Prevalence, management and burden of episodic and chronic headaches--a cross-sectional multicentre study in eight Austrian headache centres

Prevalence and Associated Factors of Depression among Adults Suffering from Migraine in Spain

Considering the significance of migraine and the limited amount of research conducted on its association with depression in population-based studies in Spain, this study aimed to determine the prevalence and change of depression from 2017 to 2020 among adults with migraine in Spain and to analyze the sociodemographic and health-related variables linked to depression in migraine sufferers. A cross-sectional study on 5329 adults with migraine from the Spanish National Health Survey 2017 and the European Health Survey in Spain 2020 was performed. Binary logistic regression was used to examine the factors related to depression. A total of 26.32% of people with migraine suffered from depression. No significant changes in that prevalence between 2017 and 2020 were observed. The risk factors associated with depression included being between the ages of 25 and 44 (p = 0.018), being separated or divorced (p = 0.033), being unemployed (p < 0.001), not engaging in recreational physical activity (p = 0.016), perceiving one's health as average, poor, or very poor (p < 0.001), experiencing moderate to severe pain in daily activities (p = 0.011, p = 0.004, p < 0.001, respectively), and having 1-2 or ≥3 chronic conditions (p = 0.003, p < 0.001, respectively). Conversely, being married (p = 0.001) and alcohol consumption (p = 0.007) were identified as protective factors.

Who cares about migraine? Pathways and hurdles in the European region - access to care III

BACKGROUND

Migraine is a highly prevalent primary headache disorder and a leading cause of disability. Difficulties in access to care during diagnostic and therapeutic journey contribute to the disease burden. Several target-specific drugs have reached the market in the past four years and have modified the treatment paradigm in migraine. The aim of this study is to provide an updated snapshot of the pathways and hurdles to care for migraine in different European countries by directly asking patients.

METHODS

In 2021 the European Migraine and Headache Alliance proposed a 39-item questionnaire that was administered online to an adult migraine population in European countries. Questions were focused on socio-demographic and migraine data, access to diagnosis and treatment, disease-related burden and the main channel for disease information.

RESULTS

A total of 3169 questionnaires were returned from 10 European countries. Responders were predominantly females, age range 25-59 years, with a migraine history longer than 10 years in 82% of cases, and with at least 8 headache days per month in 57% of cases. Respondents reported limitations in social, working and personal life during both the ictal and interictal phase. The activities mostly impaired during the attacks were driving (55%), cooking or eating (42%), taking care of family/childcare (40%) and getting medicines at the pharmacy (40%). The most frequently reported unmet need was the long delay between the first visit and migraine diagnosis: 34% of respondents had to see ≥ 4 specialists before being correctly diagnosed, and between the diagnosis and treatment prescription: > 5 years in 40% of cases. The most relevant needs in terms of quality of life were the desire for a lower migraine frequency, an effective treatment and a greater involvement in society.

CONCLUSIONS

Data from the present survey point to the existence and persistence of multiple hurdles that result in significant limitations to access to care and to the patients' social life. A close cooperation between decision makers, healthcare workers and patients is needed to overcome these barriers.

The New National Headache Management System is an easy solution to provide more efficient and evidence-based headache services

Headaches make up 30% of all Neurology outpatient consultations.1 There is distinct variability in the management of headaches by Neurologists, leading to unnecessary disparities in the standard of care and likelihood of response between patients. A significant proportion of patients with headache diagnoses do not receive the evidence-based treatments recommended in national or international guidelines,2 and substantial numbers of patients are not receiving preventive therapies.3  Ziegeler et al. found that a third of patients reporting to a tertiary headache centre had not received preventive therapy in line with guidelines, and half had never been prescribed a preventive treatment.2 Considering that 46% of the global adult population are estimated to have a headache disorder,4 this lack of a consistent, evidence-based approach is somewhat incongruent with the patient socio-economic impact. It is probable that lack of adherence to current headache guidelines is a multi-faceted issue. This variation in treatment (and therefore patient outcome), although unexplored,2 is not likely to be a simple educational issue. To add to this, an educational approach, in the form of seminars and workshops, does not have entirely positive evidence to support its use in implementing changes to patient care.5  It seems more probable that there are also structural issues within the health service that in some way preclude patients with headache disorders from gaining appropriate care.  For example, using only doctors to care for patients with such a common condition may cause bottle-necking in access, and may not be an appropriate use of clinical resource.  The current context of a global pandemic has shown us the importance of using the skillsets of all NHS staff working together for patient care.  For headache care this could involve greater use of nursing colleagues or allied health professionals such as Pharmacists. To facilitate such an aim, an easily used and standardised approach is essential. We believe that the guidelines from the British Association for the Study of Headache (BASH),6 could facilitate such an approach.

Learning the full impact of migraine through patient voices: A qualitative study

OBJECTIVE

To better characterize the ways that migraine affects multiple domains of life.

BACKGROUND

Further understanding of migraine burden is needed.

METHODS

Adults with migraine randomized to mindfulness-based stress reduction or headache education arms (n = 81) in two separate randomized clinical trials participated in semistructured in-person qualitative interviews conducted after the interventions. Interviews queried participants on migraine impact on life and were audio-recorded, transcribed, and summarized into a framework matrix. A master codebook was created until meaning saturation was reached and magnitude coding established code frequency. Themes and subthemes were identified using a constructivist grounded theory approach.

RESULTS

Despite most participants being treated with acute and/or prophylactic medications, 90% (73/81) reported migraine had a negative impact on overall life, with 68% (55/81) endorsing specific domains of life impacted and 52% (42/81) describing impact on emotional health. Six main themes of migraine impact emerged: (1) global negative impact on overall life; (2) impact on emotional health; (3) impact on cognitive function; (4) impact on specific domains of life (work/career, family, social); (5) fear and avoidance (pain catastrophizing and anticipatory anxiety); and (6) internalized and externalized stigma. Participants reported how migraine (a) controls life, (b) makes life difficult, and (c) causes disability during attacks, with participants (d) experiencing a lack of control and/or (e) attempting to push through despite migraine. Emotional health was affected through (a) isolation, (b) anxiety, (c) frustration/anger, (d) guilt, (e) mood changes/irritability, and (f) depression/hopelessness. Cognitive function was affected through concentration and communication difficulties.

