Efficacy of Multidisciplinary Treatment in a Tertiary Referral Headache Centre

The Nursing Role in the Management of Medication Overuse Headache: Realities and Prospects

This review aims to analyze the current literature to identify articles related to the role of nurses and, in general, the nursing management of patients suffering from medication overuse headache (MOH), a globally spread disease. We specifically argue for non-pharmacological approaches to pain management, such as multidisciplinary team approaches, holistic treatment, cognitive behavioral therapy and exercise. For this review, we investigated international scientific databases, including PubMed, CINAHL, Scopus and Embase, in the period between 2000 and 2024. We observed a wealth of scientific articles related to MOH, but a poverty of articles relating to the nursing management of headache. The research included the presence of academic-level training for nurses, whereas there are few institutions that train competent professionals in both pharmacological and non-pharmacological management of MOH patients. Nursing assessment and assistance strategies are indicated to plan tailored treatment paths related to the specific needs of these patients.

Oxytocin Receptors on Calvarial Periosteal Innervation: Therapeutic Target for Post-Traumatic Headache?

OBJECTIVE

Following a mild traumatic brain injury (mTBI), the most prevalent and profoundly debilitating occurrence is the emergence of an acute and persistent post-traumatic headache (PTH), for which there are presently no approved treatments. A crucial gap in knowledge exists regarding the consequences of an mTBI, which could serve as a foundation for the development of therapeutic approaches. The activation of trigeminal sensory nerve terminals that innervate the calvarial periosteum (CP)-a densely innervated tissue layer covering the calvarial skull-has been implicated in both migraines and PTHs. We have previously shown that trigeminal oxytocin receptors (OTRs) may provide a therapeutic target for PTHs. This study examined the expression of oxytocin receptors on trigeminal nerves innervating the periosteum and whether these receptors might serve as a therapeutic target for PTHs using a direct application of oxytocin to the periosteum in a rodent model of PTH.

METHODS

We used retrograde tracing and immunohistochemistry to determine if trigeminal ganglion (TG) neurons innervating the periosteum expressed OTRs and/or CGRPs. To model the impact of local inflammation that occurs following an mTBI, we applied chemical inflammatory mediators directly to the CP and assessed for changes in immediate-early gene expression as an indication of neuronal activation. We also determined whether mTBI would lead to expression changes to OTR levels. To determine whether these OTRs could be a viable therapeutic target, we assessed the impact of oxytocin injections into the CP in a mouse model of PTH-induced periorbital allodynia.

RESULTS

The results of these experiments demonstrate the following: (1) the cell bodies of CP afferents reside in the TG and express both OTRs and CGRPs; (2) inflammatory chemical stimulation of the periosteum leads to rapid activation of TG neurons (phospho-ERK (p-ERK) expression), (3) mTBI-induced inflammation increased OTR expression compared to the sham group; and (4) administration of oxytocin into the periosteum on day 2 and day 40 blocked cutaneous allodynia for up to one hour post-administration for both acute and persistence phases in the PTH model-an effect that was preventable by the administration of an OTR antagonist.

CONCLUSION

Taken together, our observations suggest that periosteal trigeminal afferents contribute to post-TBI craniofacial pain, and that periosteum tissue can be used as a potential local target for therapeutics such as oxytocin.

Consensus recommendations on the role of nurses in headache care: A European e-Delphi study

BACKGROUND

Nurses work at headache centres throughout Europe, and their care for migraine patients is acknowledged. However, the specific roles and tasks of nursing vary, and a unified understanding is lacking, posing challenges to knowledge sharing and research.

OBJECTIVES

Using an e-Delphi study method, the objective is to obtain healthcare professional headache experts' opinions on nursing-specific roles and tasks and combine this into consensus statements for nurse recommendations for migraine treatment.

METHODS

A three-round questionnaire study was conducted with nurses and neurologists from 18 specialised headache centres in 10 countries. In round 1, statements were compiled from a systematic examination of existing literature and expert opinions. In rounds 2 and 3, the experts rated the importance of statements (from round 1) on a 5-point Likert scale. Statements were analysed using a content analysis method, and the consensus of pre-defined statements was evaluated with gradually increased predetermined criteria using descriptive statistics.

RESULTS

Twenty-one experts, representing all 10 countries, participated. The predetermined consensus of ≥70% agreement was reached for 42 out of the initial 63 statements. These statements formed the final recommendations within two themes: "The nurses' roles and tasks in the clinical setting" and "The nurses' roles and tasks in educating patients and colleagues." The consensus level of statements was strong, with 40% receiving unanimous agreement (100%) and 97% achieving relatively high agreement (>80%).

CONCLUSION

Nursing plays a vital role with diverse tasks in migraine care. This study offers practical recommendations and a framework for nurses, equipping them with a clinical tool to enhance care and promote a coordinated approach to migraine treatment.

Headache Specialists' Perceptions of the Role of Health Psychologists in Headache Management: A Qualitative Study

Background Since headache specialists cannot treat all the patients with headache disorders, multidisciplinary teams that include health psychologists are becoming more prevalent. Health psychologists mainly use a form of cognitive-behavioral therapy (CBT), along with biofeedback on occasion, to effectively address patients' pain and headache disorders. The Veterans Health Administration (VHA) is one setting that routinely includes a health psychologist with advanced training in pain disorders in their pain care to its veterans. The VHA has established Headache Centers of Excellence (HCoE) around the country to provide multidisciplinary treatment for patients with headache disorders, which enables headache specialists to regularly interact with health psychologists. Objective The study's objective is to evaluate headache specialists' views of health psychologists in the treatment of patients with headache disorders. Method Semi-structured interviews were conducted with headache specialists in academic-based healthcare settings, the community, and VHA HCoE sites. The interviews were audio-recorded and de-identified so they could be transcribed and analyzed using content matrix analysis. Results Four themes emerged: headache specialists desired to work with health psychologists and included them as members of multidisciplinary teams; valued health psychologists because they provided non-pharmacological treatments, such as CBT and biofeedback; preferred in-person communication with health psychologists; and used multiple titles when referring to health psychologists. Conclusion Headache specialists valued health psychologists as providers of behavioral and non-pharmacological treatments and considered them essential members of multidisciplinary teams. Headache specialists should strive to work with a headache psychologist, not just a general health psychologist. By committing to this, headache specialists can foster changes in the quality of care, resource allocation, and training experiences related to health psychologists.

