Transformed or evolutive migraine

Treatment of chronic migraine with Botox (onabotulinumtoxinA): Development, insights, and impact

Chronic migraine (CM) is a neurological disease characterized by frequent migraine attacks that prevent affected individuals from performing daily activities of living, significantly diminish quality of life, and increase familial burden. Before onabotulinumtoxinA was approved for CM, there were few treatment options for these seriously disabled patients and none had regulatory approval. The terminology and recognition of CM evolved in parallel with the onabotulinumtoxinA clinical development program. Because there were no globally accepted classification criteria for CM when onabotulinumtoxinA was in development, the patient populations for the trials conducted by Allergan were determined by the Allergan migraine team in collaboration with headache scientists and clinicians. These trials and collaborations ultimately led to improvements in CM classifications. In 2010, onabotulinumtoxinA became the first medication and first biologic approved specifically to prevent headaches in patients with CM. Approval was based on 2 similarly designed phase 3, double-blind, randomized, placebo-controlled, multicenter clinical studies. Both studies showed significantly greater improvements in mean change from baseline in headache-day frequency in patients with CM receiving onabotulinumtoxinA compared with those receiving placebo. The safety and effectiveness of onabotulinumtoxinA have been established globally in >5000 patients with CM with or without medication overuse treated in clinical and observational studies. Benefits also include improvements in quality of life, fewer psychiatric comorbidities, and reduced healthcare resource utilization. Across studies, onabotulinumtoxinA was well tolerated; adverse events tended to be mild or moderate in severity and to decline over subsequent treatment cycles.

Chronic Migraine: An Update on Diagnosis and Management

Background

Chronic migraine is an under-recognized and under-treated disorder. A greater understanding of the pathophysiology of migraine and transformation to chronic migraine has led to the first targeted treatments for chronic migraine. In this review, we review current approaches to the diagnosis and management of chronic migraine and discuss recent and emerging novel therapies.

Objective

The aim of this study was to provide an update on the diagnosis and management of chronic migraine.

Methods and Material

The PubMed database was searched for relevant articles published on or before October 2020.

Results and Conclusions

Chronic migraine is an under-recognized and under-treated disorder. Prompt diagnosis and appropriate management can lead to a significant improvement in the quality of life with subsequent socioeconomic benefits.

The Evolution of Medication Overuse Headache: History, Pathophysiology and Clinical Update

Medication overuse headache (MOH), the development or worsening of chronic headache resulting from frequent and excessive intake of medications used for acute treatment of headache, is a common secondary headache disorder and is associated with significant personal and societal burdens. The plausible physiologic mechanism is that chronic exposure to acute care migraine treatment leads to suppression of endogenous antinociceptive systems, consequently facilitating the trigeminal nociceptive process via up-regulation of the calcitonin gene-related peptide (CGRP) system. Recognizing and preventing its development is an integral aspect of migraine management, as medication overuse is a modifiable risk factor in the progression from episodic to chronic migraine. Over the years, MOH has been difficult to treat and has generated much controversy. Ongoing debates exist over the diagnostic criteria and treatment strategies, particularly regarding the roles of formal detoxification and preventive treatment. The arrival of the anti-CGRP monoclonal antibodies has also challenged our views of MOH and its treatment. This review outlines the evolution of MOH diagnostic criteria, presents the current understanding of MOH pathogenesis and discusses the debates over its development and treatment. Data on the efficacy of anti-CGRP monoclonal antibodies in the setting of medication overuse is also presented. These results indicate that patients with medication overuse, who are treated with these new medications, may not need to be detoxified in order to treat MOH. In light of these developments, it is likely that in the future MOH will be more readily diagnosed and treatment will result in better outcomes.

Clinical success of greater occipital nerve blockade in improving sleep quality of chronic migraineurs: a prospective observational study

BACKGROUND

The success of various therapy methods in the treatment of insomnia and poor quality sleep, both of which play an active role in the chronicization process of migraine, has been the subject of investigation. The aim of this research was to evaluate the success, acceptability, and efficacy of greater occipital nerve block (GON-B) therapy in chronic migraine (CM) patients in improving their sleep quality and developing their beliefs about sleep .

METHODS

The study included 40 patients with CM from the general population who agreed to receive blockade therapy. Before the injection treatment, 1-week sleep diaries as well as depression and anxiety symptoms were examined. The Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), Epworth Sleepiness Scale (ESS), and Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scales were measured and evaluated both before and after the completion of 3 months of treatment.

RESULTS

Thirty-seven patients with CM successfully completed our 12-week treatment period. The anxiety and depression scales of the patients decreased after 3 months (p < 0.001). PSQI and its subgroups ratings significantly improved after treatment (p < 0.001). Similarly, ISI, ESS, PSAS, and DBAS test scores also improved after treatment (p < 0.001).

CONCLUSIONS

This study provides evidence as to the applicability and acceptability of GON-B in CM treatment in terms of increased sleep quality; improved sleep beliefs, attitudes, and behaviors; and arousals and decreased insomnia findings.

Changes in patient functioning and disability: results from a phase 3, double-blind, randomized, placebo-controlled clinical trial evaluating galcanezumab for chronic migraine prevention (REGAIN)

PURPOSE

To evaluate secondary outcomes including changes in functioning and disability associated with galcanezumab, a humanized monoclonal antibody to calcitonin gene-related peptide, in patients with chronic migraine.

METHODS

Patients randomly received galcanezumab (120 mg n = 278, 240 mg n = 277) or placebo (n = 558) during 3 months of double-blind treatment, followed by a 9-month open-label extension. The Migraine-Specific Quality-of-Life Questionnaire v2.1 (MSQv2.1) measured the impact of migraine on patient functioning. The Migraine Disability Assessment (MIDAS) quantified headache-related disability. Changes from baseline were analyzed with mixed model repeated measures or analysis of covariance.

