Chronic Frequent Headache in the General Population: Comorbidity and Quality of Life

Refractory Headaches

Medication overuse headache (MOH), new daily persistent headache (NDPH), and persistent refractory headache attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection represent a significant burden in terms of disability and quality of life, and a challenge in terms of definition, pathophysiology, and treatment. Regarding MOH, prevention without withdrawal is not inferior to prevention with withdrawal. Preventive medications like topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP) monoclonal antibodies improve chronic migraine with MOH regardless of withdrawal. The differential diagnosis of NDPH is broad and should be carefully examined. There are no guidelines for the treatment of NDPH, but options include a short course of steroids, nerve blocks, topiramate, nortriptyline, gabapentin, CGRP monoclonal antibodies, and onabotulinumtoxinA. The persistence of headache 3 months after SARS-CoV2 infection is a predictor of poor prognosis.

Quality-of-Life in Achilles Tendinopathy: An Exploratory Study

OBJECTIVE

This research aimed to explore the quality-of-life and experiences of people with Achilles tendinopathy.

DESIGN

This mixed-methods research used the 8-dimension Assessment of Quality-of-Life (AQoL-8D), focus groups and grounded theory analysis. AQoL-8D scores were compared with population normative scores. In focus groups, participants discussed their experiences with Achilles tendinopathy.

SETTING

An online survey was completed, followed by focus groups and interviews held at the University of Canberra.

PARTICIPANTS

Adults with Achilles tendon pain were eligible to participate in the online survey, which was distributed through email and social media.

RESULTS

Complete survey responses were obtained from 92 individuals, and 11 individuals participated in focus groups and interviews. AQoL-8D scores were significantly lower in those with Achilles tendinopathy (79 ± 11 vs 81 ± 13). AQoL-8Ds of mental health, pain, senses, and the physical "super dimension" were also significantly lower. The difference exceeded the AQoL-8D minimum clinically important difference of 6% only for the pain dimension. Themes identified included adapting lifestyles, living with the condition, changes in mental and social well-being, conflict with identity, frustration, and individual experiences.

CONCLUSIONS

Achilles tendinopathy is associated with a lower quality-of-life score, but on average, the difference does not exceed the minimum clinically important difference. In focus groups, some individuals described profound impacts on their life. This discrepancy likely reflects the variability of the impact across individuals. For some people, the effect is minimal, yet for those who tie their identity and social activities to fitness and physical activity, the effect can be profound.

The treatment modalities of masticatory muscle pain a network meta-analysis

BACKGROUND

Numerous treatment modalities have been attempted for masticatory muscle pain in patients with temporomandibular disorders (TMD). To compare the treatment efficacy of more than 2 competing treatments, a network meta-analysis (NMA) was conducted.

METHODS

This study was reported with reference to the extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting of systematic reviews incorporating network meta-analyses. Medline via Pubmed, Embase via OVID, and Cochrane Library Central were searched (up to February 11, 2019). Axis I protocol of Diagnostic Criteria or Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD, RDC/TMD) were chosen as diagnostic standards. The PICOS (Problem/patient, Intervention, Comparison, Outcome, Study design) method was used to screen trials under eligibility criteria. And the NMA was performed with mvmeta commands in Stata (StataCorp, Tex).

RESULTS

Of 766 studies searched, 12 randomized clinical trials (RCTs) were finally included. Nineteen different therapies were found and further categorized into 9 treatment modalities. The general heterogeneity was not found among included trials. But predictive intervals (PrIs) were conspicuously wider than confidential intervals (CIs) of all pairwise comparisons, indicating that heterogeneity may exist between studies. Complementary therapy showed the greatest probability (42.7%) to be the best intervention. It also had the highest mean rank (2.3) in the rankogram and the biggest value of surface under the cumulative ranking (SUCRA, 84.1%).

