Form Of Headache Research Articles

Disability in young patients suffering from primary headaches

During the last decade researchers have begun to employ standardised methodologies to investigate the global impact of primary headaches. Disease-specific instruments have been developed to measure headache-related disability. The MIDAS Questionnaire, which is the most extensively studied of these instruments, was designed to assess the overall impact of headaches over the 3 months before compilation. The MIDAS Questionnaire is an optimal tool to assess headache-related disability in adults in relation to patients' daily activities. Primary headaches are a recurrent problem for children and adolescents. Forty percent of children have experienced headaches by the age of 7 years increasing to 75% by the age of 15. In a recent report we determined the suitability of the MIDAS Questionnaire in its original form for assessing disability in children and adolescents suffering from different kinds of headache. This was the first step of a line of research aimed to develop a new MIDAS Questionnaire adapted for young patients. In this second study the aims were: (1) to produce a new version of the MIDAS Questionnaire specific for young patients suffering from different forms of headache; (2) to assess the reliability of this new instrument; (3) to assess its sensitivity to treatment intervention.

Headache in children and adolescents: conventional and unconventional approaches to treatment

Headache is one of the most common conditions to affect children and adolescents in industrialised countries. Studies indicate a prevalence of 8% to 60%. In over 40% of migraineurs the condition begins before 18 years of age. For clinical researchers, headache in the young is of interest because its causes are easier to investigate than in older people, as the clinical history is brief, the condition has had no time to become chronic, and it is not accompanied by changes in pain neuromodulation and neurotransmission, or the development of a chronic pain/stress-related personality that is common in adults with longstanding headache. The wide variation in reported headache prevalence in young people may be ascribed to lack of representativity of studies and vagueness of diagnostic criteria in studies performed before 1988. The publication of the International Headache Society IHS classification in 1988 for the first time made it possible to accurately diagnose the various headache forms. The diagnostic criteria for adults were adopted for use in young patients. Since that time a burgeoning number of studies on headache in young people have been published.

Strategies for the treatment of autonomic trigeminal cephalalgias

Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by two main clinical characteristics: pain and oculofacial autonomic phenomena. Three headache forms are grouped as TACs: cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). These are distinguished mainly on the basis of attack duration. It lasts from 15 to 180 min in CH, from 2 to 30 min in PH and from 5 to 240 s in SUNCT. The most effective drug preventative in PH is indomethacin even if in few cases other non-steroidal anti-inflammatory drugs have been reported to be effective. SUNCT is commonly described as drug resistant. Recent studies report that lamotrigin may be the drug of choice for SUNCT.

Primary headaches in children and adolescents

Headache is one of the commonest conditions to affect children and adolescents in industrialised countries. Studies indicate a prevalence of 8-60%. In over 40% of migraineurs the condition begins before 18 years of age. For clinical researchers, headache in the young is of interest because its causes are easier to investigate than in older people, as the clinical history is brief, the condition has had no time to become chronic, and it is not accompanied by changes in pain neuromodulation and neurotransmission, or the development of a chronic pain/stress-related personality that is common in adults with longstanding headache. The wide variation in reported headache prevalence in young people may be ascribed to lack of representativity of studies and vagueness of diagnostic criteria in studies performed before 1988. The publication of the International Headache Society IHS classification in 1988 for the first time made it possible to accurately diagnose the various headache forms. The diagnostic criteria for adults were adopted for use in young patients. Since that time a burgeoning number of studies on headache in young people have been published.

Swimmer's Headache, or Supraorbital Neuralgia

Associated with the fitness movement in the USA is an increased number of participants in water sports. Swimmers wear goggles to allow better vision underwater and to protect their eyes from irritation from chlorine or salt. Goggles come in many sizes and shapes; usually a swimmer finds a particular brand and model most effective and comfortable. I recently saw a patient who complained of “painful hair.” He had been swimming for 6 years and had recently developed pain and tenderness on the right side of his scalp. Palpating along the tender areas, I outlined the distribution of the right supraorbital nerve. Just prior to the development of the scalp pain, he had developed a leak in his goggles that allowed water to enter the orbital area, causing eye irritation. As he had done before, he tightened the goggle strap to stop the leak. He continued with the swim workout and subsequent workouts 3 to 4 times per week. After approximately 1 week, the scalp pain began. A Medline search on this topic found 2 letters to the editor in the New England Journal of Medicine in 1983. The first related the experience of a neurologist who developed bitemporal headaches after 1 to 2 hours of swimming. The father of the neurologist, who was a sporting goods retailer, noted that some of his customers complained of headaches associated with the use of ill-fitting swim goggles. The headaches stopped after use of the swim goggles was discontinued and returned when the goggles were worn again. By using goggles that were made of a softer rubber compound and had a looser-fitting strap around the head, the neurologist was able to continue swimming without headaches (1). The second letter to the editor, in response to the first, was from another neurologist who developed neuralgia in the distribution of the supraorbital nerve. The headaches and supraorbital-notch pain resolved 3 weeks after he abstained from wearing goggles (2). This neuralgia is similar to that experienced by my patient after he tightened the strap on his goggles. Swimmers with a supraorbital notch (< 100% bony encasement of the nerve) rather than a supraorbital foramen have a greater risk of developing this problem due to the exposed portion of the nerve (3). The affected nerves in these cases of swimmer's headache are illustrated in the Figure. Figure Nerves affected in the 3 described cases of swimmer's headache, (a) Nerves affected in letter 1. (b) Nerves affected in letter 2 and in the author's recent patient. LifeArt image copyright Lippincott Williams and Wilkins. All rights reserved. Prevention is the best treatment; however, if this condition does occur, the following may help: careful placement of the goggles, use of a different type of goggle with softer rubber and/ or a smaller area of seal around the eyes, and placement of the goggles in different locations to prevent repeated pressure trauma. A trial block with local anesthesia can confirm the diagnosis so that proper remedial steps can be taken. Other conditions associated with swimming goggles are eyelid neuromas due to the edge of the goggles (4, 5) and periorbital leukoderma due to contact with the chemical compounds used in goggle manufacture (6). When goggles are worn too tightly, “purpura gogglorum,” or periorbital purpura, can occur (7). Goggles can cause injury to the globe, including rupture (8), and this was the reason the use of goggles was banned by the Royal Life Saving Society during the conduct of its practical examination taken in the water and in initiative tests in competition (9). An excellent review of eye injuries in young athletes has been published in Pediatric Annals (10). Those of us who see patients with head and neck problems need to be aware of supraorbital neuralgia and include this entity in our differential diagnosis. Various types of headache and pain occur in the craniofacial area. Swimmer's migraine is a sudden, severe headache occurring during swimming (11); it is a form of exertional headache that has an explosive onset with exercise, including sexual activity (12). Frontal sinus infection (13), trigeminal neuralgia (14), cluster headaches, migraines, and other pain syndromes (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, or SUNCT [15]) occur. Perineural involvement of the periorbital sensory nerves by skin cancer also is a consideration in patients who have a skin cancer or a history of cutaneous malignancy (16). Correct diagnosis of supraorbital neuralgia is critical in choosing therapy. A change in the type of goggles may be all that is necessary. For persistent or recurrent pain, acupuncture (17), injection of phenol/glycerol (18) or botulism toxin (19), neurolysis (20), and root section (21) of the trigeminal nerve are methods that have been successfully employed to treat this condition.