RESULTS

Total MSQ score at baseline was 44.88 ± 18.02 (mean ± SD), indicating significant functional impairment. At Month 3, least squares (LS) mean change ± SE in total MSQ for galcanezumab-treated patients were 20.51 ± 1.49 (120 mg) and 20.49 ± 1.49 (240 mg), both statistically significantly greater vs placebo-treated patients (14.55 ± 1.21; both P < 0.001). Total MIDAS score at baseline was 67.24 ± 57.31 (mean ± SD). At Month 3, LS mean change ± SE from baseline in total MIDAS for galcanezumab-treated patients was statistically significantly greater than placebo for 120 mg group (placebo: - 11.53 ± 3.38 vs 120 mg: - 20.27 ± 4.07; P < 0.05) but not for 240 mg group (- 17.02 ± 4.05). At Month 12, within-group mean changes from baseline for total MSQ (28.56 ± 1.19 previous placebo; 29.53 ± 1.51 previous 120 mg; 25.83 ± 1.49 previous 240 mg) and MIDAS scores (- 28.47 ± 2.95 previous placebo; - 31.47 ± 3.69 previous 120 mg; - 31.13 ± 3.62 previous 240 mg) were statistically significant (P < 0.001) for the open-label treatment population regardless of previous double-blind treatment assignment.

CONCLUSIONS

Galcanezumab-treated patients with chronic migraine reported statistically significant improvements in functioning and disability, representing a clinically significant change.

TRIAL REGISTRATION

ClinicalTrials.gov registry: NCT02614261. Registered 25 November 2015.

[Tension type headaches : Quo vadis?]

Episodic tension type headache is considered to be the most prevalent primary headache. If tension type headache occurs on more than 15 days per month for at least 3 consecutive months, it is classified as chronic tension type headache. In recent years, it has become obvious that it is difficult to distinguish between episodic tension type headache and a moderate migraine attack and also between chronic tension type headache and chronic migraine. In the paper, we discuss how the differential diagnosis can be more specific and which therapy is supported by the literature. In addition, we discuss differences and similarities of tension type headache and migraine and a possible similar pathophysiology of both (convergence hypothesis).

Characterizing opioid use in a US population with migraine: Results from the CaMEO study

Objective

To determine the prevalence of and risk factors associated with opioid use in the treatment of migraine, we examined demographics and clinical characteristics of 867 individuals who reported using opioids for the treatment of migraine.

Methods

We analyzed data from the CaMEO study (Chronic Migraine Epidemiology and Outcomes), a cross-sectional, longitudinal, Internet study, to compare sociodemographics, clinical characteristics, and migraine burden/disability of opioid users vs nonusers. Covariates were entered as categorical or continuous variables. Factors associated with opioid use were identified using nested, multivariable binary logistic regression models.

Results

Of 2,388 respondents with migraine using prescription medications for acute treatment, 36.3% reported that they currently used or kept on hand opioid medications to treat headaches. Current opioid users had significantly more comorbidities, greater headache-related burden, and poorer quality of life than nonusers. Regression models revealed factors significantly associated with opioid use, including male sex, body mass index, allodynia, increasing monthly headache frequency, Total Pain Index score (excluding head, face, neck/shoulder), anxiety, depression, ≥1 cardiovascular comorbidity, and emergency department/urgent care use for headache in the past 6 months. Self-reported physician-diagnosed migraine/chronic migraine was associated with significantly decreased likelihood of opioid use.

Conclusions

Of respondents who were using acute prescription medications for migraine, more than one-third used or kept opioids on hand, contrary to guidance. This analysis could not distinguish risk factors from consequences of opioid use; thus further research is needed to guide the development of strategies for reducing the inappropriate use of opioids in migraine.

Mechanisms of migraine as a chronic evolutive condition

Understanding the mechanisms of migraine remains challenging as migraine is not a static disorder, and even in its episodic form migraine remains an "evolutive" chronic condition. Considerable progress has been made in elucidating the pathophysiological mechanisms of migraine, associated genetic factors that may influence susceptibility to the disease, and functional and anatomical changes during the progression of a migraine attack or the transformation of episodic to chronic migraine. Migraine is a life span neurological disorder that follows an evolutive age-dependent change in its prevalence and even clinical presentations. As a disorder, migraine involves recurrent intense head pain and associated unpleasant symptoms. Migraine attacks evolve over different phases with specific neural mechanisms and symptoms being involved during each phase. In some patients, migraine can be transformed into a chronic form with daily or almost daily headaches. The mechanisms behind this evolutive process remain unknown, but genetic and epigenetic factors, inflammatory processes and central sensitization may play an important role.

Predictors of episodic migraine transformation to chronic migraine: A systematic review and meta-analysis of observational cohort studies

BACKGROUND AND PURPOSE

An estimated 2.5-3.1% of people with episodic migraine develop chronic migraine in a year. Several risk factors are associated with an increased risk for this transformation. We conducted a systematic review and meta-analysis to provide quantitative and qualitative data on predictors of this transformation.

METHODS

An electronic search was conducted for published, prospective, cohort studies that reported risk factors for chronic migraine among people with episodic migraine. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. Quality of evidence was determined according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Effect estimates were retrieved and summarized using risk ratios.

RESULTS

Of 5695 identified publications, 11 were eligible for inclusion. The pooled analysis (GRADE system) found "high" evidence for monthly headache day frequency ≥ 10 (risk ratio = 5.95), "moderate" evidence for depression (risk ratio = 1.58), monthly headache day frequency ≥ 5 (risk ratio = 3.18), and annual household income ≥ $50,000 (risk ratio = 0.65) and "very low" evidence for allodynia (risk ratio = 1.40) and medication overuse (risk ratio = 8.82) in predicting progression to chronic migraine.

CONCLUSIONS

High frequency episodic migraine and depression have high quality evidence as predictors of the transformation from episodic migraine to chronic migraine, while annual household income over $50,000 may be protective.

