Chronic Migraine Headache Research Articles

Medication overuse headache: Updating of the French recommendations regarding the treatment strategies.

Regular and frequent use of analgesics and acute antimigraine drugs can increase the frequency of headache, and induce the transition from episodic to chronic migraine or medication-overuse headache (MOH). The one-year prevalence of this condition is between 1% and 2% in Europe, provoking substantial burden. MOH is more prevalent in people with comorbid depression, anxiety, and other chronic pain conditions. This paper aims at presenting an updating of French recommendations regarding treatments strategies. Prior French recommendations, published in 2014, were written in French. A literature search in the major medical databases including the terms "medication overuse headache", "symptomatic medication overuse", published between 2010 and 2020 was carried out. Three main strategies can be recommended and conducted in parallel: education and explanations about the negative consequences of overusing acute antimigraine drugs, discontinuation of the overused medication, and finally, preventive drug therapy and non-pharmacological prevention. Medication overuse headache remains a debated problem and evidence for the most effective treatment strategy is needed.

Other Primary Headache Disorders.

This article provides an overview of a diverse group of primary headache disorders that are categorized in the International Classification of Headache Disorders, 3rd Edition (ICHD-3), as "other primary headache disorders." This article provides clinicians with a distilled understanding of the diagnoses and their epidemiology, pathophysiology, and management. Cough-induced headache requires neuroimaging to exclude posterior fossa pathology and recently has been reported as a common symptom in patients with CSF-venous fistula. Clinical overlap is observed between patients with primary exercise headache and primary headache associated with sexual activity. Patients with recurrent thunderclap headache associated with sexual activity should be presumed to have reversible cerebral vasoconstriction syndrome until proven otherwise. De novo external-pressure headache is a common sequela among health care workers using personal protective equipment during the COVID-19 pandemic. New daily persistent headache is an important mimicker of chronic migraine or chronic tension-type headache and is distinguished by a daily-from-onset progression of persistent headache; a treatment-refractory course is often observed, and early involvement of a multidisciplinary team, including a psychotherapist, is advised. Patients with primary headache disorders that are classified as "other primary headache disorders" have presentations with unique diagnostic and management considerations. The disorders are highly recognizable, and an appreciation of the diagnoses will aid clinicians in providing safe and effective care for patients presenting with headache.

Impact of COVID-19 on chronic migraine treated with erenumab: a case report

BackgroundHeadache is a frequent symptom of the novel coronavirus 19 disease (COVID-19). To date, there are limited information on how COVID-19 affects migraine and its treatment.Case descriptionA 47-year-old patient, suffering from chronic migraine and medication-overuse headache, in September 2020 started erenumab at 70 mg once monthly. Two months later, monthly migraine days decreased from 20 to 5. On the third month, the patient developed mild COVID-19 symptoms, experiencing extreme fatigue, hyposmia, and attention deficit, resulting positive for SARS-Cov-2 RNA. A significant increase in migraine attacks frequency was reported. Brain MRI and EEG were normal. Erenumab was increased to 140 mg/month, and attacks decreased to 3 monthly migraine days and remained stable. All the headaches experienced by our patient during the infection fulfilled the criteria of the migraine attacks, without tensive-like features.ConclusionWe report the first case showing the effects of SARS-CoV-2 infection in a patient with chronic migraine and medication-overuse headache treated with erenumab. Our case description suggests that inflammatory processes induced by SARS-CoV-2 infection may increase the frequency of migraine attacks, probably through an activation of the trigeminovascular system. Whether treatment with CGRP receptor antagonist may influence COVID is still debated. Additional studies regarding anti-CGRP monoclonal antibodies in COVID-19 patients are warranted.

Is new daily persistent headache a fallout of somatization? An observational study.

