Pharmacotherapy of tension-type headache (TTH)

Development and Validation of a Japanese-Language Questionnaire to Screen for Tension-Type Headaches and Migraines

Introduction Migraine and tension-type headache (TTH) are chronic diseases associated with significant socioeconomic losses and social and psychological impact (current global prevalence: 10% and 38%, respectively). Thus, they require accurate identification and classification. In clinical practice, validated screening tools able to quickly determine migraine and TTH with high sensitivity and specificity help provide an objective and multifaceted understanding of patients' headache symptoms. However, no tool has been developed or validated yet in Japan to ask multifaceted questions about headache-related symptoms in order to identify migraine and TTH and understand these symptoms. This study aimed to develop a questionnaire for screening TTH and migraine. Methods The study was conducted from March to June 2022 at a medical institution in Osaka, Japan. The questionnaire - comprising 24 questions that were generated based on the 3rd edition of the International Classification of Headache Disorders - was used to screen for migraine and TTH, aiming for a deeper understanding of related symptoms. The participants were patients aged ≥18 years with at least one of the following diagnoses: migraine, TTH. The participants were asked to respond in writing or online. The inclusion criteria were age ≥18 years; headache patients attending a hospital; and diagnoses of at least one of the following: migraine, TTH. The informativeness and discriminating ability of the screening items were evaluated using the item response theory. Items with a calculated discrimination ≥1.35 (high or very high) were retained for screening purposes. Basic questions required to screen for primary headaches were retained, despite their limited computational discrimination power. Ultimately, nine and eight screening items were finalized for migraine and TTH, respectively. The previous neurologists' clinical diagnosis of each patient was used as the gold standard reference for calculating sensitivity, specificity, and positive and negative predictive values regarding the screening items. Cohen's kappa coefficients with 95% CIs were also calculated to determine the agreement between the neurologists' clinical diagnosis and the questionnaire results. Results The study population comprised 69 patients aged 19-89 years who were assisted at a hospital division specializing in headache medicine and diagnosed by neurologists. Of these, 22 patients had migraine, 30 had TTH, and 17 had migraine/TTH. Comparing the neurologists' clinical diagnosis with our screening questionnaire results, the sensitivity and specificity were 72.7% and 86.7% for migraine and 50.0% and 86.4% for TTH, respectively. Conclusions Our brief screening tool was highly specific for diagnosing migraine and TTH in individuals with headache symptoms but lacked sufficient sensitivity, especially for TTH. The high specificity for migraine and TTH suggests that the screening tool we developed in this study can correctly identify those who do not have migraine and TTH. The sensitivity was also relatively high for migraine, suggesting that the tool can correctly identify migraine-positive individuals. However, the sensitivity for TTH was low. This tool could help clinicians in providing detailed course assessment of migraine symptoms and TTH symptoms; however, the issue of low sensitivity for TTH needs to be addressed.

Recent advancements in tension-type headache: a narrative review

INTRODUCTION

Tension-type headache (TTH) is the most common primary headache disorder with a prevalence of up to 78% in general population and huge expenses in terms of health service. Despite its high incidence and impact on life's quality the knowledge on the pathophysiology and efficacious treatment of TTH was still limited.

AREAS COVERED

In recent years, a series of studies highlighted the heterogeneous nature of this pathology that seems to be determined by a complex interaction between genetic, environmental, and neuromuscular factors, which result in nociceptive system activation. In this setting, alongside the simple analgesic therapies used during the acute attack, a series of therapeutic options based on newly acquired experiences have taken hold.

EXPERT REVIEW

Not having a single substrate or a typical site of pathophysiology, TTH must be analyzed in a global and multidisciplinary way. Herein, we perform a narrative review of the most recent advancement stimulating the concept of this disease as the tip of the iceberg of a more complex individual malaise secondary to different alterations. Strategies based solely on symptomatic drugs should therefore be avoided by experienced personnel and treatment should aim at taking charge of the patient considering the processes behind this complex pathology.

