Headache Management in Military Primary Care: Findings from a Nationwide Cross-Sectional Study

AimPrimary headache disorders such as migraine and tension-type headache are highly prevalent in military populations and may severely impact operational performance and readiness. Despite this, data from many European armed forces are lacking. This study investigates headache phenotypes, diagnosis, treatment and functional impairment in active-duty personnel of a major European military organization.MethodsThis cross-sectional cohort study utilized an anonymous 33-item online questionnaire distributed across military medical centers in Germany between May and July 2023. The survey assessed demographics, headache types according to the International Classification of Headache Disorders, 3rd edition (ICHD-3), diagnostic awareness, treatment history and headache-related disability using the Migraine Disability Assessment Score (MIDAS).ResultsOf the 1189 participants, 914 (77%) completed the survey. Among them, 839 (94.9%) reported experiencing headaches in the past 12 months. Based on ICHD-3 criteria, 227 individuals (27.1%) met the complete set of criteria for migraine, while 246 (29.2%) were classified as probable migraine. Tension-type headache was reported by 222 respondents (26.5%), and cluster headache was resported by 34 (4.1%). Notably, 61.4% of participants had never received a formal diagnosis and only 38.6% had ever sought medical care for their headaches. Functional impairment was substantial: 63.8% reported losing at least one workday in the past three months due to headache. Among those with migraine, an average of 3.9 workdays per month were lost. Despite this burden, only 27.3% of individuals with migraine had ever used preventive medication.ConclusionsPrimary headache disorders are common, underdiagnosed and inadequately treated in this military population, leading to significant functional and operational impairment. Our findings underscore the urgent need for improved screening, diagnosis and evidence-based treatment strategies in uniformed health systems. The results may inform similar efforts in other military and high-demand occupational settings.

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.

1. Heidi K. Blume, MD, MPH 1. Division of Pediatric Neurology, Seattle Children’s Hospital and Research Institute, Seattle, WA. * Abbreviations: CSF: : cerebrospinal fluid ICH: : intracranial hemorrhage ICP: : intracranial pressure IIH: : idiopathic intracranial hypertension NDPH: : new daily persistent headache NSAID: : nonsteroidal anti-inflammatory drug SVT: : sinus venous thrombosis TAC: : trigeminal autonomic cephalalgia Headaches are common in children; while most are caused by a benign problem or primary headache disorder, headaches can be a sign of a serious underlying condition. Pediatricians must be aware of the most recent recommendations for evaluating and managing headaches. After reading this article, readers should be able to: 1. Understand the evaluation of a child who has headache. 2. Recognize the diagnostic criteria for pediatric migraine. 3. Recognize “red flags” for elevated intracranial pressure or other underlying conditions in the child who has headache. 4. Discuss treatment strategies for migraine, tension, and chronic headache disorders. Headaches are common in children and adolescents and are a frequent chief complaint in office and emergency department visits. The vast majority of childhood headaches are due to a primary headache disorder, such as migraine, or an acute, relatively benign process, such as viral infection. However, clinicians also need to consider other causes of headaches in children. Even when headaches are benign, they may cause significant dysfunction for the child and family and must be managed appropriately to minimize disability and optimize function. In this review, we discuss the epidemiology of childhood headache, evaluation of the child who has headaches, when to consider secondary headache syndromes, and the diagnosis and management of primary headache disorders such as migraine and tension-type headaches. Acute and chronic headaches are relatively common in children and adolescents, although estimates of the precise prevalence of headache and migraine vary widely. Depending on the study definition of headache, population involved, and time periods studied, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. (1 …

Many headache patients complain of poor sleep, and sleep disturbance has been shown to play a role in chronic pain. We recorded nocturnal sleep with a 4-channel cassette EEG monitoring device in 10 common migraine patients, 10 individuals with muscle contraction (tension) headache, and 10 chronic tension-vascular headache sufferers. Migraine patients had essentially normal sleep, although rapid eye movement (REM) sleep and REM latency were increased. Patients with tension headache had reduced sleep time and sleep efficiency, decreased sleep latency but frequent awakenings, increased nocturnal movements, and marked reduction in slow wave sleep, without change in REM sleep or latency. Mixed-element headaches with both tension and vascular features were associated with reduced sleep, increased awakening, diminished slow wave sleep, and REM sleep that was decreased in amount and reduced in latency. The findings suggest that patients with intermittent migraine may have minimal sleep disturbance, while chronic headache may be worsened by chronically poor sleep. Muscle contraction headache may be associated with frequent awakenings and decreased slow wave sleep similar to the sleep changes of fibrositis, while chronic tension-vascular headache may have a depressive substrate. Four-channel sleep recording may miss contributory sleep apnea, but nonetheless cassette EEG may facilitate outpatient evaluation of refractory headaches.

