Head and Neck Cancer-Related Pain: A Proposal for Unifying Diagnostic Category.

Primary headache syndromes may generally be distinguished as being either episodic, such as typical migraine or cluster headache, or chronic, such as chronic tension-type headache (CTTH) or hemicrania continua. In truth it is chronic headache, and most particularly chronic daily headache (CDH) in its various forms, that gives the sub-speciality of headache a bad name. Daily headache in all its manifestations probably effects 5% of the population (Scher et al ., 1998; Castillo et al ., 1999), of which about half is clear-cut, at least on clinical grounds, CTTH. If neurology is to take headache into the next century, as either necessity or interest dictate, then the common headache syndromes must be adequately understood and it is timely to think about daily headache. It is on this background that we can greet the positive observations that Olesen's group report in this issue of Brain (Ashina et al. , 1999 a ), and the similarly challenging therapeutic data recently reported in The Lancet (Ashina et al. , 1999 b ). Two fundamental issues need to be answered in regard to CTTH: the first is its nature or basis, and the second, related issue is how TTH should be handled in terms of nosology. This new work contributes in some measure to both questions. Crucial to any attempt to improve the management of CTTH in clinical practice is to develop an understanding of what the syndrome actually represents. The International Headache Society (IHS) Diagnostic Classification (Headache Classification Committee of the International Headache Society, 1988) sets out clear operational criteria, but they are essentially nihilistic. The IHS classification says more of what CTTH is not than of what it is: preferably …

Les céphalées chroniques quotidiennes de l’enfant et de l’adolescent

To the Editor

A strict relationship between migraine and psychiatric factors has been suggested, but the exact role and the influence on evolution of headache is unknown. The most frequent diagnosis was a comorbidity of anxiety and mood disorders. The comorbidity of psychiatric disorders and headache has important implications as far as treatment is concerned. In comparing DSM-V, ICHD-3β and ICD10 criteria on headache and psychopathology, diagnostic criteria agree on pre-existing headache with the characteristics of a primary headache disorder becoming chronic, or made significantly worse, in close temporal relation to a psychiatric disorder, both in the initial headache diagnosis and psychiatric diagnosis. Headache attributed to psychiatric disorder should be given, provided that there is good evidence that that disorder can cause headache. When a causal relationship cannot be confirmed, the pre-existing primary headache and the psychiatric disorder are diagnosed separately. Thus, the diagnostic categories are limited to those few cases in which a headache occurs in the context and as a direct consequence of a psychiatric condition known to be symptomatically manifested by headache. Diagnostic criteria must be restrictive enough not to include false positive cases, but must set the threshold low enough to admit the majority of affected patients. Headache disorders occur coincidentally with a number of psychiatric disorders. Although criteria for headaches attributed to psychiatric disorders have suggested that headache occurring exclusively in association with several common psychiatric disorders, such as, depressive, anxiety and trauma/stress-related disorders, might be considered as attributed to these disorders, because of uncertainties concerning the causal relationships and relative lack of evidence in this context. Evidence suggests that the presence of a comorbid psychiatric disorder tends to worsen the course of migraine and/or tension-type headache by increasing the frequency and severity of the headache and/or making it less responsive to treatment. Thus, identification and treatment of any comorbid psychiatric condition is important for the proper management of these headaches. It should be noted that somatization disorder per se is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), it has been replaced by the category Somatic Symptom Disorder, characterized by one or more somatic symptoms. Thus, ICHD-3 beta continues to refer to the DSM-IV definition of somatization disorder. Using WHO's criteria and methods for measuring burden of disease in DALYs, headache disorders can be placed correctly in the context of other mental and neurological disorders and other chronic illnesses. In order to know the full burden attributable to headache disorders, however, further epidemiological work must be conducted around the world and this must encompass assessments of clinical, economic and humanistic impacts.

Central and peripheral mechanisms in chronic tension-type headache

Prise en charge des céphalées chroniques quotidiennes chez l’enfant et l’adolescent

ObjectiveTo investigate the frequency of diagnoses seen among new referrals to neurology outpatient services; to understand how these services are used through exploratory analysis of diagnostic tests and follow-up appointments;...

The purpose of this study was to test the feasibility and usefulness of the International Classification of Headache Disorders, third edition, beta version (ICHD-3β), and compare the differences with the International Classification of Headache Disorders, second edition (ICHD-2). Consecutive first-visit patients were recruited from 11 headache clinics in Korea. Headache classification was performed in accordance with ICHD-3β. The characteristics of headaches were analyzed and the feasibility and usefulness of this version was assessed by the proportion of unclassified headache disorders compared with ICHD-2. A total of 1,627 patients were enrolled (mean age, 47.4±14.7 yr; 62.8% female). Classification by ICHD-3β was achieved in 97.8% of headache patients, whereas 90.0% could be classified by ICHD-2. Primary headaches (n=1,429, 87.8%) were classified as follows: 697 migraines, 445 tension-type headaches, 22 cluster headaches, and 265 other primary headache disorders. Secondary headache or painful cranial neuropathies/other facial pains were diagnosed in 163 patients (10.0%). Only 2.2% were not classified by ICHD-3β. The main reasons for missing classifications were insufficient information (1.6%) or absence of suitable classification (0.6%). The diagnoses differed from those using ICHD-2 in 243 patients (14.9%). Among them, 165 patients were newly classified from unclassified with ICHD-2 because of the relaxation of the previous strict criteria or the introduction of a new diagnostic category. ICHD-3β would yield a higher classification rate than its previous version, ICHD-2. ICHD-3β is applicable in clinical practice for first-visit headache patients of a referral hospital.

