Transformed Migraine Is a Cause of Chronic Daily Headaches

Association of psychiatric co-morbidity and efficacy of treatment in chronic daily headache in Indian population

OBJECTIVE

To study the prevalence of psychiatric co-morbidity in patients of chronic daily headache (CDH) and compare the efficacy of treatment between various type of headache associated with psychiatric co-morbidity.

MATERIALS AND METHODS

Prospective case control cohort study, 92 consecutive patients of CDH meeting eligibility criteria. The diagnosis of various subtypes of CDH was made according to the IHS criteria. Age, sex, educational, marital and socioeconomic status, matched controls were also selected. Patients were evaluated with the Mini International Neuropsychiatric Interview (MINI) scale at the time of enrolment and at 3 months.

RESULTS

CDH accounted for 28% of all headache patients. The mean age of presentation was 30.2 ± 10.3 years, male: Female ratio of 28:64 and mean duration of 4.56 ± 0.56 years. Chronic migraine (CM) accounted for 59 patients, chronic tension type headache (CTTH) 22 patients, new daily persistent headache (NDPH) 3 patients and miscellaneous 8 patients. Psychiatric co-morbidity was present in 53.3% patients with CDH, and was more common in CM (62.7%) as compared to CTTH (36.4%). Single psychiatric co-morbidity was seen in 26 patients, while 23 patients had multiple co-morbidity. Major depressive episode, anxiety disorder, agoraphobia and dysthymia were significant psychiatric co-morbidities. Patients with CM were treated with topiramate or divalproex sodium ER and CTTH were treated with amitriptyline. 55 patients came for follow up at 3 months, improvement in headache was seen in 29 patients.

CONCLUSION

Psychiatric co-morbidity was present in more than 50% patients with CDH and its presence along with a duration of ≥2 years was associated with a poor response to treatment.

From drug-induced headache to medication overuse headache. A short epidemiological review, with a focus on Latin American countries

Medication overuse headache (MOH) is a daily or almost-daily type of headache that results from the chronicization, usually migraine or tension-type headache, as a consequence of the progressive increase of intake of symptomatic drugs. MOH is now the third most frequent type of headache and affects a percentage of 1-1.4% of the general population. The currently available data on the impact of chronic headache associated with analgesic overuse in specialist headache centres confirm, beyond doubt, the existence of a serious health problem. Limited amount of data exists on the burden and impact of MOH in Latin American Countries. In this review, we summarise the reliable information from the literature on the epidemiological impact of MOH.

Application of the ICHD-II Criteria to the Diagnosis of Primary Chronic Headaches Via a Computerized Structured Record

BACKGROUND

The authors recently developed a software program designed to analyze clinical data from patients affected by primary headache. The program is based exclusively on the International Classification of Headache Disorders 2nd edition (ICHD-II) criteria. This software examines all the diagnoses of primary headaches on the basis of the variables needed to fulfill these mandatory criteria.

METHODS

We tested the software, Primary Headaches Analyser 1.0 INT (PHA), by entering and analyzing clinical data from 200 consecutive patients affected by primary chronic headaches and evaluating the corresponding output diagnoses.

RESULTS

The diagnosis of chronic migraine (1.5.1) was obtained in 68 cases (34 %) and that of probable chronic migraine (1.6.5) plus probable medication-overuse headache (8.2.8) in 46 (23%). Chronic tension-type headache (2.3) and probable chronic tension-type headache (2.4.3) plus probable medication-overuse headache (8.2.8) were diagnosed in 24 (12%) and 2 (1%) patients, respectively. Moreover, 4 and 12 patients, respectively, received both the diagnosis of chronic migraine (1.5.1) plus chronic tension-type headache (2.3) and of probable migraine (1.6.1) without aura plus chronic tension-type headache (2.3). In the remaining 44 cases (22%), none of the chronic primary headaches disorders defined by ICHD-II received an output diagnosis from the program. This was due mainly to the fact that the criteria fulfilled were insufficient for the diagnoses of migraine without (1.1) aura plus chronic migraine or, more infrequently, chronic tension-type headache.

CONCLUSIONS

Our software program permitted diagnoses of chronic migraine, chronic tension-type or their probable forms (with or without MOH) in 78% of 200 patients with headache 15 or more days per month. In the remaining cases the inability to provide a specific diagnosis may be explained in part by the fact that the criteria for both diagnoses are too stringent and do not accurately reflect variations of the headache pattern in these chronic forms.