This research utilized a cross-sectional design secondarily analyzing data from active duty military health care personnel who anonymously completed the "2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel." Sample for this analysis of Operation Iraqi Freedom/Operation Enduring Freedom deployed mental health seeking service members was N = 447. Religiosity/spirituality and psychological distress experienced by active duty military personnel who sought help from military mental health providers (MH), military chaplains (CHC) or both (CHC & MH) were explored and compared. Greater psychosocial distress seen in the CHC & MH group could be a reflection of a successful collaborative model for mental health care that is currently promoted by the military where chaplains are first line providers in an effort to provide services to those in greatest need and ultimately provide them with care from a trained mental health professional. Research and evaluation of chaplain training programs and collaborative models is recommended.

BackgroundSince 2020, several specialized follow-up outpatient clinics have been established across Germany to address the complex needs of patients with Long COVID/ Post-COVID-19 Condition (PCC). This article reviews the current landscape of these specialized clinics in Germany and critically evaluates their diagnostic and treatment algorithms.MethodsThis study employed a mixed-method approach, combining publicly available information on post-COVID-19 outpatient clinics with an observational cross-sectional online survey among lead doctors of PCC follow-up outpatient clinics in Germany. The survey was conducted from November 2023 to January 2024. Descriptive statistics and t-tests for group-comparisons were employed, with statistical significance set at p < 0.05.ResultsAt the time of the survey, 112 specialized PCC outpatient clinics were identified in Germany through publicly available information. Forty-five PCC outpatient clinic lead doctors (40.2%) responded to our survey. Treatment of PCC patients is personalized and symptom-oriented rather than standardized. Patient characteristics of the two identified main treatment domains, focusing on respiratory and neurocognitive symptoms, differed only in sex distribution. A higher proportion of females (63.9%) presented with pulmonary symptoms compared to patients with neurocognitive impairments (50.2%, p < 0.05). The level of distress among patients is generally perceived as high and outpatient clinic lead doctors are convinced that their outpatient counseling services offer significant benefits.ConclusionsAs the demand for PCC follow-up outpatient clinics persists, the establishment of new services continues, particularly to address the growing need for neurocognitive care services. PCC outpatient care is currently personalized and symptom-orientated, leading to high variability across clinics. Further standardization of treatment protocols and diagnostic algorithms could improve patient care and facilitate professional exchange.

Background Since 2020, several specialized follow-up outpatient clinics have been established across Germany to address the complex needs of patients with Long COVID/ Post-COVID-19 Condition (PCC). This article reviews the current landscape of these specialized clinics in Germany and critically evaluates their diagnostic and treatment algorithms. Methods This study employed a mixed-method approach, combining publicly available information on post-COVID-19 outpatient clinics with an observational cross-sectional online survey among lead doctors of PCC follow-up outpatient clinics in Germany. The survey was conducted from November 2023 to January 2024. Descriptive statistics and t-tests for group-comparison were employed, with statistical significance set at p &lt; 0.05. Results At the time of the survey, 112 specialized PCC outpatient clinics were identified in Germany through publicly available information. Forty-five experts (40.2%) responded to our survey. Treatment of PCC patients is personalized and symptom-oriented rather than standardized. Patient characteristics of the two identified main treatment domains, focusing on respiratory and neurocognitive symptoms, differed only in sex distribution. A higher proportion of females (63.9%) presented with pulmonary symptoms compared to patients with neurocognitive impairments (50.2%, p &lt; 0.05). The level of distress among patients is generally perceived as high and outpatient clinic lead doctors are convinced that their outpatient counseling services offer significant benefits. Conclusions As the demand for PCC follow-up outpatient clinics persists, the establishment of new services continues, particularly addressing the growing need for neurocognitive care services. PCC outpatient care is currently personalized and symptom-orientated, leading to high variability across clinics. Further standardization of treatment protocols and diagnostic algorithms could improve patient care and facilitate professional exchange.

