Stress and Headache Chronification

Association between receiving work communications outside of work hours via telecommunication devices and work-related headaches and eyestrain: a cross-sectional analysis of the 6th Korean Working Conditions Survey

Background

The rise in telecommuting or non-face-to-face work owing to the coronavirus disease 2019 pandemic has fueled conversations regarding the "right to disconnect." Although evidence suggests that receiving work-related communications through telecommunication devices outside of work hours may lead to various symptoms and illnesses, limited research has been undertaken on these symptoms. This study therefore aims to investigate the correlation between receiving work communications through telecommunication devices after work hours and the occurrence of work-related headaches and eyestrain in full-time, non-shift white-collar workers.

Methods

This study used data from the 6th Korean Working Conditions Survey. The frequency of using telecommunication devices for work purposes outside of working hours was divided into five categories: "Every day," "Several times a week," "Several times a month," "Rarely," and "Never." Work-related headaches and eyestrain were categorized based on a "yes" or "no" response to the survey questions. Descriptive statistics, χ2 tests, and multiple logistic regression analyses were performed using SPSS 27.0.

Results

After adjusting for sex, age, income level, education, occupation, workplace size, work hours, and sleep disorders, the odds ratio (OR) of work-related headaches and eyestrain based on frequency of telecommunication device usage were as follows: "rarely" (OR: 1.292; 95% confidence interval [CI]: 1.111-1.503), "several times a month" (OR: 1.551; 95% CI: 1.249-1.926), "several times a week" (OR: 1.474; 95% CI: 1.217-1.784), and "every day" (OR: 1.548; 95% CI: 1.321-1.813).

Conclusions

Employees who use telecommunication devices for work after regular hours are more susceptible to experiencing work-related headaches and eyestrain compared to those who do not. However, there is a dearth of research examining the physical and mental health impacts of using telecommunication devices for after-hours work. Furthermore, the existing preventative measures in Korea are insufficient. Consequently, it is imperative to develop effective measures and conduct additional research to address this issue.

The insufficiency of a simple stress question in assessing stress for chronic daily headache in clinical practice

BACKGROUND

In managing chronic daily headaches (CDH), a comprehensive approach is necessary to evaluate stress, a closely linked factor. However, limited time and costs often lead to the use of a simple stress question in clinical settings. This study aims to assess the validity of using a simple stress question for CDH patients and explore its implications for clinical practice.

METHODS

We recruited 103 patients with CDH who completed structured self-administered questionnaires, including a simple stress question ("Have you had any stress or concerns in the last 4 weeks?") and validated Korean versions of questionnaires for depression, anxiety, insomnia, and the Brief Encounter Psychosocial Instrument (BEPSI). A headache specialist conducted clinical interviews. The stress group consisted of patients who acknowledged overt stress (answering "yes" to the simple question) and covert stress (initially answering "no" but later admitting during the interview). Results showed no statistical difference between the subgroups, so they were combined as the "acknowledged stress" group.

RESULTS

Out of 103 patients, 54.4% had chronic migraine, 45.6% had chronic tension-type headache, and 66 patients (64.1%) acknowledged experiencing stress. No significant differences were found in demographic and clinical characteristics, BEPSI stress assessment, or depression, anxiety, and insomnia profiles between patients with overt stress (n = 51) and covert stress (n = 15). The average BEPSI score was 2.3 ± 0.9, with 45.6% of patients exceeding the criteria (>2.4). Two (5.4%) patients in denial of stress had scores above the BEPSI criteria. Among patients below the criteria of BEPSI, 21 acknowledged stress, while 35 denied stress, with no significant differences observed.

CONCLUSIONS

This study suggests the limitations of relying solely on a simple stress question for assessing stress in patients with CDH in clinical practice. It is possible to encounter covert stress, include individuals who do not exhibit noticeable stress, and misclassify stress levels. To overcome these limitations, it is necessary to foster a supportive environment for open communication on stress and implement a comprehensive assessment strategy when needed.

Chronic craniomandibular pain after craniotomy: A long-term clinical study

OBJECTIVE

Chronic craniomandibular/cervical pain and temporomandibular disorders have not been studied in patients who had a craniotomy several years previously. The aim of the current clinical work was to address these issues.

METHODS

A total group of 150 ambulant patients who had a previous craniotomy was subclassified according to whether or not the temporalis muscle was manipulated.

RESULTS

The average incidence of multiple subsite regional head and neck pain was 69.3% a number of years after a craniotomy. Evidence of internal derangement of the temporomandibular joint was significantly higher in the group that required manipulation of the temporalis muscle during the procedure.

CONCLUSION

The pattern of chronic craniomandibular/cervical pain experienced years after a craniotomy supports the brain neuromatrix theory of pain.

Smartphones, the Epidemic of the 21st Century: A Possible Source of Addictions and Neuropsychiatric Consequences

Background and Objectives: Phonoholism is the excessive and harmful use of a smartphone. We are now observing this phenomenon among adults more often. Using a smartphone for several hours may lead to somatic and psychological symptoms, such as headaches and depression. The aim of this study is to assess the prevalence of phonoholism and to assess the association between smartphone overuse and neuropsychiatric disorders. Materials and Methods: A total of 368 people (70.1% were woman), aged between 19 and 82 years (average age 26.1), took part in an anonymous questionnaire consisting of the following elements: Hospital Anxiety and Depression Scale (HADS), Mobile Phone Problem Use Scale (MPPUS-9), and original questions regarding headaches and sleep quality, along with a subjective assessment of the use of smartphones and an objective evaluation based on data from the applications “Stay Free” and “Screen Time”. Results: A total of 61 respondents (16.6%) obtained a score on the MPPUS-9 scale, which revealed their problematic use of mobile devices. Patients with phonoholism had significantly more headaches (85% vs. 58.7%, p = 0.027). Subjects with phonoholism had significantly shorter mean sleep duration (7.14 h vs. 7.42 h, p = 0.0475) and were less likely to feel sleepy during the day (43.33% vs. 59.73%, p = 0.0271). The group with phonoholism had significantly higher scores on the HADS-A anxiety scale (8.29 vs. 10.9, p = 0.015), but a statistical significance was not confirmed for depressive symptoms. Conclusions: The excessive use of the telephone negatively affects both somatic and mental health and can pose a significant clinical problem.