CONCLUSIONS

Migraine has a global negative impact on overall life, cognitive and emotional health, work, family, and social life. Migraine contributes to isolation, frustration, guilt, fear, avoidance behavior, and stigma. A greater understanding of the deep burden of this chronic neurological disease is needed to effectively target and treat what is most important to those living with migraine.

The Effect of Flunarizine Prophylactic Treatment on Headache Frequency and Plasma Glutamate Levels in Chronic Tension-type Headache Patients

Background: Previous research has shown that flunarizine may be used for the prophylactic treatment of migraine and that plasma glutamate level monitoring in patients with migraine can serve as a biomarker of response to treatment. Our aim was to assess the efficacy of flunarizine and the correlation of glutamate levels in Chronic Tension-type Headache (CTTH) with response to medication. Methods: We studied 19 patients with diagnosis of CTTH according to International Classification of Headache Disorder, 2nd edition criteria. The level of plasma glutamate was measured before and after 8-weeks prophylactic treatments. Subjects were randomized into three interventional groups (flunarizine 5 mg, flunarizine 10 mg and placebo). Glutamate levels were measured by means of Glutamate ELISA Kit KA1909 Abnova.        Results: Flunarizine 5 mg group had lower mean plasma glutamate levels significantly compared to placebo (p < 0.00; 95% CI: 0.40-1.07). Flunarizine 10 mg group had lower mean of plasma glutamate levels significantly compared to placebo (p< 0.00; 95% CI: 0.53-1.27). However, there were no significant differences of mean plasma glutamate levels between flunarizine 5 mg group and flunarizine 10 mg group (p < 0.37; 95% CI: -(0.54) - 0.21). There were no significant differences in headache frequency reduction among the three interventional groups. Conclusions: The usage of flunarizine as prophylactic treatment can reduce plasma glutamate levels significantly in CTTH patients. Either flunarizine or placebo showed no significant difference in reducing headache frequency in CTTH patients.

CGRP-antibodies, topiramate and botulinum toxin type A in episodic and chronic migraine: A systematic review and meta-analysis

Background

The approval of monoclonal antibodies for prevention of migraine has revolutionized treatment for patients. Oral preventatives are still considered first line treatments as head-to-head trials comparing them with antibodies are lacking.

Methods

The main purpose of this study was to provide a comparative overview of the efficacy of three commonly prescribed migraine preventative medication classes. For this systematic review and meta-analysis, we searched the databases CENTRAL, EMBASE, and MEDLINE until 20 March 2020. We included RCTs reporting the 50% response rates for topiramate, Botulinum Toxin Type A and monoclonal antibodies against CGRP(r). Studies were excluded if response rates were not reported, treatment allocation was unclear, or if study quality was insufficient. Primary outcome measure were the 50% response rates. The pooled odds ratios with 95% confidence intervals were calculated with the random effects model. The study was registered at PROSPERO (CRD42020222880).

Findings

We identified 6552 reports. Thirty-two were eligible for our review. Studies assessing monoclonal antibodies included 13,302 patients and yielded pooled odds ratios for the 50% response rate of 2.30 (CI: 2.11–2.50). Topiramate had an overall effect estimate of 2.70 (CI: 1.97–3.69) with 1989 included patients and Botulinum Toxin Type A achieved 1.28 (CI: 0.98–1. 67) with 2472 patients included.

Interpretation

Topiramate, botulinum toxin type A and monoclonal antibodies showed higher odds ratios in achieving a 50% response rate compared to placebo. Topiramate numerically demonstrated the greatest effect size but also the highest drop-out rate.

Cognitive performance in patients with chronic tension-type headache and its relation to neuroendocrine hormones

Background

Tension-type headache is the most common headache to be seen in clinical practice. Depression is highly prevalent in chronic tension-type headache (CTTH) patients attending the clinical settings. Cognitive impairment and neuroendocrine dysregulation had been reported in patients with depression and patients with CTTH.

Objective

To assess the cognitive performance and investigate its possible relations to neuroendocrine levels in patients with CTTH.

Subjects and methods

Patients with CTTH, depression, and control subjects were recruited. CTTH was diagnosed according to the International Classification of Headache Disorders. Cognitive performance, depression severity, and pain intensity were assessed by the Montreal Cognitive Assessment Arabic version, Beck’s Depression Inventory, and McGill Pain Questionnaire respectively. Blood samples were collected in the morning within 60 min after waking up from 8:00 to 9:00 a.m. to measure serum levels of basal plasma CRH, ACTH, Cortisol, TSH, FT3, and FT4.

Results

Both patients with CTTH and depression had impaired cognitive performance. Patients with CTTH and patients with depression had altered the hypothalamus-pituitary-adrenal axis, and pituitary-thyroid axis. The hormonal levels significantly correlated with cognitive function in patient groups, especially patients with CTTH.

Conclusion

Patients with CTTH had cognitive dysfunction which could be related to neuroendocrine hormonal dysregulation.

The Effect of Psychiatric Comorbidities on Headache-Related Disability in Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

OBJECTIVE

To examine the influences of depression and anxiety on headache-related disability in people with episodic migraine or chronic migraine.

BACKGROUND

Depression and anxiety are common comorbidities in people with migraine, especially among those with chronic migraine.

METHODS

This cross-sectional analysis of data from the longitudinal, internet-based Chronic Migraine Epidemiology and Outcomes Study assessed sociodemographic and headache features, and headache-related disability (Migraine Disability Assessment Scale). Four groups were defined based on scores from validated screeners for depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder Scale): depression alone, anxiety alone, both, or neither.

