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

Reduction of neck pain severity in patients with medication-overuse headache

BACKGROUND

Neck pain and primary headache disorders are highly prevalent in populations and clinical cohorts. Medication-overuse headache (MOH) is a treatable secondary headache, mainly developing in migraine sufferers, that accounts for the majority of patients presenting to headache clinics. Nevertheless, the association between neck pain and MOH has not been reported. This study evaluated the prevalence and clinical course of neck pain in patients with MOH before and after MOH treatment.

METHODS

We analyzed 635 MOH patients enrolled in a nationwide, prospective, multicenter MOH registry. Demographics and clinical data were collected at baseline and 3 months to evaluate changes in the status and severity of neck pain and headache. Severity of neck pain was graded into 4 groups, and severe neck pain was defined as grade 3 or 4.

RESULTS

Among 635 patients with MOH, 366 (57.6%) reported neck pain at baseline. MOH patients with neck pain had an earlier onset of their primary headache disorder (23.4 ± 12.7 vs. 26.2 ± 13.3 years, p = 0.007). Although monthly headache days were comparable between the patients with neck pain and those without neck pain, the neck pain group had higher levels of anxiety (7.4 ± 5.8 vs. 6.4 ± 5.4, p = 0.017), more severe cutaneous allodynia (2.4 ± 3.3 vs. 1.8 ± 3.0, p = 0.038), and poorer quality of life (171.7 ± 70.4 vs. 184.0 ± 68.9, p = 0.029). At 3 months, 456 (71.8%) were followed-up, and 257 (56.4%) were recovered from MOH. Compared to the baseline, the proportion of severe neck pain (40.4% vs. 19.4%, p < 0.001) was decreased. The proportion of severe neck pain was much lower in patients with recovery from MOH compared to those without (4.7% vs. 15.1%, p < 0.001).

CONCLUSIONS

Neck pain in MOH patients was associated with earlier onset of headache, higher levels of anxiety and allodynia, and poorer quality of life. Improvement in neck pain improvement was linked to recovery from MOH. These findings suggest the potential importance of integrating and management of neck pain into clinical practice for MOH.

Brain structural network modular and connectivity alterations in subtypes of patients with migraine and medication overuse headache

Migraine, one of the most prevalent and debilitating neurological disorders, can be classified based on attack frequency into episodic migraine (EM) and chronic migraine (CM). Medication overuse headache (MOH), a type of chronic headache, arises when painkillers are overused by individuals with untreated or inadequately treated headaches. This study compares regional cortical morphological alterations and brain structural network changes among these headache subgroups. Sixty participants, including 20 in each of the following patient groups (EM, CM, MOH), and healthy controls (HC) completed the study. Our results show that the EM group exhibited cortical thickness (CTs) thinning predominantly in the left limbic, whereas CM patients exhibited CTs thinning across both left and right hemispheres. The MOH group demonstrated the most widespread CTs thinning. Both CM and MOH exhibited comparable patterns of CTs thinning within lobes, leading to reduced intra-lobe connectivity. While there were no significant differences in total inter-lobe connectivity between migraine groups and HC, both CM and MOH groups exhibited significantly decreased inter-limbic connectivity compared to HC and EM groups. In addition, they showed increased inter-frontal and inter-parietal connectivity, suggesting possible compensatory mechanisms to offset the loss of inter-lobe connectivity between the limbic and other lobes. Both CM and MOH groups exhibited a significant loss of global efficiency and a decrease in betweenness centrality in their brain networks, with MOH showing the most pronounced decrease and CM showing the second largest decrease. Our results suggest that aberrant structural brain networks in CM and MOH are less efficient, less centralization, and abnormally segregated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical features of new daily persistent headache: A retrospective chart review of 328 cases

OBJECTIVE

To describe the clinical features of new daily persistent headache (NDPH) at an outpatient neurology clinic with a subspecialty interest in headache in Houston, Texas.

METHODS

A retrospective chart review was performed by a neurologist subspecialty certified in headache medicine of all patients seen from September 1, 2011 through February 28, 2020 (8.5 years) with a provisional diagnosis of NDPH and abstracted charts meeting criteria for primary NDPH.