Medication-overuse headache-a review of different treatment strategies

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.

A Descriptive Review of Medication-Overuse Headache: From Pathophysiology to the Comorbidities

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is an important problem worldwide, with different areas of controversy regarding its entity. This article reviews the risk factors, comorbidities, pathophysiology, clinical presentation, effective management, and prognosis of MOH by summarizing and integrating the results and findings from previously performed more than 15,000 studies (from 2010 to 2023) available from the scientific database of the University Medical Library in the University Clinical Center of Niš, which aimed to investigate and define the complexity of this type of headache.

RECENT FINDING

It has been proposed that all acute migraine medications can lead to MOH, with differences in the propensity of different agents to cause the problem. Early data suggests that triptans and other painkillers used for the acute treatment of migraine may be an exception. Recent studies show that practitioners and the general public are still largely unaware of the problem of medication overuse and its damaging effects.

SUMMARY

Although it is likely that MOH does occur, restricting the number of acute medications is necessary to prevent it. It is also possible that increasing amounts of acute medications are simply a reflection of poorly controlled headaches rather than a cause. Further research needs to be developed to identify more precise mechanisms for effective MOH management and its evolution.

Secondary headaches - red and green flags and their significance for diagnostics

A small percentage of patients suffer from a secondary headache syndrome. It is imperative that clinicians are able to differentiate primary headache syndromes from secondary headache syndromes, as failure to do so significantly worsens morbidity and mortality. Recent advances in our understanding of pathobiological mechanisms offer useful information on these enigmatic disorders. We now understand that the causes of secondary headache syndromes can vary significantly - these may be infectious, inflammatory, vascular, traumatic or structural in origin. A well-taken history and targeted physical examination coupled with appropriate investigations can enable these syndromes to be recognized consistently and thus allow their timely and appropriate treatment. Along with their epidemiology, some of their key characteristics shall thus be discussed in this review so as to aid the busy clinician at the bedside. Red flags including sudden onset, high pain intensity, pattern of change of a preexisting headache, focal neurological signs or seizure, systemic signs and precipitation by physical activity can guide the clinician to suspect a secondary headache. Importantly a preexisting headache is not an exclusion of a secondary headache - it might even be a predisposition in certain cases.

Repeat mild traumatic brain injuries (RmTBI) modify nociception and disrupt orexinergic connectivity within the descending pain pathway

Repeat mild traumatic brain injuries (RmTBI) result in substantial burden to the public health system given their association with chronic post-injury pathologies, such as chronic pain and post-traumatic headache. Although this may relate to dysfunctional descending pain modulation (DPM), it is uncertain what mechanisms drive changes within this pathway. One possibility is altered orexinergic system functioning, as orexin is a potent anti-nociceptive neuromodulator. Orexin is exclusively produced by the lateral hypothalamus (LH) and receives excitatory innervation from the lateral parabrachial nucleus (lPBN). Therefore, we used neuronal tract-tracing to investigate the relationship between RmTBI and connectivity between lPBN and the LH, as well as orexinergic projections to a key site within the DPM, the periaqueductal gray (PAG). Prior to injury induction, retrograde and anterograde tract-tracing surgery was performed on 70 young-adult male Sprague Dawley rats, targeting the lPBN and PAG. Rodents were then randomly assigned to receive RmTBIs or sham injuries before undergoing testing for anxiety-like behaviour and nociceptive sensitivity. Immunohistochemical analysis identified distinct and co-localized orexin and tract-tracing cell bodies and projections within the LH. The RmTBI group exhibited altered nociception and reduced anxiety as well as a loss of orexin cell bodies and a reduction of hypothalamic projections to the ventrolateral nucleus of the PAG. However, there was no significant effect of injury on neuronal connectivity between the lPBN and orexinergic cell bodies within the LH. Our identification of structural losses and the resulting physiological changes in the orexinergic system following RmTBI begins to clarify acute post-injury mechanistic changes that drive may drive the development of post-traumatic headache and the chronification of pain.

Consensus recommendations on the role of nurses in the care of headache patients: protocol for a european e-delphi study

BACKGROUND

Nurses play an important role in the treatment of headache patients at the specialized headache centers in Europe, however, a unified definition of nursing tasks and conduction of tasks is lacking. The objective of this e-Delphi study is twofold. Initially, to obtain healthcare professional headache experts' opinions on which tasks are associated with nurses' care in migraine treatment. Then, through an iterative multi-staged process, to combine the opinions into group consensus statements and develop evident European nursing recommendations for migraine treatment.