A randomized, controlled trial of acupuncture for chronic daily headache

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A qualitative analysis of psychological processes mediating quality of life impairments in chronic daily headache

Quality of life impairments are greater in chronic daily headache (CDH) than in episodic headache conditions like migraine. This qualitative interview study aimed to identify psychological processes associated with quality of life impairments among individuals meeting diagnostic criteria for CDH. Grounded theory analysis showed that perceived loss of control was the central experience mediating the impact of CDH on quality of life. The results provide explanations for previous quantitative findings about quality of life impairments in CDH, and could inform interventions to reduce the impact of CDH. Further research could also examine the roles played by perceived control in the onset and development of CDH, including possible links with pre-emptive analgesic use.

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.

Psychiatric comorbidity in chronic daily headache: pathophysiology, etiology, and diagnosis

Chronic daily headache is a challenge for clinical practitioners and researchers. Etiology, pathophysiology, diagnosis, treatment, and prognosis of chronic daily headache present many questions that need answers. A chance occurrence of psychiatric disorders (mostly anxiety and mood disorders) in patients with chronic daily headache should not be excluded. This results in the need to understand the involved mechanisms, which requires us to draw new insights into the etiology, diagnosis, treatment, and prognosis of chronic daily headache. Psychiatric comorbidity seems to be cross-related to each of these dimensions, although the meanings need to be drawn. Each domain is discussed, considering the status of knowledge and stressing the future lines of research.

Practical approaches to migraine management

Migraine is a recurrent clinical syndrome characterised by combinations of neurological, gastrointestinal and autonomic manifestations. The exact pathophysiological disturbances that occur with migraine have yet to be elucidated; however, cervico-trigemino-vascular dysfunctions appear to be the primary cause. Despite advances in the understanding of the pathophysiology of migraine and new effective treatment options, migraine remains an under-diagnosed, under-treated and poorly treated health condition. Most patients will unsuccessfully attempt to treat their headaches with over-the-counter medications. Few well designed, placebo-controlled studies are available to guide physicians in medication selection. Recently published evidence-based guidelines advocate migraine-specific drugs, such as serotonin 5-HT(1B/1D) agonists (the 'triptans') and dihydroergotamine mesylate, for patients experiencing moderate to severe migraine attacks. Additional headache attack therapy options include other ergotamine derivatives, phenothiazines, nonsteroidal anti-inflammatory agents and opioids. Preventative medication therapy is indicated for patients experiencing frequent and/or refractory attacks.

Chronic daily headache in children and adolescents presenting to tertiary headache clinics

BACKGROUND

Adults with chronic daily headache often describe a transformation from episodic migraine and partial retention of migrainous features. Although chronic daily headache has not been investigated as carefully in the pediatric population, one study showed a predominance of coexisting daily headache and episodic migraine, without a clear history of transformation.

OBJECTIVE

To identify the clinical features of chronic daily headache in children and adolescents, to evaluate the efficacy of current headache classification criteria, and to compare the features of coexistent daily and episodic headaches so as to determine whether they represent separate syndromes or different stages in the "transformation" process.

DESIGN

We surveyed 189 consecutive patients, 18 years of age or younger, who presented for initial evaluation of daily or near daily headache at one of 9 tertiary headache clinics. Data were collected in semistructured interviews employing a standard questionnaire and analyzed using Statistical Analysis Systems and Stata statistical software computer programs.

RESULTS

Of the patients enrolled, 70% were female and 87% were white. Mean age was 13.0 +/- 3.1 years. Male gender was associated with a higher degree of reported disability. A family history of headache (typically migraine) was described in 79%. Use of nonsteroidal anti-inflammatory drugs 5 days per week or more was reported by 44% of patients. The International Headache Society (IHS) criteria failed to classify 64% of patients and criteria proposed by Silberstein et al failed to classify 31% of patients. Participating physicians misclassified patients according to criteria of the IHS and Silberstein et al in one third of cases. Nearly one quarter of patients reported two separate headache types with distinguishing characteristics. "Baseline" headache was present 27.3 +/- 4.1 days per month with a mean pain intensity of 5.9 +/- 2.1 on a 10-point scale. Superimposed episodic headache occurred 4.7 +/- 3.8 days per month with a mean pain intensity of 8.4 +/- 1.4, and was more often accompanied by other migrainous symptoms. After logistic regression to control for pain intensity, the only statistically significant difference between the two headache types was a lower prevalence of tension-type head pain with the superimposed headache.

CONCLUSIONS

Our data suggest that rather than having two coexistent headache types, children and adolescents with chronic daily headache have a single syndrome that, in many cases, will paroxysmally worsen and gather migrainous features.

