Diagnosis and management of headache disorders in osteopathic practice: A qualitative study

The diagnosis and management of headache disorders in the elderly are challenging. The evaluation of the elderly patient with new-onset or recurrent headache requires a grasp of the heterogeneous set of causes of secondary head pain disorders. Once such aetiologies are excluded, the correct primary headache disorder must be diagnosed. Although tension-type headache is the leading cause of new-onset headache in the elderly, other primary headache disorders such as migraine can manifest in later life, and one disorder, hypnic headache, occurs almost exclusively in the elderly. Primary chronic daily headache persists in elderly patients to a greater extent than the primary episodic headache disorders do. The treatment of elderly patients with primary headache disorders is multifaceted, including acute, prophylactic and at times transitional treatments. Knowledge of drug interactions is particularly important as polypharmacy is the rule. Concomitant illnesses may require adjustments in choice or dose of drugs. In addition, as many acute and preventive treatments are either contraindicated or poorly tolerated in the elderly, modifiable risk factors for headache progression and perpetuation must be addressed. In spite of these treatment complexities, there are numerous opportunities to bring relief to older patients with primary headache disorders from the currently available therapies. New treatment options for elderly patients with headache will soon be available, including acute, prophylactic and interventional techniques.

A headache is defined as “pain found in the head above the orbito-meatal line and or nuchal ridge” and widely affects both males and females globally. Chiropractic treatment and the management of headaches is substantial, with one in five new patients’ chief complaint being a headache and, thus, the use of chiropractic care in the management and treatment of headaches is popular. The term “self-perceived preparedness” refers to how people view themselves in terms of confidence and competency with regard to certain skills. Self-perceived preparedness is essential as it relates to one’s confidence and the ability to accurately diagnose and manage headache disorders. There is a definite scarcity in South African literature as to the self-perceived preparedness of students in the diagnosis and management of headache disorders. In a South African chiropractic context, the literature, with regard to students’ confidence, awareness and self-assessment of skills is lacking. There are a number of advantages that can come from exploring the concept of self-perceived preparedness. The benefits include, but are not limited to, the assessment of whether or not the curricula goals have been achieved, the readiness of chiropractic students to confidently and correctly diagnose and manage patients sufficiently, and the different aspects that can lead to one feeling unprepared. Aim The aim of this study was to explore and describe the self-perceived preparedness of the chiropractic students’ in the diagnosis and management of headache disorders. Methodology This study design employed a qualitative, explorative and descriptive design. Purposeful sampling was utilised and individual, semi-structured interviews were conducted with 13 Master’s degree students in the chiropractic programme. These interviews took place “in person” and an interview guide was utilised in each interview. The interviews were conducted over a week from the 18th to the 23rd of September 2023. The questions surrounded the topics of self-perceived preparedness, confidence, challenges (whether educational or personal) and the effect of clinical exposure on one’s confidence and skills. The interviews were analysed and themes were extracted utilising Tesch’s eight-step approach of data analysis. Results The chief themes that emerged from the data collection included the level of preparedness, educational and environmental challenges, as well as the positive role that clinical exposure had on students’ views of their self-perceived preparedness. The participants felt largely unprepared to deal clinically with headache disorders. This stemmed from the feeling of isolation within academia, lack of support from staff and clinicians, lack of practical aspects within the curriculum and the COVID-19 pandemic, which resulted in a lack of in-person interaction. Conclusion The findings of this study highlighted the lack of confidence and feeling of under-preparedness to deal with headache disorders within a clinic setting by chiropractic Master’s students. This was mainly attributed to educational and environmental challenges. However, the exposure students gained within a clinical environment greatly improved their feeling of overall self-perceived preparedness