METHODS

In Delphi studies there are no unambiguous methodological guidelines and this protocol is being published to ensure transparency and quality in the study process. We invite nurses working in specialized headache centers and neurologists co-working with nurses in Finland, Denmark, Norway, Sweden, United Kingdom, Netherlands, Germany, Ireland, Estonia and Switzerland to participate anonymously in the expert panel. This e-Delphi study consists of three rounds of online questionnaires. We use Open-ended questions to capture the essentials of nurse tasks as understood by the expert panel members. Data are analyzed using content analysis. Predefined statements are applied for the experts to rate the importance of nurses' tasks synthesized from a systematic examination of the existing literature. Consensus is measured using descriptive statistics; median, Interquartile range (IQR) and percentage agreement. Measurement of agreement between participants will be analyzed using inferential statistics; Kendall's coefficient and stability between rounds; Wilcoxon rank-sum test. Statements, which receive consensus in the third round, are included in the final compilation of European recommendations for nurse care for migraine patients.

DISCUSSION

The e-Delphi study will provide European recommendations on nurse care in migraine treatment, which could not be created on the basis of the existing literature. The recommendations can open for the conduction of further research including measurement of efficacy of clinical implementation of the recommended tasks.

TRIAL REGISTRATION

The study is registered at The Region of Southern Denmark (21/52,885). According to The Regional Ethical Committee and Danish law, no additional approval is relevant (20212000-145). A written informed consent is obtained from all participants before inclusion in the study.

Chronic headache patients' health behavior and health service use 12 months after interdisciplinary treatment - what do they keep in their daily routines?

BACKGROUND

We do not yet know whether or the extent to which multimodal therapy changes the health behaviors and health service use of chronic headache patients in the long term. Associations are expected between pain symptoms and pain management abilities for patients who are categorized as successfully treated and those who remain unchanged.

METHODS

Routine longitudinal data of an enrolment period of five years from 101 headache patients treated with a two-week, full-day, semi-inpatient multimodal pain therapy at the Interdisciplinary Pain Center of the University Clinic Erlangen were available when therapy began and 12 months after treatment. To investigate long-term changes in health behavior and health service use as well as their associations with the outcome "reduction in pain days," we used descriptive and inferential statistics (i.e., binary logistic regression).

RESULTS

Patients who underwent interdisciplinary treatment showed statistically significant changes in their health behavior in five areas. Twelve months after treatment, we found a significantly higher frequency of engagement in athletic sports (p < .001) as well as increases in the use of relaxation techniques (p < .001), TENS devices for relaxation purposes (p = .008), psychological coping strategies (p < .001), and mindfulness-based techniques for dealing with pain (p < .001). 52.8% of the sample reported a reduction in the number of pain days 12 months after treatment. Binary logistic regression (χ2 (12) = 21.419; p = .045; R2 = .255) revealed that a reduction in pain days 12 months after treatment was positively associated with regular physical activity in the form of muscle strengthening and stretching (athletic sports) (p = .012).

CONCLUSION

Chronic headache patients acquired long-term skills from an interdisciplinary treatment concerning the use of relaxation techniques, the use of psychological coping strategies, and physical activity in the form of athletic exercise. Of those, regular athletic exercise was positively associated with a smaller number of pain days in the long term. Thus, a physical activity module should be an element of interdisciplinary treatment for chronic headache patients.

A systematic evaluation of primary headache management apps leveraging behavior change techniques

BACKGROUND

Mobile health apps have the potential to promote adherence to headache management through the use of evidence-based behavior change techniques (e.g., self-monitoring). While many headache management apps exist, the extent to which these apps include behavior change techniques remains unknown. Thus, the present study systematically evaluated the content and quality of commercially available headache management apps.

METHODS

Headache apps were identified using a systematic search in the Apple App and Google Play stores. A total of 55 apps were evaluated using the taxonomy of behavior change techniques and app quality using the Mobile App Rating Scale.

RESULTS

Headache management apps included 0-14 behavior change techniques (Mean [M] = 5.89) and 0-8 headache management behavior change techniques (M = 4.29). App quality ranged from 2.84-4.67 (M = 3.73) out of 5.00. Three apps, Migraine Trainer, Easeday: Headache & Migraine, and PainScale, included the highest number of overall and headache management behavior change techniques along with good quality scores.

CONCLUSIONS

While randomized controlled trials are necessary to determine the efficacy of individual headache apps, most existing apps include evidence-based headache management behavior change techniques. Headache apps often focus on either self-monitoring or stress management via relaxation training, suggesting that patients' needs should be used to inform app selection.

The impact of COVID-19 pandemic on headache symptoms and drug withdrawal among patients with medication overuse headache: a cross-sectional study

Background

Coronavirus disease 2019 (COVID-19) bring about a range of psychological distress and symptom deterioration to headache patients especially to some migraineurs. Compared to migraineurs or normal control, medication overuse headache (MOH) patients are more likely to experience a worse psychological distress and poorer outcome in non-COVID-19 time. However, in COVID-19 pandemic, whether MOH patients would have greater physical and mental symptom deterioration or worse relief of headache symptoms and medications overuse remained unclear. We aim to investigate the impact of COVID-19 on MOH patients to guide for a better management in this study.

Methods

We enrolled MOH patients who were diagnosed and treated at headache clinic of West China Hospital. Information of the pre-pandemic 3 months period and COVID-19 pandemic period was collected. Univariate and multivariate logistic regression were performed to identify independent factors associated with changes in headache symptoms and drug withdrawal.

Results

Seventy-eight MOH patients were enrolled into the study ultimately. In comparison to pre-pandemic period, fewer MOH patients reported decreased headache days, intensity and days with acute medications per month during the pandemic. Available access to regular prophylactic medications was significantly associated with a reduction of at least 50% in headache days and decrease in headache intensity per month with respective odds ratios of 39.19 (95% CI 3.75–409.15, P = 0.002) and 10.13 (95% CI 2.33–44.12, P = 0.002). Following abrupt withdrawal and high educational level were both significant factors in decreasing headache intensity. Male sex was significantly associated with decrease in days with acute medication per month during the pandemic (odds ratios 4.78, 95%CI 1.44–15.87, P = 0.011).