Cognitive or daily stress association with headache and pain induction in migraine and tension-type headache patients: a systematic review

INTRODUCTION

Primary headache disorders, such as migraine and tension-type headache (TTH), represent a significant public health concern. Besides, cognitive/mental stress was suggested to contribute to TTH and migraine physiopathology. Thus, this study aimed to evaluate the existence of a causal relationship between stress (mental/cognitive or daily stress) and headache or pain improvement in migraine and TTH patients.

AREAS COVERED

We developed a systematic review of the literature, including studies that utilized mental/cognitive stress tasks or daily stress by lifestyle questionnaire in migraine and TTH patients. Necessarily, these studies should have healthy patients and a pain measure (quantitative sensory tests or headache/migraine detection). PubMed, EMBASE, and SCOPUS were searched, using terms about stress and primary headaches.

EXPERT OPINION

Both mental/cognitive stress and daily stress (perceived) were related to an increase in pain perception and related to the development of headache or enhanced transient pain intensity in migraine and TTH patients. Different factors could enrich the comprehension of the influence of stress on pain/headache induction in migraine and TTH patients, including methodological standardization, consistency of assessing, and isolating the many headache triggers in randomized controlled trial studies.

The role of the vagus nerve in fibromyalgia syndrome

Fibromyalgia (FM) syndrome is a common illness characterized by chronic widespread pain, sleep problems, fatigue, and cognitive difficulties. Dysfunctional neurotransmitter systems that influence the body's endogenous stress response systems are thought to underlie many of the major FM-related symptoms. A model of FM pathogenesis suggests biological and psychosocial variables interact to influence the genetic predisposition, but the precise mechanisms remain unclear. The Polyvagal Theory provides a theoretical framework from which to investigate potential biological mechanisms. The vagus nerve (VN) has anti-inflammatory properties via its afferent and efferent fibers. A low vagal tone (as assessed by low heart rate variability), has been observed in painful and inflammatory diseases, including FM, while the ventral branch of the VN is linked to emotional expression and social engagement. These anti-inflammatory and psychological (limbic system) properties of the VN may possess therapeutic potential in treating FM. This review paper summarizes the scientific literature regarding the potential role of the VN in transducing and/or therapeutically managing FM signs and symptoms.

Impact of abuse on migraine-related sensory hypersensitivity symptoms: Results from the American Registry for Migraine Research

BACKGROUND AND OBJECTIVES

Prior studies have established an association between a history of abuse and the development of migraine. This cross-sectional observational study explored the relationship between self-reported abuse history with migraine-related sensory hypersensitivity symptoms.

METHODS

In total, 588 adult patients with migraine from the American Registry for Migraine Research completed questionnaires: Generalized Anxiety Disorder-7, Patient Health Questionnaire-2 for depression, Photosensitivity Assessment Questionnaire, Hyperacusis Questionnaire, and Allodynia Symptom Checklist. Using four binary screening questions, patients were asked to self-report if they believed they had suffered emotional, physical, or sexual abuse in their lifetime. Differences in questionnaire scores between groups with and without a history of abuse were determined. Regression models adjusted for age, sex, and basic headache features analyzed the relationship between abuse history and sensory hypersensitivity symptoms. Moderation analysis explored the role of headache frequency in this relationship. Mediation analysis assessed the indirect (Mediated) effect (IE) of abuse on sensory hypersensitivity through depression or anxiety. Additional models analyzed relationships between sensory hypersensitivity symptoms and abuse subtypes or the number of abuse subtypes.

RESULTS

Of 588 participants, 222 (38%) reported a history of abuse. Patients with a history of abuse reported statistically significantly greater average headache frequency (7.6 vs. 4.7 days, p = 0.030). Patients with a history of abuse also reported higher average or median questionnaire scores: anxiety (7.6 vs. 4.7, p < 0.001, d = 0.56), depression (1.7 vs. 1.3, p = 0.009, d = 0.24), photophobia (0.54 vs. 0.44, p < 0.001, d = 0.32), hyperacusis (19.6 vs. 14.9, p < 0.001, d = 0.49), ictal allodynia (6.0 vs. 3.0, p < 0.001, d = 0.46), and interictal allodynia (1.0 vs. 0.0, p < 0.001, d = 0.30). After controlling for patient age, sex and years lived with headache, abuse maintained a significant association with every sensory hypersensitivity measure. Headache frequency significantly moderated the relationship between a history of abuse with increased ictal allodynia (p = 0.036). Anxiety significantly mediated the relationships between abuse with photophobia (IE = 0.03, 95% CI = 0.01-0.04), hyperacusis (IE = 1.51, 95% CI = 0.91-2.24), ictal allodynia (IE = 0.02, 95% CI = 0.01-0.04), and interictal allodynia (IE = 0.02, 95% CI = 0.01-0.06). Depression significantly mediated the relationship between abuse with photophobia (IE = 0.02, 95% CI = 0.01-0.03) and with hyperacusis (IE = 0.45, 95% CI = 0.11-0.88). The association between the individual subtypes of abuse and the number of subtypes of abuse with sensory hypersensitivity symptoms varied.

CONCLUSION

A history of abuse is associated with greater migraine-related sensory hypersensitivity symptoms. To reduce the impact of abuse on migraine symptoms, future studies should explore mechanistic connections between abuse and migraine-associated symptoms.

Mask-associated 'de novo' headache in healthcare workers during the COVID-19 pandemic

OBJECTIVES

The pandemic caused by the new coronavirus (COVID-19) has changed care activities of health professionals. We analysed the possible association between the appearance of 'de novo' headache according to the type of mask used, the related factors and the impact of the cephalalgia on health professionals.

METHODS

Cross-sectional study in a tertiary hospital in Extremadura, Spain. We provided an online questionnaire to healthcare workers during the period of maximum incidence of COVID-19 in our setting.

RESULTS

The subjects are n=306, 244 women (79.7%), with an average age of 43 years (range 23-65). Of the total, 129 (42.2%) were physicians, 112 (36.6%) nurses and 65 (21.2%) other health workers. 208 (79.7%) used surgical masks and 53 (20.3%) used filter masks. Of all those surveyed, 158 (51.6%) presented 'de novo' headache. The occurrence of a headache was independently associated with the use of a filter mask, OR 2.14 (95% CI 1.07 to 4.32); being a nurse, OR 2.09 (95% CI 1.18 to 3.72) or another health worker, OR 6.94 (95% CI 3.01 to 16.04); or having a history of asthma, OR 0.29 (95% CI 0.09 to 0.89). According to the type of mask used, there were differences in headache intensity, and the impact of a headache in the subjects who used a filter mask was worse in all the aspects evaluated.