Migraine Progression: A Systematic Review

BACKGROUND

Migraine is a common and often debilitating neurological disease. It can be divided into episodic and chronic subforms based on the number of monthly headache days. Because only a subset of individuals with episodic migraine (EM) progress to chronic migraine (CM) over any given time period, understanding the factors that predict the new onset of CM or "migraine progression" may provide insights into the mechanisms, pathophysiology, prevention, and treatment of CM. In this review, we identify and summarize studies that report risk factors associated with the new onset of CM or related chronic headache diagnoses, group these risk factors and report the strength of evidence for the identified risk factors.

OBJECTIVE

To conduct a systematic review of studies that identify risk factors for the new onset of CM or related chronic headache diagnoses such as transformed migraine (TM) and chronic daily headache (CDH).

METHODS

Herein we summarize the findings of studies of risk factors associated with the new onset of CM/TM, CDH, or related diagnoses from the English language literature published before March 2018. The PubMed database was searched for relevant studies. Longitudinal studies with follow-up data and case-control studies were included in this qualitative synthesis. We report methodology, analytic criteria, and results for each manuscript and for the parent study. Next, we review the strength of evidence for each of the identified risk factors using a modified version of AB Hill's criteria for causation and rank evidence as fair, moderate, or strong. We categorized risk factors as nonmodifiable, modifiable and based on putative mechanisms. We further categorized risk factors into sociodemographics, lifestyle factors and habits, headache features, comorbid and concomitant diseases and conditions and pharmacologic treatment-related. Finally, we review theories of the pathophysiology underlying the development of new onset chronic migraine or increasing attack frequency.

RESULTS

The PubMed search yielded 1870 records after duplicates were removed. Nine additional records were identified through expert consultation and other methods (eg, citations found as references in manuscripts identified in the literature review and through communication with the authors of manuscripts included in the review). The 1879 manuscripts were screened against the inclusion and exclusion criteria and 109 were found to be potentially eligible. Of 109 full-text articles, 17 studies were identified as meeting the prespecified criteria based on the consensus of all authors. Of the 17 full texts, 13 were longitudinal cohort studies and 4 were case-controlled studies. We found strength of evidence ranging from fair to strong for the identified risk factors. The strongest data were found for increased headache day frequency, depression, and medication overuse/high-frequency use. Risk factors for new onset CM and CDH in children and adolescents were similar to those identified in adults.

CONCLUSIONS

A range of risk factors for the new onset of CM/TM, CDH, or related chronic headache diseases were identified with the strongest data supporting increased headache day frequency, acute medication overuse/high-frequency use and depression, which are potentially modifiable risk factors. Modifiable risk factors may provide targets for intervention. The lack of strong evidence or any evidence does not imply that there is not a relationship between a particular risk factor and new onset CM or related disease; but may indicate little or no research or that research did not have sufficient methodological rigor. In addition, it is likely that additional risk factors exist which have not yet been identified. Putative factors include pro-inflammatory states and pro-thrombotic states. Development of central sensitization and increased activation of the trigeminal nociceptive pathways may be drivers of the new onset of CM or CDH. Future research may include the systematic testing of interventions targeting modifiable risk factors to determine if progression can be prevented as well as continued exploration of the benefits of treating these risk factors among people with CM in an effort to increase rates of remission. Future work should also consider the natural fluctuations in headache day frequency and examine progression in terms of continuous definitions rather than or in addition to a dichotomous boundary.

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.

Mix headache: A valid clinical entity?

BACKGROUND

Chronic daily headache (CDH) patients respond better with a combination of anti-migraine and anti-stress medications, irrespective of clinical diagnosis of chronic migraine (CM) or chronic tension-type headache (CTTH).

HYPOTHESIS

"CDH: Mix headache" type is a valid clinical entity.

MATERIALS AND METHODS

A total of 70 participants fulfilling the diagnosis of "primary CDH", aged between 15 and 55 years were taken up for the present study. All these patients were subdivided into either CM or CTTH, based on the predominance of symptom profiles in these patients, in confirmation with the International Headache Society guidelines (International Classification of Headache Disorders-2, 2004). Schedules for clinical assessment in neuropsychiatry (SCAN) were applied to these patients to collect information about any mental or behavioral symptoms present at the time of the study. Psychiatric comorbidity was confirmed according to the International Classification of Diseases (ICD)-10.

RESULTS

Forty-eight (68.6%) patients could be differentiated into CM and rest 22 (31.4%) patients were given a diagnosis of CTTH. SCAN and ICD-10 diagnosis revealed the presence of comorbid anxiety and depressive illness in 47 (67.2%) patients. Thirty-four of them belonged to CM (MH) group and the rest 13 had CTTH.

DISCUSSION

We propose that these 47 (67.2%) patients of CDH form our special category of "CDH - mix headache" subtype. Thus, 14 (20%) patients constitute "CDH - migraine" subtype and rest 9 (12.8%) patients have a diagnosis of "CDH - tension headache" subtype.

CONCLUSION

Findings of the present study validate the concept of "mix headache" and explains the clinical observation that chronic daily headache (CDH) patients responds better with a combination of anti-migraine and anti-stress medications.

Chronic Daily Headache in Children and Adolescents: A Multi-Faceted Syndrome

Chronic daily headache (CDH) is a multi-faceted, often complex pain syndrome in children and adolescents. Chronic daily headache may be primary or secondary. Chronic migraine and chronic tension-type are the most frequent subtypes. Chronic daily headache is co-morbid with adverse life events, anxiety and depressive disorders, possibly with other psychiatric disorders, other pain syndromes and sleep disorders; these conditions contribute to initiating and maintaining CDH. Hence, early management of episodic headache and treatment of associated conditions are crucial to prevention. There is evidence for the benefit of psychological therapies, principally relaxation and cognitive behavioral, and promising information on acupuncture for CDH. Data on drug treatment are based primarily on open label studies. The controversies surrounding CDH are discussed and proposals for improvement presented. The multifaceted nature of CDH makes it a good candidate for a multi-axial classification system. Such an approach should facilitate biopsychosocial management and enhance consistency in clinical research.