RESULTS

Respondents (N = 16,788) were predominantly women (74.4% [12,494/16,788]) and white (84.0% [14,044/16,788]); mean age was 41 years. Depression was more likely in persons with chronic migraine vs episodic migraine (56.6% [836/1476] vs 30.0% [4589/15,312]; P < .001), as were anxiety (48.4% [715/1476] vs 28.1% 4307/15,312]; P < .001) and coexisting depression and anxiety (42.0% [620/1476] vs 20.8% [3192/15,312]; P < .001). After controlling for headache frequency and other covariates, depression alone, and anxiety alone were associated with 56.0% (rate ratio [RR], 1.56; 95% confidence interval [CI], 1.46-1.66) and 39.0% (RR, 1.39; 95% CI, 1.30-1.50) increased risks of moderate/severe migraine-related disability (both P < .001), respectively; the combination had an even greater effect on risk of moderate/severe disability (79.0% increase; RR, 1.79; 95% CI, 1.71-1.87; P < .001).

CONCLUSIONS

Depression alone and anxiety alone are associated with greater headache-related disability after controlling for sociodemographic and headache features. Coexisting depression and anxiety are more strongly associated with disability than either comorbidity in isolation. Interventions targeting depression and anxiety as well as migraine itself may improve headache-related disability in people with migraine.

Medication overuse headache in 787 patients admitted for inpatient treatment over a period of 32 years

BACKGROUND

Definitions of medication overuse headache have changed over time.

OBJECTIVE

To evaluate the clinical characteristics of medication overuse headache patients admitted for inpatient withdrawal therapy over a period of 32 years.

METHODS

We included all patients with medication overuse headache treated from 1 January 1984 to 31 December 2015. We obtained all data from the medical reports and defined three periods, P1 (1984-1993), P2 (1994-2003), and P3 (2004-2015). The p-value adjusted for multiple comparisons was set to 0.005.

RESULTS

Within 32 years, a total of 787 patients accounted for 904 admissions for MOH. From P1 to P3, the proportion of patients with preexisting migraine increased from 44.3% to 53.3% (chi² = 9.0, p = 0.01) and that with preexisting tension-type headache decreased from 47.9% to 34.6% (chi² = 9.3, p < 0.01). The median time since onset of headache and medication overuse headache decreased from 20 to 15 years (p < 0.001) and from 3 to 2 years (p < 0.001). The median cumulative number of single doses decreased from 120 to 90 per month (p = 0.002). Overuse of triptans, non-opioid analgesics, and opioids increased, whereas overuse of ergotamines decreased over time (p < 0.001 for all tests). The use of prophylactic medication before admission increased from 8.3% to 29.9% (chi² = 89.5, p < 0.001).

CONCLUSION

This retrospective study in a large number of patients with medication overuse headache admitted for inpatient withdrawal therapy over a period of 32 years shows a trend towards changes in the preexisting headache type, a decrease in the time since onset of headache and medication overuse headache, a decrease in the number of drug doses used per month, changes in the type of drugs overused, and an increase in, but still low rate, of prophylactic medication prior to admission.

Osteopathic Manipulative Therapy in Patients With Chronic Tension-Type Headache: A Pilot Study

CONTEXT

Nonpharmacologic treatment, such as osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) may be a beneficial complementary treatment for tension-type headache. However, to the authors' knowledge, the benefit of OMTh in the management of tension-type headache has not been explored, especially chronic tension-type headache (CTTH).

OBJECTIVE

To investigate the effectiveness of OMTh compared with traditional treatment in reducing pain intensity, frequency, and duration of CTTH, and to evaluate the objective postural measurement of the forward head posture (FHP) as an integral parameter in the assessment of the effects of OMTh and traditional management of CTTH.

METHODS

Patients with CTTH were registered at the Headache Centre of Trieste in Italy. At the time of the study, none of the patients had been taking any headache prophylaxis in the past 3 months. A 3-month baseline period was recorded by all patients with an ad hoc diary. Patients were randomly placed in the test or control group using a simple randomization program in Excel (Microsoft). Patients in the OMTh group underwent a 3-month period of OMTh, and patients in the control group were treated with amitriptyline. Pain intensity, frequency, and duration of headaches, as well as FHP were analyzed.

RESULTS

The study enrolled 10 patients (mean [SD] age, 42.6 [15.2] years) in the OMTh group and 10 patients (51.4 [17.3] years) in the control group. The final assessment of OMTh patients showed statistically significant changes in all headache parameters: pain intensity decreased from a mean (SD) score of 4.9 (1.4) to 3.1 (1.1) (P=.002); frequency decreased from 19.8 (6) to 8.3 (6.2) days per month (P=.002); and the duration of headaches decreased from 10 (4.2) to 6 (3) hours (P=.01). Significant improvement of all parameters was found in the control group as well: pain intensity decreased from a mean (SD) score of 5.9 (0.7) to 4.2 (1.75) (P=.03); frequency decreased from 23.4 (7.2) to 7.4 (8.7) days per month (P=.003); and duration decreased from 7.8 (2.9) to 3.6 (2.1) hours (P=.002). Forward head posture significantly improved in OMTh patients (P=.003).

CONCLUSIONS

Our data suggested that OMTh may be an effective treatment to improve headaches in patients with CTTH. Our results also suggest that OMTh may reduce FHP.

Life With Migraine: Effects on Relationships, Career, and Finances From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

Objective

To assess the effects of migraine on important life domains and compare differences between respondents with episodic and chronic migraine and between sexes.

Background

Migraine is associated with a substantial personal and societal burden and can also affect the interpersonal dynamics, psychological health and well‐being, and financial stability of the entire family of the person with migraine.

Methods

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study is a prospective, longitudinal, Web‐based survey study undertaken between September 2012 and November 2013 in a systematic U.S. sample of people meeting modified International Classification of Headache Disorders, 3rd edition migraine criteria: 19,891 respondents were invited to complete the Family Burden Module, which assessed the perceived impact of migraine on family relationships and life, career and finances, and overall health. Respondents were stratified by episodic migraine (<15 headache days/month) and chronic migraine (≥15 headache days/month) and sex for comparisons.

