Analgesic Overuse Research Articles

Increased VIP levels in peripheral blood outside migraine attacks as a potential biomarker of cranial parasympathetic activation in chronic migraine.

The aim of this article is to determine vasoactive intestinal peptide (VIP) levels outside migraine attacks in peripheral blood as a potential biomarker for chronic migraine (CM). Women older than 17 and diagnosed as CM were recruited. Matched healthy women with no headache history and women with episodic migraine (EM) served as control groups, together with a series of patients with episodic cluster headache in a pain-free period. VIP levels were determined in blood samples obtained from the right antecubital vein by ELISA outside a migraine attack, the patients having taken no symptomatic medication the day before. For ethical reasons, preventives were not stopped. We assessed plasma samples from 119 women with CM, 33 healthy women, 51 matched women with EM and 18 patients (16 males) with cluster headache matched for age. VIP levels were significantly increased in CM (165.1 pg/ml) as compared to control healthy women (88.5 pg/ml) and episodic cluster headache patients (101.1 pg/ml). VIP levels in EM (134.9 pg/ml) were significantly higher compared to controls and numerically lower than those of CM. Thresholds of 71.8 and 164.5 pg/ml optimized the sensitivity and specificity to differentiate CM from healthy controls and EM, respectively. Variables such as age, CM duration, the presence of aura, analgesic overuse, depression, fibromyalgia, vascular risk factors, history of triptan consumption or kind of preventive treatment did not significantly influence VIP levels. Increased interictal VIP level measured in peripheral blood could be a biomarker helping in CM diagnosis, though it does not clearly differentiate between EM and CM.

White matter lesions in chronic migraine with medication overuse headache: a cross-sectional MRI study

Analgesic overuse often happens to migraine patients, especially chronic migraineurs, and migraine has been demonstrated to be associated with white matter lesions (WMLs). The aim of this study was to investigate the relationship between medication overuse headache (MOH) and WMLs in chronic migraine (CM) patients. Subjects were enrolled and divided into three groups: healthy controls, CM without MOH (CMwoMOH), and CM with MOH (CM-MOH). Most of the CM patients used non-steroidal anti-inflammatory drugs (NSAIDs) as acute headache medications. All the participants underwent magnetic resonance imaging scans and images were obtained for WML evaluation with semiquantitative scales. One hundred and forty-one participants were included, 45 of them for controls, 38 for CMwoMOH, and 58 for CM-MOH. In women, CMwoMOH patients had a higher prevalence of high WML load compared with controls and CM-MOH patients. In men, however, all the study groups showed no differences in the prevalence of high WML load. CMwoMOH women had increased risks of high deep white matter lesion (DWML) load compared with controls, while they had no risks of high periventricular white matter lesion (PVWML) load. CM-MOH women had no risks of high DWML load, but they had reduced risks of high PVWML load. The association of CM-MOH with high WML load in women was not changed when compared with CMwoMOH. Age was independently associated with high WML load among women. These data suggest that MOH caused by NSAIDs is not a risk factor for WMLs. Rather, NSAID overuse probably protects MOH patients from WMLs through anti-inflammatory effects.

Does Analgesic Overuse Contribute to Chronic Post-traumatic Headaches in Adolescent Concussion Patients?

BackgroundThe causes of persistent headache following concussion are poorly understood. The objective of this study is to explore analgesic overuse as a potential cause of chronic post-traumatic headache among adolescents referred to a headache clinic following concussion. MethodsA retrospective chart review was conducted of all adolescent concussion patients referred to our pediatric headache clinic over the 16-month period between August 1, 2011, and November 30, 2012. Those patients with chronic post-traumatic headaches of 3-12 months' duration who also met International Headache Society criteria for probable medication-overuse headache were identified. Demographic data, concussion symptoms, and headache features were characterized from the initial evaluation and from follow-up visits. ResultsOf 104 adolescent concussion patients referred during the study period, 77 had chronic post-traumatic headache of 3-12 months' duration. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache. Only simple analgesics were overused. Thirty-seven patients (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics; seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up. ConclusionExcessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents. Management of patients with chronic post-traumatic headache should include analgesic detoxification when medication overuse is suspected.