New daily persistent headache (NDPH) is characterized by daily, persistent headache with clearly remembered onset, preceding events or triggers and treatment refractoriness of headache. The pathophysiology of NDPH is still unresolved. NDPH has been associated with somatoform disorder (DSM 4 TR). Somatization is characterized by vivid memory, disproportionate and persistent thought about symptoms that may explain many characteristics of NDPH. However, tendency towards somatization has not been studied in NDPH patients. In this cross-sectional study, we evaluated somatization in NDPH, chronic migraine (CM), and chronic tension type headache (CTTH) by comparing the prevalence of somatic symptom disorder (SSD, DSM-5). We evaluated the past tendencies to somatization by comparing various characteristics of past somatic symptoms (number, duration, type, clearly remembered onset, etc.) between NDPH, CM, and CTTH. Forty-seven patients each of NDPH and CTTH and 46 patients of CM were evaluated. Criteria for SSD was fulfilled by 85.1% of NDPH and CTTH patients and only 45.7% of CM. Past history of somatic symptoms was seen in 70% patients with NDPH, 15.2% CM, and 23.4% CTTH (p<0.001). Median number of past somatic symptoms was higher in NDPH. All NDPH patients clearly remembered the onset of at least one past somatic symptom. None of CM and CTTH patients remembered the onset of past somatic symptoms. NDPH patients displayed significant past history of somatization. Continuation of past tendencies to manifest as NDPH suggests that NDPH may be an epiphenomenon of somatization.

Cerebrovascular Reactivity Measures Are Associated With Post-traumatic Headache Severity in Chronic TBI; A Retrospective Analysis.

ObjectiveTo characterize the relationship between persistent post-traumatic headache (pPTH) and traumatic cerebrovascular injury (TCVI) in chronic traumatic brain injury (TBI). Cerebrovascular reactivity (CVR), a measure of the cerebral microvasculature and endothelial cell function, is altered both in individuals with chronic TBI and migraine headache disorder (Amyot et al., 2017; Lee et al., 2019b). The pathophysiologies of pPTH and migraine are believed to be associated with chronic microvascular dysfunction. We therefore hypothesize that TCVI may contribute to the underlying migraine-like mechanism(s) of pPTH.Materials and Methods22 moderate/severe TBI participants in the chronic stage (>6 months) underwent anatomic and functional magnetic resonance imaging (fMRI) scanning with hypercapnia gas challenge to measure CVR as well as the change in CVR (ΔCVR) after single-dose treatment of a specific phosphodiesterase-5 (PDE-5) inhibitor, sildenafil, which potentiates vasodilation in response to hypercapnia in impaired endothelium, as part of a Phase2a RCT of sildenafil in chronic TBI (NCT01762475). CVR and ΔCVR measures of each participant were compared with the individual’s pPTH severity measured by the headache impact test-6 (HIT-6) survey.ResultsThere was a moderate correlation between HIT-6 and both CVR and ΔCVR scores [Spearman’s correlation = –0.50 (p = 0.018) and = 0.46 (p = 0.03), respectively], indicating that a higher headache burden is associated with decreased endothelial function in our chronic TBI population.ConclusionThere is a correlation between PTH and CVR in chronic moderate-severe TBI. This relationship suggests that chronic TCVI may underlie the pathobiology of pPTH. Further, our results suggest that novel treatment strategies that target endothelial function and vascular health may be beneficial in refractory pPTH.

Negative affect moderates the effect of respiratory gated vagal nerve stimulation on pain severity in patients with chronic low back pain

Chronic low back pain (CLBP) is the leading cause of disability in the United States. There is considerable interest in the development of safe, effective, nonpharmacological approaches to managing CLBP. Respiratory-gated electrical stimulation of the somatosensory vagal afferent receptors in the ear (RAVANS), has been shown to reduce chronic pelvic pain and migraine headache pain. Further, there is evidence to suggest that the benefits of RAVANS are enhanced when paired with mindful meditation. The purpose of the current study was to examine the effects of RAVANS on pain sensitivity and back pain severity among patients with CLBP. Nineteen adults (mean age =54) with CLBP who had previous mindfulness meditation training participated. Participants attended two laboratory sessions. During each session, they completed brief quantitative sensory testing (QST) including punctate pain ratings (PPR) and pressure pain thresholds (PPT) and rated their back pain severity. Participants then completed a 28-minute stimulation session paired with a mindfulness of breath meditation. During one visit, participants received RAVANS stimulation and during the other, they received sham stimulation. Session order was randomized. Following stimulation, participants repeated QST and provided pain ratings. Results of 2 (treatment: RAVANS vs Sham) X 2 (time: pre- vs. post-stimulation) RMANOVAS indicated that, regardless of treatment condition, PPT increased while PPR and back pain severity decreased post-stimulation. Greater negative affect (e.g., depression and anxiety) was associated with greater improvement in backpain in the RAVANS condition and less improvement in the sham condition. Greater mindfulness was associated with greater improvement in back pain in the sham condition, ut not the RAVANS condition. This suggests that the analgesic effects of mindfulness meditation may have overshadowed any effect of RAVANS stimulation, especially given the brief duration and single session design. Moreover, patients with more negative affect may be more likely to benefit from RAVANS.

