A Study of Exertional Headache's Prevalence and Characteristics Among Conscripts

Indomethacin-responsive headaches-A narrative review

BACKGROUND

Indomethacin is a nonsteroidal anti-inflammatory drug whose mechanism of action in certain types of headache disorders remains unknown. The so-called indomethacin-responsive headache disorders consist of a group of conditions with a very different presentation that have a particularly good response to indomethacin. The response is so distinct as to be used in the definition of two: hemicrania continua and paroxysmal hemicrania.

METHODS

This is a narrative literature review. PubMed and the Cochrane databases were used for the literature search.

RESULTS

We review the main pharmacokinetic and pharmacodynamics properties of indomethacin useful for daily practice. The proposed mechanisms of action of indomethacin in the responsive headache disorders, including its effect on cerebral blood flow and intracranial pressure, with special attention to nitrergic mechanisms, are covered. The current evidence for its use in primary headache disorders, such as some trigeminal autonomic cephalalgias, cough, hypnic, exertional or sexual headache, and migraine will be covered, as well as its indication for secondary headaches, such as those of posttraumatic origin.

CONCLUSION

Increasing understanding of the mechanism(s) of action of indomethacin will enhance our understanding of the complex pathophysiology that might be shared by indomethacin-sensitive headache disorders.

Effects of endurance exercise on serum concentration of calcitonin gene-related peptide (CGRP): a potential link between exercise intensity and headache

Background

Calcitonin gene-related peptide (CGRP) is a powerful neuropeptide that is strongly involved in headache pain pathogenesis by triggering vasodilation, mast cell degranulation and neurogenic inflammation. This evidence has prompted us to investigate the acute influence of endurance exercise on CGRP concentration in blood.

Methods

The study population consisted of 48 male amateur runners, who ran a half-marathon distance at 75%–85% of maximal oxygen uptake. Blood was drawn before the run (pre-run) and immediately after each runner ended his trial (post-run). The serum concentration of CGRP was measured with a commercial enzyme-linked immunosorbent assay (ELISA) technique.

Results

Overall, 22/48 subjects (45.8%) reported suffering from headache, three of whom (6.2%) had an exertional headache, whilst 26/48 (54.2%) subjects did not report at least one headache episode during the previous 6 months (i.e. headache-free). All 48 athletes successfully covered the 21.1 km distance. Serum concentration of CGRP significantly increased by 1.5-fold in the entire group, as well as in the headache-positive and headache-free cohorts. Univariate Spearman’s correlation revealed that post-run variation of serum CGRP was significantly and inversely associated with running time (r = −0.30; p = 0.036).

Conclusions

The serum concentration of CGRP is significantly enhanced by medium-distance endurance exercise and the post-exercise increase is dependent on running intensity. Accordingly, high-exercise intensity might be directly related to triggering both exertional headache and/or migraine episodes.

Other primary headaches-thunderclap-, cough-, exertional-, and sexual headache

This article reviews the disorders of thunderclap, cough, exertional and sexual headache. These are a group of paroxysmal and precipitated headaches, which often occur in bouts with prolonged remissions. Indometacin seems to be the most effective preventative. Each can occur in primary and secondary form. Thunderclap headache is the most frequently reported headache syndrome associated with a secondary pathology. Discussed are the complexities of whether all patients with thunderclap headache should have further investigation if timely computerised tomography is normal and, the relevance of abnormal imaging in these disorders, differentiating what is deemed to be secondary and managing the pain.

Assessing Appropriateness of CT and MRI Referrals for Headache and Lumbar: A Canadian Perspective on Patient-Centered Referrals

BACKGROUND

Inappropriate diagnostic imaging is a burgeoning problem within the Canadian healthcare system and imposes considerable burdens to efficiency and timeliness of care. Low back pain and headaches affect an immense portion of the general population and have become exceedingly common complaints from patients seeking diagnostic imaging from primary care physicians.

METHODS

A total of 399 magnetic resonance imaging (MRI) and computed tomography (CT) requisitions for lumbar and head scans were reviewed and assessed for appropriateness in concordance with published Choosing Wisely guidelines for head and lumbar diagnostic imaging. Requisitions were classified as appropriate, inappropriate, or incomplete. Baseline data collection showed 51.6% appropriateness, 12.0% inappropriateness, and 36.3% incompleteness. New patient-centered referral forms containing evidence-based red flags by Choosing Wisely Canada were created for head and lumbar MRI and CT. The aim was to increase awareness and consideration of the guidelines during the referral process. The new referrals were distributed among 149 local family physicians in addition to information pamphlets summarizing the need to reduce unnecessary diagnostic imaging for head and lower back pain.

RESULTS AND CONCLUSION

After collection and review of 251 requisitions in the postintervention period, incomplete referrals dropped from 36.3% to 13.15%. Despite insignificant changes in appropriateness, it is promising that the intervention educated local physicians on the information required to complete the CT or MRI forms as further evidence is provided showing the efficacy of the patient-centered referrals. This study provides insight on the importance of appropriate diagnostic imaging and what methods can be used at the primary care level.