Results

A total of 13,064 respondents (episodic migraine: 11,944 [91.4%]; chronic migraine: 1120 [8.6%]) provided valid data. Approximately 16.8% of respondents not currently in a romantic relationship (n = 536 of 3189) and 17.8% of those in a relationship but not living together (n = 236 of 1323) indicated that headaches had contributed to relationship problems. Of those in a relationship and living together (n = 8154), 3.2% reported that they chose not to have children, delayed having children or had fewer children because of migraine (n = 260; episodic migraine: n = 193 of 7446 [2.6%]; chronic migraine: n = 67 of 708 [9.5%]; P < .001). Of individuals responding to career/finance items (n = 13,061/13,036), 32.7% indicated that headaches negatively affected ≥1 career area (n = 4271; episodic migraine: n = 3617 of 11,942 [30.3%]; chronic migraine: n = 654 of 1119 [58.4%]), and 32.1% endorsed worry about long‐term financial security due to migraine (n = 4180; episodic migraine: n = 3539 of 11,920 [29.7%]; chronic migraine: n = 641 of 1116 [57.4%]).

Conclusions

Migraine can negatively affect many important aspects of life including marital, parenting, romantic and family relationships, career/financial achievement and stability, and overall health. Reported burden was consistently greater among those with chronic migraine than among people with episodic migraine; however, few differences were seen between the sexes.

Comparison of Pain-Related and Psychological Variables between Acute and Chronic Migraine Patients, and Factors Affecting Headache Chronicity

Background:

Migraine headache is classified as acute or chronic. In recent years, efforts have been made to identify the factors that might predispose individuals to develop the chronic-type headache. The present study aimed to draw a comparison between patients with acute and chronic migraine in terms of demographic, pain-related, and psychological variables. In addition, we also investigated factors affecting headache chronicity in such patients.

Methods:

The present cross-sectional study was conducted during 2017-2018. The target sample consisted of 250 patients with acute or chronic migraine who referred to various clinics affiliated to Shiraz University of Medical Sciences (SUMS), Shiraz, Iran, recruited by convenience sampling. All the participants filled in the questionnaires related to demographic characteristics, pain intensity, disability, depression, emotional intelligence, and anger. The data were analyzed using SPSS software (version 22.0) with t test, Chi-square test, and logistic regression analysis. P<0.05 was considered statistically significant.

Results:

Patients suffering from chronic migraine experienced higher levels of disability, depression, anger, and had lower levels of emotional intelligence compared to those with acute migraine. Based on the logistic regression analysis, variables that had a significant effect on headache chronicity were female gender (OR=5.81), married status (OR=3.77), patients with lower level of education (OR=0.26), headache duration (OR=1.53), disability (OR=0.28), depression (OR=3.66), and anger (OR=5.04).

Conclusion:

Variables such as disability, depression, and lack of anger control were among the key factors associated with headache chronicity in migraine patients.

Manual therapy for chronic migraine: a pragmatic randomised controlled trial study protocol

Introduction

Chronic migraine is a largely refractory condition affecting between 1 and 2.2% of the overall population worldwide, with females more affected than males. There are also high health and socioeconomic costs associated both for the individual and society. The mainstay of chronic migraine management is pharmacological, but the options available have limited efficacy and there are often unwanted side effects. There is some evidence for manual therapy as a treatment option for migraine, but its effectiveness for chronic migraine is unknown. Therefore, we have designed a pragmatic randomised control trial to investigate whether adding manual therapy to the tertiary specialist treatment of chronic migraine improves patient-reported outcomes.

Methods

A pragmatic, randomised controlled trial in a hospital tertiary headache clinic. Participants will be randomised into one of two groups: treatment as usual or treatment as usual plus manual therapy. The primary outcome measure will be a change in the Headache Impact Test score. Secondary outcomes will also be measured over the 12-week study period including changes in headache frequency, migraine specific quality of life and reductions in relevant medicine consumption. The manual therapy group will have five treatment sessions each lasting 30 min. The recruitment target of 64 participants will allow power at 80% with p = 0.05 using minimal clinical difference for Headache Impact Test of 3.7 and includes provision for a 10% dropout rate. Recruitment will take place between August 2018 and February 2019. The results will form part of a doctoral study and be published in peer-reviewed journals and presented at national/international conferences.

Discussion

Current pharmacological approaches have limited effects in the management of chronic migraine and there is a requirement to improve treatment options and reduce the health and economic burden of the condition. Manual therapy has been shown to be effective in other chronic pain conditions as well as other primary headaches. This study will explore the effectiveness of manual therapy as an adjunctive approach to the management of chronic migraine.

Trial registration

The trial has received a favourable opinion from the UK Health Research Authority (IRAS 228901) and is registered at ClinicalTrials.gov.number NCT03395457. Registered 1st March 2018.

The influence of rapid eye movement sleep deprivation on nociceptive transmission and the duration of facial allodynia in rats: a behavioral and Fos immunohistochemical study

Background

Disrupted sleep is associated with a reciprocal influence on headaches and is one of the contributing factors in the process of chronicity. The goal of the present study was to investigate the influence of sleep on headaches using animal rapid eye movement (REM) sleep deprivation and supradural capsaicin infusion models.

Method

Sprague-Dawley rats underwent REM sleep deprivation (REMSD) for 96 h. The sensory threshold to mechanical stimuli, assessed by the von Frey monofilament test, was measured during the REMSD period. Additionally, the Fos protein expression level was measured in the trigeminocervical complex, periaqueductal gray, and hypothalamus. Following supradural infusion of capsaicin, we evaluated the duration of facial allodynia for 28 days after REMSD.