A randomized trial of telephone-based motivational interviewing for adolescent chronic headache with medication overuse

Nearly 2% of youths suffer from chronic migraine or chronic tension-type headache (CTTH). A contributing factor in approximately 20%-50% of these youths is medication overuse, which involves taking analgesics three or more times per week for three months. The objective of this study was to test motivational interviewing (MI) as an approach to promote adherence to recommendations regarding not only analgesic overuse but also other aspects of treatment plans. A randomized controlled trial was conducted comparing the experimental condition (standard of care clinic-based treatment with supplemental MI phone calls; N = 24) to a control condition (standard of care clinic-based treatment without these supplemental MI phone calls; N = 23). Four months after enrollment, a research assistant who was blinded to study condition telephoned adolescents inquiring about headache frequency, headache severity, and disability. Headache frequency was lower in the experimental condition versus control condition for those with relatively lower initial levels of headache frequency. In contrast, we did not find greater improvement in headache severity and disability for the experimental condition relative to the control condition. Our findings provided some preliminary, albeit limited, support for MI as an approach to improve outcomes for adolescent medication-overuse headache (MOH).

Chronic migraine does not increase posterior circulation territory (PCT) infarct-like lesions

Two population-based studies have found an increased prevalence of posterior circulation territory (PCT) infarct-like lesions in migraine, which seemed to increase with attack frequency. ObjectiveTo determine whether chronic migraine (CM) patients are at increased risk of PCT infarct-like lesions. MethodsWe prospectively obtained brain MRIs from adult women fulfilling CM criteria. To keep radiologists blinded we also obtained brain MRIs in 15 episodic migraine (EM) patients. MRIs were acquired on a 1.5T unit. Protocol included whole brain weighted images in sagittal T1 (5mm slices), axial FLAIR T2 (3mm) and combined proton density and T2 fast spin echo (3mm). Two independent neuroradiologists carefully analyzed all the images. ResultsOne hundred women with CM participated. Their ages ranged from 18 to 68years (mean 43.7) and the length of CM ranged from 0.5 to 38years (mean 9.8). Sixty-three patients (63%) had at least one vascular risk factor. Thirty-three met analgesic overuse criteria. Fifty-one had a history of migraine with aura attacks, though aura frequency was below one per month in all patients except one. Eleven were not on preventatives. We found PCT infarct-like lesions in only 6 CM patients aged 42–64years (mean age 54years) who had at least two vascular risk factors. ConclusionsAs frequency of PCT infarct-like lesions in our CM patients was in the low range than that found for EM in general population studies, we conclude that frequency of migraine attacks itself is not a factor increasing PCT infarct-like lesion risk.

Decrease of Gray Matter Volume in the Midbrain is Associated with Treatment Response in Medication-Overuse Headache: Possible Influence of Orbitofrontal Cortex

Patients with chronic daily headache and overuse of analgesics, triptans, or other acute headache compounds, are considered to suffer from medication-overuse headache (MOH). This implies that medication overuse is the cause of headache chronification. It remains a key question why only two-thirds of patients with chronic migraine-like headache and overuse of pain medication improve after detoxification, whereas the remainder continue to have chronic headache. In the present longitudinal MRI study, we used voxel-based morphometry to investigate gray matter changes related to medication withdrawal in a group of humans with MOH. As a main result, we found that only patients with significant clinical improvement showed a significant decrease of previously increased gray matter in the midbrain including periaqueductal gray matter and nucleus cuneiformis, whereas patients without improvement did not. Patients without treatment response had less gray matter in the orbitofrontal cortex. Another striking result is the correlation of treatment response with the amount of orbitofrontal gray matter. Thus, we demonstrate adaptive gray matter changes within the pain modulatory system in patients with MOH who responded to detoxification, probably reflecting neuronal plasticity. Decreased gray matter in the orbitofrontal cortex at baseline may be predictive of poor response to treatment.