CONCLUSION

The appearance of 'de novo' headache is associated with the use of filter masks and is more frequent in certain healthcare workers, causing a greater occupational, family, personal and social impact.

Efficacy of adding midazolam to paracetamol in pain control of patients with a primary headache: A randomized, clinical trial study

OBJECTIVES:

This study aimed to determine the effect of adding intravenous midazolam to paracetamol in the treatment of patients with primary headache referring to the emergency department.

METHODS:

In a randomized clinical trial, 120 patients (18–65 years old) with primary headache referring to the emergency department were enrolled. Patients were divided into two groups (case: paracetamol + midazolam and control: paracetamol + placebo), and the treatment was administered based on the treatment group. The severity of pain (according to the initial Visual Analog Scale) and at different times after the treatment onset (15, 30, and 60 min) and the degree of satisfaction with the treatment were compared in two groups of patients.

RESULTS:

There were no statistically difference between the two groups about the median of pain severity at the time of 0 min (case: 8 vs. control: 8), 15 min (case: 6 vs. control: 6), and 30 min (case: 4 vs. control: 4) with P > 0.05. Headache severity at 60 min after the treatment onset in the case group (median: 1) was less than that of the control group (median: 3). There was also a statistically significant difference in the median of patient satisfaction in the case group (case: 9 and control: 7 with P < 0.001) and satisfaction in the case group was higher.

CONCLUSIONS:

Based on our primary and secondary outcomes and the results of the study, we conclude that adding intravenous midazolam to paracetamol do not improve the therapeutic response ratio over time, but the effect of this intervention appeared after 1 h.

Yoga for Treating Headaches: a Systematic Review and Meta-analysis

BACKGROUND

Headache disorders are currently the sixth leading cause of disability across the globe and therefore carry a significant disease burden. This systematic review and meta-analysis aims to investigate the effects of yoga on headache disorders.

METHODS

MEDLINE/PubMed, Scopus, the Cochrane Library, and PsycINFO were screened through May 2019. Randomized controlled trials (RCTs) were included when they assessed the effects of yoga in patients with a diagnosis of chronic or episodic headache (tension-type headache and/or migraine). Usual care (no specific treatment) or any active treatments were acceptable as control interventions. Primary outcome measures were headache frequency, headache duration, and pain intensity. For each outcome, standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated.

RESULTS

Meta-analysis revealed a statistically significant overall effect in favor of yoga for headache frequency (5 RCTs; standardized mean difference (SMD) = - 1.97; 95% confidence interval (CI) - 2.75 to - 1.20; I² = 63.0%, τ² = 0.25, P = 0.03), headache duration (4 RCTs; SMD = - 1.45; 95% CI - 2.54 to - 0.37; I² = 69.0%, τ² = 0.33, P = 0.02), and pain intensity (5 RCTs; SMD = - 3.43; 95% CI - 6.08 to - 0.70, I² = 95.0%, τ² = 4.25, P < 0.01). The significant overall effect was mainly due to patients with tension-type headaches. For patients with migraine, no statistically significant effect was observed.

DISCUSSION

Despite discussed limitations, this review found preliminary evidence of short-term efficacy of yoga in improving headache frequency, headache duration, and pain intensity in patients suffering from tension-type headaches. Further studies are urgently needed to draw deeper conclusions from the available results.

Mindfulness-based stress reduction for treating chronic headache: A systematic review and meta-analysis

BACKGROUND

Mindfulness-based stress reduction/cognitive therapy are frequently used for pain-related conditions, but their effects on headache remain uncertain. This review aimed to assess the efficacy and safety of mindfulness-based stress reduction/cognitive therapy in reducing the symptoms of chronic headache.

DATA SOURCES AND STUDY SELECTION

MEDLINE/PubMed, Scopus, CENTRAL, and PsychINFO were searched to 16 June 2017. Randomized controlled trials comparing mindfulness-based stress reduction/cognitive therapy with usual care or active comparators for migraine and/or tension-type headache, which assessed headache frequency, duration or intensity as a primary outcome, were eligible for inclusion. Risk of bias was assessed using the Cochrane Tool.

RESULTS

Five randomized controlled trials (two on tension-type headache; one on migraine; two with mixed samples) with a total of 185 participants were included. Compared to usual care, mindfulness-based stress reduction/cognitive therapy did not improve headache frequency (three randomized controlled trials; standardized mean difference = 0.00; 95% confidence interval = -0.33,0.32) or headache duration (three randomized controlled trials; standardized mean difference = -0.08; 95% confidence interval = -1.03,0.87). Similarly, no significant difference between groups was found for pain intensity (five randomized controlled trials; standardized mean difference = -0.78; 95% confidence interval = -1.72,0.16).

CONCLUSIONS

Due to the low number, small scale and often high or unclear risk of bias of included randomized controlled trials, the results are imprecise; this may be consistent with either an important or negligible effect. Therefore, more rigorous trials with larger sample sizes are needed.

Association between temporomandibular disorders, chronic diseases, and ophthalmologic and otolaryngologic disorders in Korean adults: A cross-sectional study

INTRODUCTION

Temporomandibular disorders (TMDs) are common musculoskeletal conditions in the maxillofacial area. Although strong relationships between TMDs and other pain and diseases exist, few studies have comprehensively assessed the association between chronic diseases, ophthalmologic and otolaryngologic disorders and TMD.

METHODS

Of 25,534 individuals included in the fifth Korea National Health and Nutrition Examination Survey (2010-2012), 17,575 aged ≥20 years who completed survey items on TMD symptoms were included for cross-sectional analysis. Logistic regression analysis was performed to assess the association between chronic diseases, ophthalmologic and otolaryngologic disorders and examination findings, and TMD symptoms after adjusting for various confounding variables.