Results

After REMSD, the sensory threshold to mechanical stimuli was significantly decreased (p < 0.01) and Fos-positivity in the posterior (p = 0.010) and dorsomedial hypothalamus (p = 0.024), ventrolateral periaqueductal gray (p = 0.016), and superficial layer of the trigeminocervical complex (p = 0.019) were significantly increased. The duration of facial allodynia induced by supradural capsaicin infusion was significantly longer in the REM sleep deprivation and capsaicin infusion group (Day 10 PSD vs. Day 25 PSD).

Conclusion

The present study demonstrates that REM sleep deprivation increased nociceptive transmission from trigeminal nerve endings. Furthermore, it suggests that sleep deprivation may contribute to the chronicity of facial allodynia.

The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey

BACKGROUND

Headache management is common within chiropractic clinical settings; however, little is yet known about how this provider group manage headache sufferers. The aim of this study is to report on the prevalence of headache patients found within routine chiropractic practice and to assess how chiropractors approach key aspects of headache management applicable to primary care settings.

METHODS

A 31-item cross-sectional survey was distributed to a national sample of chiropractors (n = 1050) to report on practitioner approach to headache diagnosis, interdisciplinary collaboration, treatment and outcome assessment of headache patients who present with recurrent headache disorders.

RESULTS

The survey attracted a response rate of 36% (n = 381). One in five new patients present to chiropractors with a chief complaint of headache. The majority of chiropractors provide headache diagnosis for common primary (84.6%) and secondary (90.4%) headaches using formal headache classification criteria. Interdisciplinary referral for headache management was most often with CAM providers followed by GPs. Advice on headache triggers, stress management, spinal manipulation, soft tissue therapies and prescriptive neck exercises were the most common therapeutic approaches to headache management.

CONCLUSION

Headache patients make up a substantial proportion of chiropractic caseload. The majority of chiropractors managing headache engage in headache diagnosis and interdisciplinary patient management. More research information is needed to understand the headache types and level of headache chronicity and disability common to chiropractic patient populations to further assess the healthcare needs of this patient population.

Use and overuse of triptans in Austria - a survey based on nationwide healthcare claims data

Background

To evaluate triptan use and overuse as well as prescription patterns in Austria based on a nationwide healthcare database because data on triptan use and overuse in Austria is missing.

Methods

We included all persons insured with one of 19 Austrian social security institutions in 2007. Inclusion criteria comprised an age of 18–99 years, known sex, and receipt of insurance benefits. We defined triptan use as ≥1 package of a triptan dispensed in 2007 and triptan overuse as ≥30 defined daily doses dispensed in at least one quarter.

Results

Out of 8.295 million inhabitants in Austria, 7,426,412 persons (89.5%) were insured with a social insurance carrier and 5,918,487 persons of those insured (79.7%) fulfilled the inclusion criteria. Among the latter 33,062 persons (0,56%) were triptan users and 1970 (0.033%) were triptan overusers. The estimated proportion of persons with migraine using a triptan was less than 6%. Among users 5.9% were overusers of whom 55% overused triptans in ≥2 quarters of 2007. The median number of days of sick-leave was higher in triptan users than in non-users: due to any reason of sick-leave 12 vs. 10, p < 0.001, due to migraine 3 vs. 2, p < 0.001. The proportion of hospital admissions did not differ between triptan users and non-users.

Conclusion

The rate of triptan use is low in Austria but triptan users are at risk for triptan overuse. In triptan users more days of sick-leave and the same proportion of hospital admissions as in the older non-users suggest poorer health.

The frequency of complementary and integrative medicine methods in headache patients and their spending habits

BACKGROUND

It is known that complementary and integrative medicine (CIM) methods are especially used by patients with chronic headaches. The aim of our study is to increase the knowledge on this topic, to provide objective data about use in Turkish headache patients.

METHODS

This study included 425 patients with headache. The survey form prepared was filled in under the supervision of a health professional. The questionnaire included 2 items, about CIM methods and finance.

RESULTS

Among the patients evaluated, 316 were female, and 109 were male. All of 52% answered yes to the question "did you ever use any CIM treatment method for headaches during your life?". The most frequently used methods were combined (herbal+one or more other method) (29.6%), herbal (9.4%) and cupping therapy (4.2%). Among the patients that used combined methods, 26.9% had spent 30-100TL (5-25euro), 20.6% had spent 100-300TL (25-70euro), 26.9% had spent 300-500TL (70-120euro) and the last two groups that formed 12.6% had spent 500-1000 (120-250euro) and >1000TL (>250euro).

CONCLUSION

Half of the patients that applied to outpatient clinic with headaches use one or more of these methods and make budgets in accordance with their income levels. Physicians should have sufficient knowledge and clinical opinions about the CIM methods used by headache patients.

Burden of migraine in a Kuwaiti population: a door-to-door survey

Background

Migraine prevalence and disability imprints on Kuwaiti population are underreported. We aimed to measure the prevalence of migraine and to assess its burden in Kuwait.

Methods

A cross-sectional community-based study was conducted which included biologically unrelated Kuwaiti adult population aged 18–65 years. They were randomly recruited from all six governments of Kuwait using stratified multistage cluster sampling. Trained interviewers visited the samples in door-to-door approach. The Headache-Attributed Restriction, Disability, and Social Handicap and Impaired Participation (HARDSHIP) questionnaire was used to collect the data. Demographic enquires were followed by diagnostic and disability questions.

Results

A total of 15,523 subjects were identified; of whom 3588 (23%) were diagnosed as episodic migraine and 845 (5.4%) as chronic headache. Prevalence of episodic migraine was 31.71% in female versus 14.88% in males (P < 0.01) with a mean age of 34.56 ± 10.17 years. Most of migraine cohort (64.4%) sought medical advice with respect to their migraine headaches and the majority (62.4%) were seen by general practitioners (GPs) while 17.2% were assessed by neurologists and 3.7% was seen by other specialties. Tension type headache and sinus-related headaches were diagnosed in 8.9% and 2.1% of migraine subjects respectively. The majority (94.6%) of migraine subjects used symptomatic drugs for headache attacks, whereas 39.9% were taking preventive medication. In the preceding 3 months to the survey, subjects with episodic migraine had lost a mean of 1.97 days from their paid work or school attendance compared to 6.62 days in chronic headache sufferers (P < 0.001). Additionally, subjects with episodic migraine lost a mean of 1.40 days from household work compared to 5.35 days in subjects with chronic headache (P < 0.001). Participants with episodic migraine and chronic headache missed a mean of 2.81 and 3.85 days on social occasions, in the preceding 3 months (P < 0.001).