RESULTS

A total of 328 patients met the International Classification of Headache Disorders, 3rd edition criteria including 215 (65.5%) female patients. The mean age of onset was 40.3 years (range 12-87 years) with a mean age at first consultation in the study clinic of 42.6 years (range 12-87 years). The median [25th, 75th] duration of NDPH at initial consultation was 0.7 [0.3, 2.0] years, and at last visit, it was 1.9 [0.7, 4.8] years. The headaches were side-locked unilateral in 28/328 (8.5%). 12/328 cases (3.6%) with a thunderclap onset are reported. There was no obvious seasonal or other cyclical variation. The pain was usually moderate to severe and more often severe for the migraine phenotype (MP; 260/328 [79.3%] of cases) than for the tension-type phenotype (TTP). Precipitating factors were the following: stressful life events, 67/328 (20.4%); upper respiratory infection or flu-like illness, 33/328 (10.1%); and extracranial surgery, 5/328 (1.5%). Exacerbating or aggravating factors similar to migraine triggers were more often reported with the MP than with the TTP in this sample. For the MP, vertigo or dizziness was reported by 19/260 (7.3%) and a visual aura by 21/260 (8.1%) with descriptions provided. The prognostic types were the following for all patients: persisting (refractory), 305/328 (93.0%); relapsing-remitting, 9/328 (2.7%); and remitting (self-limited), 14/328 (4.3%).

CONCLUSION

NDPH is typically of moderate to severe intensity often with migraine features without obvious seasonal or other cyclical variation. Most cases are refractory. 3.6% have a thunderclap onset often with a good response to treatment.

Efficacy, tolerability, and safety of eptinezumab in patients with a dual diagnosis of chronic migraine and medication-overuse headache: Subgroup analysis of PROMISE-2

OBJECTIVE

To evaluate the efficacy, tolerability, and safety of eptinezumab 100 and 300 mg compared with placebo in patients with the dual diagnosis of chronic migraine (CM) and medication-overuse headache (MOH).

BACKGROUND

Eptinezumab, a humanized monoclonal antibody targeting calcitonin gene-related peptide, may be effective for treating patients with a dual diagnosis of CM and MOH.

METHODS

PROMISE-2 (NCT02974153) was a double-blind, randomized, placebo-controlled, phase 3 study that comprised a screening visit, a 28-day pretreatment period, and a 32-week study duration. Patients in this exploratory analysis of a prespecified subgroup had confirmed diagnoses of both CM and MOH at screening. Patients were randomly assigned to receive intravenous eptinezumab 100, 300 mg, or placebo every 12 weeks. Efficacy outcomes included mean changes from baseline in monthly migraine days (MMDs) during weeks 1-12, migraine responder rates at week 12, and percentages of patients below International Classification of Headache Disorders thresholds for CM and MOH over weeks 1-24.

RESULTS

There were 431 patients who were diagnosed with CM and MOH as specified in the protocol and received eptinezumab 100 mg (n = 139), 300 mg (n = 147), or placebo (n = 145). During the baseline period, these patients experienced an average of 16.7 migraine days across treatment arms. Over weeks 1-12, eptinezumab-treated patients experienced greater reductions from baseline in MMDs than placebo patients (100 mg, change from baseline = -8.4, difference from placebo [95% confidence interval (CI)] = -3.0 [-4.56, -1.52], p < 0.0001 vs. placebo; 300 mg, change from baseline = -8.6, difference from placebo [95% CI] = -3.2 [-4.66, -1.78], p < 0.0001 vs. placebo; placebo, -5.4). Compared with placebo, more eptinezumab-treated patients were ≥50% migraine responders (100 mg, 84/139 [60.4%]; 300 mg, 91/147 [61.9%]; placebo, 50/145 [34.5%]) or ≥75% responders (100 mg, 38/139 [27.3%]; 300 mg, 44/147 [29.9%]; placebo, 21/145 [14.5%]) over weeks 1-12. Therapeutic benefits with eptinezumab were observed from day 1 after dosing, and improvements were sustained with an additional dose. For the full 24-week treatment period, 71/139 (51.1%), 80/147 (54.4%), and 47/145 (32.4%) of 100, 300 mg, and placebo-treated patients, respectively, were below CM thresholds, and of the patients who provided sufficient acute medication data, 47/93 (50.5%), 53/107 (49.5%), and 26/96 (27.1%), respectively, were below medication-overuse thresholds.

CONCLUSIONS

In patients diagnosed with both CM and MOH, eptinezumab treatment resulted in greater reductions in MMDs, higher responder rates, and fewer patients meeting CM and MOH criteria, thus demonstrating the efficacy and clinical utility of eptinezumab in this patient population.

Integrative East-West Medicine Intervention for Chronic Daily Headache: A Case Report and Care Perspective

Chronic daily headache is a group of headache syndromes including most commonly chronic migraine and chronic tension-type headache, which often overlap, are complicated by medication overuse and are disabling, costly, and variable responsive to western pharmacotherapeutic interventions. There is growing research and awareness of integrative health approaches and therapies to address patients with chronic headache, yet limited examples of how to deliver this approach. This article reviews a commonly seen challenging case of a patient with overlapping chronic migraine and chronic tension-type headache complicated by medication overuse managed with an integrative east-west medicine intervention. This included person-centered biopsychosocial history taking, traditional Chinese medicine informed acupuncture, trigger point injections, and contributing factors modifications. A narrative review of the literature is presented to demonstrate an evidence-informed rationale for incorporating nonpharmacologic approaches to effectively help reduce the symptom burden of this patient population.