RESULTS

Out of 17,575 participants, 2,059 (11.75%) reported experience of ≥1 TMD symptom(s). Compared to individuals without chronic disease, those with asthma (odds ratio (OR) 1.46; 95% confidence interval (CI) 1.09-1.96), migraine (1.44; 1.26-1.65), osteoarthritis (1.51; 1.20-1.89), thyroid dysfunction (1.49; 1.13-1.96), and depressive symptoms (1.51; 1.29-1.77) had higher ORs for TMD prevalence. Participants with tinnitus (1.97; 1.70-2.27), hearing difficulties (1.55; 1.29-1.87), dizziness (1.52; 1.27-1.82), rhinitis (1.46; 1.28-1.65), and xerophthalmia (1.82; 1.57-2.12) also displayed higher ORs for TMD prevalence. Patients diagnosed with chronic rhinosinusitis upon otolaryngologic examination exhibited an OR of 1.44 (95% CI 1.11-1.87) for TMD prevalence, while that for individuals with abnormal laryngoscopic results was 0.57 (95% CI 0.36-0.90).

CONCLUSIONS

These findings imply that TMDs, chronic diseases, and ophthalmologic and otolaryngologic disorders hold various correlations, suggesting the need for multitarget approaches to effectively address this phenomenon.

Forecasting Individual Headache Attacks Using Perceived Stress: Development of a Multivariable Prediction Model for Persons With Episodic Migraine

OBJECTIVE

To develop and validate a prediction model that forecasts future migraine attacks for an individual headache sufferer.

BACKGROUND

Many headache patients and physicians believe that precipitants of headache can be identified and avoided or managed to reduce the frequency of headache attacks. Of the numerous candidate triggers, perceived stress has received considerable attention for its association with the onset of headache in episodic and chronic headache sufferers. However, no evidence is available to support forecasting headache attacks within individuals using any of the candidate headache triggers.

METHODS

This longitudinal cohort with forecasting model development study enrolled 100 participants with episodic migraine with or without aura, and N = 95 contributed 4626 days of electronic diary data and were included in the analysis. Individual headache forecasts were derived from current headache state and current levels of stress using several aspects of the Daily Stress Inventory, a measure of daily hassles that is completed at the end of each day. The primary outcome measure was the presence/absence of any headache attack (head pain > 0 on a numerical rating scale of 0-10) over the next 24 h period.

RESULTS

After removing missing data (n = 431 days), participants in the study experienced a headache attack on 1613/4195 (38.5%) days. A generalized linear mixed-effects forecast model using either the frequency of stressful events or the perceived intensity of these events fit the data well. This simple forecasting model possessed promising predictive utility with an AUC of 0.73 (95% CI 0.71-0.75) in the training sample and an AUC of 0.65 (95% CI 0.6-0.67) in a leave-one-out validation sample. This forecasting model had a Brier score of 0.202 and possessed good calibration between forecasted probabilities and observed frequencies but had only low levels of resolution (ie, sharpness).

CONCLUSIONS

This study demonstrates that future headache attacks can be forecasted for a diverse group of individuals over time. Future work will enhance prediction through improvements in the assessment of stress as well as the development of other candidate domains to use in the models.

The Association Between Childhood Traumatic Events and Headache-Related Parameters in Patients with Migraine: A Cross-Sectional Study in Turkish Population

Introduction

The aim of this study is to investigate the association between childhood traumatic events and headache-related clinical parameters in migraine patients.

Methods

95 patients diagnosed with migraine and 50 healthy controls were included in the study. A socio-demographic form, the Childhood Trauma Questionnaire (CTQ), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were completed by all participants. Additionally, the Visual Analog Scale (VAS) and the Migraine Disability Assessment Test (MIDAS) were applied to migraine patients.

Results

Positive correlations were found between emotional abuse, physical abuse, physical neglect, CTQ total scores, and headache frequency (r=0.33, r=0.24, r=0.26 and r=0.28 respectively) in migraine patients. A positive correlation was found between physical neglect and headache duration (r=0.28). Positive correlations were also found between emotional abuse and physical neglect, and MIDAS total scores (r=0.22 and r=0.23, respectively). Emotional abuse and CTQ total scores were associated with younger mean age of headache onset (r=-0.24 and r=-0.23).

Conclusion

Childhood traumatic events are associated with more frequent and more severe headache episodes, and younger headache onset in migraine patients.

Temporal change in headache and its contribution to the risk of developing first-onset temporomandibular disorder in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study

While cross-sectional studies have demonstrated an association between headache and temporomandibular disorder (TMD), whether headache can predict the onset of TMD is unknown. The aims of this study were to evaluate the contribution of headache to the risk of developing TMD and describe patterns of change in headache types over time. An initially TMD-free cohort of 2410 persons with low frequency of headache completed quarterly questionnaires assessing TMD and headache symptoms over a median 3.0-year follow-up period. First-onset TMD was confirmed by clinical examination in 199 participants. Baseline reports of migraine (hazard ratio [HR] = 1.67, 95% confidence interval [CI]: 1.06-2.62) or mixed headache types (HR = 4.11, 95% CI: 1.47-11.46), or headache frequency (HR = 2.13, 95% CI: 1.31-3.48) predicted increased risk of developing TMD. In addition, headache dynamics across the follow-up period before the TMD onset were evaluated in a nested case-control study where 248 incident TMD cases were matched to 191 TMD-free controls. Both headache prevalence and frequency increased across the observation period among those who developed TMD but not among controls. Patients with TMD were more likely to experience worsening in the headache type compared with that by controls, eg, prevalence of definite migraine among TMD cases increased 10-fold. Among all headache types experienced by patients with TMD before the TMD onset, migraine had the highest odds of progression relative to remission (odds ratio = 2.8, 95% CI: 1.6-4.8), whereas for controls this ratio was significant only for the tension-type headache (odds ratio = 2.1, 95% CI: 1.2-3.9). The important clinical implication of these findings is that adequate treatment of migraine may reduce the risk for developing TMD.

Perceived triggers of primary headache disorders: A meta-analysis

Objective To quantitatively synthesize extant literature on perceived triggers of primary headache disorders. Methods A meta-analytic review of headache trigger survey studies was conducted. Endorsement rates, assessment method, and headache and sample characteristics were extracted from included articles. Separate random-effects models were used to assess trigger endorsement rates and post-hoc meta-regressions examined potential moderator variables. Results 85 articles from 1958 to 2015 were included, involving 27,122 participants and querying 420 unique triggers (collapsed into 15 categories). Four-fifths (0.81; 95% CI .75 to .86) of individuals with migraine or tension-type headache endorsed at least one trigger. Rates increased with the number of categories queried (OR: 1.18, 1.08-1.30) and year of publication (OR: 1.04, 1.00-1.08). The triggers most commonly endorsed were stress (.58, .53-.63) and sleep (.41, .36-.47). Conclusions Extreme heterogeneity characterizes the headache trigger literature. Most individuals with a primary headache disorder perceive their attacks to be triggered by one or more precipitants, the most common of which are stress and sleep. However, trigger endorsement is influenced by method of assessment. Enhancing methodological consistency and prioritizing experimental studies would improve our understanding of headache triggers.