Conclusions

Migraine in Kuwait is highly prevalent and it has a significant impact on activity of daily living, schooling/ employment and social occasions of patients. Accurate diagnosis, effective abortive and preventive treatments of migraine are paramount to improve quality of life and as well as cost saving.

[Quality assurance of pain care in Austria : Classification of management facilities]

In Austria there is no nationwide coverage of pain management, which meets even approximately international criteria. At present there are about 30 interdisciplinary pain management offices and clinics providing care according to a concept of the Austrian Pain Society (ÖSG), about 10 other outpatient pain clinics are located in district and country hospitals. A few years ago, there still were about 50 pain clinics. Yet closure of outpatient clinics and cost-cutting measures in the health sector jeopardize adequate pain relief for patients with chronic pain conditions.Hence, the supply of care for approx. 1.8 mio. Austrians with chronic pain is not guaranteed due to lack of a comprehensive demand planning of pain care facilities. Furthermore, existing structures such as specialized clinics or emergency services in hospitals are primarily based on the personal commitment of individuals. At present, the various centres for pain management in Austria are run with very different operating times, so that for 74% of the chronic pain patients the desired requirements for outpatient pain management are not met and about 50 full-time pain clinics are missing.Under the patronage of the Austrian Pain Society, various national specialist societies have defined the structure and quality criteria for pain management centres in Austria, include, among others, proof of training, cooperation in interdisciplinary teams or minimum number of new patients per year, depending on the classification of the institution.This stepwise concept of care provision for pain patients is intended as first step to help improve the care of pain patients in Austria!

Invasive and Non-invasive Electrical Pericranial Nerve Stimulation for the Treatment of Chronic Primary Headaches

Chronic primary headaches are widespread disorders which cause significant quality of life and socioprofessional impairment. Available pharmacological treatments have often a limited efficacy and/or can generate unbearable side effects. Electrical nerve stimulation is a well-known non-destructive method of pain modulation which has been recently applied to headache management. In this review, we summarise recent advances in invasive and non-invasive neurostimulation techniques targeting pericranial structures for the treatment of chronic primary headaches, chiefly migraine and cluster headache: occipital nerve, supraorbital nerve, vagus nerve, and sphenopalatine ganglion stimulations. Invasive neurostimulation therapies have offered a new hope to drug-refractory headache sufferers but are not riskless and should be proposed only to chronic patients who failed to respond to most existing preventives. Non-invasive neurostimulation devices are user-friendly, safe and well tolerated and are thus taking an increasing place in the multidisciplinary therapeutical armamentarium of primary headaches.

Impact of headaches on university students in Durban, South Africa

Background

Introspection into the factors that affect student success at higher education institutions has gained significant momentum in recent years. Teaching and learning has come under the spotlight with quality enhancement and teaching development funding focussing on student support, enhancing the student environment, and enhancing academics as teachers. Included in this are aspects that try to understand the student. An aspect that is not receiving attention is student health, specifically headaches which could impact student success. The aim of this study was to investigate the impact of primary headaches on student academic, family and social life at one higher education institution in South Africa.

Method

Data was collected using a questionnaire based descriptive cross sectional survey. Multistage sampling using a ballot method allowed for sampling to obtain representation from across the institution. To achieve a 95 % confidence level, 384 students from across the university were invited to participate after informed consent. Data was analysed using Chi square tests at a probability of p < 0.05.

Results

Majority of the participants were undergraduates and non-smokers. Half of the population suffered from primary headaches. Headache sufferers experienced limited concentration due to an increased headache intensity during tests and/or the examination period. This negatively impacted on studying which was aggravated by consumption of caffeinated energy drinks, coffee and chocolate resulting in a less effective study session. Activities of daily living and participation in social events which usually leads to relaxation were neglected. Personal and emotional well-being was also negatively affected. Altered sleeping patterns and absence of study breaks also led to headaches.

Conclusion

Headaches were found to impact on the students study and sleep patterns, their attention levels during lectures and their social and emotional life. Headaches negatively impacted on some participants leading to reduced focus on academic, family, social or leisure activities. Intensity of headaches increased during tests and examinations which could impact their success at University.

Outcome of Chronic Daily Headache or Chronic Migraine

Chronic daily headache (CDH) is a common neurological condition that affects 1-4% of the general population. Recent epidemiological studies have shown that CDH is mainly represented by chronic migraine (CM). Owing to the frequent headaches, associated symptoms, and comorbid conditions associated with CDH/CM, disability, quality of life (QoL), economic burden, and treatment outcome have become important personal and social issues. There have been several studies assessing the disability, QoL, and economic burden associated with CDH/CM. These studies, conducted in different settings, consistently reported significantly higher disability and economic burden and lower QoL among CDH/CM patients compared to patients with episodic headache (EH) or episodic migraine (EM). Treatment outcome of CDH/CM is often poor. In this review, we describe and summarize the results of relevant studies performed to date.

The psychometric properties of the Comprehensive Headache-related Quality of life Questionnaire (CHQQ) translated to Serbian

Background

The Comprehensive Headache-related Quality of life Questionnaire (CHQQ), is a recently developed and validated instrument, intended for measuring quality of life of patients with all headache types. Currently no validated headache-specific quality of life questionnaires are available in Serbian. The aim of this study was to translate the CHQQ from Hungarian to Serbian, to make necessary cultural adaptations and to test its psychometric properties in a sample of outpatients with headache.

