatment options for migraine and other primary headache disorders

Primary headache disorders are highly prevalent worldwide. The impact of primary headaches to the individual is significant and reflects physical suffering and decreased social and occupational functioning. The economic burden to society is enormous and represents direct healthcare costs and the indirect costs associated with decreased workplace productivity and work absences. The last decade has witnessed tremendous advances both in our understanding of the biology of headache and in our therapeutic armamentarium. This review outlines how these developments may be rationally implemented by highlighting individual treatment options and general treatment strategies. The state-of-the-art methods for the abortive and prophylactic treatment of tension-type headache, migraine and cluster headache are reviewed.

The prevalence of headache may be related with the latitude: a possible role of Vitamin D insufficiency?

According to recent observations, there is worldwide vitamin D insufficiency (VDI) in various populations. A number of observations suggest a link between low serum levels of vitamin D and higher incidence of chronic pain. A few case reports have shown a beneficial effect of vitamin D therapy in patients with headache disorders. Serum vitamin D level shows a strong correlation with the latitude. Here, we review the literature to delineate a relation of prevalence rate of headaches with the latitude. We noted a significant relation between the prevalence of both tension-type headache and migraine with the latitude. There was a tendency for headache prevalence to increase with increasing latitude. The relation was more obvious for the lifetime prevalence for both migraine and tension-type headache. One year prevalence for migraine was also higher at higher latitude. There were limited studies on the seasonal variation of headache disorders. However, available data indicate increased frequency of headache attacks in autumn–winter and least attacks in summer. This profile of headache matches with the seasonal variations of serum vitamin D levels. The presence of vitamin D receptor, 1α-hydroxylase and vitamin D-binding protein in the hypothalamus further suggest a role of vitamin D deficiency in the generation of head pain.

Epidemiology of headache

Epidemiological studies conducted in the general population point to average headache prevalence rates of 46% for 1-year prevalence and of 64% for lifetime prevalence. For migraine, most studies conducted in the adult general population of western Europe and North America indicate rates between 5% and 9% in men, and between 12% and 25% in women. Non-western countries report lower figures. Migraine shows no gender differences in children, while in the elderly its frequency appears much reduced in both genders. About one-third of migraineurs suffer from migraine with aura. For tension-type headache, prevalence data reports in the literature are few and conflicting: rates range from 11% in Singapore to 20-40% in the USA and over 80% in Denmark. It is worth noting that the highest figures are found in studies where a personal interview has been employed. This probably indicates that the prevalence of this headache subtype is particularly sensitive to the method of data collection. Cluster headache occurs in 1-3 per thousand of the general population, with a gender (M:F) ratio of about 3:1. About 4% of the adult general population suffers from chronic daily headache.

Temperament traits of children with episodic tension-type headaches

BACKGROUND

The association between headache and stress is discussed. A powerful source of stress and the ways of relation between stress and headache can differed. The individual vulnerability to stress may be related to one's temperament.

OBJECTIVE

The purpose of the present study was to evaluate the role of temperament traits in children with episodic tension-type headaches (ETTH).

METHODS

We examined 120 children, 6-16 years of age, in the Department of Developmental Neurology of the Medical University of Gdansk. All children were diagnosed with ETTH. The control group consisted of 60 age-matched children without headaches. The following instruments of assessment were used: survey-interview, EAS Temperament Survey (Buss and Plomin), and Stress Response Scale (Chandler). The results were evaluated using statistical analysis.

RESULTS

Our results showed differences in temperament traits in children with ETTH compared to children without headaches. The former demonstrated greater temperament instability, i.e., higher emotionality, an intensified level of fear, a lower level of vigour, and a higher level of shyness compared to the control group.

CONCLUSION

Children with ETTH have some different traits than children without headache.

The prevalence of headache with emphasis on tension-type headache in rural Tanzania: a community-based study

The aim of the study was to assess the prevalence of headache with special attention to tension-type headache (TTH) in a rural area in northern Tanzania. A door-to-door study was performed using a standardized and validated questionnaire. A total of 7412 participants were screened. The total headache prevalence during the past year was 12.1%; the overall 1-year prevalence of TTH was 7%; 5% reported episodic TTH and 0.4% chronic TTH. Borderline cases (International Headache Society code 2.3) were described in 1.6%. The prevalence of headache was highest in the 41-50-year-old group in women and in the 61+ age group in men. This is the first account of the prevalence of TTH in a rural Tanzanian population, and shows that headache in general and, more specifically, TTH are prevalent disorders that deserve attention. However, the prevalence of primary headache seems to be lower than in Western countries.

Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria

We investigated the 1-year prevalence, clinical features and mode of treatment of headache in medical students of the University of Lagos, Nigeria, using a self-administered headache questionnaire. Headache prevalence was 46.0% and was significantly higher in women than in men (62.8% vs. 34.1%). Prevalence of tension-type headache was higher than that of migraine (18.1% vs. 6.4%). Although tension-type headache had a similar prevalence in both sexes (male 17.3%, female 19.2%), migraine was three times more common in women (10.9% vs. 3.2%). A family history of headache was present in 22.0%. Only 4.6% sought medical assistance, whereas 68.2% took non-prescription drugs, mainly simple analgesics. Specific drugs for migraine and tension-type headache were rarely used. In conclusion, 1-year headache prevalence is high among medical students at this university. The low consultation rate and the rarity of usage of specific anti-headache drugs probably reflect inadequacies in the management of primary headaches in this population.

Chronic Daily Headache in Brazil: A Nationwide Population-Based Study

The objectives of this study were to estimate the 1-year prevalence of chronic daily headache (CDH) and the degree of the association of CDH with some sociodemographic characteristics of the adult population of Brazil. This was a cross-sectional, population-based study. We conducted telephone interviews with 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age and some sociodemographic factors. The estimated 1-year gender- and age-adjusted prevalence of CDH was 6.9±. CDH was 2.4 times more prevalent in women, 1.72 times more in unemployed, 1.63 times more in subjects with high household income and two times greater in those who did not exercise. The overall prevalence of CDH in Brazil is high. CDH is significantly more prevalent in women, the unemployed, subjects with higher income, and in those who do not exercise.

A nationwide population-based study of tension-type headache in Brazil

OBJECTIVES

To estimate the 1-year prevalence of tension-type headache (TTH) and the degree of the association of TTH with some sociodemographic characteristics of a representative sample of the adult population of Brazil.

METHODS

This was an observational, cross-sectional, population-based study. We conducted telephone interviews on 3848 people, aged 18-79 years, randomly selected from the 27 states of Brazil. Trained lay interviewers administered the structured questionnaire. It included questions about the sociodemographic characteristics of the population, as well as questions about headache. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age, years of education, marital status, household income, job status, body mass index (BMI), and physical exercise.

RESULTS

The estimated 1-year gender- and-age-adjusted prevalence of TTH was 13.0% (95% CI: 11.8-14.2%); 15.4% in males and 9.5% in females. The prevalence of probable TTH was 22.6% (95% CI: 21.1-24.1%). Most (86.2%) subjects reported episodic TTH; 6.4% had chronic TTH. The prevalence was higher at 18-29 years of age (16.2%). TTH was 1.6 times more prevalent in men, and 1.54 times more in subjects with more than 11 years of education. There was no significant association of TTH with marital or job status, household income, BMI, and physical activity.

CONCLUSION

This is the first nationwide epidemiological study of TTH in Brazil. The overall prevalence of TTH in Brazil is low, at 13%. TTH is significantly more prevalent in males and subjects with higher education level.

European principles of management of common headache disorders in primary care

The objective of this study was to investigate the importance of genetics in tension-type headache. A MEDLINE search from 1966 to December 2006 was performed for "tension-type headache and prevalence" and "tension-type headache and genetics". The prevalence of tension-type headache varies from 11 to 93%, with a slight female preponderance. Co-occurrence of migraine increases the frequency of tension-type headache. A family study of chronic tension-type headache suggests that genetic factors are important. A twin study analysing tension-type headache in migraineurs found that genetic factors play a minor role in episodic tension-type headache. Another twin study analysing twin pairs without co-occurrence of migraine showed a significantly higher concordance rate among monozygotic than same-gender dizygotic twin pairs with no or frequent episodic tension-type headache, while the difference was minor in twin pairs with infrequent episodic tension-type headache. Frequent episodic and chronic tension-type headache is caused by a combination of genetic and environmental factors, while infrequent episodic tension-type headache is caused primarily by environmental factors.

Prevalence of primary chronic headache in a population-based sample of 30- to 44-year-old persons. The Akershus study of chronic headache

BACKGROUND

Prevalence data on primary chronic headache in the general population based on clinical interviews by physicians are lacking.