Reports suggest pain is common in head and neck cancer (HNC). However, past studies are limited by small sample sizes and design and measurement heterogeneity. Using data from the Head and Neck 5000 longitudinal cohort, we investigated pain over a year post-diagnosis. We assessed: temporal trends; compared pain across HNC treatments, stages, sites and by HPV status; and identified subgroups of patients at increased risk of pain. Sociodemographic and clinical data and patient-reported pain (measured by EORTC QLQ-C30 and QLQ-H&N35) were collected at baseline (pre-treatment), 4- and 12- months. Using mixed effects multivariable regression, we investigated time trends and identified associations between (i) clinically-important general pain and (ii) HN-specific pain and clinical, socio-economic, and demographic variables. 2,870 patients were included. At baseline, 40.9% had clinically-important general pain, rising to 47.6% at 4-months and declining to 35.5% at 12-months. HN-specific pain followed a similar pattern (mean score (sd): baseline 26.4 (25.10); 4-months. 28.9 (26.55); 12-months, 17.2 (19.83)). Across time, general and HN-specific pain levels were increased in: younger patients, smokers, and those with depression and comorbidities at baseline, and more advanced, oral cavity and HPV negative cancers. There is high prevalence of general pain in people living with HNC. We identified subgroups more often reporting general and HN-specific pain towards whom interventions could be targeted. Greater emphasis should be placed on identifying and treating pain in HNC. Systematic pain screening could help identify those who could benefit from an early pain management plan.

The present study sought to derive an algorithm using factor analysis and structural equation modeling (SEM) to describe headache and orofacial pain patients using measures of behavioral and psychological functioning. This investigation further examined whether the underlying factor structure differed in 3 presumed distinct diagnostic categories: myofascial, neuropathic, and neurovascular pain. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Multidimensional Pain Inventory (MPI), Beck Depression Inventory-II (BDI-II), and visual analog scale for functional limitation (VAS-FL) were administered to the subjects. A split group design was used. Exploratory factor analysis (EFA) was used to describe distinct factor domains in the first group. Confirmatory factor analysis (CFA) using SEM tested this structure in the second group and described causal relationships between the revealed (latent) factors. Analysis of variance (ANOVA) was used to test for differences in demographic variables and diagnostic group factor structure. The Pain Center is a comprehensive, multidisciplinary pain medicine program at Cedars-Sinai Medical Center, Los Angeles, California. Three hundred and ninety (N = 390) subjects were assigned to 1 of 3 diagnostic categories: myofascial pain syndrome, neuropathic pain, or neurovascular pain. EFA revealed a 3-factor solution. The factors were labeled Depression, Illness Conviction, and Pain Impact, reflecting the content of their respective variables with highest loadings. CFA using SEM validated the 3-factor solution, and further revealed that Depression was a critical causal factor determining Illness Conviction and Pain Impact. No causal relationship was observed between Illness Conviction and Pain Impact. ANOVA found no differences in demographics. No difference in factor structure emerged for the 3 diagnostic categories. Analysis derived a 3-factor solution. The factors were Pain Impact, Illness Conviction, and Depression. SEM revealed the critical causal pathway showing that Depression determined Illness Conviction and Pain Impact. We conclude that the main target for pain treatment is depression. No differences in factor structure were found for the 3 diagnostic categories of myofascial, neuropathic, or neurovascular pain. This suggests that psychological processes are similar in chronic headache and orofacial pain patients despite their presumed distinct underlying pathophysiological mechanisms. SME is a powerful methodology to construct causal models that has been underutilized in the pain literature.

IntroductionSince the response of spouses has been proven to be an important reinforcement of pain behaviour and disability it has been addressed in research and therapy. Fordyce suggested pain behaviour...

Pain is a common symptom of head and neck cancers. In some instances, pain may not resolve with conventional modalities and become refractory. Chemical neurolysis is a technique that utilizes chemical neurolytic agents to temporarily denervate a targeted nerve and provide relief in pain-related symptoms. The aim of this investigation was to determine the effectiveness, safety, and predictors of chemical neurolysis procedures for management of refractory head and neck cancer-related pain. A retrospective chart review of patients who underwent chemical neurolysis procedure in the regions of head and neck for management of head and neck cancer-related pain was conducted between November 2017 and November 2018. All adult male and female patients who had undergone chemical neurolysis procedure in the head and neck region for management of refractory head and neck related pain, in Orofacial Pain Clinic, Shaukat Khanum Memorial Cancer Hospital and Research Center were included in the investigation. Among 33 participants enrolled, 72.7% of participants experienced 75% or greater relief in pain at the 1-month follow-up. However, 9.1% reported experiencing an adverse effect following neurolysis. A statistically significant association was found between neurolysis effectiveness and chronicity of pain. Chemical neurolysis can provide significant relief to patients with refractory head and neck cancer-related pain as an adjunctive therapy. However, it was found to be associated with mild risk of manageable adverse effects. Shorter chronicity of pain was found to be associated with successful outcome.