A Decade of mTBI Experience: What Have We Learned? A Summary of Proceedings From a NATO Lecture Series on Military mTBI

Mild traumatic brain injury (mTBI, also known as a concussion) as a consequence of battlefield blast exposure or blunt force trauma has been of increasing concern to militaries during recent conflicts. This concern is due to the frequency of exposure to improvised explosive devices for forces engaged in operations both in Iraq and Afghanistan coupled with the recognition that mTBI may go unreported or undetected. Blasts can lead to mTBI through a variety of mechanisms. Debate continues as to whether exposure to a primary blast wave alone is sufficient to create brain injury in humans, and if so, exactly how this occurs with an intact skull. Resources dedicated to research in this area have also varied substantially among contributing NATO countries. Most of the research has been conducted in the US, focused on addressing uncertainties in management practices. Development of objective diagnostic tests should be a top priority to facilitate both diagnosis and prognosis, thereby improving management. It is expected that blast exposure and blunt force trauma to the head will continue to be a potential source of injury during future conflicts. An improved understanding of the effects of blast exposure will better enable military medical providers to manage mTBI cases and develop optimal protective measures. Without the immediate pressures that come with a high operational tempo, the time is right to look back at lessons learned, make full use of available data, and modify mitigation strategies with both available evidence and new evidence as it comes to light. Toward that end, leveraging our cooperation with the civilian medical community is critical because the military experience over the past 10 years has led to a renewed interest in many similar issues pertaining to mTBI in the civilian world. Such cross-fertilization of knowledge will undoubtedly benefit all. This paper highlights similarities and differences in approach to mTBI patient care in NATO and partner countries and provides a summary of and lessons learned from a NATO lecture series on the topic of mTBI, demonstrating utility of having patients present their experiences to a medical audience, linking practical clinical care to policy approaches.

Current complications and treatment of aspirin-exacerbated respiratory disease

INTRODUCTION

Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.

Headache and migraine: a leading cause of absenteeism

Migraine and tension-type headache, the two dominant primary headache disorders, are among the most common causes of lost work time. The population impact of both disorders is similar, but the demographics and individual impact differ. Approximately 18% of females and 6% of males have migraine in the general population. Prevalence is highest around age 40, when individuals are at the peak of their work abilities. Headaches cause substantial individual impact on work productivity and employer and societal burden from direct medical costs, lost work time, and underemployment, and, in more severe persistent headache, unemployment. The lost work time costs greatly exceed medical care costs. Chronic daily headache (15 or more headache days per month) represents a widely accepted stage of pain progression that occurs in 2-4% of the population. Treatment of headaches can be acute or preventive. The goals of acute treatment are timely alleviation of pain and associated symptoms without recurrence, the restoring of ability to function, minimizing the use of back-up and rescue medications with minimal adverse events, and providing the best cost-effective management. Migraine-preventive medications are used to decrease future attack frequency, severity, and duration, improving responsiveness to acute treatments, and improving overall function and decreasing disability. Preventing analgesic overuse that leads to chronic daily headache is another goal of using preventive treatment. Preventive medications should be considered in migraine patients reporting either 3-6 or more headache days per month, depending on how headaches impair function.

Posttraumatic headache

Headache is a common symptom after traumatic head injury and is a frequent feature of the postconcussive syndrome. A variety of headache subtypes can be precipitated by head trauma, although posttraumatic headaches most often resemble migraine or tension-type headache. A lack of clinical trials limits evidence-based treatment recommendations for both acute and chronic posttraumatic headaches. However, numerous pharmacologic and nonpharmacologic interventions can be used to successfully manage posttraumatic headaches. This article reviews the classification, epidemiology, prognosis, and pathophysiology of headaches after head trauma and provides a practical clinical approach for evaluating and treating patients with posttraumatic headaches.

Pediatric posttraumatic headache: two cases using steroids as abortive therapy

Pediatric traumatic brain injury is a common occurrence, and even an ostensibly mild injury may result in disabling posttraumatic headaches. The headache may result in a number of subsequent unremitting symptoms refractory to many standard headache therapies. Current treatment recommendations are sparse because there is a lack of clinical trial data recommendations and outcomes. From these 2 cases, we report the effectiveness of steroids for severe posttraumatic headache, along with recommended treatment strategies for acute pain management and prevention.