METHODS

In a cross-sectional epidemiological survey, a random sample of 30,000 persons from Akershus County, aged 30-44 years, were sent a postal questionnaire. Those with self-reported chronic headache within the last month and/or year were invited to a semi-structured diagnostic interview and a physical and neurological examination conducted by 2 neurological residents with experience in headache diagnostics. The diagnoses were made according to the International Classification of Headache Disorders, 2nd edition, 2004, and relevant revisions.

RESULTS

The questionnaire response rate was 71%, and the participation rate of the interview was 74%. The 1-year prevalence of primary chronic headache was 2.9%. Chronic tension-type headache (CTTH) and probable chronic tension-type headache (pCTTH) had 1-year prevalences of 1.6 and 1.2%, respectively. The prevalences of other primary chronic headaches were: chronic migraine (CM) 0.01%, probable CM 0.09% and other subtypes 0.04%. Co-occurrence of migraine was frequent, as 42% with CTTH and 55% with pCTTH had migraine.

CONCLUSION

Primary chronic headache is prevalent in the general population. The majority has CTTH or pCTTH, while CM and other primary chronic headaches are rare.

Genetics of tension-type headache: a population based twin study

The purpose was to investigate the importance of genetic and environmental factors in tension-type headache using a genetic modeling analysis. Twins age 12-41 years old from the population based Danish Twin Registry received a validated posted questionnaire about tension-type headache and migraine. Inclusion required that both twins in a pairs replied on the questionnaire and known zygosity. Twin pairs where one or both twins had co-occurrence of migraine were excluded. Migraine significantly increases the risk as well as the frequency of tension-type headache. The quantitative genetic modeling included 2,437 monozygotic (MZ), 2,720 same gender dizygotic (DZ), and 2,203 opposite gender DZ twin pairs without co-occurrence of migraine. Polychoric correlations were significantly higher in MZ than same gender DZ twin pairs analyzed separately by gender, while polychoric correlation were higher in same gender than opposite gender DZ twin pairs, although this was not significant in the comparison with male same gender DZ twin pairs. The best fitting model is based on gender specific prevalence and variance components without gender specific genetic effects. Heritability estimates of 48% in men and 44% in women were obtained. Genetic effects contribute to nearly half of variance in the liability to tension-type headache.

The differential diagnosis of chronic daily headaches: an algorithm-based approach

Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for "red flags" that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is > or =4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.

Which strategy should be applied? Design of a Norwegian epidemiological survey on chronic headache

BACKGROUND

Large-scale population-based epidemiological surveys on chronic headache based on clinical interview by a physician are lacking.

AIMS OF THE STUDY

To describe a method that aims to provide valid information on chronic headache.

METHOD

A self-administered questionnaire including two questions about headache frequency within the last month and within the last year was used to screen for possible chronic headache. Respondents with self-reported headache more than half of the days were interviewed by neurological residents with experience in headache diagnostics.

DISCUSSION

Previous studies have shown that a single question from a self-administered questionnaire can be used to screen for chronic headache. However, a precise headache diagnosis requires an interview by a physician experienced in headache diagnostics, as diagnoses extracted from questionnaires or provided by lay interviewers are not sufficiently precise.

CONCLUSIONS

A combination of a screening questionnaire and a clinical interview by a physician is likely to be a cost-effective method to conduct an epidemiological survey on chronic headache.

The global burden of headache: a documentation of headache prevalence and disability worldwide

This study, which is a part of the initiative 'Lifting The Burden: The Global Campaign to Reduce the Burden of Headache Worldwide', assesses and presents all existing evidence of the world prevalence and burden of headache disorders. Population-based studies applying International Headache Society criteria for migraine and tension-type headache, and also studies on headache in general and 'chronic daily headache', have been included. Globally, the percentages of the adult population with an active headache disorder are 46% for headache in general, 11% for migraine, 42% for tension-type headache and 3% for chronic daily headache. Our calculations indicate that the disability attributable to tension-type headache is larger worldwide than that due to migraine. On the World Health Organization's ranking of causes of disability, this would bring headache disorders into the 10 most disabling conditions for the two genders, and into the five most disabling for women.