Chronic Daily Headache and Medication Overuse Headache in First-Visit Headache Patients in Korea: A Multicenter Clinic-Based Study

Background and Purpose

Chronic daily headache (CDH) is defined as a headache disorder in which headaches occur on a daily or near-daily basis (at least 15 days/month) for more than 3 months. Chronic migraine (CM) and medication overuse headache (MOH) are very disabling headaches that remain underdiagnosed. The aim of this study was to establish the frequency of CDH and its various subtypes, and examine the associations with MOH among first-visit headache patients presenting at neurology outpatient clinics in Korea.

Methods

Eleven neurologists enrolled first-visit patients with complaints of headaches into outpatient clinics for further assessment. Headache disorders were classified according to the International Classification of Headache Disorder (third edition beta version) by each investigator.

Results

Primary CDH was present in 248 (15.2%) of the 1,627 included patients, comprising CM (143, 8.8%), chronic tension-type headache (CTTH) (98, 6%), and definite new daily persistent headache (NDPH) (7, 0.4%). MOH was associated with headache in 81 patients (5%). The association with MOH was stronger among CM patients (34.5%) than patients with CTTH (13.3%) or NDPH (14.3%) (p=0.001). The frequency of CDH did not differ between secondary and tertiary referral hospitals.

Conclusions

The frequencies of CDH and MOH diagnoses were 15.2% and 5%, respectively in first-visit headache patients presented at secondary or tertiary referral hospitals in Korea. CM was the most common subtype of CDH and was most frequently associated with MOH.

Harnessing the Therapeutic Potential of Capsaicin and Its Analogues in Pain and Other Diseases

Capsaicin is the most predominant and naturally occurring alkamide found in Capsicum fruits. Since its discovery in the 19th century, the therapeutic roles of capsaicin have been well characterized. The potential applications of capsaicin range from food flavorings to therapeutics. Indeed, capsaicin and few of its analogues have featured in clinical research covered by more than a thousand patents. Previous records suggest pleiotropic pharmacological activities of capsaicin such as an analgesic, anti-obesity, anti-pruritic, anti-inflammatory, anti-apoptotic, anti-cancer, anti-oxidant, and neuro-protective functions. Moreover, emerging data indicate its clinical significance in treating vascular-related diseases, metabolic syndrome, and gastro-protective effects. The dearth of potent drugs for management of such disorders necessitates the urge for further research into the pharmacological aspects of capsaicin. This review summarizes the historical background, source, structure and analogues of capsaicin, and capsaicin-triggered TRPV1 signaling and desensitization processes. In particular, we will focus on the therapeutic roles of capsaicin and its analogues in both normal and pathophysiological conditions.

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.

Prevalence of personality disorders in patients with chronic migraine

BACKGROUND

The present study aimed to investigate the prevalence of personality disorders (PDs) in patients with chronic migraine (CM).

METHODS

This study included 105 CM patients who were diagnosed according to the criteria of the International Headache Society (IHS) and 100 healthy volunteers. PDs were diagnosed with the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders, and pain severity and level of disability were assessed with the Migraine Disability Assessment (MIDAS) test.

RESULTS

Of the 105 CM patients, 85 (81%) had at least one PD. PDs were more prevalent in the patient group than in the healthy control group, and the most common PDs were obsessive-compulsive (n=53, 50.5%), dependent (n=20, 19%), avoidant (n=20, 19%), and passive-aggressive (n=14, 13.3%) PDs. The MIDAS scores of the CM patients with PDs were higher than those of the CM patients without PDs.

CONCLUSION

PDs, particularly obsessive-compulsive, dependent, avoidant, and passive-aggressive PDs, were frequently observed in CM patients in the present study.

Migraine Days Decline with Duration of Illness in Adolescents with Transformed Migraine

The aim of this study was to assess the proportion of subjects with transformed migraine (TM) who have 15 or more migraine days per month as a function of duration of chronic daily headache (CDH) in an adolescent sample. CDH is a syndrome characterized by 15 or more headache days per month. In specialty care, TM is the most common type of CDH. Most adults who meet criteria for TM do not meet the International Headache Society (IHS) criteria for chronic migraine (CM). TM criteria require 15 or more headache days per month (not necessarily migraine), with a current or past history of migraine. CM requires 15 or more migraine days per month. As TM develops, attack frequency increases and the number of migraine features diminishes. If this observation is correct, individuals who meet criteria for TM but not CM may be at a later stage in the evolution of the disease, compared with those who meet criteria for CM. We reviewed charts of 267 adolescents (13-17 years) seen in a headache centre, to identify 117 with TM. We divide subjects with TM into those with recent onset (1 year) vs. longer duration (>1 year) and examined the number of migraine days per month and demographic features. We modelled predictors of CM (>15 migraine days per month) using logistic regression. Of 117 adolescents with TM, 55 (47%) had recent-onset (<1 year) and 62 (53%) had long-duration TM. Those with recent-onset TM were much more likely also to meet criteria for CM (74.5% vs. 25.8%, P < 0.001). This was verified in the TM with medication overuse subgroup (recent onset 66.7%, vs. long duration 37%, P = 0.01) and in the TM without medication overuse subgroup (62.2% vs. 19.2%, P = 0.001). Modelling the dichotomous outcome of CM (>15 days of migraine/month) in logistic regression, CM was predicted by recent onset of CDH, recent onset of migraine (<36 months), and younger ages (15 years), but not gender or use of migraine preventive drugs or medication overuse. Among adolescents with TM, CM is more likely in individuals who are young, whose episodic headache began recently, and with CDH of recent onset. These findings suggest that early in the process of transformation, migraine is more frequent, and that as CDH evolves, fewer typical attacks of IHS migraine occur.