Peripheral Nerve Stimulation in Pain Management: A Systematic Review

Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. To assess the clinical evidence of PNS in the treatment of acute or chronic pain. A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.

Experience of Botulinum Toxin A Injections for Chronic Migraine Headaches in a Pediatric Chronic Pain Clinic.

Prevalence of chronic migraine in children can reach 7.7%, causing decreased school performance, difficulty with extracurricular activities (including sports, theater, or music), and changes in sleep and mood. Many studies confirm that botulinum toxin type A injections effectively alleviate chronic migraines in adults; however, the literature regarding children is sparse. This study aims to analyze the safety and effectiveness of botulinum type A injections in a group of pediatric patients diagnosed with chronic migraines in a pediatric pain clinic. In this retrospective (2013-2018) study, the effects of botulinum toxin type A injections were analyzed using data from 65 pediatric patients diagnosed with chronic migraines. The study group ranged from 11 to 18 years of age. A pediatric pain management physician administered the botulinum using the Phase 3 Research Evaluating Migraine Prophylaxis Therapy program protocol and followed the pain pattern. Dosages, tolerance, and side effects were measured. In this study, 74% of the patients tried more than 6 medications before the injections. There was a decrease in the visual analog scale score of 5.2 ± 2.2 points upon 6-week follow-up. The mean amount of medication used was 173.2 ± 35 units, and patients received an average of 2.8 ± 1.1 units/kg. Adverse events include one patient who developed dizziness and another who had low-grade fevers with enlarged cervical lymph nodes; both resolved within few minutes. This study supports the use of botulinum type A for chronic migraines in pediatric patients. Multicentered, randomized studies with larger population are needed to evaluate the long-term safety and efficacy of this therapy.

The Effect of Propofol Anesthesia on the Pain Severity and Frequency of Migraine Attacks in Patients with Chronic Migraine Headache over a Six Month Follow Up: An Observational Study.

Propofol is a short-acting intravenous anesthetic that is commonly used for induction and maintenance of anesthesia. Subanesthetic low doses of propofol has also been used to treat intractable migraine attacks in emergency wards with dramatic results. However, there is little information on the long-term efficacy of this drug in migraine headaches. The aim of this nonrandomized prospective observational study was to assess the effect of propofol anesthesia on the pain severity and frequency of migraine attacks in a 6-month follow-up period after anesthesia in patients with migraine headaches. The study was conducted on 51 known cases of migraine ranging in age from 21 to 66 years. Before anesthesia, patients completed a questionnaire including their characteristics, pain intensity of the headache using a visual analog scale, and a number of headache repetitions per month. All patients received propofol as the main anesthetic agent. At the end of anesthesia, the total amount of propofol usage was recorded. Patients were then followed up by telephone in the first, third, and sixth months after anesthesia, and the severity and frequency of the headache were recorded. Pain intensity or pain frequency significantly improved in 22 patients (43.1%), remained unchanged in 24 (47%), and worsened in 5 cases (9.8%) 6 months after anesthesia compared to before the anesthesia. In conclusion, since about half of the patients had significant improvement in the headache, propofol anesthesia may be considered as an acceptable anesthetic method in patients with migraine.

The Second Short Form of the McGill Pain Questionnaire as the useful additional tool for differential diagnostics of migraine and cervicogenic headache

OBJECTIVE To study the effectiveness of the Second Short Form of the McGill Pain Questionnaire (SF-MPQ-2) as an instrument for assessment and comparison of quantitative characteristics of pain in patients with chronic musculoskeletal impairment of the cervical spine and nonspecific neck pain accompanied by chronic migraine or cervicogenic headache (CeH). MATERIAL AND METHODS Forty-nine patients, aged from 19 to 60 years (mean age 42.8±10.4), were divided into 2 comparable by age and gender groups with migraine (n=18) and CeH (n=31). Neck pain and headache intensity was measured by the 11-points Numerical Rating Scale (NRS). Quality of pain and related symptoms were measured by SF-MPQ-2. Multidisciplinary and multimodal approaches were applied for treatment, including several modalities of manual therapy. RESULTS Headache intensity was higher in the migraine group in comparison with the CeH group (7.8±1.7 vs 6.0±1.5, respectively; p<0.05). No significant differences in neck pain intensity were found (6.2±1.8 vs 5.3±1.7; p=0.08). Patients with migraine usually chose more descriptors than patients with CeH (14 vs 4, respectively) and higher range of their intensity (p<0.001). By the end of treatment session, the number of descriptors and their intensity decreased significantly on all SF=MPQ-2 scales (p<0.001) in both groups. Most patients of migraine and CeH group were satisfied with treatment (83% and 97%, respectively) and marked «much improved» and «very much improved» on the 7-point Patient Global Impression of Change scale. CONCLUSION SF-MPQ-2 is a useful tool for differential diagnosis of migraine and CeH, as it contains the sufficient number of descriptors and the scale for measuring their intensity.