CONCLUSIONS

Based on the limited evidence of available trials, complementary therapy seemed to be slightly more effective than remaining treatment modalities for pain reduction in TMD patients with masticatory muscle pain. High-quality randomized controlled trials are expected to validate the findings.

Psychological, clinical, and therapeutic predictors of the outcome of detoxification in a large clinical population of medication-overuse headache: A six-month follow-up of the COMOESTAS Project

Aim

To identify factors that may be predictors of the outcome of a detoxification treatment in medication-overuse headache.

Methods

Consecutive patients entering a detoxification program in six centres in Europe and Latin America were evaluated and followed up for 6 months. We evaluated anxious and depressive symptomatology (though patients with severe psychiatric comorbidity were excluded), quality of life, headache-related disability, headache characteristics, and prophylaxis upon discharge.

Results

Of the 492 patients who completed the six-month follow up, 407 ceased overuse following the detoxification (non overusers), another 23 ceased overuse following detoxification but relapsed during the follow-up. In the 407 non-overusers, headache acquired an episodic pattern in 287 subjects (responders). At the multivariate analyses, lower depression scores (odds ratio = 0.891; p = 0.001) predicted ceasing overuse. The primary headache diagnosis – migraine with respect to tension-type headache (odds ratio = 0.224; p = 0.001) or migraine plus tension-type headache (odds ratio = 0.467; p = 0.002) – and the preventive treatment with flunarizine (compared to no such treatment) (odds ratio = 0.891; p = 0.001) predicted being a responder. A longer duration of chronic headache (odds ratio = 1.053; p = 0.032) predicted relapse into overuse. Quality of life and disability were not associated with any of the outcomes.

Conclusions

Though exploratory in nature, these findings point to specific factors that are associated with a positive outcome of medication-overuse headache management, while identifying others that may be associated with a negative outcome. Evaluation of the presence/absence of these factors may help to optimize the management of this challenging groups of chronic headache sufferers.

Hypothalamus as a mediator of chronic migraine

Objective:

To identify pathophysiologic mechanisms of migraine chronification using a recently standardized protocol for high-resolution brainstem imaging of trigeminal nociceptive stimulation.

Methods:

Eighteen episodic migraineurs (EMs), 17 chronic migraineurs (CMs), and 19 healthy controls (HCs) underwent painful ammonia stimulation of the left nostril in a 3T MRI scanner. Functional images were acquired with a brainstem-optimized protocol for high-resolution echo-planar imaging.

Results:

We detected a significantly stronger activation of the anterior right hypothalamus in CMs compared to HCs. To exclude the headache as a prime mediator of the hypothalamic activations, we compared all migraineurs with headaches (EMs and CMs) with all migraineurs without headaches (EMs and CMs) and HCs in a second analysis and found a more posterior region of the hypothalamus to be more activated bilaterally during headaches.

Conclusions:

Our data corroborate the fact that the hypothalamus plays a crucial role in the pathophysiology of migraine chronification and acute pain stage of migraineurs. While the more posterior part of the hypothalamus seems to be important for the acute pain stage, the more anterior part seems to play an important role in attack generation and migraine chronification.

Chronic migraine: risk factors, mechanisms and treatment

Chronic migraine has a great detrimental influence on a patient's life, with a severe impact on socioeconomic functioning and quality of life. Chronic migraine affects 1-2% of the general population, and about 8% of patients with migraine; it usually develops from episodic migraine at an annual conversion rate of about 3%. The chronification is reversible: about 26% of patients with chronic migraine go into remission within 2 years of chronification. The most important modifiable risk factors for chronic migraine include overuse of acute migraine medication, ineffective acute treatment, obesity, depression and stressful life events. Moreover, age, female sex and low educational status increase the risk of chronic migraine. The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors, combined with frequent headache pain, lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine. Treatment options include oral medications, nerve blockade with local anaesthetics or corticoids, and neuromodulation. Well-defined diagnostic criteria are crucial for the identification of chronic migraine. The International Headache Society classification of chronic migraine was recently updated, and now allows co-diagnosis of chronic migraine and medication overuse headache. This Review provides an up-to-date overview of the classification of chronic migraine, basic mechanisms and risk factors of migraine chronification, and the currently established treatment options.