The International Classification of Headache Disorders Revised Criteria for Chronic Migraine—Field Testing in a Headache Specialty Clinic

In the absence of a biological marker and expert consensus on the best approach to classify chronic migraine (CM), recent revised criteria for this disease has been proposed by the Headache Classification Committee of the International Headache Society. This revised criteria for CM is now presented in the Appendix. Herein we field test the revised criteria for CM. We included individuals with transformed migraine with or without medication overuse (TM+ and TM-), according to the criteria proposed by Silberstein and Lipton, since this criterion has been largely used before the Second Edition of the International Classification of the Headache Disorders (ICHD-2). We assessed the proportion of subjects that fulfilled ICHD-2 criteria for CM or probable chronic migraine with probable medication overuse (CM+), as well as the revised ICHD-2 (ICHD-2R) criteria for CM (≥15 days of headache, ≥8 days of migraine or migraine-specific acute medication use—ergotamine or triptans). We also tested the ICHD-2R vs. three proposals. In proposal 1, CM/CM+ would require at least 15 days of migraine or probable migraine per month. Proposal 2 required ≥15 days of headache per month and at least 50% of these days were migraine or probable migraine. Proposal 3 required ≥15 days of headache and at least 8 days of migraine or probable migraine per month. Of the 158 patients with TM-, just 5.6% met ICHD-2 criteria for CM. According to the ICHD-2R, a total of 92.4% met criteria for CM ( P < 0.001 vs. ICHD-2). The ICHD-2R criterion performed better than proposal 1 (47.8% of agreement, P < 0.01) and was not statistically different from proposals 2 (87.9%) and 3 (94.9%). Subjects with TM+ should be classified as medication overuse headache (MOH), and not CM+, according to the ICHD-2R. Nonetheless, we assessed the proportion of them who had ≥8 days of migraine per month. Of the 399 individuals with TM+, just 10.2% could be classified as CM+ in the ICHD-2. However, most (349, 86.9%) had ≥8 days of migraine per month and could be classified as MOH and probable CM in the ICHD-2R ( P < 0.001 vs. ICHD-2). We conclude that the ICHD-2R addresses most of the criticism towards the ICHD-2 and should be adopted in clinical practice and research. In the population where use of specific acute migraine medications is less common, the agreement between ICHD-2R CM and TM may be less robust.

Clinical Features and Pharmacological Treatment of Migraine Patients Referred to Headache Specialists in Canada

We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada.

Placebo Response in a Patient with Chronic Migraine and Ergotic Overuse

Facilitation of nociceptive systems has been implicated in Chronic-Migraine pathogenesis. Daily consumption of medication may be a contributing factor. The patient was male, aged 76 years, with history of migraine without aura. Six years ago, he presented with a mild-moderate daily pulsating headache. He was overusing analgesics and ergotamine. After withdrawing, the patient started a non-pulsating headache, diffuse and constant. During follow up, he was refractive to several symptomatic and prophylactic treatments. When we treated him with placebo capsules, the headache responded very well. At first, pain-relief occurred for 6 h and progressively, extended. Two years later, when our patient started to use transdermal patches of fentanyl for treatment of a complex regional pain syndrome type 1, his headache did not improve. Patient has maintained prolonged response to placebo. Actually, he is pain-free for 2-3 days with 1 placebo capsule. We discuss mechanisms of chronic-migraine, drug-overuse, drug-induced headache and placebo addiction. Powerful psychological mechanisms could determine response to placebo in this patient.

Chronic Daily Headaches in Children and Adolescents

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

Chronic Daily Headache in Children and Adolescents: A Clinic Based Study from India

Chronic Daily Headache (CDH) is uncommon in Indian children compared to their adult counterpart. This is a retrospective study looking at the headache phenomenology of CDH in Indian children and adolescents. The validity of the case definitions of subtypes of chronic primary headaches mentioned in the HIS 2004 classification have been evaluated. 22 children (age range 8-15 years; M : F-16 : 6) diagnosed as having primary CDH using a modified definition seen between 2002 and 2003 have been studied. CDH has been defined as daily or near daily headaches > 15d/month for > 6 weeks. The rationale for this modified definition has been discussed. Majority of children (15/22) had a more or loss specified time of onset of regular headache spells resembling New Daily Persistent Headache (NDPH) but did not fulfil totally the diagnostic criteria of NDPH as laid down by IHS 2004. In all cases headache phenomenology included a significant vascular component. Headache phenomenology closely resembled Chronic Tension Type Headache (CTTH) in 4 patients and Chronic Migraine in 3 patients. However, in no patient in these groups, a history of evolution from the episodic forms of the diseases could be elicited. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (19/22). Only a minority of patients (3/22) had anxiety and depression related to interpersonal relationships in the family. Medication overuse was not implicated in any patient. CDH in children in India is very much different from CDH in adults with the vast majority of patients exhibiting overlapping features of migraine and tension-type headache. There is need for a modified diagnostic criteria and terminology for chronic primary headaches in children.

OnabotulinumtoxinA improves quality of life and reduces impact of chronic migraine over one year of treatment: Pooled results from the PREEMPT randomized clinical trial program

BACKGROUND

Chronic migraine (CM) is associated with high impact and reduced health-related quality of life (HRQoL).

METHODS

Patients with CM from PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy) were randomized (1:1) to receive onabotulinumtoxinA or placebo for two 12-week cycles in the double-blind (DB) phase, followed by three 12-week cycles of open-label (OL) onabotulinumtoxinA (onabotulinumtoxinA/onabotulinumtoxinA (O/O) and placebo/onabotulinumtoxinA (P/O) groups, respectively). HRQoL endpoints were assessed over 56 weeks using the Headache Impact Test (HIT-6) and the Migraine-Specific Quality of Life Questionnaire (MSQ). HIT-6 score reductions ≥2.3 and ≥5 denoted between-group minimally important difference and within-patient clinically meaningful response, respectively.

RESULTS

A total of 1236 participants (O/O, n = 607; P/O, n = 629) participated in both phases. The DB phase showed significantly reduced HIT-6 and MSQ for onabotulinumtoxinA versus placebo (all p < 0.001). The OL phase showed significantly reduced HIT-6 for O/O versus P/O at weeks 28, 36, and 48, but not 56. All three MSQ domains showed improved HRQoL relative to baseline, but only the role restrictive domain showed a significant difference between O/O and P/O at week 56.