There have been no prior studies assessing the status of undergraduate headache training and education in Singapore. Unmet needs of undergraduate medical students in terms of knowledge-practice gaps pertaining to diagnosis and management of headache disorders are unknown. The possible underemphasis of this aspect of the curriculum as compared to other chronic conditions such as diabetes mellitus has also not been ascertained. The aim of this article is to assess the knowledge base and perceptions, thereby identifying the unmet needs of headache disorder education in undergraduate medical students. Students reported their perceived time that was devoted to the subject matter and this was recorded and reported. In order to provide a comparative indication on the level of prioritization, the total duration within the syllabus dedicated to headache education vs other chronic diseases (using diabetes mellitus as a surrogate) was sought. A comprehensive survey consisting of questions assessing the headache curriculum, knowledge, and perceptions was developed. The questionnaire was distributed to final year medical students attending a full-day Neurology review course in their last semester. Attendees were given the duration of the course to complete the questionnaire, and forms were collected at the end of the day. About 127 final year medical students completed our survey. More than half (55.1%) did not receive formal teaching on how to take a complete headache history. The majority (90.6%) have not attended a headache sub-specialty clinic. The mean total number of hours exposed to headache disorders was 5.69h (SD ± 5.19). The vast majority (96.1%) were unfamiliar with locally published clinical practice guidelines, and a significant proportion (74.0%) were unfamiliar with the third edition (beta) of the International Classification of Headache Disorders. Nearly half (47.2%) were unfamiliar with 'medication overuse headache' as a disease entity. Only one (0.8%) respondent was able to correctly classify all listed primary and secondary headache disorders correctly. Only 37.0% were able to identify all 4 indications (headaches that were new, worsening, and unresponsive to treatment or associated with neurological symptoms) that warranted neuroimaging in a patient with a pre-existing diagnosis of migraine. The antidepressants were the most frequently reported incorrect option for the abortive treatment of migraine (16.5%). Nearly one-fifth (18.9%) were unable to name a single abortive treatment correctly, while a significant proportion (39.4%) could not identify a single correct prophylactic migraine treatment. A large proportion (62.2%) opined that their exposure to 'headache diagnosis and management' was inadequate, with a minority (3.1%) being 'very comfortable' in the diagnosing migraine. A significant proportion felt uncomfortable in treating special population groups diagnosed with migraine - pregnant (79.5%), elderly (48.0%), those with cardiac conditions (51.2%). The current medical undergraduate curriculum on headache disorders in Singapore may harbor significant unmet needs. A review of the syllabus to increase headache education may be one method to address this gap. Further studies in this area are required.

Introduction: Headache disorders are among the most common health conditions worldwide, with a significant global burden, particularly from primary headaches such as migraine and tension-type headache (TTH). In Nepal, the prevalence of headache disorders is high, with a considerable portion of the population affected by these conditions. Primary headache disorders have been shown to negatively impact the quality of life (QoL) of individuals, both physically and mentally. Objective: This study aimed to assess the quality of life in patients diagnosed with primary headache disorders, including migraine, TTH, and other related conditions, at the Tribhuvan University Teaching Hospital in Nepal. Materials and methods: An observational descriptive cross-sectional study design was used, with a sample size of 211 patients diagnosed with primary headache disorders. Participants were selected using a non-probability convenience sampling method. A structured questionnaire was administered to collect demographic, clinical, and QoL-related data. The Quality of Life was measured using the Short Form (SF-36) questionnaire, which provides two key summary measures: the Physical Component Summary (PCS) and Mental Component Summary (MCS). Data was analyzed using SPSS Version 29, employing descriptive statistics, independent t-tests, ANOVA, and multiple linear regression to identify associations and predictors of QoL. Results: Preliminary results indicate that primary headache disorders significantly impair both the physical and mental health of affected individuals, as evidenced by lower PCS and MCS scores. Factors such as age, duration of illness, type of headache disorder, and medication use were identified as key determinants influencing the quality of life in these patients. Conclusion: The findings of this study highlight the substantial impact of primary headache disorders on the quality of life of individuals. Understanding the factors that contribute to the reduced QoL in these patients is crucial for developing effective interventions and improving the management of primary headache disorders in Nepal.