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

Introduction. Chronic headache, including migraine and tension-type headache, affects a significant proportion of the population worldwide, posing a serious challenge to the healthcare system. Although diagnostic techniques are constantly improving, the definition of chronic primary headache remains a challenging task. Aim. To evaluate the effectiveness of integrating specialized scales and questionnaires to improve the diagnosis and prognosis of chronic tension-type headache and chronic migraine. Materials and methods. The study included 61 individuals diagnosed with “Chronic Tension Headache” (CTH) or “Chronic Migraine” (CM) (according to the International Classification of Headache-3), and 18 individuals control group without chronic headache. All patients underwent a clinical and neurological examination and assessment using scales and questionnaires that determined the qualitative and quantitative characteristics of pain, concomitant symptoms, and quality of life of patients. To determine the discriminatory ability of the questionnaires used in the study for differentiating between CTH and CM, a correlation analysis and ROC curve were conducted. Results. The study revealed mainly strong direct correlations between the results of the McGill pain questionnaire (MPQ), the headache severity questionnaire НIT-6, the hospital anxiety and depression scale (HADS) and the visual analogue scale (VAS) in patients. A direct relationship was determined between the intensity of pain on the visual analogue scale and the HIT-6 score. The best operational characteristics (the highest sensitivity and specificity, AUC) were: the headache severity questionnaire HIT-6 (Se=96.67%; Sp=96.77%; AUC=0.990; p&lt;0.01); MPQ: motivational-affective component (Se=100%; Sp=87.1%; AUC=0.990; p&lt;0.01); visual analogue scale (Se=90%; Sp=96.77%; AUC=0.981; p&lt;0.01); and the McGill pain questionnaire: sensory-discriminative component (Se=96.67%; Sp=100%; AUC=0.971; p&lt;0.01). Conclusions. The HIT-6, Visual Analogue Scale and McGill Pain Questionnaire (motivational-affective and sensory-discriminative components) can be used as an additional tool for differentiating chronic tension-type headache from chronic migraine in patients. The prediction of the course of chronic migraine and chronic headache using questionnaires and scales depends on the severity of anxiety and depression, quality of life indicators and pain characteristics. Questionnaires and scales are relevant additional diagnostic methods in establishing the diagnosis of primary headache.

Introduction. MIDAS is a valid and reliable short questionnaire for assessment of headache related disability. Linguistic validation of Persian MIDAS and assessment of psychometric properties between tension type headache (TTH) and migraine were the aims of this study. Methods. Patients with migraine or TTH were included. At the first visit, we administered a headache symptom questionnaire, MIDAS, and SF-36. Patients filled out MIDAS in second and third visit within three and eight weeks after base line visit. Internal consistency (Cronbach α) and test-retest reproducibility (Spearman correlation coefficient) were used to assess reliability. Convergent validity and MIDAS capability to differentiate between chronic and episodic headaches (migraine and TTH) were also assessed. Results. The 267 participants had episodic migraine (EM-64%), chronic migraine (CM-13.5%), episodic TTH (ETTH-13.5%), and chronic TTH (CTTH-9). Internal consistency reliability was 0.8 for the entire sample, 0.72 for TTH, and 0.82 for migraine. Test-retest reliability for all questions between visit 1 and visit 2 varied from 0.54 to 0.71. Convergent validity was assessed using SF-36 as an external referent. Patients with episodic headaches (EM and ETTH) had significantly lower MIDAS scores than chronic headaches (CM and CTTH). Conclusion. Persian MIDAS is a valid and reliable questionnaire for migraine and TTH that can differentiate between episodic headache and chronic headache.

To compare the prevalence of co-morbid depression between patients with chronic primary headache syndromes and chronic posttraumatic headaches. A prospective cross-sectional analysis of all patients presenting sequentially to a community-based general neurology clinic during a 2-year period for evaluation of chronic headache pain was conducted. Headache diagnosis was determined according to the International Headache Society's Headache Classification criteria. Depression was determined through a combination of scores on the clinician administered Hamilton Rating Scale for Depression and patients' self-report. An additional group of patients who suffered traumatic brain injuries (TBI) but did not develop post-traumatic headaches was included for comparison. A total of 83 patients were included in the study: 45 with chronic primary headaches (24 with chronic migraine headaches, 21 with chronic tension headaches), 24 with chronic post-traumatic headaches, and 14 with TBI but no headaches. Depression occurred less frequently among those with chronic post-traumatic headaches (33.3%) compared to those with chronic migraine (66.7%) and chronic tension (52.4%) headaches (Chi-Square = 7.68; df = 3; p = 0.053), and did not significantly differ from TBI patients without headaches. A multivariate logistic regression model using depression as the outcome variable and including headache diagnosis, gender, ethnicity, and alcohol and illicit substance use was statistically significant (Chi-Square = 27.201; df = 10; p < 0.01) and identified primary headache (migraine and tension) diagnoses (Score = 7.349; df = 1; p = 0.04) and female gender (Score = 15.281; df = 1; p < 0.01) as significant predictor variables. The overall model accurately predicted presence of co-morbid depression in 74.7% of the cases. Co-morbid depression occurs less frequently among patients with chronic post-traumatic headaches and TBI without headaches than among those with chronic primary headaches.