Conclusions

Our findings reflect that MOH patients experienced a worse relief of headache symptoms and drug withdrawal during the pandemic. Available access to regular prophylactic medications was the significant independent factor for improvement of headache symptoms. Male sex was significantly associated with decreased days with acute medications per month.

Migraine: epidemiology and systems of care

Migraine is a neurovascular disorder that affects over 1 billion people worldwide. Its widespread prevalence, and associated disability, have a range of negative and substantial effects not only on those immediately affected but also on their families, colleagues, employers, and society. To reduce this global burden, concerted efforts are needed to implement and improve migraine care that is supported by informed health-care policies. In this Series paper, we summarise the data on migraine epidemiology, including estimates of its very considerable burden on the global economy. First, we present the challenges that continue to obstruct provision of adequate care worldwide. Second, we outline the advantages of integrated and coordinated systems of care, in which primary and specialist care complement and support each other; the use of comprehensive referral and linkage protocols should enable continuity of care between these systems levels. Finally, we describe challenges in low and middle-income countries, including countries with poor public health education, inadequate access to medication, and insufficient formal education and training of health-care professionals resulting in misdiagnosis, mismanagement, and wastage of resources.

Interprofessional Collaboration in Dentistry: Role of physiotherapists to improve care and outcomes for chronic pain conditions and sleep disorders

Physiotherapists can manage chronic pain patients by using technical interventions such as mobility, strengthening, manual therapy, or flexibility in a specific and functional manner, being a key component of a multidisciplinary team. Dentists are involved in the management of different chronic pain conditions such as temporomandibular disorders and sleep disorders such as obstructive sleep apnea. However, they are frequently unaware of the benefits of collaborating with physical therapists. In this review, the collaboration of physical therapists and dentists will be explored when managing orofacial pain, headaches, and sleep disorders. The physical therapist is important in the management of these disorders and also in the screening of risk factors.

Persistent post-traumatic headache: a migrainous loop or not? The clinical evidence

BACKGROUND

Headache is a common complication of traumatic brain injury. The International Headache Society defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following trauma. Acute post-traumatic headache resolves after 3 months, but persistent post-traumatic headache usually lasts much longer and accounts for 4% of all secondary headache disorders.

MAIN BODY

The clinical features of post-traumatic headache after traumatic brain injury resemble various types of primary headaches and the most frequent are migraine-like or tension-type-like phenotypes. The neuroimaging studies that have compared persistent post-traumatic headache and migraine found different structural and functional brain changes, although migraine and post-traumatic headache may be clinically similar. Therapy of various clinical phenotypes of post-traumatic headache almost entirely mirrors the therapy of the corresponding primary headache and are currently based on expert opinion rather than scientific evidence. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, especially impaired sleep and post-traumatic disorder. There are also effective options for non-pharmacologic therapy of post-traumatic headache, including cognitive-behavioral approaches, onabotulinum toxin injections, life-style considerations, etc. CONCLUSION: Notwithstanding some phenotypic similarities, persistent post-traumatic headache after traumatic brain injury, is considered a separate phenomenon from migraine but available data is inconclusive. High-quality studies are further required to investigate the pathophysiological mechanisms of this secondary headache, in order to identify new targets for treatment and to prevent disability.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

The Many Faces of Medication-Overuse Headache in Clinical Practice

The management of medication-overuse headache (MOH) is multifaceted and headache experts have different views on the optimal strategy to tackle this type of secondary headache. The purpose of this review is to provide an overview of the literature on the management of MOH, and to highlight important considerations in the clinical evaluation of the MOH patient. Managing MOH in clinical practice starts by evaluating the headache patient with medication overuse, determining the overused drug(s), assessing the impact of headaches on the patient and assessing comorbid conditions and disorders. Withdrawal of the overused medication is the cornerstone of treatment. An inpatient or outpatient setting is chosen based on the clinical profile of the patient. There is evidence for abrupt withdrawal combined with headache preventive treatment. Bridging therapy to bring relief to withdrawal headaches and/or symptoms should be offered. Education and motivational work through multidisciplinary assessment show benefits in sustaining withdrawal and preventing relapse. Although the reversal of chronic headache after cessation of overused acute medication has been noticed worldwide, different aspects of the management of MOH, such as complete or gradual withdrawal, or preventive treatment with or without withdrawal are still debated.

How Does Migraine Change After 10 Years? A Clinical Cohort Follow-Up Analysis

OBJECTIVE

To describe the 10-year evolution of a cohort of migraine patients, focusing on prognostic factors of improvement.

BACKGROUND

Migraine is one of the most prevalent and disabling diseases and migraineurs often want to know about the evolutionary timeline of their condition. Yet, data from longitudinal studies with a long-term follow-up is scarce.

METHODS

This is a 10-year longitudinal study. In 2008, we recruited 1109 consecutive migraine patients who answered an initial survey. In 2018, we did a follow-up. We compared initial and final (after 10 years) data. A reduction ≥50% in Headache days/month was considered as improvement. A comparative study was carried out to identify predictors of improvement or no improvement.

RESULTS

After 10 years, 380 patients completed the survey (34.3% of the initial cohort), 77.1% (293/380) were women; mean age 41.0 ± 10.6 years and 73.7% (280/380) had an initial diagnosis of episodic migraine (EM). After 10 years, 48.2% (183/380) of patients did not have a medical follow-up of their migraine; 47.4% (180/380) decreased ≥50% in frequency, which increased the proportion of EM (73.7% vs 87.4%) (P < .001) as compared to the initial results. Factors independently associated with improvement were: a baseline frequency >10 days/month (OR[95%]: 3.04 [1.89, 4.89]; P < .001), nonsmoking (2.13 [1.23, 3.67]; P = .006) and a medical follow-up for migraine (2.45 [1.54, 3.90]; P < .001). Additionally, after 10 years, we observed a reduction in the use of preventive treatment (48.7% vs 23.5%) and an increase in monotherapy (42.2% vs 72.7%) (P < .001).