Methods

The CHQQ was translated and adapted according to internationally accepted guidelines, and then tested on a sample of 216 Serbian headache patients (171 females and 45 males, mean age 42.3 years/SD 13.35; range 18–75). The majority of patients suffered from episodic tension-type headache (TTH); 27 (12.5 %) had episodic migraine. We calculated the internal consistency (Cronbach’s alpha), criterion validity (correlations of individual items, dimensions and whole questionnaire with the clinical characteristics of headache), convergent validity (correlations of the abovementioned scores with results of other instruments measuring headache severity and impact), and discriminative validity (comparison of the scores in the two diagnostic groups) of the CHQQ. We used factor analysis to explore the underlying construct.

Results

The Serbian translation of CHQQ showed excellent internal consistency, both for the whole instrument (Cronbach’s alpha 0.937) and its dimensions. The validity of the instrument in all aspects (criterion, convergent and discriminative validity) was also excellent when the whole sample and the subgroup of patients with TTH were analyzed, while the results for patients with migraine were less favorable. Factor analysis suggested the existence of a single dimension in this sample.

Conclusions

The Serbian translation of CHQQ is as reliable and valid specific instrument for measuring headache-related quality of life in patients with TTH and probably in patients with migraine.

Similar impact of multiple sclerosis and migraine on sexual function in women : Is the multiple sclerosis impact scale questionnaire useful?

Background

Sexuality is an integral part of overall health but the impact of neurological diseases on sexual function still receives too little attention.

Aim

The aim of this case control study was to compare frequencies and characteristics of sexual dysfunction in women with stable relapsing-remitting multiple sclerosis (MS) and migraine.

Methods

Sexually active women aged 18–50 years were recruited at the MS and headache outpatient clinics of a university hospital and asked to complete questionnaires on sexual function using the multiple sclerosis intimacy and sexuality questionnaire (MSISQ-19) adapted for patients with migraine, depression using the Beck depression inventory (BDI-II) and quality of life using the short form-36 questionnaire (SF-36).

Results

At least one symptom of sexual dysfunction was “almost always” or “always” present in 35.7 % of 42 patients with MS and in 22.6 % of 30 patients with migraine (p = 0.3). The MSISQ-19 total score did not differ between the two groups (31.6 ± 10.8 vs. 28.2 ± 11.6, respectively, p = 0.2). Sexual dysfunction was categorized as primary, secondary and tertiary in 66.7 %, 40 % and 33.3 % of MS patients and in 57.1 % (p = 0.7), 71.4 % (p = 0.2) and 71.4 % (p = 0.1) of migraine patients, respectively. Depressive symptoms were more common in women with sexual dysfunction than in those without both in MS (p = 0.001) and migraine (p = 0.006). The SF-36 showed decreasing quality of life with increasing MSISQ-19 sum scores (mental subscale p < 0.001 and physical subscale p = 0.04).

Conclusions

Sexual dysfunction is a major problem both in women with MS and in women with migraine and is strongly associated with comorbid depression and impaired quality of life. Thus, categorizing sexuality as done by MSISQ-19 is limited by its complex biopsychosocial interactions.

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

Background and Purpose

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

Methods

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

Results

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

Conclusions

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

Treatment of chronic daily headache with comorbid anxiety and depression using botulinum toxin A: a prospective pilot study

BACKGROUND

Psychiatric comorbidities, including depression and anxiety, are clinical entities associated with chronic daily headache (CDH). Botulinum toxin A (BTA) is a Food and Drug Administration approved drug for the treatment of chronic migraine, a subtype form of CDH. This study aimed to investigate the potential efficacy and safety of BTA for controlling psychiatric symptoms in CDH patients.

METHODS

A prospective, open-label, pilot study (n = 30; 7 males, 23 females) was performed. A single low-dose of BTA (40-120 U) was injected into the pericranial muscle at multiple sites. Participants were evaluated before and 1, 4, 8, 12, 16, 20 and 24 weeks after BTA treatment. Primary outcomes included: (1) headache severity, determined by a visual analog scale; (2) depression and anxiety severity, assessed via the Hamilton Depression and Anxiety Rating Scales (HAM-D and HAM-A, respectively); (3) headache frequency per month and (4) single headache episode duration.

RESULTS

Headache severity was significantly ameliorated one week after treatment. Depression and anxiety symptoms were significantly reduced one month after treatment. At month four, the headache incidence per month decreased from 28.83 ± 2.95 to 17.57 ± 11.30 d (p < 0.001), and the single headache duration decreased from 12.03 ± 9.47 to 6.63 ± 8.98 h (p < 0.001). Furthermore, the percentage of patients who required analgesics significantly decreased. BTA was well tolerated, and the adverse events were mild and transient.

CONCLUSION

BTA treatment alleviated the severity and frequency of CDH, with improvements in depression and anxiety. These novel findings indicate that BTA may represent an effective and safe intervention to target psychiatric comorbidities in CDH.

Correlation between headaches and affective symptoms in patients with epilepsy

Headaches are a neglected entity in patients with epilepsy (PWE), although PWE have a high chance of suffering from seizure-related as well as seizure-unrelated headaches. We aimed to identify the prevalence and characteristics of headaches and investigate the correlation between headaches and affective symptoms in PWE. Consecutive PWE who visited our tertiary outpatient clinic were interviewed about headaches and epilepsy. Affective symptoms were evaluated using the Korean version of the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and suicidality portion of the Mini-International Neuropsychiatric Interview. We classified headaches as interictal or seizure-related headaches (SRHs; pre- and postictal). Tension-type headache and migraine were defined based on International Classification of Headache Disorders criteria. From the initial cohort of 177 patients (92 men, mean age: 37.1years), 73 (41.2%) reported suffering from interictal (N=34, 19.2%), preictal (N=3, 1.7%), and postictal (N=48, 27.1%) headaches. Univariate analysis revealed significantly higher BDI and BAI scores in the headache group. Tension-type headaches were the most frequent, and half of the interictal headaches and most of the SRHs were untreated. Spearman's partial correlation analyses showed that headaches overall were significantly related with depression and anxiety. Interictal headaches were correlated with depression only, and postictal headaches were correlated with depression as well as suicidality, separately. These results show that investigating and controlling headaches may relieve affective symptoms and ultimately improve the quality of life of PWE.