Headache in African Americans: An Overlooked Disparity

PURPOSE

The persistence of health disparities in the U.S. has necessitated additional research on race-related health disparities among Americans. Remarkably little research has examined race differences in persons with headache disorders, even though 45 million Americans experience episodic or chronic headaches annually. This review paper examined peer-reviewed publication to examine potential race differences in persons with headache disorders in the areas of headache epidemiology, headache characteristics, psychiatric comorbidity, treatment utilization, and treatment outcomes.

PROCEDURES

A multi-database search (PubMed, Web of Science, PsychlNFO) identified U.S. studies that enrolled racially diverse samples of persons with headache disorders and qualitatively examined potential race-related disparities.

MAIN FINDINGS

Compared to their Caucasian counterparts, African American headache patients are more likely to (i) be diagnosed with comorbid depressive disorders; (ii) report headaches that are more frequent and severe in nature, (iii) have their headaches under-diagnosed and/or undertreated; and (iv) discontinue treatment prematurely, regardless of socioeconomic status.

PRINCIPAL CONCLUSIONS

State of the science treatments for chronic headaches are efficacious; unfortunately, race-related disparities prevent African American headache patients from benefiting from these treatments. Research is needed that enables African Americans with severe headaches to access current headache treatments to alleviate headache burden on the African American community.

Medication-overuse headache: a review

Medication-overuse headache (MOH) is a worldwide health problem with a prevalence of 1%–2%. It is a severe form of headache where the patients often have a long history of headache and of unsuccessful treatments. MOH is characterized by chronic headache and overuse of different headache medications. Through the years, withdrawal of the overused medication has been recognized as the treatment of choice. However, currently, there is no clear consensus regarding the optimal strategy for management of MOH. Treatment approaches are based on expert opinion rather than scientific evidence. This review focuses on aspects of epidemiology, diagnosis, pathogenesis, prevention, and treatment of MOH. We suggest that information and education about the risk of MOH is important since the condition is preventable. Most patients experience reduction of headache days and intensity after successful treatment. The first step in the treatment of MOH should be carried out in primary care and focus primarily on withdrawal, leaving prophylactic medication to those who do not manage primary detoxification. For most patients, a general practitioner can perform the follow-up after detoxification. More complicated cases should be referred to neurologists and headache clinics. Patients suffering with MOH have much to gain by an earlier treatment-focused approach, since the condition is both preventable and treatable.

Preventive treatment for migraine in primary care, a population-based study in the Netherlands

Background

Preventive treatment of migraine contributes to reducing the impact of migraine but its extent of use in routine care is unknown.

Objective

The objective of this article is to assess current use, previous use, duration and course of preventive treatment of migraine in Dutch general practice.

Methods

We conducted a retrospective cohort study, for the period between 1997 and 2007, in the Interdisciplinary Processing of Clinical Information (IPCI) database, a GP research database in the Netherlands (source population of more than half a million subjects). All prevalent and incident migraine patients ( N = 7367) were included.

Results

About 13% of all migraine patients currently use preventive therapy and almost half of migraine patients have prior use. Of those starting with preventive treatment, 56% (95% CI: 54.3–64.7) still used it after nine months. There was a long delay between migraine diagnosis and preventive treatment start. Forty-four percent (95% CI 43.0–45.7) started preventive therapy in the study period.

Conclusion

This large primary-care database study shows that a limited number of patients are current users of preventive treatment, but many patients have prior use. After diagnosis there is often an extended time before preventive treatment is applied. Also there is often only one attempt. The continuation in time seems appropriate. Preventive therapy in migraine still deserves focus.