Interictal increase of CGRP levels in peripheral blood as a biomarker for chronic migraine

To determine calcitonin gene-related peptide (CGRP) levels outside migraine attacks in peripheral blood as a potential biomarker for chronic migraine (CM). Women older than 17 years and diagnosed with CM were recruited. Matched healthy women with no headache history and women with episodic migraine (EM) served as control groups, together with a series of patients with episodic cluster headache in a pain-free period. CGRP levels were determined in blood samples obtained from the right antecubital vein by ELISA outside a migraine attack and having taken no symptomatic medication the day before. For ethical reasons, preventatives were not stopped. We assessed plasma samples from 103 women with CM, 31 matched healthy women, 43 matched women with EM, and 14 patients with episodic cluster headache matched for age. CGRP levels were significantly increased in CM (74.90 pg/mL) as compared with control healthy women (33.74 pg/mL), women with EM (46.37 pg/mL), and patients with episodic cluster headache (45.87 pg/mL). Thresholds of 43.45 and 58.22 pg/mL optimize the sensitivity and specificity to differentiate CM from healthy controls and EM, respectively. In the CM group, CGRP levels were significantly increased in women with a history of migraine with aura vs those only experiencing migraine without aura. Variables such as age, analgesic overuse, depression, fibromyalgia, vascular risk factors, history of triptan consumption, or kind of preventative treatment did not significantly influence CGRP levels. Increased CGRP level measured in peripheral blood outside migraine attacks and in the absence of symptomatic medication could be a biomarker helping in the diagnosis of CM.

Elevated blood pressure and analgesic overuse in chronic daily headache: an outpatient clinic-based study from China.

BackgroundMany studies have reported that hypertension is common in chronic daily headache (CDH) and its subtype chronic migraine (CM), but the reason is still poorly understood. Our clinical literature review suggested that analgesic overuse may be associated with elevated blood pressure (BP), so we performed the present study to investigate the frequency of elevated BP and its link with analgesic overuse in CDH and its subtypes.MethodsA cross-sectional study was conducted in neurology outpatients with a diagnosis of CDH according to International Headache Society criteria. CDH patients were classified into CM and non-CM groups, and subclassified with or without analgesic overuse.ResultsElevated BP was present in 27.96% of CDH patients. Compared with non-CM patients, patients with CM had a longer duration of headache and more severe pain intensity, and a family history of headache and analgesic overuse were also more common, but the elevated BP frequency was not different between the two groups. Almost one-third of the patients had analgesic overuse; 96.8% of which comprised acetaminophen-containing agents. Those with analgesic overuse had a higher frequency of headache than those without analgesic overuse in both the CM and non-CM groups.ConclusionsAlthough the CM patients had a longer duration of headache, more severe intensity, the frequency of elevated BP wasn’t higher than non-CM group. Analgesic overuses maybe the reason of higher frequency of elevated BP in CDH and its subtypes. This may have predictive value for clinicians to improve CDH management.

Increased levels of CGRP in peripheral blood in women with chronic migraine: A reliable biological marker

The biology of chronic migraine (CM) as a true entity or as a consequence of analgesic overuse is controversial. There are no available biological markers for CM, while CGRP, a marker of trigemino-vascular activation, has been shown to be increased during acute migraine attacks in episodic migraine [1].

Prevalence of medication overuse headache in an interdisciplinary pain clinic

BackgroundMedication overuse headache (MOH) has been recognized as an important problem in headache patients although the pathophysiological mechanisms remain unclear. The diagnosis of MOH is based on clinical characteristics defined by the International Headache Society. The aim was the evaluation of the diagnostic criteria of MOH in a mixed population of chronic pain patients to gain information about the prevalence and possible associations with MOH.MethodsData of all patients referred to the interdisciplinary pain clinic at the University Hospital of Zurich between September 2005 and December 2007 were retrospectively analyzed. Demographic data (age, sex, history of migration), as well as data about duration of pain disease, category of pain disease (neurological, psychiatric, rheumatologic, other), use of medication, history of trauma, and comorbidity of depression and anxiety have been collected.ResultsTotally 178 of 187 consecutive chronic pain patients were included in the study. A total of 138 patients (78%) used analgesics on 15 or more days per month. Chronic headache was more prevalent among patients with analgesic overuse (39.8%) than without analgesic overuse (18%). The prevalence of MOH was 29%. The odds ratio (OR) for a patient with medication overuse to have chronic headache was 13.1 if he had a history of primary headache, compared to a patient without a primary headache syndrome. Furthermore, history of headache (OR 2.5, CI [1.13;5.44]), history of migration (OR 2.9, CI [1.31;6.32]) and comorbid depression (OR 3.5, CI [1.46;8.52]) were associated with overuse of acute medication, in general.ConclusionsPrimary headaches have a high risk for chronification in patients overusing analgesics for other pain disorders. Whereas history of headache, history of migration and comorbidity of depression are independentely associated with analgesic overuse in this group of patients.

