Transformed migraine

Rates and risk factors for migraine progression using multiple definitions of progression: Results of the longitudinal OVERCOME (US) study

OBJECTIVE

To estimate rates of migraine progression and assess predictors of progression in a large, longitudinal cohort study using the traditional definition and two alternative definitions of migraine progression.

BACKGROUND

Traditionally, migraine progression is defined as moving from episodic migraine (EM) with ≤ 14 monthly headache days (MHD) to chronic migraine (CM) with ≥ 15 MHDs of which 8 are attributable to migraine. This definition does not take into account changes in the full range of potential headache days, disability, or impact on function.

METHODS

The Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study identified, characterized, and followed a representative sample of adults with migraine in the United States. Migraine was defined based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria. We estimated rates of migraine progression at 1 year of follow-up using three definitions: (1) traditional EM-to-CM transition, (2) increase of ≥ 5 MHDs (MHD progression), and (3) increase of ≥ 5 points on the Migraine Disability Assessment (MIDAS) scale (MIDAS progression). The analysis identified sociodemographic, clinical, and migraine-related characteristics associated with each definition of progression from a set of 67 candidates and then determined the association with progression for each candidate predictor and each definition of progression.

RESULTS

A total of 11,634 participants met ICHD-3 criteria for migraine at baseline and completed the 1-year follow-up survey. The average age was 48.2 years, and average years living with migraine was 22.8 years. The sample was 75.6% female (8793/11,634), 84.4% White (9814/11,634), 6.5% Black (757/11,634), and 7.6% Hispanic (889/11,634). The majority (89.2%, 10,374/11,634) had EM at baseline, and among these, 4.7% progressed to CM over 1 year of follow-up. Rates of progression at 1 year were higher using other definitions of progression, with 9.6% (1087/11,329) reporting an increase in ≥ 5 MHDs and 21.7% (2519/11,630) reporting an increase of ≥ 5 MIDAS points. Across all three definitions of progression, ever taking preventive medications for migraine placed people at lower odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 0.7 [0.57-0.85]; MHD progression, 0.9 [0.75-1.00]; MIDAS progression, 0.8 [0.73-0.91]), while the presence of depression placed people at higher odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 1.3 [1.05-1.69]; MHD progression, 1.4 [1.21-1.67]; MIDAS progression, 1.2 [1.04-1.34]).

CONCLUSION

This work expands the concept of migraine progression, exploring two alternative definitions that modify the potential range of MHD changes and take disability into account. This analysis identified never having used preventive medications for migraine and presence of depression as risk factors across all three definitions of progression. This work may more accurately identify persons with progression and at risk of migraine progression, setting the stage for trials of preventive intervention and ultimately more effective practice.

Arterial hypertension in the chronic evolution of migraine: bystander or risk factor? An overview

BACKGROUND

Several risk factors are associated with the chronic evolution of migraine. Clinical and preclinical studies have provided data about the role of hypertension (HT) as one of the potential modifiable risk factors of chronic migraine (CM). This review is focused on the biological and clinical evidence supporting common mechanisms underlying HT and migraine and the potential role of HT in the transition from episodic to chronic migraine.

METHODS

We conducted a narrative review from a literature search covering the available evidence from studies investigating: i) the role of HT in the transition to CM in clinical practice; ii) the biological mechanisms potentially underpinning the association between HT and evolution to CM; iii) the role of antihypertensive medications in migraine prophylaxis.

RESULTS

HT proved to be at the base of multiple mechanisms underlying migraine and migraine chronicization. Endothelial dysfunction, blood-brain barrier alterations, calcitonin gene-related peptide signaling, and renin-angiotensin-aldosterone system dysregulation are involved in the worsening effect of HT on migraine frequency, and the role of HT in the transition to CM is supported by clinical observations.

CONCLUSIONS

The observed evidence supports HT contribution to CM evolution due to shared pathophysiologic mechanisms. While a bidirectional influence appears to be ascertained, data are still lacking about the one-way role of HT as direct risk factor for CM transition. Further research is needed to confirm a causal role of HT in this process.

Risk factors for migraine disease progression: a narrative review for a patient-centered approach

BACKGROUND

In individuals with migraine, attacks may increase in frequency, severity, or both. Preventing migraine progression has emerged as a treatment goal in headache subspecialty practice, but there may be less awareness in general neurology or primary care settings where most people with migraine who seek treatment consult. Herein, we review the definition of and risk factors for migraine progression and consider strategies that could reduce its risk.