Multimorbidity in older women: the negative impact of specific combinations of chronic conditions on self-rated health

BACKGROUND

Chronic diseases are considered major threats to self-rated health (SRH). In many elderly people multimorbidity is present, in elderly women more than in elderly men. This study aims at establishing the impact of multimorbidity and specific disease combinations on SRH in elderly women.

OBJECTIVES

To study the relationship between the number of chronic diseases and SRH and explore possible effects of combinations of chronic conditions on SRH in elderly women.

METHODS

Health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. From the 12 699 respondents, 315 were females between 70 and 74 years old.

RESULTS

Of the women, 87% reported one or more chronic condition. Women without any chronic condition rated their health significantly better than those with one or more chronic conditions. Either severe back pain or severe headache was included in return the most prevalent combinations of two chronic conditions with a significantly higher negative impact on SRH than expected.

CONCLUSION

All combinations including severe headache and some combinations including severe back pain and another chronic condition had a significantly more negative impact on SRH than expected in women aged 70-74 years. General practitioners should be alert on severe headache and severe back pain in elderly women to improve proactive the quality of care and thus add to the quality of later years of life.

Quality of life, depression, and anxiety 6 months after inpatient withdrawal in patients with medication overuse headache: an observational study

OBJECTIVES

Patients with medication overuse headache (MOH) experience decreased quality of life (QoL) and increased psychiatric comorbidity. We performed an observational study in patients with MOH to assess whether QoL (primary outcome parameter), depression, and anxiety (secondary outcome parameters) improve after inpatient withdrawal therapy.

METHODS

Forty-two patients undergoing the usual regimen established for inpatient withdrawal therapy at our department completed a structured questionnaires (the Short Form-36 health survey, Self-Rating Depression Scale, and Self-Rating Anxiety Scale) immediately before inpatient withdrawal. Six months after withdrawal, they were examined again with the same questionnaires.

RESULTS

Thirty-two patients (27 female) aged 46.8±9.4 years could be interviewed twice. At baseline, QoL was decreased compared with normative data (z-scores ranging from -1.2 to -2.0). Depression was present in 65.6% and anxiety disorder in 71.9% of the patients. At follow-up, physical QoL (P<0.001) and mental QoL (P=0.019) had improved, but QoL was still impaired (z-scores ranging from -0.3 to -1.3). Depression and anxiety scores had decreased significantly. Poor mental QoL and high scores of depression and anxiety at baseline correlated with frequent headaches at follow-up (P=0.013, P=0.024, and P=0.008, respectively).

DISCUSSION

QoL is impaired in patients with MOH, and many patients are depressed and anxious. Inpatient withdrawal therapy lead to a statistically significant improvement of QoL, depression, and anxiety. Poor baseline mental QoL as well as depression and anxiety are associated with poor outcome in terms of headache frequency.

To control or not? A motivational perspective on coping with pain

Pain relief is often the primordial treatment objective in pain patients. However, an exclusive focus upon pain relief may have costs. Evidence is accumulating that persistent attempts to gain control over pain may, paradoxically, hinder successful adaptation to pain and increase frustration and limitations due to pain. To better understand these apparently paradoxical findings, we propose to adopt a motivational perspective on coping with pain. Within this perspective, pain control is recast as an attempt to protect and restore valued life goals threatened by pain. This framework explains why some patients engage excessively in pain control strategies despite the costs associated with this, such as overuse of medication. A clinical implication is that cautiousness is warranted in promoting strategies exclusively aimed at pain relief. Beyond standard medical care, interventions should also be aimed at the improvement of functioning despite pain. Certainly those patients for whom there is no definite or sound cure to pain and who increasingly experience emotional and physical problems due to pain might benefit from paramedical help by psychologists and/or physiotherapists.