CONCLUSION

After 10 years, in almost half of the patients who answered the survey, migraine improved. Other than the natural pathophysiology of migraine, having a medical follow-up and healthy habits such as nonsmoking were independent factors associated with improvement.

The features and burden of headaches within a chiropractic clinical population: A cross-sectional analysis

OBJECTIVES

The aim of this study is to a) investigate the headache features and level of headache severity, chronicity, and disability found within a chiropractic patient population and b) to ascertain if patient satisfaction with headache management by chiropractors is associated with headache group or reason for consulting a chiropractor.

DESIGN AND SETTING

Consecutive adult patients with a chief complaint of headache participated in an online cross-sectional survey (n = 224). Recruitment was via a randomly selected sample of Australian chiropractors (n = 70). Headache features were assessed using International Classification of Headache Disorders criteria and level of headache disability measured using the Headache Impact Test instrument.

RESULTS

One in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. 'Severe' levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches.

CONCLUSION

Many with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.

Acute and preventive pharmacological treatment of post-traumatic headache: a systematic review

Background

Post-traumatic headache (PTH) is associated with considerable disability and reduced health-related quality of life. Despite the very high prevalence of PTH, there are no evidence-based guidelines for PTH treatment. Thus, we found it timely to provide a systematic review of the current literature on acute and preventive pharmacological treatment of PTH using PubMed and Embase databases.

Findings

Included studies involved acute and preventive pharmacological treatment of headache attributed to traumatic injury to the head in adherence to the International Classification of Headache Disorders (ICHD) criteria. Of 1424 potentially relevant articles identified, 63 were retrieved for detailed evaluation and seven studies (one prospective and six retrospective) met the inclusion criteria. None of the seven included studies were randomized clinical trials (RCTs) or used a placebo-controlled study design.

Conclusion

We found that there is a lack of high-quality evidence-based studies on the pharmacological treatment of PTH. Future studies are highly needed and must emphasize open-label studies with rigorous methodology or RCTs with a placebo-controlled design.

Non-Pharmacological Treatment for Primary Headaches Prevention and Lifestyle Changes in a Low-Income Community of Brazil: A Randomized Clinical Trial

BACKGROUND

Primary headaches can be reduced by lifestyle changes, such as stress management and physical activity. However, access to programs focused on behavioral interventions is limited in underserved, poor communities.

OBJECTIVES

We performed a randomized open-label clinical trial to test the therapeutic and behavioral effects of aerobic exercise, relaxation, or the combination of both, in individuals with primary headaches of a small, low-income community of the Brazilian Amazon.

METHODS

Participants were screened from the riverine/rural population, and individuals with primary headache were included. We assessed clinical characteristics and physical activity levels. Interventions were delivery 3 times/week for 6 months. The primary outcome variable was changes in days with headache, while changes in duration of attacks, pain intensity, and physical activity levels were secondary outcomes variables.

RESULTS

Seven hundred and ninety individuals were screened (15.3% of rural/riverine population). Seventy-four participants were randomly assigned to relaxation (n = 25), physical activity orientation program (n = 25), or both (n = 24) interventions. Intention to treat analyses showed all interventions as effective to reduce days with headaches and duration of attacks (both P < .01). Pain intensity was reduced only in relaxation and relaxation + physical activity groups (both P < .01). Physical activity levels increased only in the relaxation + physical activity group (P < .05).

CONCLUSIONS

Non-pharmacological interventions such as physical activity and relaxation are effective for reducing headaches, while combining such interventions promote health behavior toward higher physical activity levels in low-income populations with primary headaches.

CLINICAL TRIAL REGISTRATION NUMBER

SGPP 1544.

Medication-overuse headache: a widely recognized entity amidst ongoing debate

Medication overuse in primary headache disorders is a worldwide phenomenon and has a role in the chronification of headache disorders. The burden of disease on individuals and societies is significant due to high costs and comorbidities. In the Third Edition of the International Classification of Headache Disorders, medication-overuse headache is recognized as a separate secondary entity next to mostly primary headache disorders, although many clinicians see the disease as a sole complication of primary headache disorders. In this review, we explore the historical background of medication-overuse headache, its epidemiology, phenomenology, pathophysiology and treatment options. The review explores relevant unanswered questions and summarizes the current debates in medication-overuse headache.

Complete detoxification is the most effective treatment of medication-overuse headache: A randomized controlled open-label trial

Background There is lack of evidence on how to detoxify medication-overuse headache. Aim To compare the effect of complete stop of acute medication with restricted intake. Methods Medication-overuse headache patients were included in a prospective, outpatient study and randomized to two months' detoxification with either a) no analgesics or acute migraine-medication (program A), or b) acute medication restricted to two days/week (program B). Detoxification was followed by preventives if indicated. Patients were followed up at 2, 6 and 12 months. Percentage reduction in headache days/month after 6 months was the primary outcome. Results We included 72 medication-overuse headache patients with a primary migraine and/or tension-type headache diagnosis. Fifty-nine completed detoxification, 58 (81%) were followed up at month 6 and 53 (74%) at month 12. At month 6, program A reduced headache days/month by 46% (95% CI 34-58) compared with 22% (95% CI 11-34) in program-B ( p = 0.005), and 70% in program A versus 42% in program B were reverted to episodic headache ( p = 0.04). Migraine-days/month were reduced by 7.2 in program A ( p < 0.001) and 3.6 in program B ( p = 0.002) after 6 months. Conclusion Both detoxification programs were very effective. Detoxification without analgesics or acute migraine-medication was the most effective program. Trial registration Clinicaltrials.gov (NCT02903329).