Associations of Elderly Onset Headache With Occurrence of Poor Functional Outcome, Cardiovascular Disease, and Cognitive Dysfunction During Long-term Follow-up

Background

Although the frequency and intensity of headaches decrease in older adults, headaches in this population are still an important neurological disorder. The purpose of this study was to investigate the associations of headache characteristics in older adults with the development of cardiovascular disease and cognitive dysfunction.

Methods

We prospectively enrolled 125 older (≥65 years old) patients with headache who were making their first visit to outpatient clinics and who had no prior history of cognitive dysfunction from 11 hospitals in Korea between August 2014 and February 2015. We investigated the occurrence of newly developed/or recurrent headache, cardiovascular disease, cognitive dysfunction, and poor functional outcomes.

Results

The mean age of all included patients was 72.6 years, 68.8% were women, and 43 (34.4%) had newly developed/or recurrent headache during follow-up. During a median follow-up of 31 months (interquartile range, 28–34 months), 21 participants (16.8%) experienced cardiovascular disease, and 26 (20.8%) developed cognitive dysfunction. Upon multivariate analysis and after adjusting for sex, age, and other factors, presence of newly developed/or recurrent headache was found to be associated with cardiovascular disease (hazard ratio [HR], 4.03; 95% confidence interval [CI], 1.28–12.61; p=0.017) and frequency of headache for the recent 3 months was related with cognitive dysfunction (HR, 1.05; 95% CI, 1.00–1.09; p=0.017) and poor functional outcomes (HR, 1.06; 95% CI, 1.01–1.11; p=0.011).

Conclusion

Our study demonstrated that there is an increased risk of cardiovascular disease, cognitive dysfunction, and poor functional outcomes in older patients with frequent, newly developed, or recurrent headache.

APPROACHES TO PERSONALIZED THERAPY

Approaches to personalized therapy based on practical work of physicians are discussed. Personalized treatment considers patient’s interests and position, mechanisms of symptoms, somatic and mental comorbidities, chrono medicine, environment, genetics, and prognosis. Personalized treatment may be more effective, safe and inexpensive in compare with of traditional standardized care based on randomized controlled trials and clinical practice guidelines. Limitations and weaknesses of medical guidelines of authoritative professional societies are also discussed. Recommendations of clinical guidelines are based on randomized controlled trials with strict selection of patients without severe comorbid diseases. Accordingly, trials and guidelines conclusions cannot be applied for patients with heavy comorbidity. This justifies the need for organizational solutions and computer programs for support personalized treatment of patients. It is important to develop institute of primary care physicians and to train specialists in field of comorbid somatic diseases and mental disorders.

Neuroimaging of headaches in patients with normal neurological examination: protocol for a systematic review

INTRODUCTION

Headache disorders (HD) are among the most frequent neurological disorders seen in neurology practice. Because secondary HD are rare, patients' examination is most often unremarkable. However, the will to relieve patients' anxiety and the fear of prosecutions lead to overuse of neuroimaging thus resulting in the discovery of incidental findings (IF) or normal variants that can lead to futile or harmful procedures. Knowing the probability of identifying a potentially clinically significant lesion in patients with isolated headache could facilitate decision-making and reduce health costs. This review aims to determine the prevalence of incidental findings and normal anatomic variants (NAV) on neuroimaging studies performed in patients presenting with headache and normal neurological examination.

METHOD AND ANALYSIS

Studies reporting neuroimaging findings in patients with headache and normal neurological examination and published before the 30 September 2017 will be identified by searching PubMed, Medline and EMBASE (Excerpta Medica Database). Relevant unpublished papers and conference proceedings will also be checked. Full texts of eligible studies will then be accessed and data extracted using a standard data extraction sheet. Studies will be assessed for quality and risk of bias. Heterogeneity of studies will be evaluated by the χ² test on Cochrane's Q statistic. The prevalence of NAV and IF across studies and in relevant subgroups will be estimated by pooling the study-specific estimates using a random-effects meta-analysis. Visual analysis of funnel plot and Egger's test will be used to detect publication bias. The report of this systematic review will be compliant with the Meta-analysis of Observational Studies in Epidemiology guidelines.

ETHICS AND DISSEMINATION

The current study is based on published data; ethical approval is, therefore, not required. The final report of this systematic review will be published in a peer-reviewed journal. Furthermore, findings will be presented at conferences and submitted to relevant health authorities.

TRIAL REGISTRATION NUMBER

CRD42017079714.