Complementary and Alternative Medicine Use Among US Adults With Headache or Migraine: Results from the 2012 National Health Interview Survey

BACKGROUND

Given the safety concerns regarding pharmacological agents, and the considerable impact of headache and migraine on the sufferer's quality of life, many people seek other treatment options beyond conventional medication and care to address their symptoms; this includes complementary and alternative medicine (CAM). Some CAM interventions have shown promising results in clinical trials of headache and migraine management. Nonetheless, there has been little research exploring the reasons for using CAM, and the types of CAM used, among this population.

OBJECTIVE

The study aimed to answer the following questions: (1) Which CAM modalities are used most frequently among migraine/headache sufferers? and (2) What are the self-reported reasons for CAM use among migraine/headache sufferers?

METHODS

This secondary analysis of data from the 2012 U.S. NHIS (a national cross-sectional survey) examined the use of CAM among migraine/headache sufferers, including the main reasons related to CAM use. Data were weighted and analyzed using STATA 14.0.

RESULTS

The sample of 34,525 adults included 6558 (18.7%) headache/migraine sufferers. Of the headache/migraine sufferers, a substantial proportion (37.6%, n = 2427) used CAM for various conditions; however, CAM use specifically for headache/migraine was much less prevalent (3.3%, n = 216). Of those who used CAM for headache/migraine, about half used CAM in conjunction with prescription (47.8%, n = 100) or over-the-counter medication (55.1%, n = 113). As severity of headache/migraine increased so did the likelihood of using CAM (severe migraine odds ratio [OR] = 2.32; 95% confidence interval [CI]: 1.41, 3.82; both recurring headache/severe migraine OR = 3.36; 95% CI: 2.08, 5.43; when compared to those with recurring headache only). The most frequently used CAM modality among all headache/migraine sufferers (N = 6558) was manipulative therapy (22.0%, n = 1317), herbal supplementation (21.7%, n = 1389) and mind-body therapy (17.9%, n = 1100). The top 3 reasons for using CAM for headache were general wellness (28.7%, n = 60/209), improving overall health (26.8%, n = 56/209), and reducing stress (16.7%, n = 35/209).

CONCLUSIONS

Although CAM is used by many sufferers of headache/migraine, the use of CAM specifically for the treatment of headache/migraine is relatively low in the United States. The study also assesses the key differences of CAM use among headache/migraine sufferers in NHIS 2012 compared with those in NHIS 2007, and identifies shortfalls in the evidence-base of several CAM modalities used by U.S. adults for headache/migraine. This information may assist health providers and consumers in making informed decisions about the safest and most appropriate approach to managing headache/migraine.

Using Search Engines to Investigate Shared Migraine Experiences

OBJECTIVES

To investigate migraine patterns in the United States using Google search data and utilize this information to better understand societal-level trends. Additionally, we aimed to evaluate time-series relationships between migraines and social factors.

BACKGROUND

Extensive research has been done on clinical factors associated with migraines, yet population-level social factors have not been widely explored. Migraine internet search data may provide insight into migraine trends beyond information that can be gleaned from other sources.

METHODS

In this longitudinal analysis of open access data, we performed a time-series analysis in which about 12 years of Google Trends data (January 1, 2004 to August 15, 2016) were assessed. Data points were captured at a daily level and Google's 0-100 adjusted scale was used as the primary outcome to enable the comparison of relative popularity in the migraine search term. We hypothesized that the volume of relative migraine Google searches would be affected by societal aspects such as day of the week, holidays, and novel social events.

RESULTS

Several recurrent social factors that drive migraine searches were identified. Of these, day of the week had the most significant impact on the volume of Google migraine searches. On average, Mondays accumulated 13.31 higher relative search volume than Fridays (95% CI: 11.12-15.51, P ≤ .001). Surprisingly, holidays were associated with lower relative migraine search volumes. Christmas Day had 13.84 lower relative search volumes (95% CI: 6.26-21.43, P ≤ .001) and Thanks giving had 20.18 lower relative search volumes (95% CI: 12.55-27.82, P ≤ .001) than days that were not holidays. Certain novel social events and extreme weather also appear to be associated with relative migraine Google search volume.

CONCLUSIONS

Social factors play a crucial role in explaining population level migraine patterns, and thus, warrant further exploration.

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here?

Pediatric chronic pain is a significant problem associated with substantial functional impairment. A variety of risk factors have been found to be associated with chronic pain in youth. The greatest amount of evidence appears to support that temperament, anxiety, depression, subjective experience of stress, passive coping strategies, sleep problems, other somatic-related problems, and parent and/or family factors are important variables. However, a great deal of this research focuses on a single risk factor or on multiple risk factors in isolation. Much of the literature utilizes older diagnostic criteria and would benefit from replication, larger sample sizes, and comparison across pain disorders. Problems also exist with disagreement across definitions, resulting in inconsistency or unclear use of terms. Furthermore, recent consideration has suggested that outcome measures should include functional disability in addition to pain. A second generation of research is needed to shed light on the complex interactions that likely play a role in the transition from acute to chronic pain. Building on recent calls for changes in research in this area, we propose the next steps for this research, which involve consideration of both biopsychosocial and developmental contexts.

Functional dyspepsia and irritable bowel syndrome in teenagers: Internet survey

BACKGROUND

Only a handful of studies have investigated children with functional dyspepsia (FD) and irritable bowel syndrome (IBS) classified according to the Rome III criteria, and limited information is available on the lifestyle of affected patients.

METHODS

We conducted an Internet questionnaire survey of 2060 parents among the general public in Japan who lived with their children aged 10-15, who were screened for FD and IBS.

RESULTS

The prevalence of FD and IBS was 2.8% and 6.1%, respectively, and 1.4% of the subjects met the criteria for both FD and IBS. The lifestyles of 155 subjects who met the criteria for FD, IBS, or both were compared with those of 1745 control subjects. In comparison with the controls, a significantly higher percentage of subjects with FD, IBS, or both thought that their sleep was insufficient, ate meals irregularly, were susceptible to stress and to dizziness on standing, had difficulty in getting out of bed or felt sluggish in the morning, had a tendency to faint when standing, and had migraine/chronic headache.