Topiramate: safety and efficacy of its use in the prevention and treatment of migraine

Migraine headaches are typically episodic in nature and may affect nearly 10% of the population. In addition to treatment, prevention of subsequent episodes or progression to a chronic migraine state is an important therapeutic area. Topiramate is a centrally acting medication approved for both the prevention of seizures and migraine headache. At this time, the exact mechanism of how topiramate assists in migraine prevention is unknown. Several large randomized, controlled trials have aided in establishing topiramate's role in migraine prevention. Despite a favorable pharmacokinetic and adverse effect profile established in clinical trials, several additional studies, case reports and toxicology reports have demonstrated topiramate as a cause of cognitive and behavioural changes. The use of topiramate in migraine prevention can improve a patient's quality of life and is a cost-effective option for migraine prevention.

Predictors of outcome in patients consulting their general practitioners for headache: a prospective study

Headache is the most common neurological symptom presenting to general practitioners (GPs). Identifying factors predicting outcome in patients consulting their GPs for headache may help GPs with prognosis and choose management strategies which would improve patient care. We followed up a cohort of patients receiving standard medical care, recruited from 18 general practices in the South Thames region of England, approximately 9 months after their initial participation in the study. Of the baseline sample (N=255), 134 provided both full baseline and follow-up data on measures of interest. We determined associations between patients' follow-up scores on the Headache Impact Test-6 and baseline characteristics (including headache impact and frequency scores, mood, attributions about psychological/medical causes of their headaches, satisfaction with GP care and illness perceptions). Greater impact and stronger beliefs about the negative consequences of headaches at baseline were the strongest predictors of poor outcome at follow-up.

Triptan overuse in the Dutch general population: A nationwide pharmaco-epidemiology database analysis in 6.7 million people

Introduction: A population-based observational study was used to assess the prevalence, demographics, risk factors, and costs of triptan overuse, defined as more than 30 (International Headache Society criteria) or 54 (stringent criteria) defined daily doses per 3 months.

Methods: Analysis of the Dutch Health Care Insurance Board Database for 2005, which included prescriptions for 6.7 million people (46% of the total Dutch population).

Results: Triptans were used by 85,172 (1.3%) people; of these, 8,844 (10.4%; 95% CI 10.2–10.6) were overusers by International Headache Society and 2,787 (3.3%; 95% CI 3.2–3.4) were overusers by stringent criteria. The triptan-specific odds ratios for the rate of International Headache Society overuse compared with sumatriptan were: 0.26 (95% CI 0.19–0.36) for frovatriptan; 0.34 (95% CI 0.32–0.37) for rizatriptan; 0.76 95% CI 0.68–0.85) for naratriptan; 0.86 (95% CI 0.72–1.02) for eletriptan; 0.97 (95% CI 0.88–1.06) for zolmitriptan; and 1.49 (95% CI 1.31–1.72) for almotriptan. Costs for overuse were 29.7 million euros; for the International Headache Society criteria this was 46% of total costs and for stringent criteria it was 23%.

Discussion: In the Dutch general population, 1.3% used a triptan in 2005, of which 10.3% were overusers and accounted for half of the total costs of triptans. Users of frovatriptan, rizatriptan and naratriptan had a lower level of overuse.

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

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

Decision analysis of treatment options for vestibular schwannoma

Object

Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications.

Methods

The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared.

Results

After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.

Conclusions

At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.

Chronic headaches and medication overuse

Chronic headaches represent a significant burden for the affected individuals and for the society, and a major challenge for successful care. Among the various types of chronic headaches, those that are associated with medication overuse (medication-overuse headache, MOH) are of particular importance because of the large proportion of patients who complain of this condition and their poor outcome. Most patients with MOH had migraine as primary headache. Practically, almost all drugs used for the symptomatic relief of migraine, including triptans and analgesics can cause MOH. Although the pathophysiology of MOH is unknown, recent studies hypothesize that plastic changes in specific pain areas of the central nervous system are main contributors to establishing MOH. Not infrequently, drug overuse is associated with habituation and failure of previously effective medications. Finally, treatment of MOH is poorly evidence based and mostly relies on clinical experience and belief.