Differentiated approach to the treatment of chronic migraine and tension-type headache

Differentiated approach to the treatment of chronic migraine and tension-type headache

Identification of predictors of response to Erenumab in a cohort of patients with migraine

Background:The migraine-specific monoclonal antibody Erenumab targeting the calcitonin gene related peptide receptor is an effective and well tolerated preventive treatment of episodic and chronic migraine. However, its price limits its use as a first line therapy against migraine. Therefore, identifying patients who will adequately respond to such treatment is paramount.Methods:In this retrospective, real-life cohort study, 172 adult patients with refractory episodic or chronic migraine treated with Erenumab were included. To identify the predictors of response to Erenumab, bivariate subgroup analysis of several potential factors was performed, and multivariate logistic regression modeling was done to obtain Odds Ratio (OR).Results:Of the 172 patients, 57.0% achieved a successful treatment response (reduction of monthly migraine days by ≥50%). Statistically significant predictors of a treatment response were the presence of chronic migraine, tension-type headache, and a positive response to triptan with an odd ratio of 0.473 (95% CI, 0.235–0.952), 0.485 (95% CI, 0.245–0.962) and 3.985 (95% CI, 1.811–8.770), respectively (P &lt; 0.05).Conclusions:Successful Erenumab treatment response rate was 57.0% in this retrospective cohort. As chronic migraine and tension-type headache were negative predictors of Erenumab response while triptan response was a positive predictor, this data suggests the potential for Erenumab monotherapy without the need for traditional preventive treatment in refractory migraine sufferers improving side effect profile and treatment adherence for a cohort of patients difficult to treat.

Highly sensitive Thin-Layer Chromatographic–Densitometric assay for quantitation of Amisulpride & Zolmitriptan in synthetic mixture: Application to pharmaceutical formulation & biological fluids

A new and sensitive (TLC) assay has been estimated for quantitation of synthetic binary mixtures of antipsychotic drug Amisulpride (AMS) with antimigarine drug Zolmitriptan (ZOL). These medications co-administered with each other for treatment of chronic migraine headache associated with psychosis. The synthetic mixture has been separated on precoated silica TLC plates G60 F254 by using mobile phase which consist of mixture of Chloroform: Ethyl acetate: Methanol: Ammonia in ratio (30:30:73:3 v/v/v/v). The mixture has been determined at λmax 231 nm. Retardation factor (RF) values for AMS and ZOL have been 0.6 and 0.43 respectively. Calibration graphs have been linear in range 50–500 ng/spot for all studied drugs. The detection limits have been 6.04 & 10.5 ng/spot and the quantitation limits have been 18.3 & 31.834 ng/spot for AMS and ZOL respectively. The described assay has been utilized for quantitation of synthetic mixture in pharmaceutical tablet &biological fluids.

Highly Sensitive Thin-Layer Chromatographic–Densitometric Assay for Quantitation of Amisulpride &amp; Zolmitriptan in Synthetic Mixture: Application to Pharmaceutical Formulation &amp; Biological Fluids

A new and sensitive (TLC) assay has been estimated for quantitation of synthetic binary mixtures of antipsychotic drug Amisulpride (AMS) with antimigarine drug Zolmitriptan (ZOL). These medications co-administered with each other for treatment of chronic migraine headache associated with psychosis. The synthetic mixture has been separated on precoated silica TLC plates G 60 F 254 by using mobile phase which consist of mixture of Chloroform: Ethyl acetate: Methanol: Ammonia in ratio ( 30:30:73:3 v/v/v/v ). The mixture has been determined at λ max 231 nm. Retardation factor (RF) values for AMS and ZOL have been 0.6 and 0.43 respectively. Calibration graphs have been linear in range 50-500 ng/spot for all studied drugs. The detection limits have been 6.04 & 10.5 ng/spot and the quantitation limits have been 18.3 & 31.834 ng/spot for AMS and ZOL respectively. The described assay has been utilized for quantitation of synthetic mixture in pharmaceutical tablet &biological fluids.