METHODS

A group of headache expert healthcare professionals, clinicians, and researchers reviewed published evidence documenting factors associated with increased or decreased rates of migraine progression and established expert opinions for disease management recommendations. Strength of evidence was rated as good, moderate, or based solely on expert opinion, using modified criteria for causation developed by AB Hill.

RESULTS

Migraine progression is commonly operationally defined as the transition from ≤ 15 to ≥ 15 monthly headache days among people with migraine; however, this does not necessarily constitute a fundamental change in migraine biology and other definitions should be considered. Established and theoretical key risk factors for migraine progression were categorized into five domains: migraine disease characteristics, treatment-related factors, comorbidities, lifestyle/exogenous factors, and demographic factors. Within these domains, good evidence supports the following risk factors: poorly optimized acute headache treatment, cutaneous allodynia, acute medication overuse, selected psychiatric symptoms, extra-cephalic chronic pain conditions, metabolism-related comorbidities, sleep disturbances, respiratory conditions, former/current high caffeine intake, physical inactivity, financial constraints, tobacco use, and personal triggers as risk factors. Protective actions that may mitigate migraine progression are sparsely investigated in published literature; our discussion of these factors is primarily based on expert opinion.

CONCLUSIONS

Recognizing risk factors for migraine progression will allow healthcare providers to suggest protective actions against migraine progression (Supplementary Fig. 1). Intervention studies are needed to weight the risk factors and test the clinical benefit of hypothesized mitigation strategies that emerge from epidemiological evidence.

Fatigue, chronic fatigue syndrome and migraine: Intersecting the lines through a cross-sectional study in patients with episodic and chronic migraine

Objectives

Fatigue is a common symptom occurring in a variety of disorders. Chronic fatigue syndrome (CFS) is characterized by debilitating fatigue as the core symptom. The risk of CFS is nearly 1.5 times higher in migraine while headaches have been reported in 59% of cases with CFS. However, details of its occurrence and severity remain largely unexplored. The primary objective of our study was to determine the occurrence and severity of fatigue and CFS in patients with episodic and chronic migraine. The secondary objectives were to define their relationship with other common comorbidities.

Materials and Methods

60 migraine patients (30 each, episodic [EM] and chronic migraine [CM]) were recruited from Neurology Outpatient Department, GIPMER a tertiary referral center in New Delhi, India. Patients' headache severity was analyzed using the Headache impact test-6 (HIT-6) score while fatigue and other migraine accompaniments were assessed using Fatigue severity scale (FSS), Chalder fatigue scale, CDC diagnostic criteria for CFS, American College of Rheumatology Diagnostic Criteria for fibromyalgia, Hamilton Depression Scale, the Generalized Anxiety Disorder 7-Item Scale, and Epworth sleepiness Scale (ESS). Comparative analysis was further done among migraine patients with and without fatigue and CFS.

Results

The mean HIT-6 score was significantly higher in CM versus EM. The CM group had a higher mean FSS score (47.87 vs. 37.3 in EM; P = 0.004), a percentage of patients with severe fatigue (60% vs. 20% in EM; P = 0.004), and a higher percentage of patients with pathological fatigue (83.3% vs. 63.3% in EM; P = 0.04). Around 23.33% of CM patients fulfilled the criteria of CFS. Fatigue correlated positively with severity, frequency, attack duration and chronicity of the migraine episodes, along with depression, anxiety, and excessive daytime sleepiness.

Conclusion

Fatigue and related comorbid disorders are significantly more common in CM than in EM, expanding the morbidity of the condition and underscores the need to address these accompanying symptoms for devising a holistic treatment plan.

Clinical characteristics, medication use, and impact of primary headache on daily activities: an observational study using linked online survey and medical claims data in Japan

BACKGROUND

Limited epidemiological data are available for headache disorders in Japan, and no recent studies have reported the impact of several primary headache disorders in Japan. This study aimed to report the up-to-date epidemiological data and impact of primary headaches on daily activities as well as the use of medical care, clinical features, and pain severity/activity impairment using nationwide data in Japan.

METHODS

We used anonymized online survey data coupled with medical claims data, from individuals aged 19-74 years old, that were provided by DeSC Healthcare Inc. The outcomes included the prevalence of migraine, tension-type headache, cluster headache, and other headache types stratified by age and sex, use of medical care, clinical features, medication use, and severity of pain/activity impairment. All outcomes were examined separately for each headache type. This is the second paper reported concurrently with this research.