CONCLUSIONS

Benefits of onabotulinumtoxinA on HRQoL versus baseline persisted throughout the OL phase. Statistical superiority in favor of O/O was demonstrated for HIT-6 through 48 weeks and for MSQ (role restrictive) at 56 weeks.

Safety, tolerability, and efficacy of TEV-48125 for preventive treatment of chronic migraine: a multicentre, randomised, double-blind, placebo-controlled, phase 2b study

BACKGROUND

Benefits of calcitonin-gene related peptide (CGRP) inhibition have not been established in chronic migraine. Here we assess the safety, tolerability, and efficacy of two doses of TEV-48125, a monoclonal anti-CGRP antibody, in the preventive treatment of chronic migraine.

METHODS

In this multicentre, randomised, double-blind, double-dummy, placebo-controlled, parallel-group phase 2b study, we enrolled men and women (aged 18-65 years) from 62 sites in the USA who had chronic migraine. Using a randomisation list generated by a central computerised system and an interactive web response system, we randomly assigned patients (1:1:1, stratified by sex and use of concomitant preventive drugs) to three 28-day treatment cycles of subcutaneous TEV-48125 675/225 mg (675 mg in the first treatment cycle and 225 mg in the second and third treatment cycles), TEV-48125 900 mg (900 mg in all three treatment cycles), or placebo. Investigators, patients, and the funder were blinded to treatment allocation. Daily headache information was captured using an electronic diary. Primary endpoints were change from baseline in the number of headache-hours during the third treatment cycle (weeks 9-12) and safety and tolerability during the study. Secondary endpoint was change in the number of moderate or severe headache-days in weeks 9-12 relative to baseline. Efficacy endpoints were analysed for the intention-to-treat population. Safety and tolerability were analysed using descriptive statistics. This trial is registered with ClinicalTrials.gov, number, NCT02021773.

FINDINGS

Between Jan 8, 2014, and Aug 27, 2014, we enrolled 264 participants: 89 were randomly assigned to receive placebo, 88 to receive 675/225 mg TEV-48125, and 87 to receive 900 mg TEV-48125. The mean change from baseline in number of headache-hours during weeks 9-12 was -59.84 h (SD 80.38) in the 675/225 mg group and -67.51 h (79.37) in the 900 mg group, compared with -37.10 h (79.44) in the placebo group. The least square mean difference in the reduction of headache-hours between the placebo and 675/225 mg dose groups was -22.74 h (95% CI -44.28 to -1.21; p=0.0386), whereas the difference between placebo and 900 mg dose groups was -30.41 h (-51.88 to -8.95; p=0.0057). Adverse events were reported by 36 (40%) patients in the placebo group, 47 (53%) patients in the 675/225 mg dose group, and 41 (47%) patients in the 900 mg dose group, whereas treatment-related adverse events were recorded in 15 (17%) patients, 25 (29%) patients, and 28 (32%) patients, respectively. The most common adverse events were mild injection-site pain and pruritus. Four (1%) patients had serious non-treatment-related adverse events (one patient in the placebo group, one patient in the 675/225 mg group, and two patients in the 900 mg group); no treatment-related adverse events were serious and there were no relevant changes in blood pressure or other vital signs.

INTERPRETATION

TEV-48125 given by subcutaneous injection every 28 days seems to be tolerable and effective, thus supporting the further development of TEV-48125 for the preventive treatment of chronic migraine in a phase 3 trial.

FUNDING

Teva Pharmaceuticals.

Risk factors of chronic daily headache or chronic migraine

Chronic daily headache (CDH) is a common neurological condition that affects 1-4 % of the general population. Most individuals with CDH originally suffered from episodic headaches, but over time, this developed into CDH. Although the pathophysiology of CDH is not fully understood, recent clinical and epidemiological studies suggest some risk factors that are associated with an increased risk of transformation from episodic headaches. If risk factors can be identified, they could provide a base for aggressive preventive intervention and thus decrease the transformation from episodic headaches to eventual CDH. In this article, we review and summarize the current data on risk factors for CDH.

Integrated care for chronic migraine patients: epidemiology, burden, diagnosis and treatment options

Migraine is a common neurological disorder, characterised by severe headaches. Epidemiological studies in the USA and Europe have identified a subgroup of migraine patients with chronic migraine. Chronic migraine is defined as ≥15 headache days per month for ≥3 months, in which ≥8 days of the month meet criteria for migraine with or without aura, or respond to treatment specifically for migraine. Chronic migraine is associated with a higher burden of disease, more severe psychiatric comorbidity, greater use of healthcare resources, and higher overall costs than episodic migraine (<15 headache days per month). There is a strong need to improve diagnosis and therapeutic treatment of chronic migraine. Primary care physicians, as well as hospital-based physicians, are integral to the identification and treatment of these patients. The latest epidemiological data, as well as treatment options for chronic migraine patients, are reviewed here.

The diagnosis and treatment of chronic migraine

Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.

Accuracy of family history reports of migraine in a community-based family study of migraine

BACKGROUND

Family history of migraine is the most potent and consistent risk factor for migraine. However, there has been limited systematic research on the reliability of family history information in detecting migraine based on valid diagnostic interviews. This study systematically evaluated the accuracy of migraine defined by the International Classification of Headache Disorders (ICHD-II) based on a direct structured interview compared to structured family history reports. The aim of the present study was to assess the validity of migraine diagnosis provided by family history compared with direct interview using a validated diagnostic interview of headache syndromes in the context of a family study of migraine comorbidity.

METHODS

The sample included 921 study participants identified in a cross-sectional community-based controlled family study of comorbidity of migraine and affective disorders recruited from the greater Washington, DC community. Lifetime migraine and tension-type headache were ascertained by direct clinical interview using a validated interview that collects ICHD-II criteria for headache syndromes. A structured history of headache was also collected from all interviewed probands and relatives regarding their relatives. All family history reports were reviewed by the study neurologist according to ICHD-II criteria. Family history ratings and diagnoses were made by the neurologist, who was blinded to the headache diagnosis obtained by direct interview.