A growing number of clinical trials are testing Chinese acupuncture in the management of headache disorders. Little is known, however, about the relationship between International Headache Society diagnostic criteria and traditional Chinese medicine (TCM) diagnosis in primary headache disorders. We conducted a secondary analysis of the data of the prospective, controlled, blinded German acupuncture trials for migraine and tension-type headache. Data were collected from 1042 headache patients, of whom 633 were diagnosed with migraine and 409 with tension-type headache. We found that the diagnoses of migraine and tension-type headache were mirrored by different patterns of TCM diagnoses, with the patterns Liver Yang Rising, Liver Fire Rising, and Phlegm appearing to be best suited to differentiating between migraine and tension-type headache. Although not unexpected, given that the diagnosis of primary headache disorders in both diagnostic systems is based largely on the nature and quality of patient-reported symptoms, this finding suggests that migraine and tension-type headache are associated with different patterns of TCM diagnosis.

International Classification of Headache Disorders

To explore the self-perceived preparedness and clinical proficiency in headache diagnosis and management of Australian chiropractic students in senior years of study. Australian chiropractic students in the 4th (n = 134) and 5th year (n = 122) of 2 chiropractic university programs were invited to participate in an online cross-sectional survey. Descriptive analyses were conducted for all variables. Post hoc analyses were performed using simple linear regression to evaluate the relationship between self-perceived preparedness and correctness of headache diagnosis and management scores. Australian chiropractic students in senior years demonstrated moderate overall levels of self-perceived preparedness and proficiency in their ability to diagnose and manage headache disorders. Final-year students had a slightly higher self-perceived preparedness and proficiency in headache diagnosis and management compared to those students in the 4th year of study. There was no relationship between self-perceived preparedness and correctness of headache diagnosis and management for either 4th- or 5th-year chiropractic students. Our findings suggest that there may be gaps in graduate chiropractic student confidence and proficiency in headache diagnosis and management. These findings call for further research to explore graduate chiropractic student preparedness and proficiency in the diagnosis and management of headache disorders.

Botulinum neurotoxin for the treatment of migraine and other primary headache disorders

The WHS classification of Head, Neck and Face pain, Edition 1 Version 1 (WHS-MCH1) is the official document of the World Headache Society. It was conceptualized and developed by the Society’s Classification Committee. The work began with a clean slate to create a comprehensive, updated and holistic classification of headache disorders; where ‘headache’ was defined as any pain above the shoulders, thus including head, neck and face pain. This new classification reflects a scientifically robust understanding of disease and also places patient experience in the qualia of pain. It is a training manual to be used at the bedside and office as an aid to the diagnosis and management of headache disorders. The dynamic nature of this first ever live classification of headaches also means that ultra-rapid updates, or versions, will be available electronically. It is not a disease criteria but a classification criteria (1) and is useful to pick extended spectra and ‘mimickers’ of diseases. Although increased sensitivity usually comes at the expense of reduced specificity, an expanded spectrum of diseases in this case also means increased specificity. WHS-MCH1 is a syndromic classification. A syndrome is a recognizable complex of symptoms and physical findings which may have more than one aetiology. Although disease is nominalist and culture-relativistic (2), a syndrome based approach reflects the discipline of first widening the view of possibilities before analysing each to formulate a diagnostic hypothesis. Such an approach provides a useful framework for organizing the complexity of clinical experience in order to derive inferences about outcome and guide decisions about treatment. WHS-MCH1 has a vertical grouping designed for use by clinicians of all levels of experience; this is linked to the horizontal groupings which are syndrome-based. The syndrome groups are also interlinked to one another. This design enables clinicians to efficiently create the ‘big picture’ so as not to miss any diagnosis. Axis 1 and 2 are the vertical and horizontal grouping categories, respectively. Axis 3 is the patient narrative of bothersome symptoms and level of impairment. Axis 4 are biomarkers that may be derived from investigations and this is the best example of the continuum of better understanding of disease-defining markers. Axis 5 is an objective impairment scale that clinicians may choose based on availability. The World Headache Society hopes that the use of such a robust and inclusive framework will lead to better patient outcomes and improved patient and clinician satisfaction with the investigative and diagnostic process. Keywords: Classification; Syndromes; Headache disorders; Neck pain; Facial pain; Aaxis classification; Head pain; Face pain; Headache; Multiaxis