CONCLUSIONS

Children with FD and IBS are susceptible to stress, have impaired sleep and eating habits, and have more frequent symptoms of comorbid orthostatic dysregulation and headache.

Psychological predictors of headache remission in children and adolescents

OBJECTIVE

Longitudinal studies on headaches often focus on the identification of risk factors for headache occurrence or "chronification". This study in particular examines psychological variables as potential predictors of headache remission in children and adolescents.

METHODS

Data on biological, social, and psychological variables were gathered by questionnaire as part of a large population-based study (N=5,474). Children aged 9 to 15 years who suffered from weekly headaches were selected for this study sample, N=509. A logistic regression analysis was conducted with remission as the dependent variable. In the first step sex, age, headache type, and parental headache history were entered as the control variables as some data already existed showing their predictive power. Psychological factors (dysfunctional coping strategies, internalizing symptoms, externalizing symptoms, anxiety sensitivity, somatosensory amplification) were entered in the second step to evaluate their additional predictive value.

RESULTS

Highly dysfunctional coping strategies reduced the relative probability of headache remission. All other selected psychological variables reached no significance, ie, did not contribute additionally to the explanation of variance of the basic model containing sex and headache type. Surprisingly, parental headache and age were not predictive. The model explained only a small proportion of the variance regarding headache remission (R(2) =0.09 [Nagelkerke]).

CONCLUSION

Successful coping with stress in general contributed to remission of pediatric headache after 2 years in children aged between 9 and 15 years. Psychological characteristics in general had only small predictive value. The issue of remission definitely needs more scientific attention in empirical studies.

Headache-related disability among medical students in Amazon: a cross-sectional study

OBJECTIVE

To evaluate the prevalence of headache in medical students, and quantify the degree of disability through HIT-6 and MIDAS SCALE.

METHOD

The criteria established by International Headache Society were used and the HIT-6 and MIDAS, to asses disability.

RESULTS

140 medical students from UFAM were evaluated. 16.43% cases of migraine headache, 6.43% of probable migraine, and 23.57% of tension headaches were detected. 6.42% reported an absence of headache; and another 11.42% had secondary headache. According to the HIT-6 questionnaire, in 7.14% and 18.57% of the students, headaches were classified as having substantial to severe impact, respectively.

CONCLUSION

Migraine and probable migraine had higher scores than the other types of headache and, therefore, led to higher levels of disability. The present study did not find a significant correlation between student semester, age or extracurricular activities on the impact generated by headache.

Anxiety sensitivity and headache: diagnostic differences, impact, and relations with perceived headache triggers

BACKGROUND

Anxiety sensitivity (AS), the fear of arousal-related bodily sensations due to beliefs about presumed harmful consequences, predicts fear and avoidance among musculoskeletal pain patients but remains largely unexplored in headache. The aims of this cross-sectional study were to evaluate AS among young adult migraine and tension-type headache sufferers and to assess relations with headache impact and perceived susceptibility to headache triggers.

METHODS

A total of 2350 young adults (72.6% with primary headache; 64.9% female; 22.5% minority) completed measures of AS and headache symptomatology. Generalized linear models assessed relations between AS and ICHD-II diagnosis, headache-related disability, and perceived trigger susceptibility. Canonical correlation analyses quantified relations with headache symptomatology.

RESULTS

AS reliably differentiated headache sufferers from those without headache, being highest among chronic migraineurs and episodic migraineurs with aura. AS accounted for 8.4% of variance in headache symptomatology and was most strongly associated with prototypical migraine symptoms. AS predicted headache-related disability and trigger variables, even after controlling for headache frequency and severity. AS accounted for more unique variance in disability than depression and anxiety symptoms combined.

CONCLUSIONS

AS predicts pain itself, adjustment to pain, and evaluation of factors influencing pain among primary headache sufferers, even after controlling for headache burden. Further study of AS among headache patients is warranted.

Can weight loss improve migraine headaches in obese women? Rationale and design of the Women's Health and Migraine (WHAM) randomized controlled trial

BACKGROUND

Research demonstrates a link between migraine and obesity. Obesity increases the risk of frequent migraines and is associated with migraine prevalence among reproductive-aged women. These findings are substantiated by several plausible mechanisms and emerging evidence of migraine improvements after surgical and non-surgical weight loss. However, no previous study has examined the effect of weight loss on migraine within a treatment-controlled framework. The WHAM trial is an RCT to test the efficacy of behavioral weight loss as a treatment for migraine.

STUDY DESIGN

Overweight/obese women (n=140; BMI=25.0-49.9 kg/m(2)) who meet international diagnostic criteria for migraine and record ≥3 migraines and 4-20 migraine days using a smartphone-based headache diary during a 4-week baseline period, will be randomly assigned to 4 months of either group-based behavioral weight loss (intervention) or migraine education (control). Intervention participants will be taught strategies to increase physical activity and consume fewer calories in order to lose weight. Control participants will receive general education on migraine symptoms/triggers and various treatment approaches. Both groups will use smartphones to record their headaches for 4 weeks at baseline, after the 16-week treatment period, and at the end of a 16-week follow-up period. Changes in weight and other potential physiological (inflammation), psychological (depression), and behavioral (diet and physical activity) mediators of the intervention effect will also be assessed.

CONCLUSION

The WHAM trial will evaluate the efficacy of a standardized behavioral weight loss intervention for reducing migraine frequency, and the extent to which weight loss and other potential mediators account for intervention effects.

Psychological evaluation of a primary headache patient

A patient's experience with headache is influenced, not only by the frequency and pain of the attacks, but also by the patient's perception of the controllability of the attacks, their willingness to engage in activities despite attacks and their attitude towards the medications used to treat the headaches. Clinicians are often aware of the need to evaluate their patients for the existence of comorbid psychiatric disorders but may be less aware of the importance of these nonpathological beliefs/attitudes that are present to some degree in every headache sufferer. This article gives an overview (by no means exhaustive) of several important psychological constructs, with an emphasis on how these constructs can be assessed in headache patients using freely available paper-pencil questionnaires.