RESULTS

The sensitivity and specificity of family history reports of migraine compared with direct interview were 38.6% and 96.8%, respectively, indicating that the false positive rate was very low, whereas the false negative rate was substantial. The positive and negative predictive values of migraine diagnosis provided by family member report are 90.0% and 67.6%, respectively.

CONCLUSIONS

Our results confirm that migraine assessed by family member report largely underestimates migraine in relatives. This demonstrates the value of direct interviews with relatives rather than reliance on family history report in both clinical practice and family and genetic studies. Potential steps to improve the reliability of family history report in clinical settings are described.

Revised 2004 International Classification of Headache Disorders: New Headache Types

In 1988, the International Headache Society created a classification system that has become the standard for headache diagnosis and research. The International Classification of Headache Disorders galvanized the headache community and stimulated nosologic, epidemiologic, pathophysiologic, and genetic research. It also facilitated multinational clinical drug trials that have led to the basis of current treatment guidelines. While there have been criticisms, the classification received widespread support by headache societies around the globe. Fifteen years later, the International Headache Society released the revised and expanded International Classification of Headache Disorders second edition. The unprecedented and rapid advances in the field of headache led to the inclusion of many new primary and secondary headache disorders in the revised classification. Using illustrative cases, this review highlights 10 important new headache types that have been added to the second edition. It is important for neurologists to familiarize themselves with the diagnostic criteria for the frequently encountered primary headache disorders and to be able to access the classification (www.i-h-s.org) for the less commonly encountered or diagnostically challenging presentations of headache and facial pain.

A new electronic diary tool for mapping and tracking spatial and temporal head pain patterns in migraine

AIM

We present an electronic tool for collecting data on the patterns of migraine headache onset and progression.

METHODS

A digitized map consisting of 44 color-coded segments was defined based on previous reports of migraine pain and the distribution of nerves in the face, head and neck. The map was overlaid on a schematic map of the face, head and neck nerves. Thirty-six patients (N = 36, 28 female/eight male), who met ICDH-II criteria for episodic migraine and had headaches for at least three years, identified all regions where pain typically started and how pain spread and subsequently progressed.

RESULTS

Consistent with previous findings, throbbing was the most prevalent quality of migraine pain, always present in 70% of patients surveyed. For the 70% of the patients with throbbing pain, the temple was the onset site of throbbing pain, with no significant difference in the laterality of onset site (58.3% on the right vs. 55.6% on the left hemisphere). The tool was able to capture patterns of pain distribution for throbbing and pressure headache pain and also may be used to assess the change in the pattern of the pain distribution as the disease progresses.

DISCUSSION

The pain map survey may be a useful tool for recording and tracking the temporal pattern of migraine onset both for clinical and research purposes. The tool could be used to create maps of pain locations on a large population scale and thus will be a very useful tool in correlating the temporal nature of headache symptoms with potential mechanisms of disease evolution.

Galeata: chronic migraine independently considered in a medieval headache classification

BACKGROUND

Chronic migraine is a quite recent concept. However, there are descriptions suggestive of episodic migraine since the beginning of scientific medicine. We aim to review main headache classifications during Classical antiquity and compared them with that proposed in the 11th century by Constantine the African in his Liber Pantegni, one of the most influential texts in medieval medicine.

METHOD

We have carried out a descriptive review of Henricum Petrum's Latin edition, year 1539.

RESULTS

Headache classifications proposed by Aretaeus of Cappadocia, Galen of Pergamun and Alexander of Tralles, all of them classifying headaches into three main types, considered an entity (called Heterocrania or Hemicrania), comparable to contemporary episodic migraine.In ninth book of Liber Pantegni, headaches were also classified into three types and one of them, Galeata, consisted on a chronic pain of mild intensity with occasional superimposed exacerbations.

CONCLUSION

In Liber Pantegni we have firstly identified, as a separate entity, a headache comparable to that we currently define as chronic migraine: Galeata.

Chronification of migraine: what clinical strategies to combat it?

Once migraine becomes chronic and has transformed into a form of headache that occurs daily or almost, the treatment options available are few and complex. This makes it important to take action before this point is reached, using all the measures that can be obtained from our current knowledge of chronic migraine (or transformed migraine) on the one hand, and on the potential factors of chronification (or transformation) on the other. Therefore, in order to reduce the risk of migraine chronification, it would appear important to: (a) administer suitable preventive treatments for subjects who have been suffering from migraines ≥4 days a month for ≥3 months; (b) take special care not to overuse symptomatic medications, particularly when they contain substances with a sedative effect; and (c) investigate the concomitant presence of depression, hypertension and excess weight and administer appropriate treatment when present.

Primary headache disorders

Primary headache disorders include migraine, tension-type headaches, and the trigeminal autonomic cephalgias (TACs). "Primary" refers to a lack of clear underlying causative pathology, trauma, or systemic disease. The TACs include cluster headache, paroxysmal hemicrania, and short-lasting neuralgiform headache attacks with conjunctival injection and tearing; hemicrania continua, although classified separately by the International Headache Society, shares many features of both migraine and the TACs. This article describes the features and treatment of these disorders.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

IPS multicentric study: Functional somatic symptoms in depression

BACKGROUND

As a pilot project, Indian Psychiatric Society conducted the first multicentric study involving diverse settings from teaching institutions in public and private sectors and even privately run psychiatric clinics.

AIM OF THE STUDY

To study the typology of functional somatic complaints (FSC) in patients with first episode depression.

MATERIALS AND METHODS

A total of 741 patients from 16 centers across the country participated in the study. They were assessed on Bradford Somatic Symptom inventory for FSC, Beck Depression Inventory for severity of depression, and Comprehensive Psychopathological Rating Scale- anxiety index (CPRS-AI) for anxiety symptoms.