Prevalence and clinical characteristics of headache in dental students of a tertiary care teaching dental hospital in Northern India

Background: Chronic headache is as much as a problem in India as elsewhere in the world with a rising trend in young adults which negatively affects the quality of life of the affected person. In current scenario of increasing prevalence of headache in students, most of them have been found to practice self medication leading to inappropriate management and sometimes analgesic overuse causing treatment refractoriness. Methods: A questionnaire based survey was done on undergraduate dental students at a tertiary care dental teaching hospital in Northern India. Severity of headache was assessed by Numeric Rating Scale. Data collected was analyzed to assess the prevalence, pattern & triggering factors of headache along with awareness of dental students regarding treatment. Prevalence and characteristics of migraine were also assessed along with the therapeutic strategies opted by students. Results: Our study (n=186) demonstrated headache prevalence of 63.9% which was higher in females (74.3%) as compared to males (32.6%). Headache experienced by majority of student population was bilateral (36.13%), sharp stabbing (38.65%) and of moderate intensity (57.98%). Common associated symptoms were nausea/ vomiting (24.36%) and scalp tenderness (22.68%). Stress (82.3%) &irregular sleep (81.5%) were the most common triggering factors. Prevalence of migraine was 13.44% with female preponderance (87.5%). Practice of self medication was reported by 88.2% of students. Most commonly used drugs were paracetamol (36.76%), aspirin (26.47%) and combination of ibuprofen and paracetamol (25%). Specific medication use in migraineurs was found to be low (25%) showing inadequate management of migraine headache in our study population. Conclusions: The results in this study demonstrate high headache prevalence in dental students with self medication being practiced by the majority.

Frequência dos tipos de cefaleia no centro de atendimento terciário do Hospital das Clínicas da Universidade Federal de Minas Gerais

To assess the frequency of different diagnoses of headaches in the Headache Outpatient Clinic of the Hospital das Clínicas of the Universidade Federal de Minas Gerais (AmbCef-UFMG). Cross sectional study with 289 patients consecutively attended to at AmbCef-UFMG. Headaches were diagnosed based on the criteria established by the International Classification of Headache Disorders (ICDH-2004). The average age of patients was 42.6 years, mostly women (86.9%) with less than nine years of education. Primary headaches were the most common type, with migraine found in 79.8% of cases, and tension-type headache (TTH) in 20.4%. Among the secondary types, the most common was headache caused by overuse of analgesics (16.6%), followed by less common types, such as idiopathic intracranial hypertension. Chronic daily headache (CDH) was found in 31.8% of cases. This study confirms literature data showing migraine as the most common headache in tertiary care centers. The expressive number of cases of CDH and headaches caused by overuse of analgesics indicates that, starting at the primary care level, patients should be advised to avoid the abuse of symptomatic drugs.

Overuse of paracetamol caffeine aspirin powders affects cerebral glucose metabolism in chronic migraine patients

Overuse of analgesic plays a prominent role in migraine chronification. Paracetamol caffeine aspirin (PCA) powders are commonly used in Chinese migraineurs. This study investigated the effects of the specific combination analgesic on cerebral glucose metabolism in chronic migraine (CM). 18F-FDG-PET was used to measure regional metabolism in all subjects. Brain metabolisms of CM patients with analgesic overuse (AO-CM; n=10), no analgesic overuse (NAO-CM; n=10), and no regimen (NR-CM; n=10) and 17 age- and gender-matched normal controls (NC) were compared using statistical parametric mapping. Then, all patients underwent brain MRI analysis within 7 days after PET scans, as well as MMSE and MoCA scale for cognitive function tests. Glucose metabolic changes in CM patients taking different dosage of analgesic during headache-free periods and clear distinctions in several brain regions were observed. Patients with AO-CM exhibited significant metabolic reductions in thalamus, as well as increased metabolism in middle temporal gyrus and insula relative to NR-CM and NAO-CM. However, in these regions, no difference was observed in AO-CM except for increased metabolism in the right insula relative to NC group. Overusing PCA powders affects regional brain glucose metabolism in CM. Increased metabolism in the right insula may be associated with recurrently overusing of PCA powders.