A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and self-reported effectiveness

Background

Despite the expansion of conventional medical treatments for headache, many sufferers of common recurrent headache disorders seek help outside of medical settings. The aim of this paper is to evaluate research studies on the prevalence of patient use of manual therapies for the treatment of headache and the key factors associated with this patient population.

Methods

This critical review of the peer-reviewed literature identified 35 papers reporting findings from new empirical research regarding the prevalence, profiles, motivations, communication and self-reported effectiveness of manual therapy use amongst those with headache disorders.

Results

While available data was limited and studies had considerable methodological limitations, the use of manual therapy appears to be the most common non-medical treatment utilized for the management of common recurrent headaches. The most common reason for choosing this type of treatment was seeking pain relief. While a high percentage of these patients likely continue with concurrent medical care, around half may not be disclosing the use of this treatment to their medical doctor.

Conclusions

There is a need for more rigorous public health and health services research in order to assess the role, safety, utilization and financial costs associated with manual therapy treatment for headache. Primary healthcare providers should be mindful of the use of this highly popular approach to headache management in order to help facilitate safe, effective and coordinated care.

Tension-Type Headache - The Normal and Most Prevalent Headache

PREMISE

Tension-type headache (TTH) is the most prevalent form of primary headache in the general population but paradoxically the least studied headache.

PROBLEM

In this article, the epidemiology and diagnostic challenges of TTH are presented and discussed. The typical features and differential diagnosis of TTH are highlighted and the situations more likely to raise doubts are discussed.

POTENTIAL SOLUTION

A structured approach to the patient and a better comprehension of the very frequent coexistence of migraine and medication overuse headache in the clinical population are emphasized. According to the IHS classification, several diagnoses should be applied but still some clinicians prefer to apply a single combined diagnosis in the severely affected patients, namely chronic migraine. Such uneven practice may complicate the diagnostic comparability and the entire management of TTH. The present treatment strategies for TTH are summarized and hopefully an increased awareness of TTH can translate into better quality of care and a more specific diagnosis and treatment for the numerous TTH sufferers.

A Prospective Cohort Study of Outpatient Interdisciplinary Rehabilitation of Chronic Headache Patients

OBJECTIVE

To evaluate the efficacy of an intensive outpatient program designed to improve functioning and reduce psychological impairment in chronic headache patients.

BACKGROUND

Chronic headaches, occurring 15 or more days per month, for three or more months, may arise from multiple International Classification of Headache Disorders diagnoses: Chronic Migraine, Chronic Tension Type Headache, New Daily Persistent Headache, Chronic Post Traumatic Headaches, and Medication Overuse Headache. Several interdisciplinary programs that treat patients with chronic headaches have reported decreases in headache frequency. This study sought to evaluate the effect of a 3 week interdisciplinary treatment program for patients with chronic headache disorders on headache severity, functional status, and psychological impairment.

METHODS

Subjects were 379 patients admitted to an outpatient chronic headache treatment program. Assessments of headache severity, psychological status, and functional impairment were completed by 371 (97.8%) of these at the time of admission. At discharge, 340 subjects (89.7%) provided assessment data, and 152 (40.1%) provided data at 1-year follow-up.

RESULTS

Subjects' mean ratings on a 0-10 scale for their headache pain in the prior week declined, and these improvements were maintained at follow-up. (Estimated marginal means on a 0-10 scale for Average pain: admission 6.1, discharge 3.5, follow-up 3.3; for Least pain: admission 3.2; discharge 1.5; follow-up 1.3; for Worst pain: admission 8.2; discharge 6.4; follow-up 5.7), and similar results were found for current pain (admission 4.7; discharge 2.8; follow-up 2.4): Measures of functional impairment also improved following treatment, and these gains were maintained at 12 month follow up (Estimated marginal mean Headache Impact Test-6 score: admission 66.1, discharge 55.4, follow-up 51.9; Estimated marginal mean Pain Disability Index score: admission 36.2, discharge 14.1, follow-up 11.6). As measured by the Depression, Anxiety and Stress Scale, anxiety and reactivity to stress decreased following treatment, and remained improved at follow-up (Estimated marginal mean score for Anxiety: admission 8.7, discharge 5.2, follow-up 4.4; Estimated marginal mean score for stress: admission 14.9, discharge 7.2, follow-up 7.6). Depression decreased with treatment, but while 1-year follow-up depression scores remained significantly lower than at admission, they were also significantly higher than at discharge (Estimated marginal means: admission 13.3, discharge 4.1, follow-up 6.6).

CONCLUSIONS

The study supports the efficacy of the treatment model. Limitations of the study and suggestions for future research are also discussed.

Update of Inpatient Treatment for Refractory Chronic Daily Headache

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15 days per month) and last for more than 3 months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4 h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

Clinical and Demographical Characteristics of Patients with Medication Overuse Headache in Argentina and Chile: Analysis of the Latin American Section of COMOESTAS Project

BACKGROUND

Data on the characteristics of Medication Overuse Headache (MOH) in Latin American (LA) are scarce. Here we report the demographic and clinical features of the MOH patients from Argentina and Chile enrolled in the multinational COMOESTAS project in the period 2008-2010.