RESULTS

The study population comprised 691/1,441/21/5,208 individuals with migraine/tension-type headache/cluster headache/other headache types, respectively. The prevalence of migraine and tension-type headache was higher in women than in men but was similar for cluster headache (male vs. female, 1.7% vs. 7.4%, 5.3% vs. 10.8%, and 0.1% vs. 0.1%, respectively). The percentage of individuals with migraine, tension-type headache, cluster headache who had not seen a doctor was 81.0%, 92.0%, 57.1%, respectively. The common headache triggers were fatigue in migraine and tension-type headache, and weather-related phenomena and turning of the seasons in migraine. Common activities refrained from or reduced by headaches were "operating a computer or smartphone", "drinking alcohol", and "going to crowded places" in all three headache types and housework-related activities in women. Among individuals taking medicines, 16.8%, 15.8%, 47.6% with migraine, tension-type headache, and cluster headache reported moderate to severe pain, respectively, and 12.6%, 7.7%, 19.0% reported moderate to severe disability, respectively.

CONCLUSIONS

This study found various triggers of headache attacks, and daily activities refrained from or reduced by headaches. Additionally, this study suggested that the disease burden in people possibly experiencing tension-type headaches, many of whom had not seen a doctor. The study findings are of clinical value for the diagnosis and treatment of primary headaches.

Identification of candidate proteomic markers in the serum of medication overuse headache patients: An exploratory study

PURPOSE OF THE STUDY

The pathophysiological mechanism of medication overuse headache is uncertain; no distinctive markers have been described right now. The aim of this study was to conduct proteomic analyses on serum samples from patients with medication overuse headache and healthy individuals. Specifically, mono- (SDS-PAGE) and two-dimensional gel electrophoresis (2-DE) followed by liquid chromatography tandem mass spectrometry (LC-MS/MS) were used to evaluate changes in serum proteins.

MAIN FINDINGS

By SDS-PAGE, four over-expressed bands were revealed in patients, compared to controls. 2-DE combined with LC-MS/MS analysis allowed confirmation of some proteins preliminarily detected by SDS-PAGE: Hemopexin, alpha-1-acid glycoprotein 1, apolipoprotein A4 and haptoglobin. Moreover, other differential proteins were isolated, mostly increased in MOH patients: Alpha-1-antitrypsin, immunoglobulin heavy constant alpha 1, retinol binding protein and transthyretin. Only one protein, immunoglobulin kappa constant, was decreased in the patients' group.

CONCLUSIONS

The investigation of the serum proteome can offer a better understanding about biological mechanisms underlying medication overuse headache. Specifically, medication overuse headache shares some serum biochemical markers with chronic pain conditions. Further studies might uncover the relevance of these proteins in medication overuse headache.

Entrapment Neuropathy: A Concept for Pathogenesis and Treatment of Headaches-A Narrative Review

Entrapment neuropathy is a known cause of neurological disorders. In the head and neck area, this pathophysiological mechanism could be a trigger for headache. Over the last few decades, injection of botulinum toxin type A in the muscles that are causing the compression as well as surgical decompression have proved to be effective treatment methods worldwide for large numbers of patients with daily headaches. In particular the entrapment of the supraorbital nerves in the glabellar musculature and the occipital nerves in the neck musculature are triggers for headache disorders for which many patients are still seeking an effective treatment. This article reviews the literature and aims to bring the concept of neural entrapment to the attention of a wider audience. By doing so, we hope to give more exposure to an effective and relatively safe headache treatment.

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.

Headache Treatment Before and After the Consultation of a Specialized Centre: A Pharmacoepidemiology Study

Our aim was to study and compare pharmacoepidemiology of headache treatment in two different settings: inside and outside a specialized Centre. We analysed the differences in headache treatment between 612 subjects admitted for the first visit (‘naive’) (F/M: 2.41; mean age = 37.31 ± 14.09 years) and 620 subjects admitted for a control visit (F/M: 3.18; mean age = 44.30 ± 15.37 years) to the Headache Centre of the University of Modena and Reggio Emilia. Most patients suffered from migraine. As acute treatment, on the first visit, 49.4% of them were taking drugs prescribed by a doctor; 41.5% were taking over-the-counter analgesics (OTCAs); 9.1% were not taking any drug. On the control visit, 81.3% of patients were taking prescription drugs; 15.8% OTCAs; 2.9% were not taking drugs (overall chi-square = 139.229, P < 0.001). Non-selective analgesics were the most-used drugs. Triptans were used by 9.1% of ‘naive’ patients and by 31.8% of patients attending for the control visit (Fisher's Z = 7.655, P < 0.001). Nimesulide was the most-used drug. A prophylactic treatment was made by 16.8% of ‘naive’ patients, and by 58.2% of patients admitted to the control visit (Fisher's Z = 12.135, P < 0.001). Antidepressants were the class of drugs most used for prophylaxis. Amitriptyline was the drug for prophylaxis most frequently used by patients attending the control visit, while flunarizine was the most frequently used by ‘naive’ patients. Before being examined in a specialized centre, few patients take prescription drugs, triptans, or prophylactic drugs; specialized care increases the proportion of patients taking prophylactic drugs, and changes the type of acute treatment used into disease-specific medication for headache.