Botulinum Toxin in the Treatment of Headache.

Botulinum toxin type A has been used in the treatment of chronic migraine for over a decade and has become established as a well-tolerated option for the preventive therapy of chronic migraine. Ongoing research is gradually shedding light on its mechanism of action in migraine prevention. Given that its mechanism of action is quite different from that of the new monoclonal antibodies directed against calcitonin gene-related peptide (CGRP) or its receptor, it is unlikely to be displaced to any major extent by them. Both will likely remain as important tools for patients with chronic migraine and the clinicians assisting them. New types of botulinum toxin selective for sensory pain neurons may well be discovered or produced by recombinant DNA techniques in the coming decade, and this may greatly enhance its therapeutic usefulness. This review summarizes the evolution of botulinum toxin use in headache management over the past several decades and its role in the preventive treatment of chronic migraine and other headache disorders.

Increase in trigeminal ganglion neurons that respond to both calcitonin gene-related peptide and pituitary adenylate cyclase-activating polypeptide in mouse models of chronic migraine and posttraumatic headache.

A large body of animal and human studies indicates that blocking peripheral calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating polypeptide (PACAP) signaling pathways may prevent migraine episodes and reduce headache frequency. To investigate whether recurring migraine episodes alter the strength of CGRP and PACAP signaling in trigeminal ganglion (TG) neurons, we compared the number of TG neurons that respond to CGRP and to PACAP (CGRP-R and PACAP-R, respectively) under normal and chronic migraine-like conditions. In a mouse model of chronic migraine, repeated nitroglycerin (NTG) administration significantly increased the number of CGRP-R and PACAP-R neurons in TG but not dorsal root ganglia. In TG neurons that express endogenous αCGRP, repeated NTG led to a 7-fold increase in the number of neurons that respond to both CGRP and PACAP (CGRP-R&PACAP-R). Most of these neurons were unmyelinated C-fiber nociceptors. This suggests that a larger fraction of CGRP signaling in TG nociceptors may be mediated through the autocrine mechanism, and the release of endogenous αCGRP can be enhanced by both CGRP and PACAP signaling pathways under chronic migraine condition. The number of CGRP-R&PACAP-R TG neurons was also increased in a mouse model of posttraumatic headache (PTH). Interestingly, low-dose interleukin-2 treatment, which completely reverses chronic migraine-related and PTH-related behaviors in mouse models, also blocked the increase in both CGRP-R and PACAP-R TG neurons. Together, these results suggest that inhibition of both CGRP and PACAP signaling in TG neurons may be more effective in treating chronic migraine and PTH than targeting individual signaling pathways.

Peripheral Occipital Nerve Decompression Surgery in Migraine Headache.

Background:Migraine headache in the occipital region is characterized by a recurrent pain of moderate to severe intensity. However, the diagnosis can be difficult because of the multitude of symptoms overlapping with similar disorders and a pathophysiology that is not well-understood. For this reason, the medical management is often complex and ineffective.Methods:A literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted to evaluate the surgical treatment of occipital migraines. Inclusion criteria were: English language, diagnosis of migraine, occipital neuralgia, or tension headache in compliance with the classification of the International Headache Society, follow-up at minimum 3 months, and adult age. The treatment had to consist of peripheral occipital nerve surgery.Results:323 records were identified after duplicates were removed, 30 full text articles were assessed for eligibility, and 9 records were selected for inclusion. A total of 1046 patients were included in the review. General positive response after surgery (>50% reduction in occipital migraine headaches) ranged from 80.0% to 94.9%. However, many differences in the selection of patients, target of decompression surgery, and measurement outcome were described.Conclusion:Despite the decennial proven effectiveness and safeness of surgical therapy for chronic occipital migraine headaches, more significant proof is needed to definitively confirm its use as a standard therapy.

Profiling the Extent and Location of Pain in Migraine and Cervicogenic Headache: A Cross-sectional Single-Site Observational Study.