Primary headache disorders are often accompanied by neck pain or other symptoms referable to neck muscles. Therefore, physical therapy and other physical treatments are commonly prescribed for headache management. A medical literature review was completed in order to gather information regarding the efficacy of selected physical modalities in the treatment of primary and cervicogenic headache disorders. After analyzing the collected data, expert opinions were developed regarding the utility and efficacy of selected physical modalities in the management of primary and cervicogenic headaches. Based on this review, the following four expert opinions are presented: physical therapy is more effective than massage therapy or acupuncture for the treatment of tension-type headache and appears to be most beneficial for patients with a high frequency of headache attacks. Physical therapy is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training and exercise. Chiropractic manipulation demonstrated a trend towards benefit in the treatment of tension-type headache, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache than it is in the treatment of migraine. In general, strong evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality. Physical treatments are unlikely to pose a significant risk, with the exception of high velocity chiropractic manipulation of the neck. Consideration must be given to financial costs and lost treatment opportunity by prescribing potentially ineffective treatment. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management. In most cases, the use of physical modalities should complement rather than replace better validated forms of therapy. The evidence base to determine the safety and efficacy of physical treatments in the management of headache disorders would be substantially improved by using standard scientific rigor in the development and conduct of future clinical studies.

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

Establishing an open and honest physician-patient relationship is essential for the proper evaluation and management of headache disorders. Obtaining a complete headache and medical history is the most important part of the initial diagnostic evaluation. This history should include information about headache onset, pain intensity, character of the pain, presence of aura, associated autonomic symptoms, and trigger factors. Special attention must be paid to the frequency of analgesic use, both prescription and over-the-counter, to identify analgesic rebound headache. A thorough neurologic examination must also be performed; if it is normal, there is usually no need for special tests. Headaches are classified as either primary or secondary. Primary headaches have no structural or metabolic cause, while secondary headaches are caused by an underlying pathologic or metabolic process. Migraine, tension-type, cluster, and analgesic-rebound headaches are all primary headache disorders. Secondary headaches are caused by conditions such as increased intracranial pressure, pseudotumor cerebri, subdural and intracerebral hematomas, hypertension, meningitis, temporal arteritis, Lyme disease, and brain tumors. Accurate diagnosis of headache is essential to determine the appropriateness of further testing and to guide proper treatment of the patient's condition.

To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature. Review of the most current and relevant headache literature for practitioners specializing in geriatric care. Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging. The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

NICE has developed guidelines on management of primary headache disorders in young people and adults.1 The guideline is intended for non-specialist use, particularly for use in primary care where the majority of headaches can be safely diagnosed and managed. Four per cent of adults have a primary care consultation for headache per year2 but GPs lack confidence in the diagnosis and management of primary headache disorders, and can be anxious about missing serious secondary causes.3 Improved recognition of the common headache disorders and better targeting of available treatments should reduce the burden of headache without requiring substantial additional resources. If specialist advice is required the guideline recommends that this can be via a neurologist or GP with a special interest in headache. The guideline lists signs, symptoms, and possible conditions that should be considered before proceeding to a diagnosis of a primary headache disorder (Box 1). #### Box 1. Signs and symptoms to suggest possibility of secondary headache Caution should be exercised if patients have a history of malignancy, particularly if they are aged <20 years, or have had cancer that may metastasise to the brain. The possibility of central nervous system infection in immunocompromised patients or of HIV-associated neurological disease should be considered where appropriate. The guideline includes recommendations on medication-overuse headache. This is headache that has developed or worsened after taking acute treatments for headache regularly for ≥3 months. It is thought that using triptans, …

To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders. PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice. The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010-2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology. PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication-overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache. These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.