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.

Latin American consensus on guidelines for chronic migraine treatment

Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine.

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.

Fatores associados ao uso excessivo de medicação sintomática em pacientes com enxaqueca crônica

OBJETIVO: Avaliar a prevalência de transtornos psiquiátricos em pacientes com diagnóstico de enxaqueca crônica com e sem uso excessivo de medicação sintomática. MÉTODOS: Setenta e dois voluntários foram recrutados a partir de um Programa de Saúde da Família da comunidade de Paraisópolis, na cidade de São Paulo (SP). Esses pacientes foram submetidos a exames clínico e neurológico. As seguintes variáveis foram analisadas: idade, gênero, nível educacional, índice de massa corporal, tipo de uso excessivo de medicação, características da cefaleia, consumo de cafeína, presença de ansiedade e distúrbios de humor. RESULTADOS: Dos 72 pacientes, 50 (69%) tinham cefaleia crônica, com uso exagerado de medicação, e 22 (31%) tinham cefaleia crônica, sem uso excessivo de medicação. Os fatores idade, gênero, nível educacional, índice de massa corporal, tipo de uso excessivo de medicação, características da cefaleia e consumo de cafeína não mostraram diferença significante entre os grupos estudados. Os diagnósticos de ansiedade e de distúrbios de humor ao longo da vida foram mais comuns nos pacientes com uso excessivo de medicação (p=0,003 e p=0,045, respectivamente). CONCLUSÃO: Este estudo mostrou uma associação significativa entre cefaleia crônica e uso excessivo de medicação nos pacientes avaliados, quanto ao diagnóstico de transtornos de ansiedade e de humor ao longo da vida. Não foi encontrada nenhuma associação com outros distúrbios psiquiátricos pesquisados.

Chronic daily headaches

Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.

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.

Somatosensory High Frequency Oscillations reflect clinical fluctuations in migraine

OBJECTIVE

It has been demonstrated that the early part of 600 Hz High Frequency Oscillations (HFOs), probably generated in the terminal part of thalamo-cortical somatosensory radiations, are abnormally reduced between attacks in migraineurs. We aimed at verifying whether spontaneous clinical fluctuations in migraine are correlated to HFO changes.

METHODS

We recorded somatosensory evoked potentials in 28 migraine patients. Clinical fluctuations (number of attacks in the 6 months preceding and following the test) were correlated to the HFOs' amplitudes. Moreover, eight out of 28 patients underwent a longer follow-up, including HFO control and clinical observation during the 12 months following the baseline recording.

RESULTS

The amplitude of early presynaptic HFOs was significantly correlated to the clinical evolution, since spontaneous worsening was associated with reduced presynaptic HFOs, whereas spontaneous improvement was associated with enhanced presynaptic HFOs (correlation test, p<0.05). No correlation was found between the amplitude of postsynaptic HFOs and clinical fluctuations. Patients undergoing longer follow-up showed substantially unchanged HFOs, accordingly with their stable clinical condition.

CONCLUSIONS

HFOs' enhancement in spontaneously improved patients can reflect the increased activity of brainstem arousal related structures, which in turn increases the thalamo-cortical drive and the cortical lateral inhibition mediated by GABAergic interneurons.

SIGNIFICANCE

HFOs' recording could represent a useful tool in the functional assessment of migraine.

The paradoxical effects of analgesics and the development of chronic migraine

In a subgroup of individuals episodic migraine evolves into a stage where individuals have headaches on more days than not. Among the risk factors for chronification, excessive use of analgesic medications figure prominently and reviewing this topic is the scope of this article. The issue of causality is discussed and evidence suggesting that specific medications, at critical doses, are risk factors for chronic migraine (CM) is reviewed. The concept of critical dose of exposure for different classes is presented and biological plausibility and putative mechanisms are reviewed.