Migraine

Headache is a common symptom with a lifetime prevalence of 95 per cent in the general population. Migraine is the most common cause of moderate to severe headaches. Migraine is genetic and runs in families. Chronic migraine is the most disabling form of migraine. Analgesic overuse often complicates migraine.

Post-traumatic headaches: Time for a revised classification?

Post-traumatic headache (PTH) is among the most prevalent of the secondary headache disorders. As currently classified by the International Classification of Headache Disorders, 2nd edition (ICHD-2), PTH must start within 7 days of a mild, moderate, or severe traumatic brain injury (TBI). PTH transitions from an acute subtype to a chronic subtype 3 months after the injury (1). No other defining clinical characteristics set PTH apart from other primary or secondary headache disorders. In fact, most PTHs appear to have a phenotype indistinguishable from primary headache disorders and may respond to the same treatments as primary headache disorders (2,3). It seems altogether intuitive that headaches would occur acutely in the majority of individuals after a mild TBI (or concussion). More vexing, and controversial, is the link between head trauma and the subsequent development of chronic headaches (4,5). PTHs persist beyond the acute period in a significant proportion of patients. Up to 60% of TBI patients have chronic headaches persisting for up to 12 months (4,6). That chronic PTHs develop more often in mild versus moderate to severe TBI, in cases with impending litigation or in the setting of analgesic medication overuse, suggests a role for factors independent of trauma in the process of headache chronification (4,7,8). While each (or all) of these factors may be important in the genesis of chronic headaches in individual cases, there is a lack of evidence supporting them as unifying hypotheses to explain the spectrum of chronic PTHs in civilian and military patient populations. A better understanding of the processes leading to headache chronification after brain trauma is needed. Over the past 3 years, large epidemiological studies of headaches in military, civilian, and veteran populations with head trauma have been completed (9–11), providing a valuable opportunity to better understand and classify PTHs. In this issue, Lucas et al. (10) report the findings of a multi-center, longitudinal study of headaches in a population of 378 patients with moderate to severe TBI. The subjects underwent a baseline headache evaluation shortly after TBI and were then followed by telephone interview at 3, 6, and 12 months after injury to longitudinally assess headache incidence and headache characteristics. To our knowledge, this is one of the largest longitudinal studies of headaches in TBI patients. Many interesting findings emerge from this study, parts of which have been published previously (10, 11). The cumulative headache incidence in the study cohort was 71% over 12 months. Forty-three percent of patients had headaches at the baseline assessment shortly after TBI and this proportion was stable over the next 12 months. There were no differences in headache incidence between mild, moderate, and severe TBI patients. Eighteen percent of all patients had a history of headaches prior to TBI with 57% of these being migraine or probable migraine. Similar to previous studies, pre-traumatic headache and female sex were risk factors for reporting headaches after TBI. Migraine and probable migraine were the most common headache types after trauma, accounting for 52% of headaches at baseline and 60% of headaches 6 months after injury. Migrainous headaches were 2–3fold more common than tension-type headaches (TTHs; 7–21%) at all time points. The high prevalence of migraine observed by Lucas et al. (10) sharply contrasts with older studies which suggested a higher prevalence of TTH after TBI, but are similar to the findings of recent studies in military and veteran populations which found migraine in 60 to over 90% of cases (2,3,9,12). Comparing PTH studies and study populations can be difficult, but the accumulation of

Neurological Findings and Symptoms Associated with Combat-Related Concussion: Impact of Migraine and Other Co-Morbidities (P03.217)