Psychopathology and quality of life burden in chronic daily headache: influence of migraine symptoms

The aim of this study is to compare the psychopathology and the quality of life of chronic daily headache patients between those with migraine headache and those with tension-type headache. We enrolled 106 adults with chronic daily headache (CDH) who consulted for the first time in specialised centres. The patients were classified according to the IHS 2004 criteria and the propositions of the Headache Classification Committee (2006) with a computed algorithm: 8 had chronic migraine (without medication overuse), 18 had chronic tension-type headache (without medication overuse), 80 had medication overuse headache and among them, 43 fulfilled the criteria for the sub-group of migraine (m) MOH, and 37 the subgroup for tension-type (tt) MOH. We tested five variables: MADRS global score, HAMA psychic and somatic sub-scales, SF-36 psychic, and somatic summary components. We compared patients with migraine symptoms (CM and mMOH) to those with tension-type symptoms (CTTH and ttMOH) and neutralised pain intensity with an ANCOVA which is a priori higher in the migraine group. We failed to find any difference between migraine and tension-type groups in the MADRS global score, the HAMA psychological sub-score and the SF36 physical component summary. The HAMA somatic anxiety subscale was higher in the migraine group than in the tension-type group (F(1,103) = 10.10, p = 0.001). The SF36 mental component summary was significantly worse in the migraine as compared with the tension-type subgroup (F(1,103) = 5.758, p = 0.018). In the four CDH subgroups, all the SF36 dimension scores except one (Physical Functioning) showed a more than 20 point difference from those seen in the adjusted historical controls. Furthermore, two sub-scores were significantly more affected in the migraine group as compared to the tension-type group, the physical health bodily pain (F(1,103) = 4.51, p = 0.036) and the mental health (F(1,103) = 8.17, p = 0.005). Considering that the statistic procedure neutralises the pain intensity factor, our data suggest a particular vulnerability to somatic symptoms and a special predisposition to develop negative pain affect in migraine patients in comparison to tension-type patients.

Prevalence of headache in Europe: a review for the Eurolight project

The main aim of the present study was to do an update on studies on headache epidemiology as a preparation for the multinational European study on the prevalence and burden of headache and investigate the impact of different methodological issues on the results. The study was based on a previous study, and a systematic literature search was performed to identify the newest studies. More than 50% of adults indicate that they suffer from headache in general during the last year or less, but when asked specifically about tension-type headache, the prevalence was 60%. Migraine occurs in 15%, chronic headache in about 4% and possible medication overuse headache in 1-2%. Cluster headache has a lifetime prevalence of 0.2-0.3%. Most headaches are more prevalent in women, and somewhat less prevalent in children and youth. Some studies indicate that the headache prevalence is increasing during the last decades in Europe. As to methodological issues, lifetime prevalences are in general higher than 1-year prevalences, but the exact time frame of headache (1 year, 6 or 3 months, or no time frame stated) seems to be of less importance. Studies using personal interviews seem to give somewhat higher prevalences than those using questionnaires.

Epidemiology, risk factors, and treatment of chronic migraine: a focus on topiramate

The term chronic daily headache refers to a heterogeneous group of headache disorders characterized by a frequency of headaches on > or = 15 days per month. Chronic migraine is a subtype of chronic daily headache. The prevalence of chronic migraine is approximately 1%. Baseline attack frequency and acute medication overuse have been identified as potential risk factors for the progression of migraine from an episodic disorder to a chronic condition. There is an unmet patient need for effective and safe treatments for patients with chronic migraine, but data from rigorous controlled trials are limited. Previous studies have demonstrated that topiramate is an effective and safe preventive treatment for episodic migraine. In addition, pilot studies have suggested the utility of topiramate for the prevention of chronic migraine. Two randomized, double-blind, placebo-controlled, multicenter trials investigating the efficacy and safety of topiramate in the treatment of patients with chronic migraine have recently been completed. This review presents comparative data from these 2 clinical trials, which suggest that topiramate at a dose of 100 mg daily is effective and generally well tolerated in chronic migraine.