Chronic migraine classification: current knowledge and future perspectives

In the field of so-called chronic daily headache, it is not easy for migraine that worsens progressively until it becomes daily or almost daily to find a precise and universally recognized place within the current international headache classification systems. In line with the 2006 revision of the second edition of the International Classification of Headache Disorders (ICHD-2R), the current prevailing opinion is that this headache type should be named chronic migraine (CM) and be characterized by the presence of at least 15 days of headache per month for at least 3 consecutive months, with headache having the same clinical features of migraine without aura for at least 8 of those 15 days. Based on much evidence, though, a CM with the above characteristics appears to be a heterogeneous entity and the obvious risk is that its definition may be extended to include a variety of different clinical entities. A proposal is advanced to consider CM a subtype of migraine without aura that is characterized by a high frequency of attacks (10-20 days of headache per month for at least 3 months) and is distinct from transformed migraine (TM), which in turn should be included in the classification as a complication of migraine. Therefore, CM should be removed from its current coding position in the ICHD-2 and be replaced by TM, which has more restrictive diagnostic criteria (at least 20 days of headache per month for at least 1 year, with no more than 5 consecutive days free of symptoms; same clinical features of migraine without aura for at least 10 of those 20 days).

Global prevalence of chronic migraine: a systematic review

The aim of this review was to summarize population-based studies reporting prevalence and/or incidence of chronic migraine (CM) and to explore variation across studies. A systematic literature search was conducted. Relevant data were abstracted and estimates were subdivided based on the criteria used in each study. Sixteen publications representing 12 studies were accepted. None presented data on CM incidence. The prevalence of CM was 0-5.1%, with estimates typically in the range of 1.4-2.2%. Seven studies used Silberstein-Lipton criteria (or equivalent), with prevalence ranging from 0.9% to 5.1%. Three estimates used migraine that occurred ≥15 days per month, with prevalence ranging from 0 to 0.7%. Prevalence varied by World Health Organization region and gender. This review identified population-based studies of CM prevalence, although heterogeneity across studies and lack of data from certain regions leaves an incomplete picture. Future studies on CM would benefit from an International Classification of Headache Disorders consensus diagnosis that is clinically appropriate and operational in epidemiological studies.

Epidemiological classification and social impact of chronic headache

The current prevalent opinion is that a diagnosis of chronic headache should be established in patients who have had a form of primary headache other than cluster headache on at least 15 days a month for at least 3 months. Chronic headache so defined includes four different subtypes: hemicrania continua and new daily persistent headache--two rare forms currently included in the group "Other primary headaches" of the 2004 International Classification of Headache Disorders, second edition (ICHD-II)--chronic tension-type headache, and chronic migraine. Regarding the latter, which has been better known lately as transformed migraine, the current revised diagnostic criteria establish that migraine must be present on at least 8 of the at least 15 days of headache per month and that there must not be any overuse of symptomatic medication. Chronic headache affects about 3-5% of the general population and results in a variety of negative repercussions both on individuals and on society at large.

Psychiatric comorbidities and migraine chronification

A growing body of literature has implicated comorbid psychopathology as a potential risk factor for the chronification of migraine. Of the psychiatric disorders, depressive and anxiety disorders have been most consistently associated with the chronification of migraine. A shared dysfunction of the serotonergic system, medication overuse, and psychological factors have been proposed to mediate this relationship, although the responsible mechanisms are still largely unclear. This article overviews literature on psychiatric comorbidities and migraine chronification, considers mechanisms underlying this relationship, and notes directions for future clinical and empirical work.

Family history for chronic headache and drug overuse as a risk factor for headache chronification

OBJECTIVES

To assess whether family history for chronic headache (CH) and drug overuse could represent a risk factor for headache chronification.

BACKGROUND

Among factors investigated as risk factors for chronification of headache disorders, familial liability for CH and drug overuse has been rarely investigated.

PATIENTS AND METHODS

A total of 105 consecutive patients with daily or nearly daily headache, and 102 consecutive patients with episodic headache matched by age, sex, and type of headache at onset, underwent a structured direct interview about family history for episodic headache, CH with and without medication overuse, substance abuse/dependence, and psychiatric disorders.