METHODS

The LA population was formed by 240 MOH subjects, 110 from Chile and 130 from Argentina, consecutively attending the local headache centres. In each centre, specifically trained neurologist interviewed and confirmed the diagnosis according to the ICHD-II criteria. A detailed history was collected on an electronic patient record form.

RESULTS

The mean patient age was 38.6 years, with a female/male ratio of 8:2. The mean time since onset of the primary headache was 21 years, whereas duration of MOH was 3.9 years. The primary headache was migraine without aura in 77.5 % and migraine with aura in 18.8 %. Forty two % of the patients self-reported emotional stress associated with the chronification of headache; 43.8 % reported insomnia. The most overused medications were acute drug combinations containing ergotamine (70 %), NSAIDs (33.8 %) and triptans (5.4 %).

CONCLUSION

Though little described, MOH is present also in LA, where it affects mostly women, in the most active decades of life. Some differences emerge as regards the demographic and clinical characteristics of MOH in this population as compared to Europe or Northern America. What seems more worrying about MOH in Argentina and Chile is that most patients overuse ergotamine, a drug that may cause serious adverse events when used chronically. These findings once more underscore the importance of properly diagnose and treat MOH.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis

AIM

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

METHODS

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

RESULTS

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62).

DISCUSSION

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Medication overuse and chronic migraine: a critical review according to clinical pharmacology

INTRODUCTION

Chronic migraine is often complicated by medication-overuse headache (MOH), a headache due to excessive intake of acute medications. Chronic migraine and MOH are serious and disabling disorders. Since chronic migraine derives from the progression of originally episodic migraine, the fundamental therapeutic strategy is prevention. This narrative review describes how to try to prevent the development of MOH and how to manage it once it has appeared.

AREAS COVERED

A PubMed database search (from 1988 to January 2015) and a review of published studies on chronic migraine and MOH were conducted.

EXPERT OPINION

In spite of progress in migraine treatment, the prevalence of chronic headaches and MOH has not changed in the course of time. Today, a large number of migraine patients have turned to numerous expert physicians and experienced all sorts of prophylactic treatments without decisive benefits. Their condition seems to have crystallized even more as chronic and intractable. This means that to prevent chronification and MOH, we need more effective drugs and better strategies to use them. In particular, we must detect disease biomarkers and predictive factors for drug response that allow for personalized treatment when migraine is still episodic and make analgesic overuse pointless.

Inpatient management of migraine

Migraine is a frequently disabling disorder which may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials. Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy. Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length of stay may be needed for persons with intractable migraine.

Cognitive behavioural treatment for the chronic post-traumatic headache patient: a randomized controlled trial

BACKGROUND

Chronic post-traumatic headache (CPTH) after mild head injury can be difficult to manage. Research is scarce and successful interventions are lacking.To evaluate the effect of a group-based Cognitive Behavioural Therapy (CBT) intervention in relation to headache, pain perception, psychological symptoms and quality of life in patients with CPTH.

METHODS

Ninety patients with CPTH according to ICHD-2 criteria were enrolled from the Danish Headache Center into a randomized, controlled trial. Patients were randomly assigned to either a waiting list group or to a nine-week CBT group intervention. At baseline and after 26 weeks all patients completed the Rivermead Post Concussion Symptoms Questionnaire, SF-36, SCL-90-R and a headache diary.

RESULTS

The CBT had no effect on headache and pressure pain thresholds and only a minor impact on the CPTH patients' quality of life, psychological distress, and the overall experience of symptoms. The waiting-list group experienced no change in headache but, opposed to the treatment group, a significant decrease in somatic and cognitive symptoms indicating a spontaneous remission over time.

CONCLUSIONS

Our primarily negative findings confirm that management of patients with CPTH still remains a considerable challenge. Psychological group therapy with CBT might be effective in an earlier stage of CPTH and in less severely affected patients but our findings strongly underline the need for randomized controlled studies to test the efficacy of psychological therapy.

Management of medication-overuse headache

Medication-overuse headache (MOH) has developed into the third most common type of headache after tension-type headache and migraine. The prevalence reaches approximately 1% of the world's population and shows an increasing trend. Many important studies on MOH have been published in the last year, some of which investigated the pathophysiology of headache chronicity, with others focusing on the evaluation of risk factors. The International Headache Society revised its classification criteria on MOH. Several large population-based longitudinal studies clearly demonstrated that overuse of any kind of acute headache medication is the main risk factor leading to the development of chronic headache. Management of MOH remains difficult; the only effective treatment concept is consequent withdrawal therapy.

Medication-overuse headache

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is a well described clinical entity. There is a growing body of knowledge on the epidemiology of MOH, risk factors, and treatment strategies.

RECENT FINDINGS

The International Headache Society updated the classification criteria for MOH. Population-based studies provided an insight into the prevalence and peculiarities of MOH patients in eastern Europe and Asia. Large-scaled population-based longitudinal studies made it possible to analyze risk factors leading to the development of MOH. Imaging studies helped to better understand the pathophysiology of headache chronicity. New treatment strategies have been suggested.

SUMMARY

MOH is a common headache disorder and a serious public health problem all over the world. Although the treatment regimen for MOH patients is straightforward and the outcomes are favorable, it is time now to move forward and establish a predictive model for early recognition of patients at high risk, to intervene early and avoid development of chronic headache.

Chronic post-traumatic headache after mild head injury: a descriptive study

BACKGROUND

The aetiology behind chronic post-traumatic headache (CPTH) after mild head injury is unclear and management is complicated. In order to optimize treatment strategies we aimed to characterize a CPTH population.

METHODS

Ninety patients with CPTH and 45 patients with chronic primary headaches were enrolled from the Danish Headache Center. All patients were interviewed about demographic and headache data. They completed the Harvard Trauma Questionnaire (HTQ), Rivermead Post Concussion Symptoms Questionnaire, SF-36 and a headache diary.

