The Use of Botulinum Toxin in the Management of Headache Disorders

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

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.

We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007–2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007–2010, 2011–2014, and 2015–2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007–2010 to 28.3% in 2015–2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015–2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007–2010 to 79.7% in 2015–2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.

Headache disorders can be further classified as episodic (< 15 headache days per month) or chronic (≥ 15 headache days per month for more than 3 months). Chronic migraine (CM) requires that headaches occur on 15 or more days a month for more than 3 months. These headaches must be migraines on at least 8 days per month. There are seven botulinum toxin (BoNT) serotypes (A1, A2, A3, B, C1, D, E, F, and G). All serotypes inhibit acetylcholine release, although their intracellular target proteins, physiochemical characteristics, and potencies are different. Its mechanism of action in pain is being investigated. Botulinum toxin type A (BoNT-A) has been the most widely studied serotype for therapeutic purposes. A major clinical advantage of type A toxin arises from its prolonged duration of action due to the longevity of its protease (90 days in rats and probably much longer in human neurons). Clinical studies suggest that BoNT is a safe treatment and is efficacious for the prevention of some forms of migraine, such as CM, and perhaps high-frequency episodic migraine.

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

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.

Tremendous progress has been made in the past decades for the treatment of headache disorders. Chronic migraine is the most disabling type of headache and requires the use of acute and preventive medications, many of which are associated with adverse events that limit patient adherence. Botulinum toxin (BoNT) serotype A, a neurotoxin derived from certain strains of Clostridium, disrupts neuropeptide secretion and receptor translocation related to trigeminal nociception, thereby preventing pain sensitization through peripheral and possibly central mechanisms. Ever since the first randomized controlled trial on onabotulinumtoxinA (onabotA) for migraine was published two decades ago, onabotA has been the only BoNT formulation approved for use in the prevention of chronic migraine. Superior tolerability and efficacy have been demonstrated on multiple migraine endpoints in many controlled trials and real-life studies. OnabotA is a safe and efficacious treatment for chronic migraine and possibly high-frequency episodic migraine. Further research is still needed to understand its mechanism of action to fully develop its therapeutic potential.

Background: Headache disorders, particularly migraine, are a leading cause of disability among active-duty military personnel, significantly affecting operational readiness and fitness for duty. Despite their high prevalence, limited data exist on how headache disorders are managed within military primary care systems. This study aimed to evaluate diagnostic confidence, treatment strategies, and structural challenges in the management of headache disorders from the perspective of military primary care physicians. Methods: A prospective, nationwide cross-sectional survey was conducted between May and July 2023 among all active-duty military physicians in primary care roles. An anonymous 15-item questionnaire assessed diagnostic practices, therapeutic approaches, referral pathways, perceived knowledge gaps, and suggestions for system improvements. The survey was distributed across military medical centers and outpatient clinics in Germany. Results: Ninety military physicians participated. Migraine and tension-type headache were commonly encountered, with 70% having treated at least one headache patient in the week prior to the survey. Diagnostic confidence was high for migraine (83.4%) and tension-type headache (77.8%) but lower for medication-overuse headache (65.5%) and cluster headache (47.8%). Acute treatment was widely implemented, but only 27.8% of respondents regularly initiated preventive therapies. Awareness of clinical guidelines was limited: only 23.3% were familiar with the ICHD-3, and just 58.9% with national headache treatment guidelines. Respondents expressed strong demand for targeted education, practical diagnostic tools, and improved interdisciplinary coordination. Conclusions: Headache disorders are a prevalent and clinically significant issue in military primary care. While military physicians show high engagement, important gaps exist in preventive treatment, guideline familiarity, and access to specialist care. Structured training, standardized treatment protocols, and system-level improvements are essential to optimize headache care and maintain operational readiness.

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.

BackgroundThe HEAD-WINd® study was designed to examine the burden, characteristics and lived experiences of headache disorders in the Danish adult population. By integrating data from surveys, a smartphone application, and national health and social registries, the study addresses limitations of prior epidemiological research.MethodsA random sample of Danish residents aged 18-75years were invited to participate ("base population"). Two nested cohorts were recruited using a population-based approach: (i) a survey cohort consisting of individuals reporting active headache disorders ("headache population") and (ii) a smartphone application cohort, derived from the headache population, which was followed longitudinally for 12weeks. Data from these cohorts were enriched with data from national health and social registries, including information on medication use, hospital records, socioeconomic status and healthcare utilization. An adapted version of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire was used to classify multiple headache disorders and assess headache-attributed burden.ResultsOf the 100,030 invited individuals, 28,617 (28.6%) completed the general survey. Among them, 15,571 (54.4%) reported experiencing headache in the preceding year; 14,074 (90.4%) completed the headache-specific survey. In total, 663 individuals (4.7%) participated in the app-based longitudinal study. The mean±SD participant age was 53.2±15.5years, 57.4% were women and the mean±SD body mass index was 26.8±7.4 kg/m².ConclusionsHEAD-WINd® has established a comprehensive, population-based cohort of Danish residents, including individuals both with and without headache disorders. This resource provides a framework for generating population-level insights into the burden and management of headache disorders.

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.

To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities. An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties. Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities. Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.

Chronic daily headache is a major worldwide health problem that affects 3-5% of the population and results in substantial disability. Advances in the management of headache disorders have meant that a substantial proportion of patients can be effectively treated with medical treatments. However, a significant minority of these patients are intractable to conventional medical treatments. Occipital nerve stimulation (ONS) is emerging as a promising treatment for patients with medically intractable, highly disabling chronic headache disorders, including migraine, cluster headache and other less common headache syndromes. Open-label studies have suggested that this treatment modality is effective and recent controlled trial data are also encouraging. The procedure is performed using several technical variations that have been reviewed along with the complications, which are usually minor and tolerable. The mechanism of action is poorly understood, though recent data suggest that ONS could restore the balance within the impaired central pain system through slow neuromodulatory processes in the pain neuromatrix. While the available data are very encouraging, the ultimate confirmation of the utility of a new therapeutic modality should come from controlled trials before widespread use can be advocated; more controlled data are still needed to properly assess the role of ONS in the management of medically intractable headache disorders. Future studies also need to address the variables that are predictors of response, including clinical phenotypes, surgical techniques and stimulation parameters.

The purpose with the headache expert system was to develop a diagnostic and educational tool for the general practitioners (GP), in order to improve their management of headache disorders. This chapter describes the diagnostic headache diary, an expert system intended for education and diagnosing headache disorders. The diagnostic headache diary can be printed and used by headache patients at home to record their headache attacks and medicine consumption by a day to day basis. It can also be used by the GP at the clinic in order to provide the headache diagnoses. The diagnostic headache diary was written in the programming language Delphi and implemented as a stand-alone Windows 95 program. It was integrated as one of five modules in the headache tutorial described in another chapter of this book. The diagnostic headache diary consists of four modules: Patient data, diary, medication and diagnosis. Configured around a database, the diagnostic headache diary allows entries of several patients and search facilities. The diagnostic headache diary was tested and validated by entering expert-diagnosed data from different headache disorders which where compared to the computer generated diagnoses.

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.