RESULTS

In total, 80 out of 105 patients with CH received a diagnosis of medication overuse headache (MOH), 21 patients were classified as chronic migraine (CM), and 4 as chronic tension-type headache (CTTH) without drug overuse. Some 38.1% of CH patients reported family history for CH vs only 13.7% of episodic headaches (P = .001). Familiality for CH with medication overuse was reported by 25.7% of cases vs 9.8% of controls (P = .0028). A familial history of substance abuse was reported by 20% of patients vs 5.9% of controls (P = .0026). In all, 28.7% of MOH patients reported family history for CH with medication overuse (P = .0014) and 21.2% for substance abuse (P = .002). Relatives of patients with MOH were more likely than control relatives to suffer from CH (OR = 4.19 [95% CI 2.05-8.53]), drug overuse (OR = 3.7 [95% CI 1.66-8.24]), and substance abuse (OR = 4.3 [95% CI 1.65-11.19]). No differences regarding family history for episodic headache and for psychiatric disorders were found. No differences in family history for CH with drugs overuse and for substance abuse were found between CH patients without overuse and controls. Fifteen CH patients reported family history for alcohol abuse (P = .0003).

CONCLUSIONS

The significantly increased familial risk for CH, drug overuse, and substance abuse suggests that a genetic factor is involved in the process of headache chronification.

Anxiety disorders and migraine intractability and progression

Comorbid psychopathology has been implicated as a risk factor for the chronification and progression of migraine. Although past research has focused principally on depression and migraine, recent research consistently has confirmed that a disproportionate number of migraineurs suffer from one or more comorbid anxiety disorders. Moreover, this research has implicated anxiety disorders as factors potentially associated with migraine intractability and progression; growing evidence suggests that anxiety disorders may be even more prognostically significant than depression. This article summarizes these recent developments, considers mechanisms underlying this comorbidity, discusses strategies for assessing and managing comorbid anxiety, and notes directions for future clinical and empiric work.

The evolution of chronic migraine: classification and nomenclature

After nearly 3 decades of debate, the headache community still lacks globally accepted criteria for chronic migraine. This review summarizes the evolution of chronic migraine nomenclature and criteria. We concluded that although there are discrepancies in the currently proposed criteria, there is a significant amount of overlap with previously used classifications such that they all appear to describe the same subset of highly burdened migraine patients. In order to continue to understand the natural history of chronic migraine, address the unmet medical need, and develop effective therapies, field experts and physicians must have a classification that is well understood and accepted by the broader clinical community. It is our view that of the currently established classifications, the Silberstein and Lipton revised criteria for transformed migraine are the most applicable to daily clinical practice and field research.

Optimizing prophylactic treatment of migraine: Subtypes and patient matching

Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.

Correlation between migraine subtipes and depression

This study has evaluated depression in patients with episodic migraine (n=98), chronic migraine without medication overuse (n=23), and chronic migraine with medication overuse (n=57). The Beck Depression Inventory (BDI) was used to evaluate depressive symptoms in these three groups. The mean BDI score obtained in all patients was higher than that observed in asymptomatic subjects (episodic migraine=16.09±11.79, chronic migraine with medication overuse=18.91±12.53, chronic migraine without medication overuse=19.83±14.79). This finding corroborates previous studies suggesting a co-morbid association between migraine and depression. Depression did not seem to be crucial in the transformation of migraine as the median BDI scores did not differ significantly between patients with episodic and chronic migraine. The median BDI scores of the patients with chronic migraine with medication overuse and that patients with chronic migraine without medication overuse were similar as well. Therefore, medication overuse behavior may not be related with depression.

Prevalence and Associated Factors for Episodic and Chronic Daily Headache in the Colombian Population

There are multiple risk factors for chronic daily headache (CDH), but they are usually assessed in an isolated form without an adequate control for confounders. CDH is considered a variant of episodic headache, but studies have not gathered enough evidence to evaluate simultaneously CDH and episodic in the same population. We set out to establish simultaneously the factors associated with chronic daily or episodic headache in a population setting, using a cross-sectional survey in a random sample of 1505 adult urban inhabitants (Bucaramanga, Colombia). The survey asked questions about headache, family and personal history of disease, and consumption or abuse of caffeine, alcohol, hypnotics and analgesics. The association among independent variables and CDH or episodic headache was made with multinomial logistic regression. Female gender, arterial hypertension or cranial trauma history, and a high score in the depression scale are associated with episodic headache and CDH. Parents with CDH, the complaint of multiple arousals during sleep and use of hypnotics are associated with CDH, but not with episodic headache. Age < 36 years, alcoholism and snoring are factors associated only with episodic headache. Chronic daily headache and episodic headache have several common risk factors, but there are other factors not shared by both conditions.

Botulinum Toxin Type A in the treatment of chronic migraine without medication overuse

INTRODUCTION

Chronic migraine is a recent diagnostic term that has undergone evolution from its original description. Clinically it has been believed that medication overuse contributed to its development and would block attempts at prevention. Previous studies with Botulinum Toxin Type A have demonstrated that it is effective even in patients with medication overuse. This study undertakes to examine the effects of Botulinum Toxin Type A in the absence of medication overuse in patients with chronic migraine.