Management of headache and associated factors among undergraduate medicine and health science students of University of Gondar, North West Ethiopia

Background

The headache disorders, namely, migraine and tension type headache and the associated analgesic consumption is badly underestimated and thus makes a major current public health problem. The objective of this study was to determine the prevalence of migraine and tension type headaches and the associated management options used among undergraduate students of College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.

Method

Institution based cross sectional study was conducted among 720 students in May, 2014. Pretested and structured self-administered questionnaires were used as data collecting tool followed by short interview to diagnose the type of headache based on the International Headache Society diagnostic criteria. SPSS version 20 was also used to analyse the data descriptively as well as inferentially using logistic regression models to investigate factors associated with presence of headache and analgesic use.

Result

The prevalence of lifetime headache and headache in the last 12 months was 81.11 and 67.22 %, respectively. Migraine and tension type headache were having 94 (13.06 %) and 481 (66.81 %) prevalence, respectively. Prevalence of life time headache was significant among females, students with family history of headache and lack of adequate vacation time. Similarly, lifetime prevalence of analgesic use for headache was 72.45 % and it had statistical association with sex, age, type of headache, lack of adequate vacation time and family history of headache. Majority of the students, migraineurs (54.65 %) and the tension type headache sufferers (66.17 %) commonly used paracetamol.

Conclusion

High prevalence without adequate medical care seeking behaviour and the associated significant analgesic consumption necessitate the designing of all rounded strategies to improve the quality of life of individuals with such neurologic disorders.

[Possibilities of preventive therapy in frequent episodic tension-type headache]

OBJECTIVE

To study the efficacy and safety of tenoten in the preventive treatment of frequent episodic tension-type headache (FETHA) compared to patients treated with pain relievers.

MATERIAL AND METHODS

A study included 60 patients with FETHA. Patients of the main group (n=30) received tenoten in addition to standard treatment. The study comprised 3 visits: beginning of treatment, after one month and after three months. All patients underwent physical and clinical/neurological examinations. In each visit, treatment efficacy was assessed according the following parameters: VAS scores (0-10) for assessment of pain and tension in pericranial muscles in 6 standard points, mean frequency and duration of the headache episode, quality of life indices, Beck depression scores, Spilberger trait and state anxiety, autonomic symptom severity, parameters of sleep disorders, frequency of adverse effects, CGI scores (0-7).

RESULTS AND CONCLUSION

Tenoten as a preventive medication reduced the frequency of headache episodes that allowed to diagnose patients with rare episodic tension-type headache in the end of treatment. At the same time, there was a significant reduction in headache intensity during the episode and decrease in amount of analgesics used by the patients.

Impact of depression and anxiety on burden and management of episodic and chronic headaches - a cross-sectional multicentre study in eight Austrian headache centres

BACKGROUND

Recurrent and especially chronic headaches are associated with psychiatric comorbidities such as depression and anxiety. Only few studies examined the impact of depression and anxiety on episodic (EH) and chronic headache (CH), and data for Austria are missing at all. Therefore, the aim of the present study was to assess the impact of depression and anxiety on burden and management of EH and CH in patients from eight Austrian headache centres.

METHODS

We included 392 patients (84.1 % female, mean age 40.4 ± 14.0 years) who completed the Eurolight questionnaire. The treating physician recorded details about ever-before prophylactic medications. We used Hospital Anxiety and Depression Scale to assess depression and anxiety and compared patients with anxiety and/or depression to those without.

RESULTS

Depression and anxiety were more common in CH than in EH (64 % vs. 41 %, p < 0.0001). Presence compared to absence of depression and anxiety increased the prevalence of poor or very poor quality of life from 0.7 % to 13.1 % in EH and from 3.6 % to 40.3 % in CH (p = 0.001; p < 0.0001). Depression and anxiety had a statistically significant impact on employment status and on variables related to the burden of headache such as reduced earnings, being less successful in career, or feeling less understood. Neither in EH nor in CH health care use and the ever-before use of prophylactic medication was correlated with anxiety and/or depression.

CONCLUSION

Depression and anxiety have a significant impact on quality of life and increase the burden in patients with EH and CH. Improved multidimensional treatment approaches are necessary to decrease disability on the personal, social and occupational level in these patients.

An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia

PURPOSE

The extent and factors associated with codeine use in the community remain poorly understood despite the widespread global use of codeine. The aim of this study was to examine the use of prescription and over-the-counter (OTC) codeine in Australia and identify the geographic and socio-demographic characteristics associated with prescription and OTC codeine use.

METHODS

National sales data for prescription and OTC codeine (supplied by IMS Health) were used to estimate codeine utilisation (in pack sales and milligrammes) in Australia during 2013, mapped to Australian Bureau of Statistics (ABS) Statistical Local Areas (SLAs) and Remoteness Areas. Socio-demographic characteristics and total population estimates of SLAs were obtained from the ABS. SLA-level data on sex, age distribution, income, occupations involving physical labour and number of pharmacies were included in linear regression analyses to examine their association with total, prescription and OTC codeine use.

RESULTS

In total, 27,780,234 packs of codeine were sold in Australia during 2013, equating to 12,376 kg. OTC codeine preparations accounted for 15,490,207 packs (55.8 %) or 4967.30 kg (40.1 %). Nationally, an estimated 1.24 packs (or 554.10 mg) of codeine were sold per person; utilisation was higher in more remote areas. SLAs with a higher percentage of low-income earning households had the highest rates of prescription codeine use (β 0.16, p < 0.001), whereas SLAs with a higher percentage of males had the highest rates of OTC codeine use (β 0.22, p < 0.001).

CONCLUSIONS

Codeine use is common in Australia, with clear distinctions in the geographic and socio-demographic characteristics associated with prescription and OTC codeine use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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