The primary aim was to quantify and compare the location and extent of pain in people with either episodic migraine, chronic migraine, or cervicogenic headache. A secondary aim was to examine the associations between pain extent and headache features, quality of life, and psychological distress for each headache type. A cross-sectional, single-site, observational study. Headache outpatient clinic. From a sample of 390 patients, 114 patients with migraine or cervicogenic headache (48 episodic migraine, 30 chronic migraine, 36 cervicogenic headache) were eligible for the study. Pain location and extent were determined using a novel approach for digital pain drawing acquisition and analysis. Headache features included intensity and history duration. Quality of life was measured using the SF-36 and psychological distress using the Hospital Anxiety and Depression Scale. Overall, pain was most frequently reported in the frontal and temporal regions in patients with either episodic or chronic migraine, whereas pain was most frequent in the suboccipital region in patients with cervicogenic headache. A larger pain extent was moderately correlated with higher headache intensity (rs = 0.53, P = 0.003) and poorer quality of life (rs ranged from -0.36 to -0.40, P < 0.05) in patients with chronic migraine, whereas pain extent was associated with longer headache duration in those with cervicogenic headache (rs = 0.35, P = 0.04). No correlation was found between pain extent and psychological features for any headache type (P > 0.05). Despite some differences, there was a large symptomatic overlap between headache types, highlighting the limitations of using pain location in the differential diagnosis of headache.

Guideline on the preventive treatment of chronic migraine, chronic tension type headache, hemicrania continua and new daily persistent headache on behalf of the Colombian Association of Neurology

SUMMARY INTRODUCTION: Chronic daily headache is a high impact entity in the general population. Although chronic migraine and tension-type headache are the most frequent conditions, it is necessary to consider hemicrania continua and new daily persistent headache as part of the differential diagnoses to perform a correct therapeutic approach. OBJECTIVE: To make recommendations for the treatment of chronic daily headache of primary origin METHODOLOGY: The Colombian Association of Neurology, by consensus and Grade methodology (Grading of recommendations, assessment, development and evaluation), presents the recommendations for the preventive treatment of each of the entities of the daily chronic headache of primary origin group. RESULTS: For the treatment of chronic migraine, the Colombian Association of Neurology recommends onabotulinum toxin A, erenumab, topiramate, flunarizine, amitriptyline, and naratriptan. In chronic tension-type headache the recommended therapeutic options are amitriptyline, imipramine, venlafaxine and mirtazapine. Topiramate, melatonin, and celecoxib for the treatment of hemicrania continua. Options for new daily persistent headache include gabapentin and doxycycline. The recommendations for inpatient treatment of patients with chronic daily headache and the justifications for performing neural blockades as a therapeutic complement are also presented. CONCLUSION: The therapeutic recommendations for the treatment of chronic daily headache based on consensus methodology and Grade System are presented.

Profile of Migraine Patients in a Developing Country: a Multicentre Study

Migraine is a common headache disorder with significant impact on quality of life. Despite the significant progress in treatment and understanding of migraine, the care of sufferers is inadequate in low resource settings. Studies on characteristics of migraine patients receiving care in sub-Saharan Africa are limited. We aim to determine the effect of demographic characteristics on migraine diagnosis, and the adequacy of treatment offered in tertiary hospitals. This was a multi-centre, hospital-based, cross-sectional study conducted over 4 months in Northeast Nigeria. Participants were patients with known migraine on follow up at the neurology outpatient clinics. The sociodemographic, clinical records, and treatment outcome of each subject was documented. Of the 112 migraineurs who fulfilled the inclusion criteria, 104 consented to participate in the study. The mean age of the participants was 30.8 ± 10.4 years. Females constituted 74% of subjects, with a female to male ratio of 2.9:1. The difference between the mean age of migraine onset and the mean age at diagnosis was 4.6 years. On multivariate logistic regression analysis, age at headache onset (p = 0.001) and lower level of education (p = 0.03) independently predicted a delay in diagnosis of migraine. At first specialist clinic visit, 69.2% of the subjects had only a diagnosis of chronic migraine, 25% was additionally diagnosed with medication overuse headache, and about 92% was not placed on migraine preventive medication for their headaches despite meeting the criteria. Fifty-five (52.9%) patients had clinic visits in the past 12 months, among which prophylactic medications were used by 26 (45.1%) patients, while 13 (23.6%) were not adherent to preventive drug treatment, and 16 (29%) patients used their preventive medications as acute treatment. The significant delay from headache onset to migraine diagnosis has resulted in a more prevalent presentation with chronic migraine headache. Younger age at migraine onset and low educational attainment may affect diagnosis and treatment. The low prescription rate of migraine prophylactic medications by practitioners in this region may be affecting the quality of life of migraineurs.