STUDY DESIGN

Double-blind placebo-controlled randomized trial of Botulinum Toxin Type A 100 units administered in a fixed dose and site paradigm.

PATIENTS

In total, 86 patients were enrolled. A total of 60 patients were randomized and 41 patients were treated with the study medication or placebo. Five patients failed to complete the study, which lasted 4 months after the study medication was injected.

RESULTS

Botulinum Toxin Type A was statistically superior to placebo for the primary endpoint of reduction in migraine headache episodes. Six patients on Botulinum Toxin Type A compared with 3 patients on Placebo had at least a 50% reduction in their migraine episodes. Active treatment was superior to placebo for the secondary endpoints of total headache days, headache index, and quality of life measures. It showed numerical superiority to placebo for acute medication use and Migraine Disability Assessment Scores. Adverse events were rare and similar in both treatment groups.

CONCLUSIONS

The use of Botulinum Toxin Type A may be an effective treatment for chronic migraine when the patient does not have concomitant medication overuse. It was well tolerated in this trial.

The differential diagnosis of chronic daily headaches: an algorithm-based approach

Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for "red flags" that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is > or =4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.

Behavioral sleep modification may revert transformed migraine to episodic migraine

BACKGROUND

Sleep problems have been linked with headaches for more than a century, but whether the headaches are the cause or the result of the disrupted sleep is unknown.

OBJECTIVES

We previously reported that nonrestorative sleep and poor sleep habits are almost universal in a referral population of women with transformed migraine (TM). Since cognitive behavioral therapy is effective in improving sleep quality in individuals with poor sleep hygiene, we designed a randomized, placebo-controlled study to assess the impact of such treatment on TM. We hypothesized that behavioral sleep modification (BSM) would be associated with improvement in headache frequency and intensity and with reversion to episodic migraine.

METHODS

Subjects were 43 women with TM referred to an academic headache center. After obtaining informed consent, patients were randomized to receive either behavioral sleep instructions or placebo behavioral instructions in addition to usual medical care. Subjects recorded headaches in standardized diaries. The first postintervention visit was scheduled at 6 weeks. At that visit, the blind was broken and all subjects received BSM instructions. A final visit was scheduled 6 weeks later.

RESULTS

Compared to the placebo behavioral group, the BSM group reported statistically significant reduction in headache frequency [F (1, 33 = 12.42, P=.001)] and headache intensity [F(1, 33 = 14.39, P= .01)]. They were more likely to revert to episodic migraine chi2 (2, n = 43) = 7.06, P= .029. No member of the control group reverted to episodic migraine by the first postintervention visit. By the final visit, 48.5% of those who had received BSM instructions had reverted to episodic migraine.

CONCLUSIONS

In this pilot study of women with TM, we found that a targeted behavioral sleep invention was associated with improvement in headache frequency, headache index, and with reversion to episodic migraine.

Efficacy and safety of topiramate for the treatment of chronic migraine: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of topiramate (100 mg/day) compared with placebo for the treatment of chronic migraine.

METHODS

This was a randomized, placebo-controlled, parallel-group, multicenter study consisting of 16 weeks of double-blind treatment. Subjects aged 18 to 65 years with 15 or more headache days per month, at least half of which were migraine/migrainous headaches, were randomized 1:1 to either topiramate 100 mg/day or placebo. An initial dose of topiramate 25 mg/day (or placebo) was titrated upward in weekly increments of 25 mg/day to a maximum of 100 mg/day (or to the maximum tolerated dose). Concomitant preventive migraine treatment was not allowed, and acute headache medication use was not to exceed 4 days per week during the double-blind maintenance period. The primary efficacy endpoint was the change from baseline in the mean monthly number of migraine/migrainous days; the change in the mean monthly number of migraine days also was analyzed. A fixed sequence approach (ie, gatekeeper approach) using analysis of covariance was used to analyze the efficacy endpoints. Assessments of safety and tolerability included physical and neurologic examinations, clinical laboratory parameters, and spontaneous reports of clinical adverse events.