Tension-type headache in adolescents and adults: a population based study of 33,764 twins

The aim of this study was to evaluate the 1-year-period prevalence of tension-type headache in a large population based sample. The study population included 33,764 twins aged 12-41 years old from the population based new Danish Twin Registry. They received a posted headache questionnaire and the response rate was 83.5%. The self-reported 1-year-period prevalence of tension-type headache was 86.0%; 78.9% among men and 92.5% among women. The 1-year-period prevalence of infrequent episodic, frequent episodic and chronic tension-type headache was 63.5, 21.6 and 0.9%, respectively. Frequent episodic and chronic tension-type headache was significantly more frequent in women than men. The prevalence of frequent episodic tension-type headache increased slightly in men until age 39 then it declined, while it increased about 20% point in women from age 12 years to age 20-39 years old and then it declined. Congruently, the prevalence of chronic tension-type headache increased until age 39 and declined thereafter in both sexes. Chronic tension-type headache is rare in persons 12-14 years old. These effects were confirmed by age trends of the different subtypes of tension-type headache using a regression model. The prevalence of migraine varied from 7.0 to 16.8% in men and from 8.2 to 31.0% in women. It increased from age 12 to 34 years and then declined. The risk and frequency of tension-type headache was significantly higher in those with migraine than those who had never had migraine. Future large longitudinal follow-up studies are required.

The long-term prognosis of tension-type headache

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

Effect of episodic tension-type headache on the health-related quality of life in employees of a Brazilian public hospital

OBJECTIVE: To evaluate the impact of ETTH on HRQoL in a sample of employees of a Brazilian public hospital. METHOD: Three hundred and sixty Mário Gatti Hospital employees were asked about headache occurrence in the previous 6 months and completed a SF-36 and a pain questionnaires concerning impact of pain (0 to 10 scale) on daily activities, work efficiency, leisure and social activities in previous six months. Two groups were studied: 1. Episodic Tension-type headache group: 127 employees - 81 (63.8%) female and 46 (36.2%), male. 2. Control group: 124, 71 (57.3%) female and 53 (42.7%) male. RESULTS: ETTH had lowers scores than control in all domains of SF-36; in vitality and bodily pain the difference was statistically significant. CONCLUSION: Our results indicate that ETTH suffers have impact on HRQoL predominantly in vitality. Psychological factors associated to pain may explain this finding.

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.

Inpatient Treatment of Headache: An Evidence-Based Assessment

OBJECTIVE

To evaluate inpatient treatment of headache in the United States.

PARTICIPANTS

Participants were selected by the meeting chairpersons, Drs. Diamond and Silberstein as well as Dr. Freitag. Criteria for selection included participation in an inpatient treatment program, headache specialists not affiliated with an inpatient treatment program, clinician with interest in headache but not affiliated with a dedicated headache treatment program. The single meeting held in New York was by invitation only. All invitees were provided with opportunity to present their views and participate in the recommendations of the Consortium. The list of participants at the meeting were: Harvey Blumenthal, MD, Roger Cady, MD, James Couch, MD, Seymour Diamond, MD, Frederick G. Freitag, DO, R. Michael Gallagher, DO, Al Lake III, PhD, Richard Lipton, MD, NinanMathew,MD, Alan Rapoport, MD, Jay Rosenberg, MD, Joel Saper, MD, Stephen Silberstein, MD. Funding for theproject was provided by the US Headache Guidelines Consortium Project through the American Academy of Neurology and the National Headache Foundation.

EVIDENCE

Each of the authors were part of the writing committee each with specific areas that they were responsible for conducting the literature reviews and submitting a portion of the original document for editing and review. Dr. Freitag coordinated this process and assembled the first draft of the article for circulation and review among the authors and chairpersons. In the absence of class I evidence consensus expert opinion was fundamental to the process.

CONCLUSIONS

The treatment of headache is commonly delivered in the outpatient office environment. There exists a group of patients who have been refractive to outpatient treatment and in whom in patient care may be appropriate. The factors that determine the optimal treatment setting, the methodology of the treatment and the results of such treatment have come under increasing scrutiny secondary to the cost of treatment in the hospital. The US Headache Consortium guidelines project in conjunction with the national headache foundation believed that the need existed to objectively examine the issues surrounding inpatient treatment. The epidemiology of chronic headache is important to understand in this context since essentially all patients that are treated in hospital have high frequency headache often associated with significant disability. This severity of illness produces both health care costs but also is responsible for significant impact on businesses and the economy. The method of treatment of headache in the hospital environment can follow several paths based on the accessibility of the resources specific to headache treatment. While there exist these differing paths of treatment only treatment in a dedicated headache treatment unit has been investigated in depth here in the US though reports from other countries that do not have dedicated inpatient treatment lends support to options in headache treatment. Some have suggested that inpatient treatment is not required even in recidivist patients and limited reports have examined aggressive outpatient treatment as an option in headache management. None of the studies reported to date provide class one evidence for efficacy either inpatient or outpatient. Recommendations are made to assess headache treatment in patients with high frequency headaches to garner better scientific evidence for differing treatment approaches.