RESULTS

The CPTH group experienced more cognitive ( P < 0.001) and somatic symptoms ( P = 0.048) and rated their self-perceived health as more affected in terms of physical function ( P = 0.036), physical role function ( P = 0.012) and social function ( P = 0.012) than the control group. Surprisingly, 31% of the CPTH group had a score equal to or above the cut-off score for having post-traumatic stress disorder (PTSD) according to the HTQ. In terms of demographics and headache, the groups were comparable except the CPTH group were more often without affiliation to the labour market ( P < 0.001).

CONCLUSIONS

The loss of work capacity and high levels of disability for the CPTH patients suggests directions for further research into what important factors are embedded in the patients' PTSD symptoms and might explain their prolonged illness.

Headache in children: Effectiveness of multidisciplinary treatment in a tertiary paediatric headache clinic

Aim

The aim of this article is to evaluate the effectiveness of a specific multidisciplinary treatment programme for children with headache and to describe the concept and settings of the Children’s Headache Clinic in Denmark.

Method

All new patients were included and evaluations were conducted after six and 12 months. Pharmacological and non-pharmacological treatments were offered by a team of specialists (physicians, headache nurses, a physiotherapist and a psychologist).

Patients

The subjects comprised 169 children (mean age 11.7 (range 4–17), 91 females, 78 males), 39% of whom suffered from chronic headache (≥15 days/month). All children were diagnosed according to the International Classification of Headache Disorders, second edition; 20% had migraine, 34% tension-type headache, 27% mixed headache, 4% medication-overuse headache, and 15% were diagnosed with other types of headaches.

Results

Fifty per cent of the children had an improvement in headache frequency above 50% at six months. By the use of repeated measurement analysis, we found a significant decrease in headache frequency in all of the six headache groups, whereas the increase in quality of life (PedsQL™ 4.0) was significant for the group as a whole.

Conclusion

Though preliminary, the results show a good outcome for multidisciplinary treatment programmes for children who suffer from frequent or chronic headache.

School functioning and chronic tension headaches in adolescents: improvement only after multidisciplinary evaluation

Pediatric patients with chronic tension-type headaches often experience significant school impairment. Although some improve after treatment with a neurologist, many require more comprehensive treatment. The authors examined whether school functioning and attendance improved after a multidisciplinary evaluation focusing on a return to functioning despite headaches. They also examined whether patients' headaches improved. Participants were 47 adolescents ages 12-17, most of whom had not responded to past neurological treatment. Adolescents completed the PedsQL School Functioning Scale at evaluation, 2-3 months later, and again 6 months after evaluation. Information regarding headache frequency, severity and duration, and school attendance was obtained from medical records. Using repeated measures analyses of variance, the authors found that school functioning and attendance improved significantly from evaluation to follow-up, as did headache frequency and duration. An emphasis on returning to functioning can help patients with chronic, difficult-to-treat tension-type headaches improve in their school functioning and experience fewer, shorter headaches.

Adherence to migraine treatment does not depend on the number of prescribed medications

ObjectiveTo compare the adherence between monotherapy and politherapy in prophylactic migraine treatment.MethodFive hundred consecutive patients with migraine from a tertiary center were retrospectively studied as to the number of preventive medications prescribed during the first visit. Adherence, defined as returning for the next consultation after 4 to 6 weeks and following the prescribed regimens, were also evaluated and compared between patients.Results71.8% were women, and 6% of the patients did not receive any preventive medication, 11.4% received one drug, 22.2% two drugs, 41.4% three drugs, and 19% four drugs for the prevention of migraine. The overall adherence was 79.6%. Respectively, 73.7, 71.8, 82.6 and 86.3% of those who received the prescription of one, two, three and four drugs returned, complying with the treatment.ConclusionThere is no difference in adherence to monotherapy or politherapy (one to four drugs) for the prophylaxis of migraine.

Multidisciplinary integrated headache care: a prospective 12-month follow-up observational study

This prospective study investigated the effectiveness of a three-tier modularized out- and inpatient multidisciplinary integrated headache care program. N = 204 patients with frequent headaches (63 migraine, 11 tension-type headache, 59 migraine + tension-type headache, 68 medication-overuse headache and 3 with other primary headaches) were enrolled. Outcome measures at baseline, 6- and 12-month follow-ups included headache frequency, Migraine Disability Assessment (MIDAS), Hospital Anxiety and Depression Scale (HADS), standardized headache diary and a medication survey. Mean reduction in headache frequency was 5.5 ± 8.5 days/month, p < 0.001 at 6 months’ follow-up and 6.9 ± 8.3 days/month, p < 0.001 after 1 year. MIDAS decreased from 53.0 ± 60.8 to 37.0 ± 52.4 points, p < 0.001 after 6 months and 34.4 ± 53.2 points, p < 0.001 at 1 year. 44.0 % patients demonstrated at baseline an increased HAD-score for anxiety and 16.7 % of patients revealed a HAD-score indicating a depression. At the end of treatment statistically significant changes could be observed for anxiety (p < 0.001) and depression (p < 0.006). The intake frequency of attack-aborting medication decreased from 10.3 ± 7.3 days/month at admission to 4.7 ± 4.1 days/month, p < 0.001 after 6 months and reached 3.8 ± 3.5 days/month, p < 0.001 after 1 year. At baseline 37.9 % of patients had experience with non-pharmacological treatments and 87.0 % at 12-month follow-up. In conclusion, an integrated headache care program was successfully established. Positive health-related outcomes could be obtained with a multidisciplinary out- and inpatient headache treatment program.