A comparison of symptom provocation procedures in psychiatry and other areas of medicine: implications for their ethical use in research

BACKGROUND

Symptom provocation is used to study a wide variety of medical disorders. In contrast to other areas of medicine, the application of these procedures to the study of mental disease has generated significant scientific, political, and public debate. Purported differences include an overabundance of these procedures in psychiatry and a lack of diagnostic and therapeutic utility. Accurate appraisal of these research designs is needed to address scientific merit and ethical concerns. This article provides a general review of challenge studies in several areas of medical research, compares purposes and methods to those used in psychiatry, and ascertains whether fundamental differences exist.

METHODS

In total, 655 challenge studies were identified using MEDLINE and PsychInfo Boolean key word searches. Information was collected from each study including the year of publication, whether subjects were healthy or patient volunteers, the disease being studied, and the study purpose (e.g., to study pathophysiology, test treatment efficacy, or diagnosis of a disorder).

RESULTS

Differences in study design, purpose, and frequency of studies across time were similar for medical and psychiatric diseases.

CONCLUSIONS

Given extensive similarity in purpose and procedures, why are psychiatric challenge studies being subjected to public criticism and special review and approval procedures? Several relevant issues are addressed including risk, scientific merit, and clinical application.

Chronic Daily Headache: Theory to Therapy

Headaches are among the most frequent symptoms for which Americans seek physician advice and treatment. Although headache may herald a serious underlying organic or psychological illness, it more commonly represents a primary disorder of brain stem nociceptive processing and modulation. Chronic daily headache characteristically develops gradually from episodic tension or migraine-type headaches into a refractory syndrome often associated with medication overuse and disability. Better understanding of the pathophysiology and evolutionary mechanisms involved in the development of chronic headache has led to recommended changes in nosology originally proposed by the International Headache Society (IHS). Recent scientific and clinical observations prompting revised classification have also led to the integration of pathoanatomic models, which explain persistent headache. Strategies for the management of chronic craniofacial pain should emphasize key behavioral and attitudinal changes and avoidance of medication overusage.

Reversible cognitive decline accompanies migraine and cluster headaches

Vascular headaches, including migraine, cluster, and migrainous transformation to chronic daily headaches, are disabling. During and shortly after headache intervals, difficulties are reported in concentration, comprehension, and communication, not accounted for by nausea, photophobia, or sonophobia. These interfere with interpersonal relations and performance at work with economic loss. The hypothesis tested and reported here is that cognitive impairments comprise an important part of vascular headache diatheses. One hundred ninety-six otherwise normative subjects suffering from migraine or cluster, but not tension-type, headaches (136 women, 63 men; mean age, 46 years) participated in an outpatient prospective trial. One hundred thirty-three patients had migraine without aura, 39 migraine with aura, 11 periodic cluster (by IHS criteria), and 13 had migrainous transformation into chronic daily headaches. Neuropsychological testing was compared with and without headaches, by combined Mini-Mental Status Examination (MMSE), Cognitive Capacity Screening Examination (CCSE), and Hamilton Depression Rating Scale (HDRS). During headache intervals, significant decline was measured in both CCSE and MMSE scores (P <. 001) without HDRS change in all types of vascular headache and independent of headache severity, which often improved, or associated physical symptoms. Cognitive decline was promptly relieved by serotonin agonists and sleep. Disorders of cerebral serotoninergic projection systems appear to cause these reversible cognitive impairments.

Withdrawal therapy improves chronic daily headache associated with long-term misuse of headache medication: a retrospective study

Chronic daily headache (CDH) associated with long-term misuse of headache medication is a common clinical problem which is refractory to most treatments. The present study is a retrospective analysis of the effect of drug withdrawal therapy in patients with CDH and frequent long-term use of headache symptomatic medication. One hundred and one adult patients (74 women and 27 men, aged between 16 and 72 years, mean age 43 years) were evaluated 1-3 months after drug withdrawal therapy had been initiated. The mean headache frequency at baseline was 26.9+/-4.0 days per month. Fifty-seven (56%) patients were significantly improved (defined as at least 50% reduction in number of headache days) after a period of drug withdrawal therapy. Based on the outcome of the drug withdrawal therapy, the patients were divided into three categories: group I, those who had between 0 and 10 headache days per month (n = 41), group II, those who had 11-20 days (n = 37), and group III, those who had 21-30 days (n = 23). The mean headache frequencies in groups I, II and III were 5.6+/-2.8 days, 15.7+/-2.5 days and 28.7+/-2.4 days, respectively. Treatment with amitriptyline was offered to patients in whom no improvement had been achieved. Ten of those 22 patients (36%) experienced a significant (> or = 50%) reduction of headache days. It is concluded that out-patient drug withdrawal therapy is the treatment of choice in patients with CDH and frequent long-term use of headache symptomatic medication, and that about one quarter of these CDH patients do not respond to drug withdrawal therapy only.