RESULTS

The mean age of the study sample was 38.23 years (SD-11.52). There was equal gender distribution (male - 49.8% vs. females 50.2%). Majority of the patients were married (74.5%), Hindus (57%), and from nuclear family (68.2%). A little over half of the patients were from urban background (52.9%). The mean duration of illness at the time of assessment was 25.55 months. Most of the patients (77%) had more than 10 FSCs, with 39.7% having more than 20 FSCs as assessed on Bradford Somatic Inventory. The more common FSC as assessed on Bradford Somatic Inventory were lack of energy (weakness) much of the time (76.2%), severe headache (74%) and feeling tired when not working (71%), pain in legs (64%), aware of palpitations (59.5%), head feeling heavy (59.4%), aches and pains all over the body (55.5%), mouth or throat getting dry (55.2%), pain or tension in neck and shoulder (54%), head feeling hot or burning (54%), and darkness or mist in front of the eyes (49.1%). The prevalence and typology of FSCs is to a certain extent influenced by the sociodemographic variables and severity of depression.

CONCLUSION

Functional somatic symptoms are highly prevalent in Indian depressed patients and hence deserve more attention while diagnosing depression in Indian setting.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Medication-overuse headache

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is a chronic daily headache in which acute medications used at high frequency cause transformation to headache occurring 15 or more days per month for 4 or more hours per day if left untreated. MOH is a form of US Food and Drug Administration-defined chronic migraine. This review will describe (1) MOH clinical features and diagnosis, (2) pathophysiology and structural and functional MOH brain changes, and (3) prevention and treatment of MOH.

RECENT FINDINGS

MOH causes structural and functional brain changes. Any butalbital or opioid use increases the risk of transforming episodic into chronic migraine (sometimes referred to as chronification). The American Migraine Prevalence and Prevention Study demonstrated that transformation is most likely to occur with 5 days of butalbital use per month, 8 days of opioid use per month, 10 days of triptan or combination analgesic use per month, and 10 to 15 days of nonsteroidal anti-inflammatory use per month. Acute migraine treatment should be limited to 2 or fewer days per week, and opioids and butalbital should be avoided.Treatment of MOH consists of combining prophylaxis, 100% wean of overused acute medications, and provision of new acute medications, strictly limiting use to 2 or fewer days per week. Wean can be done slowly in an outpatient setting or it can be done abruptly, sometimes requiring hospitalization with medicine bridges.

SUMMARY

MOH development is linked to baseline frequency of headache days per month, acute medication class ingested, frequency of acute medications ingested, and other risk factors. Using less effective or nonspecific medication for severe migraine results in inadequate treatment response, with redosing and attack prolongation, frequently leading to chronification. Use of any barbiturates or opioids increases the transformation likelihood.Patients with MOH can usually be effectively treated. The first step is 100% wean, followed by establishing preventive medications such as onabotulinumtoxinA or daily prophylaxis and providing acute treatment for severe migraine 2 or fewer days per week. Slow wean or quick termination of rebound medications can be accomplished for most patients on an outpatient basis, but some more difficult problems may need referral for multidisciplinary day hospital or inpatient treatments.

Sinus venous stenosis-associated idiopathic intracranial hypertension without papilledema as a powerful risk factor for progression and refractoriness of headache

Data from two recent studies strongly support the hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) could represent a powerful risk factor for the progression of pain in primary headache individuals. The first study highlights that an asymptomatic IIHWOP is much more prevalent than believed in the general population and occurs only in central venous stenosis carriers. In the second study, about one half of a large consecutive series of unresponsive primary chronic headache patients shows significant sinus venous stenosis. A continuous or intermittent IIHWOP was detectable in 91% of this subgroup and in no patient with normal venography. Moreover, after the lumbar puncture, a 2- to 4-week improvement in headache frequency was observed in most of the intracranial hypertensive patients. These findings strongly suggest that patients prone to primary headache who carry central venous outflow abnormalities are at high risk of developing a comorbid IIHWOP, which in turn is responsible for the progression and the unresponsiveness of the pain. Based on the available literature data, we propose that central sinus stenosis-related IIHWOP, although highly prevalent among otherwise healthy people, represents an important modifiable risk factor for the progression and refractoriness of pain in patients predisposed to primary headache. The mechanism could refer to up to one half of the primary chronic headache patients with minimal response to treatments referring to specialized headache clinics. Due to the clinical and taxonomic relevance of this hypothesis further studies are urgently needed.

Chronic headaches and insomnia: working toward a biobehavioral model

BACKGROUND

Sleep disturbances are consistently associated with chronic headaches, yet the mechanisms underlying this relationship remain unclear. One potential barrier to generating new hypotheses is the lack of synthesis between models of headache and models of sleep. The goal of this paper is to present a perspective on the chronification of migraine and tension-type headaches based upon conceptual models used in sleep research.

METHODS

We provide a critical review of the literature on sleep and headache, highlighting the limitations in sleep methodology. Models of sleep physiology and insomnia are discussed, along with the potential implications for the chronification of migraine and tension-type headache. In addition, we propose a biobehavioral model that describes the interaction between behaviors related to coping with headache, the impact of these behaviors on insomnia and sleep physiology and the downstream propensity for future headache attacks.

CONCLUSIONS

We hope that this perspective will stimulate interdisciplinary activity toward uncovering the pathway for more effective interventions for chronic headache patients.

Sinus venous stenosis, intracranial hypertension and progression of primary headaches

The recently advanced hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) is a powerful risk factor for the progression of pain in individuals prone to episodic primary headache implies that IIHWOP is much more prevalent than it is believed to be in the general population and that it can run almost asymptomatic in most of the affected individuals. In this review, we discuss the evidence available supporting that: (a) sinus venous stenosis-associated IIHWOP is much more prevalent than believed in the general population and can run without symptoms or signs of raised intracranial pressure in most of individuals affected, (b) sinus venous stenosis is a very sensitive and specific predictor of intermittent or continuous idiopathic intracranial hypertension with or without papilledema, even in asymptomatic individuals, (c) in primary headache prone individuals, a comorbidity with a hidden stenosis-associated IIHWOP represents a very common, although largely underestimated, modifiable risk factor for the progression and refractoriness of headache.