RESULTS

The intent-to-treat population included 306 (topiramate, n = 153; placebo, n = 153) of 328 randomized subjects who provided at least 1 efficacy assessment; 55.8% of the topiramate group and 55.2% on placebo were trial completers. The mean final topiramate maintenance dose was 86.0 mg/day. The mean duration of therapy was 91.7 days for the topiramate group and 90.6 days for the placebo group. Topiramate treatment resulted in a statistically significant mean reduction of migraine/migrainous headache days (topiramate -6.4 vs placebo -4.7, P= .010) and migraine headache days relative to baseline (topiramate -5.6 vs placebo -4.1, P= .032). Treatment-emergent adverse events occurred in 132 (82.5%) and 113 (70.2%) of topiramate-treated and placebo-treated subjects, respectively, and were generally of mild or moderate severity. Most commonly reported adverse events in the topiramate group were paresthesia (n = 46, 28.8%), upper respiratory tract infection (n = 22, 13.8%), and fatigue (n = 19, 11.9%). The most common adverse events in the placebo group were upper respiratory tract infection (n = 20, 12.4%), fatigue (n = 16, 9.9%), and nausea (n = 13, 8.1%). Discontinuations due to adverse events occurred in 18 (10.9%) topiramate subjects and 10 (6.1%) placebo subjects. There were no serious adverse events or deaths.

CONCLUSIONS

Topiramate treatment at daily doses of approximately 100 mg resulted in statistically significant improvements compared with placebo in mean monthly migraine/migrainous and migraine headache days. Topiramate is safe and generally well tolerated in this group of subjects with chronic migraine, a burdensome condition with important unmet treatment needs. Safety and tolerability of topiramate were consistent with experience in previous clinical trials involving the drug.

A Practical Approach to Headache Treatment

The World Health Organization cites migraine headache as one of the 20 most disabling medical conditions. This article focuses on the diagnosis and treatment of the primary headache disorders, with special emphasis on migraine, the headache most likely to bring patients to physicians and pharmacists. This review begins with the warning signs of the ominous headache, which, although rare, can herald a life-threatening condition. Clinical characteristics of the primary headache types, migraine, tension-type headache, and cluster headache, are described. Although many individuals believe their headaches are “sinus,” or “stress or tension-induced,” most of the characteristics of these types of headaches actually meet International Headache Society criteria for migraine. Treatments of primary headaches, including acute therapies, abortive agents, and prophylactic medications, are uniquely specific for each headache syndrome. Chronic daily headache patients compose only 4% of the population yet make up the largest percentage of patients who seek treatment at specialty headache centers. Medication-overuse headache, the syndrome in which medications taken for the relief of headache actually foster future headaches, offers a particular challenge to health care providers, as does narcotic use in headache therapy. Complementary and alternative treatments proven efficacious in the treatment of primary headache are also described.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

From transformed migraine to episodic migraine: reversion factors

OBJECTIVE

To identify the factors contributing to the reversion of transformed migraine (TM) into episodic migraine.

BACKGROUND

TM, the most common and important subtype of chronic daily headache (CDH), has a great effect on a patient's quality of life. However, its clinical course and outcome predictors have rarely been studied prospectively.

METHOD

Of 1142 consecutive headache patients seen at the Headache Clinic of the Samsung Medical Center, the patients with TM (frequency >15/month for >6 months and a history of migraine meeting the ICHD-II diagnostic criteria) were followed for at least 1 year. We analyzed the demographic data, clinical course, and compliance factors, such as those of the physician's management protocol and recommended lifestyle modification.

RESULTS

A total of 136 patients finished the final follow-up assessment 1 year after the initial evaluation. Ninety-five patients (70%) converted from TM to episodic migraine. Forty-one patients (30%) continued to suffer daily headaches without a period of improvement. The demographic and clinical information collected before the treatment was not significantly related to outcome, except for chronic use of analgesics for other medical conditions (P= .01). Of the compliance factors, good compliance with preventive medication (P < .001), withdrawal from continuous use of analgesics for headache relief (P < .001), and regular exercise (P= .04) were significant positive contributors to the reversion of TM into episodic migraine.

CONCLUSION

Compliance factors are the most important factors that determine the reversion of TM into episodic migraine.

Prevalence and impact of headache and migraine among Pomeranians in Espirito Santo, Brazil

This is the first study to assess the prevalence of headache and migraine among Pomeranian descendents in Brazil. A high prevalence of headache in the last 6 months was found (53.2%). Most headache sufferers were diagnosed as having migraine (55%). More women reported to have headache than men (65% and 33.8%, respectively). Migraine was the most common headache found among women (62.2%). Among men migraine was responsible for only 37.8% of the cases of headache. A high impact of headache was found, especially among migraineurs. Most of the headache sufferers declared to seek medical assistance for headache (67%) and most of them used to take common analgesics for headache relief. None of them was under prophylactic therapy.