Philosophers, scientists and physicians alike have commented on the relationship of stress and headache for centuries. Many have attributed the onset or exacerbation of headache to a variety of stress-related emotional and cognitive states including suppressed anger (Junkerius, 1743), mental anxiety (Airy, 1870), repression and conversion (Breuer and Freud) or resentment and dissatisfaction (Wolff) (1,2). The 1970s ushered in several decades of well-designed, rigorous, interesting studies into the relationship of stress and many medical conditions including primary headache disorders. Today stress is well established as playing a significant role in headache. Both retrospective and prospective studies support the relationship as well as stress induction procedures and recent imaging research. In the current issue of Cephalalgia, Schramm and colleagues offer an intriguing new study to add to this rich, long, and ever expanding body of research (3). Assessing the relationship of stress and headache is complex and multifaceted. The term ‘‘stress’’ itself has been defined and measured in many different ways, using a variety of study designs, over a range of time periods. Stress can be operationalized as the objective occurrence of challenging, unpleasant or threatening events (e.g. major life events or daily hassles), in subjective ratings measuring perception and appraisal, or on the level of biology, using physiologic measures such as autonomic reactivity and cortisol levels. The relationship of stress, headache disorders and headache/migraine attacks may take various forms (4). Among hypotheses that have been proposed and tested, stress has been conceptualized as an etiologic factor, contributing to the first onset of a primary headache disorder. It has been seen as an exacerbating factor, associated with increasing headache/migraine attack frequency, severity or duration in individuals with a pre-existing headache disorder. And stress (and relaxation after stress) has been viewed as a trigger increasing the probability of a headache/migraine attack. In the case of migraine, it has been proposed that the perception of events and situations as stressful may be a result of changes in brain structure and function that are the result of experiencing migraine (5,6). Recent research also suggests that the perception of stress may be a premonitory symptom of an attack (7). In the current study, Schramm and colleagues measured perceived stress and linked it to both the presence of primary headache subtypes and the frequency of days with headache. Using data from the German Headache Consortium longitudinal population-based study of citizens from three different German regions, researchers asked 5159 participants to rate their perceived stress over the preceding three months using a visual analog scale with scores ranging from 0 (lowest) to 100 (highest). They repeated assessments every three months for a period of two years. They gathered data necessary to classify respondents into one of five diagnostic categories based on International Classification of Headache Disorders, second edition criteria (8): migraine or probable migraine (14.0%), tension-type headache (TTH) or probable TTH (31.0%), migraine with coexisting TTH (10.6%), ‘‘unclassifiable headache’’ (23.6%) and no headache (20.8%).

SYNOPSISForty, daily headache patients were divided into two diagnostic categories ‐ chronic scalp muscle contraction headache alone and chronic scalp muscle contraction headache associated with analgesic rebound. Electromyographic readings from the frontalis muscle and personality data from selected scales of the MMPI served as comparison variables between the two groups.A second part of the study divided these headache patients into a high muscle tension group (the ten patients with the highest frontalis muscle readings) and a low muscle tension group (the ten patients with the lowest frontalis reading). This division was made regardless of the original group membership. Personality data in these two groups were compared.Results provided information regarding the relationship between the amount of medication taken by the patient, their degree of psychopathology as measured by the MMPI, and the amount of muscle tension recorded. Suggestions for future research projects were made.

SYNOPSISMMPI' were obtained from 258 untreated headache patients, of whom 113 were males and 145 females. The diagnostic headache categories included: 1. Migraine alone; 2. Chronic scalp muscle contraction headache (SMC); 3. Combination headache (migraine and SMC); 4. Cluster headache; 5. Post‐traumatic cephalgia (P‐T); 6. conversion cephalgia.Mean scores of the validity and clinical scales were calculated and compared between diagnostic categories; males considered separately from females. As a result of this comparison, three significantly distinct groups, two categories per group, were obtained; Group A, migraine and cluster; Group B, SMC and combination headaches; Group C, P‐T and conversion cephalgia. This grouping applied to women and men similarly.In a spectrum of from most normal to most neurotic patterns, Group A was followed by Groups B and C respectively. Significant "conversion v" patterns were found in women with SMC, P‐T, and conversion cephalgia, and in men with combination headache.In an effort to determine the predictability of correct diagnoses from MMPI patterns, selective criteria were generated and tested in a blind fashion using an additional 83 coded MMPI'. The accuracy of predictability exceeded the .001 level.