Tension-type and migraine-type headaches are the most common chronic paroxysmal disorders of childhood. The goal of this study was to compare regional cerebral volumes and diffusion in tension-type and migraine-type headaches against published controls. Patients evaluated for tension-type or migraine-type headache without aura from May 2014 to July 2016 in a single center were retrospectively reviewed. Thirty-two patients with tension-type headache and 23 with migraine-type headache at an average of 4 months after diagnosis were enrolled. All patients underwent DWI at 3T before the start of pharmacotherapy. Using atlas-based DWI analysis, we determined regional volumetric and diffusion properties in the cerebral cortex, thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala, nucleus accumbens, brain stem, and cerebral white matter. Multivariate analysis of covariance was used to test for differences between controls and patients with tension-type and migraine-type headaches. There were no significant differences in regional brain volumes between the groups. Patients with tension-type and migraine-type headaches showed significantly increased ADC in the hippocampus and brain stem compared with controls. Additionally, only patients with migraine-type headache showed significantly increased ADC in the thalamus and a trend toward increased ADC in the amygdala compared with controls. This study identifies early cerebral diffusion changes in patients with tension-type and migraine-type headaches compared with controls. The hypothesized mechanisms of nociception in migraine-type and tension-type headaches may explain the findings as a precursor to structural changes seen in adult patients with chronic headache.

Objective To assess the classification and characteristics of headaches using the International Classification of Headache Disorders, 3rd edition (beta version) criteria in a headache outpatient clinic. Methods In this prospective cross-sectional study, all consecutive patients presenting with headache to a headache outpatient clinic of Peking Union Medical College Hospital between April 1 st, 2014 and February 28th, 2015 were included. Results The average age of 593 patients was (42.1±15.6) years with female-male ratio 1.89∶1. Primary headaches were found in 483(81.5%) patients, of which migraine and tension-type headache were found in 264(44.5%) patients and 168 (28.3%) patients respectively. Chronic daily headache and new headache were found in 158 (26.6%) patients and 130 (21.9%) patients, while cough headache and thunderclap headache were found in 9 (1.5%) patients and 5 (0.8%) patients respectively. Patients with migraine were more likely complicated with medication-overuse headache than patients with tension-type headache (χ2=4.21, P=0.032). Patients with tension-type headache were more likely complicated with chronic daily headache than patients with migraine (χ2=18.92, P=0.000). Conclusions In this headache outpatient clinic, most patients were primary headaches. Chronic daily headache and new headache were common, while cough headache and thunderclap headache were uncommon. These headache syndromes should be paid attention to identify the possible underlying malignant etiologies. Key words: Migraine disorders; Tension-type headache; Headache disorders, primary; Headache disorders, secondary

Migraine and tension-type headache (TTH) can increase in frequency and transform from episodic to chronic forms. The process of transformation of these primary headaches is complex and involves multiple risk factors. In this cross-sectional and longitudinal population study, we aimed to investigate the relation of clinical characteristics of primary headaches to poor outcome: new-onset or persistent chronic headache (> or =180 days/year). Individuals who had migraine + / - TTH and those who had pure TTH were studied separately. Of 740 individuals who entered this study in 1989, 673 were eligible for follow-up in 2001, and a total of 549 individuals participated in the follow-up study. At baseline in 1989, no difference was found between episodic and chronic migraine headache ( + / - TTH). Duration of headache episodes >72 hours (p = .002) was associated with pure chronic TTH at baseline in 1989 whereas aggravation of headache by physical activity (p = .045) was associated with pure frequent episodic TTH. Of 64 subjects with migraine + / - TTH, 12 had a poor outcome in 2001. For pure TTH, of 116 subjects at baseline, 11 had a poor outcome in 2001. Using multivariate logistic regression analysis with adjustment for medication overuse and use of preventive medications, poor outcome of migraine + / - TTH tended to be associated with a baseline pulsating quality and severe intensity of migraine, photophobia and phonophobia, as well as longer duration of an individual headache attack. For pure TTH, unilateral headache, nausea and individual headache attack duration greater than 72 hours was associated with poor outcome. Pooled data univariate analysis revealed that nausea, daily use of acute headache medications, use of headache preventive medications and coexistent headaches were significant predictors of chronic headache in 2001(p<.05). In conclusion, our study demonstrates that certain clinical characteristics of headaches are associated with poor outcome but alone may not predict the chronification of migraine or TTH.

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.