Objective: To describe the clinical characteristics of Service Members following acute concussion, including impact of migraine, and other acute and chronic co-morbidities. Background Acute concussion is reported to result in somatic, cognitive, and behavioral symptoms. These symptoms are not specific for concussion, and may result from pre-existing medical conditions, including migraine. In addition, combat-related concussion often in the setting of an IED blast or military vehicle accident often causing concurrent musculoskeletal injuries. The resultant acute stress reaction may too cause or aggravate underlying psychological co-morbidities which may influence symptomatology. Prior studies have identified common co-morbidities associated with the chronic post-concussive syndrome, which may also be present during the acute phase influencing symptoms and impacting recovery. Design/Methods: Retrospective chart review of 40 patients with acute concussion evaluated by single deployed neurologist, highlighting the clinical symptoms and co-morbid conditions influencing their recovery. Pre-deployment and post-traumatic headache features are shown, including triptan response. Results: Headaches were the most common reported symptom (95%), followed by insomnia, tinnitus, impaired concentration, nausea, dizziness, anxiety, impaired balance, depression, and hearing loss. Acute co-morbidities included concurrent injuries, analgesic overuse, and acute stress; chronic co-morbidities included headache, anxiety/depression, insomnia, and PTSD. Service members with three or more co-morbidites were more likely to require evacuation. Predeployment headaches with migrainous features were common (52%), though most occurred infrequently (88%). Post-deployment headaches were daily to near daily (92%), most with typical migrainous features and triggers. Of those treated with triptans (42%), most (75%) showed treatment response. Conclusions: Concussion in deployed settings does not occur in isolation. Co-morbidities are common. Presence of multiple co-morbidites appears to influence recovery. Post-traumatic headaches are often consistent with migraine, and related to pre-deployment migraine susceptibility as supported by detailed history. Disclosure: Dr. Scott has nothing to disclose.

The Effects of Headaches on Academic Performance

Research Article| April 01 2012 The Effects of Headaches on Academic Performance AAP Grand Rounds (2012) 27 (4): 42. https://doi.org/10.1542/gr.27-4-42 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation The Effects of Headaches on Academic Performance. AAP Grand Rounds April 2012; 27 (4): 42. https://doi.org/10.1542/gr.27-4-42 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: academic performance, headache Source: Souza-e-Silva HR, Roche-Filho PAS. Headaches and academic performance in university students: a cross-sectional study. Headache. 2011; 51(10): 1493– 1502; doi: https://doi.org/10.1111/j.1526-4610.2011.02012.xGoogle Scholar Researchers at the University of Pernambuco, Recife, Brazil interviewed a randomly selected group of university students to determine the one-year prevalence of headache, types of headache, and their association with academic performance. The researchers used several instruments to assess outcomes, including the International Headache Society criteria to characterize headaches as migraine or tension-type1 and the Headache Impact Test to assess the effect of headaches on daily activities (pain severity, role functioning, social functioning, vitality, emotional distress, and cognitive functioning).2 The Hospital Anxiety and Depression Scale was used to verify the occurrence of anxiety and depression among study participants.3 The independent effect of headaches on academic performance was assessed after controlling for confounding variables such as alcohol consumption, workload, and co-existence of anxiety and/or depression. A total of 380 students were randomly selected for the study and 344 (90%) participated. The students’ mean age was 23.4 years; 57.3% were women. Headache prevalence was 87.2% (migraine 48.5%, tension-type 42.4%) in the past 12 months. Migraine without aura (43%) was more common than migraine with aura (18.3%). In the three months before the study, 8.7% of participants sought emergency services because of headaches, 75.6% recorded analgesic use during headache, and 1.5% reported analgesic overuse. Forty-nine percent of students reported headache that had a substantial or very severe impact. Of note, 30.8% had missed class due to headache and 30.8% were less productive because of headaches. Screens for anxiety and depression were positive in 43.9% and 18.9%, respectively, of study participants. However, even after accounting for the co-existence of anxiety and depression and other confounders, the researchers found that serious-impact headaches were significantly associated with more subject failures and absenteeism, but not grade point average. Overall, no headache variables were associated with grade point average; however, participants who reportedly consumed alcohol had significantly lower grades than those who did not. The authors conclude that headaches are common in university students, and that high-impact headaches are associated with lower academic performance. Dr Millichap has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Headaches are common in children, and migraine headaches occur with increasing frequency through adolescence. The American Academy of Neurology (AAN) Practice Parameter, Treatment of Migraine, endorsed by the American Academy of Pediatrics, reports a migraine prevalence of 3% at age 3 to 7 years that increases to 4% to 11% at ages 7 to 11 and 8% to 23% at age 11 to 15+ years.4,5 The mean age at onset of migraine is 7.2 years for boys and 10.9 years for girls. The prevalence of migraine of 48.5% reported in the university students from the current study is more than twice that quoted in the literature for adolescents... You do not currently have access to this content.