Physicians appeals on the dangers of mobile communication--what is the evidence? Assessment of public health data

In October 2002 German physicians appealed to persons in the field of health care, politicians and the public with "great concern" ("Freiburger Appell", "Appeal of Freiburg") claiming "soaring incidences of symptoms and diseases in the general population" to be causally related to the "commence of radio (wave) burden", i.e. due to mobile radio technology. This first example was followed by several further appeals published nationally and Europe-wide up until today. The aim of the present paper is an evaluation of the scientific literature and databases to check incidence and prevalence of symptoms and diseases stated in the appeals to have "dramatically increased" or to have appeared in "greater frequency" in adults. If the allegations were true a clear time-trend should show up since the start of widely-used mobile communication technology. The following health conditions were considered: Alzheimer's disease, dementia, sleep disturbances, tinnitus, cerebrovascular disease, ischemic heart-diseases, headache, migraine. Data on the incidence of these conditions were assessed from 1993 through at least 2005. For this, a systematic search by keywords was performed in the online-database of the National Library of Medicine (pubmed) and other national and international (European and US) databases. For none of the considered symptoms or diseases a "dramatic increase" was found to have occurred since 1993. Because of the different diagnoses and terms used in the studies, direct comparability is somewhat difficult. Indeed, with the data available no time related increases and surely no "dramatic increase" can be identified, even if the limited comparability is considered. This analysis strongly suggests that the allegations of the quoted appeals are not supported by public health data.

Neuro-reflexotherapy for the management of myofascial temporomandibular joint pain: a double-blind, placebo-controlled, randomized clinical trial

PURPOSE

To assess the efficacy of neuro-reflexotherapy intervention (NRT) for treating temporomandibular joint dysfunction attributed to myofascial pain. Neuro-reflexotherapy intervention consists of the temporary implantation of epidermal devices in trigger points in the back and ear. It has shown efficacy, effectiveness, and cost-effectiveness in treating subacute and chronic common back pain. No study, however, has explored its efficacy in treating myofascial temporomandibular joint pain (MF/TMJP).

PATIENTS AND METHODS

This was a randomized, double-blind, placebo-controlled trial. Patients with MF/TMJP for more than 3 months in spite of conservative treatment, and with no evidence of major structural damage in the joint, were recruited at the Maxillofacial Department of the Hospital Clínico Universitario, a teaching hospital in Madrid, Spain. Patients were randomly assigned to an intervention group and to a control group. Patients in the treated group underwent 2 NRTs, immediately after baseline assessment and 45 days later. Sham interventions in the control group consisted of placement of the same number of epidermal devices within a 5-cm radius of the target zones. In both groups, conservative treatment during follow-up was allowed and recorded. Patients underwent clinical evaluations on 4 occasions: 5 minutes before intervention, 5 minutes after intervention, and 45 and 90 days later. The preintervention assessment was performed by the physician at the hospital service who included the patient in the study. The 3 follow-up assessments were performed independently by 1 of 2 physicians who had no connection with the research team, and who were blinded to patients' assignments. The primary outcome variable was level of pain severity during jaw movements at the last assessment (90 days), and the key comparison of interest was change in pain over time (pain levels at baseline and at 90 days). Level of pain was measured using a visual analog scale (VAS).

RESULTS

Fifty-one patients with MF/TMJP were recruited into the study. Random assignment allocated 27 patients to the intervention group, and 24 to the control group. Differences in pain severity in favor of the intervention group appeared immediately after the intervention, persisted for 45 days, and increased after the second intervention. Differences at last follow-up were highly clinically and statistically significant (4 to 5 points on the VAS, P = .000), allowing for patients in the intervention group to cease drug treatment (P = .005). There were no differences in the evolution of crepitus or clicking in the joint. There were no clinically relevant side effects associated with the intervention.

CONCLUSIONS

For patients in whom conservative treatment has failed, NRT improves the chronic pain associated with MF/TMJP syndrome.

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.