Stress and sleep duration predict headache severity in chronic headache sufferers

The objective of this study was to evaluate the time-series relationships between stress, sleep duration, and headache pain among patients with chronic headaches. Sleep and stress have long been recognized as potential triggers of episodic headache (<15 headache days/month), though prospective evidence is inconsistent and absent in patients diagnosed with chronic headaches (≥15 days/month). We reanalyzed data from a 28-day observational study of chronic migraine (n=33) and chronic tension-type headache (n=22) sufferers. Patients completed the Daily Stress Inventory and recorded headache and sleep variables using a daily sleep/headache diary. Stress ratings, duration of previous nights' sleep, and headache severity were modeled using a series of linear mixed models with random effects to account for individual differences in observed associations. Models were displayed using contour plots. Two consecutive days of either high stress or low sleep were strongly predictive of headache, whereas 2 days of low stress or adequate sleep were protective. When patterns of stress or sleep were divergent across days, headache risk was increased only when the earlier day was characterized by high stress or poor sleep. As predicted, headache activity in the combined model was highest when high stress and low sleep occurred concurrently during the prior 2 days, denoting an additive effect. Future research is needed to expand on current findings among chronic headache patients and to develop individualized models that account for multiple simultaneous influences of headache trigger factors.

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.

Sex-specific predictor analyses for the incidence of recurrent headaches in German schoolchildren

Objective: The aim of the present study was to identify psychosocial risk factors for the incidence of recurrent headache (HA) in children/adolescents (8–15 years).

Method: In 2003 (Wave 1) a representative, population-based sample of 8800 parents was mailed a questionnaire. Those who took part were asked to participate again one year later (Wave 2). Of the parents originally contacted, 47.3% participated in both surveys. Potential risk factors concerning the areas ‘school’ and ‘emotional and behavioural problems’ were collected in Wave 1. Binary logistic regression analyses were performed to assess their predictive value for HA in Wave 2.

Results: Univariable regression analyses showed that for boys and girls most of the predictor variables influenced the incidence of recurrent HA, but only to a very low extent. When all variables were assessed jointly in a multivariable model, these factors lost their predictive power for boys. For girls, ‘academic problems’ and ‘dysfunctional stress coping’ were shown to increase the chance for the incidence of recurrent HA.

Discussion: In contrast to previous findings, school-related factors and emotional and behavioural problems failed to predict HA in boys, and only two factors appeared relevant with regard to girls. This might be due to the strict unidirectional design, which focussed exclusively on the incidence of HA.

Migraine and obesity: epidemiology, possible mechanisms and the potential role of weight loss treatment

Migraine and obesity are two public health problems of enormous scope that are responsible for significant quality of life impairment and financial cost. Recent research suggests that these disorders may be directly related with obesity exacerbating migraine in the form of greater headache frequency and severity, or possibly increasing the risk for having migraine. The relationship between migraine and obesity may be explained through a variety of physiological, psychological and behavioural mechanisms, many of which are affected by weight loss. Given that weight loss might be a viable approach for alleviating migraine in obese individuals, randomized controlled trials are needed to test the effect of weight loss interventions in obese migraineurs. Large-scale weight loss trials have shown that behavioural interventions, in particular, can produce sustained weight losses and related cardiovascular improvements in patients who are diverse in body weight, age and ethnicity. Consequently, these interventions may provide a useful treatment model for showing whether weight loss reduces headache frequency and severity in obese migraineurs, and offering further insight into pathways through which weight loss might exert an effect.

Associations between stress and migraine and tension-type headache: results from a school-based study in adolescents from grammar schools in Germany

INTRODUCTION

Stress is considered the major contributor to migraine and tension-type headache in adolescents. Previous studies have focused on general stressors, whereas the aim of the present study was to investigate associations between individuals' stressful experiences and different types of headache.

METHODS

Adolescents from 10th and 11th grades of grammar schools filled in questionnaires. Stressful experiences were measured with the Trier Inventory of Chronic Stress. Type of headache was classified according to the International Classification of Headache Disorders. Linear regressions, adjusted for sex and grade, were calculated to estimate differences in stress scores that can be attributed to migraine, tension-type headache or miscellaneous headache.

RESULTS

A total of 1260 questionnaires were analysed. Tension-type headache, migraine and co-existing migraine plus tension-type headache were found in 48.7%, 10.2% and 19.8% of the participants. In subjects with migraine or co-existing migraine plus tension-type headache, high increases in stress scores were found in all investigated dimensions, whereas much weaker and inconsistent associations were found in subjects with tension-type headache only.

CONCLUSIONS

The characteristic of migraine is more associated with stressful experiences than this is the case for tension-type headache. This suggests that adolescent migraine patients might especially benefit from behavioural interventions regarding stress.

Stress and tension-type headache mechanisms

Stress is widely demonstrated as a contributing factor in tension-type headache (TTH). The mechanisms underlying this remain unclear at present. Recent research indicates the importance of central pain processes in tension-type headache (TTH) pathophysiology. Concurrently, research with animals and healthy humans has begun to elucidate the relationship between stress and pain processing in the central nervous system, including central pain processes putatively dysfunctional in TTH. Combined, these two fields of research present new insights and hypotheses into possible mechanisms by which stress may contribute to TTH. To date, however, there has been no comprehensive review of this literature. The present paper provides such a review, which may be valuable in facilitating a broader understanding of the central mechanisms by which stress may contribute to TTH.

Escitalopram and venlafaxine for the prophylaxis of migraine headache without mood disorders

There is evidence that some antidepressant drugs are beneficial in the prophylaxis of migraine. Previous reports have shown that migraine patients may respond to various antidepressant agents used for prophylactic therapy. The main purpose of this study was to compare the efficacy of antidepressants from 2 different groups (venlafaxine vs escitalopram) on people who had migraine headache without depression or anxiety. In this prospective study, we evaluated the headache diaries of 93 patients who were being treated with venlafaxine (n = 35) and escitalopram (n = 58). At the end of the 3-month period, patients were reassessed, and those with marked differences in attack frequency, duration, intensity (with visual analog scales), lost work-day equivalent index, and migraine disability assessment questionnaire were compared. There was a clear reduction in headache frequency (P < 0.0001), duration (P < 0.0001), and severity (P < 0.0001) in the venlafaxine group. In addition, there was a significant improvement in daily work performance during headaches (P < 0.0001). In the escitalopram group, monthly headache frequency (P < 0.026), duration (P < 0.002), and intensity (P < 0.027) all decreased significantly, although not to the same extent as with venlafaxine. After the third month of venlafaxine and escitalopram treatment, most of the patients (82.8% vs 96.5%) were seen to have moved to the minimal or infrequent migraine disability assessment group. According to our findings, venlafaxine and escitalopram are both effective in the prophylaxis of migraine headache without depression and anxiety. This effect was independent of mood disorder. Escitalopram should be the first choice because of its fewer side effects, but venlafaxine may be used if escitalopram is found to be insufficient.

Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification

OBJECTIVES

To assess in a headache clinic population the relationship of childhood abuse and neglect with migraine characteristics, including type, frequency, disability, allodynia, and age of migraine onset.

BACKGROUND

Childhood maltreatment is highly prevalent and has been associated with recurrent headache. Maltreatment is associated with many of the same risk factors for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity.

METHODS

Electronic surveys were completed by patients seeking treatment in headache clinics at 11 centers across the United States and Canada. Physician-determined data for all participants included the primary headache diagnoses based on the International Classification of Headache Disorders-2 criteria, average monthly headache frequency, whether headaches transformed from episodic to chronic, and if headaches were continuous. Analysis includes all persons with migraine with aura, and migraine without aura. Questionnaire collected information on demographics, social history, age at onset of headaches, migraine-associated allodynic symptoms, headache-related disability (The Headache Impact Test-6), current depression (The Patient Health Questionnaire-9), and current anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire.

RESULTS

A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (>or=15 days/month) was reported by 34%. Transformation from episodic to chronic was reported by 26%. Prevalence of current depression was 28% and anxiety was 56%. Childhood maltreatment was reported as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. In univariate analyses, physical abuse and emotional abuse and neglect were significantly associated with chronic migraine and transformed migraine. Emotional abuse was also associated with continuous daily headache, severe headache-related disability, and migraine-associated allodynia. After adjusting for sociodemographic factors and current depression and anxiety, there remained an association between emotional abuse in childhood and both chronic (odds ratio [OR] = 1.77, 95% confidence intervals [CI]: 1.19-2.62) and transformed migraine (OR = 1.89, 95% CI: 1.25-2.85). Childhood emotional abuse was also associated with younger median age of headache onset (16 years vs 19 years, P = .0002).

CONCLUSION

Our findings suggest that physical abuse, emotional abuse, and emotional neglect may be risk factors for development of chronic headache, including transformed migraine. The association of maltreatment and headache frequency appears to be independent of depression and anxiety, which are related to both childhood abuse and chronic daily headache. The finding that emotional abuse was associated with an earlier age of migraine onset may have implications for the role of stress responses in migraine pathophysiology.

Daily frustration, cognitive coping and coping efficacy in adolescent headache: a daily diary study

OBJECTIVE

To investigate both concurrent and prospective relationships between daily frustration, cognitive coping and coping efficacy on the one hand and daily headache occurrence on the other.

METHODS

Eighty-nine adolescents aged 13-21 completed an online daily diary for 3 weeks. Data were analyzed using multilevel modeling.

RESULTS

Daily frustration of goal pursuits was significantly related to both same day and next day headache occurrence. Coping efficacy beliefs were significantly related to lower next day headache occurrence (no same day relationship was found). None of the cognitive coping strategies used in response to daily frustration were related to headache occurrence on the same or next day.

CONCLUSIONS

Daily frustration to goal pursuit is suggested to be an important stressor contributing to concurrent and prospective headache occurrence. Furthermore, the extent to which adolescents believe in their ability to cope also appears to influence experience of subsequent headache. Further prospective studies are necessary to confirm these findings and to further unravel the possibly reciprocal relations between these factors. These findings offer useful insights into the dynamic interplay between daily stressful experiences and headache in youths.

How children and parents evaluate the Headache Centre's intervention

BACKGROUND

While adult headache patients' satisfaction with treatments has been widely investigated, less attention has been paid to children and adolescent headache patients' opinions and their parents' views.

OBJECTIVE

The aim of our follow-up survey was to analyze the outcomes of the Headache Centre's intervention and the evolution of headache according to patients until the age of 16 and their parents.

METHODS

We studied all outpatients suffering from episodic primary headache according to International Classification of Headache Disorders 2nd edition criteria, seen for the first time in 2005-2006 at the Headache Centre of the University Hospital of Modena (Italy), and at least one of their parents. The duration of the follow-up ranged from 1 to 3 years. For the purpose of the study, a specific questionnaire was created and administered by a telephone interview.

RESULTS

We enrolled 84 patients (38 females, 45%; 46 males, 55%; mean age +/- SD: 12.9 +/- 2.9 years) with primary headache: migraine without aura 66%, episodic tension-type headache 23%, migraine with aura 11%. At the follow-up, 70% of the patients reported that headache had improved; frequency had decreased significantly more than severity (P = .000, Fisher's exact test), both in those who had followed a prophylactic treatment and in those who had not. A high percentage of the children and parents could precisely indicate trigger factors for headache: especially excessive worrying and studying. The patients reporting an improvement attributed it to pharmacological prophylactic treatment, but also to other factors: first of all, better school results and more happiness than before. Seventy-seven percent of the parents thought that the Headache Centre's intervention had helped them to better understand and manage their children's headache.

CONCLUSIONS

Children's and adolescents' headache has in most cases a favorable prognosis; the Headache Centre's intervention is considered effective by most parents. We must increase and focus therapeutic efforts addressed to the few patients with worsening headaches in spite of treatment, since these children's/adolescents' headache also is at risk to progress in the adult age.

Chronic headache and potentially modifiable risk factors: screening and behavioral management of sleep disorders

Sleep-related variables have been identified among risk factors for frequent and severe headache conditions. It has been postulated that migraine, chronic daily headache, and perhaps other forms of chronic headache are progressive disorders. Thus, sleep and other modifiable risk factors may be clinical targets for prevention of headache progression or chronification. The present paper is part of the special series of papers entitled "Chronification of Headache" describing the empirical evidence, future research directions, proposed mechanisms, and risk factors implicated in headache chronification as well as several papers addressing individual risk factors (ie, sleep disorders, medication overuse, psychiatric disorders, stress, obesity). Understanding the link between risk factors and headache may yield novel preventative and therapeutic approaches in the management of headache. The present paper in the special series reviews epidemiological research as a means of quantifying the relationship between chronic headache and sleep disorders (sleep-disordered breathing, insomnia, circadian rhythm disorders, parasomnias) discusses screening for early detection and treatment of more severe and prevalent sleep disorders, and discusses fundamental sleep regulation strategies aimed at headache prevention for at-risk individuals.