Combination therapy for chronic migraine

Chronic migraine (CM) is a frequent and challenging condition for practicing neurologists. It affects around 2% of adults and its prevalence in middle-aged women reaches 5%.1 Management of CM is generally unsatisfactory and largely not evidence-based, in part because until recently CM has not been considered a true entity, but mostly a consequence of analgesic overuse. Evidence that distinguishes the conditions includes findings that only one-third of CM patients in the general population overuse symptomatic medications and that preventives for CM work better than analgesic withdrawal2 (and even in the absence of analgesic withdrawal3). These results support the idea that CM is a biological entity possibly due to a still unknown genetic background. As a direct consequence of this rapidly evolving concept, specific guidelines for clinical trials in CM were developed in 2008,3 which have allowed demonstration that topiramate4 and onabotulinumtoxinA5 are efficacious over placebo in CM. In fact, analgesic withdrawal, which should not be forgotten in the presence of medication overuse, improves CM together with these preventives. While very encouraging, these interventions may not be enough for numerous CM patients. From a mean of …

Self‐medication of regular headache: a community pharmacy‐based survey

This observational community pharmacy-based study aimed to investigate headache characteristics and medication use of persons with regular headache presenting for self-medication. Participants (n = 1205) completed (i) a questionnaire to assess current headache medication and previous physician diagnosis, (ii) the ID Migraine Screener (ID-M), and (iii) the Migraine Disability Assessment questionnaire. Forty-four percentage of the study population (n = 528) did not have a physician diagnosis of their headache, and 225 of them (225/528, 42.6%) were found to be ID-M positive. The most commonly used acute headache drugs were paracetamol (used by 62% of the study population), NSAIDs (39%), and combination analgesics (36%). Only 12% of patients physician-diagnosed with migraine used prophylactic migraine medication, and 25% used triptans. About 24% of our sample (n = 292) chronically overused acute medication, which was combination analgesic overuse (n = 166), simple analgesic overuse (n = 130), triptan overuse (n = 19), ergot overuse (n = 6), and opioid overuse (n = 5). Only 14.5% was ever advised to limit intake frequency of acute headache treatments. This study identified underdiagnosis of migraine, low use of migraine prophylaxis and triptans, and high prevalence of medication overuse amongst subjects seeking self-medication for regular headache. Community pharmacists have a strategic position in education and referral of these self-medicating headache patients.

Differences in Clinical Features and Disability according to the Frequency of Medication Use in Patients with Chronic Migraine

Background and PurposeChronic migraine (CM) has a significant impact on daily activities, and analgesic overuse is a major contributing factor to migraine transformation. Limited information is available on the functional consequences of CM stemming from analgesic overuse. This study evaluated the impact of the frequency of analgesic medication use on headache-related disability and clinical features in patients with CM.MethodsPatients with CM were enrolled consecutively and classified into two groups according to their frequency of medication use: <15 days/month (CM-ML, n=52) and ≥15 days/month (CM-MH, n=68). All patients completed a structured questionnaire concerning the clinical features of their migraine, a validated version of the Migraine Disability Assessment questionnaire (MIDAS), and the Headache Impact Test-6 (HIT-6).ResultsThe pain intensity, as measured by a visual analog scale, was greater in the CM-MH group than in the CM-ML group (8.5±0.2 vs. 7.7±0.3, mean±SD; p<0.05). In the disability domain, the MIDAS scores were significantly higher for CM-MH patients than for CM-ML patients (47.6±4.8 vs. 26.8±4.5, p<0.01). The impact from migraine, as measured by the HIT-6, was greater for CM-MH patients than for CM-ML patients (65.6±1.0 vs. 62.1±1.0, p<0.05).ConclusionsOur results indicate that the headache pain intensity and disability are greater in patients with CM who use medication frequently.