Disability and quality of life in different primary headaches: results from Italian studies

Headaches may have a wide range of impact on patients' lives. We report the results of Italian studies in which disability and health-related quality of life (HRQOL) in patients with different primary headaches were evaluated. The Short Form 36 (SF-36) was used to assess HRQOL; the Migraine Disability Assessment Score questionnaire (MIDAS) was used to assess disability in patients with migraine without aura or with chronic migraine. Mean MIDAS total scores were evaluated in migraine without aura and chronic migraine patients. The scores at the eight SF-36 scales were calculated in patients with the three studied headaches, and were compared with Italian normative data (Student's t-test with Bonferroni correction). Primary headaches had a considerable negative impact on patients' lives, with poor quality of life and decreased ability to function in daily duties. The mean MIDAS total score was 23.4 in 264 patients with migraine without aura, and 79.2 in 150 patients with chronic migraine. Mean SF-36 scores in migraine without aura (68 subjects), chronic migraine (84) and cluster headache (56) were lower than those from the Italian general population, with significant differences for 3 scales in migraine without aura, for 6 in chronic migraine, and for all scales in cluster headache. Our results confirmed a marked personal and social burden in patients with migraine without aura, and also in the less well-studied forms of primary headaches, cluster headache and chronic migraine.

Surgical treatment of migraine headaches by corrugator muscle resection.

The authors, a plastic surgeon (Dirnberger) and a neurologist (Becker), conducted this study after reading the article by of Bahman Guyuron et al. in the August 2000 issue of Plastic and Reconstructive Surgery (106: 429, 2000). Sixty patients were operated on between June of 2001 and June of 2002; postoperative follow-up ranged between 6 and 18 months. Patients' charts were reviewed to confirm the diagnosis of migraine headache according to the criteria of the International Headache Society. Sixty patients (13 men and 47 women) from Austria and four neighboring countries took part in the study. The patients were divided into three groups, based on the severity of their migraines: group A comprised patients with up to 4 days of migraine per month; group B included patients with 5 to 14 days of migraine per month; and group C was composed of patients with more than 15 days of headache per month ("permanent headache") or evidence of drug abuse and drug-related headaches. The effectiveness of the operation was evaluated using the following factors: percentage reduction of headache days; percentage reduction of drugs; percentage reduction of side effects, severity of headaches, and response to drugs; and patient grade of personal satisfaction, using a scale from 1 to 5 [1 = excellent (total elimination of migraine headache) to 5 = insufficient or no improvement]. From the entire group of 60 patients, 17 (28.3 percent) reported a total relief from migraine, 24 (40 percent) reported an essential improvement, and 19 (31.7 percent) reported minimal or no change. Patients with a rather mild form of migraine headache had a much better chance (almost 90 percent in group A and 75 percent in group B) to experience an improvement or total elimination of migraine than those patients (n = 27) from group C with severe migraine, "permanent headaches," and drug-induced headaches. Contrary to the reports by Guyuron, 11 patients who had a very favorable response immediately and in the first weeks after the operation experienced a gradual return of their headaches to preoperative intensity after about 4 postoperative weeks. After 3 months, the results in all patients could be declared permanent. All side effects, such as paraesthesia in the frontal region, disappeared in all patients within 3 to 9 months.

August 10 Highlights

Lipton et al. summarize the key changes in the recently published second edition of the International Classification of Headache Disorders-2 (ICHD-2). Criteria were developed for several new and treatment responsive forms of headache including the indomethacin-responsive disorders (episodic paroxysmal hemi-crania and hemicrania [continua] and the lithium-responsive disorder, hypnic headache). In addition, chronic migraine, new daily persistent headache, and benign thunderclap headache were added. see page 427 In a prospective study, Leira et al. evaluated predictors and associated factors in 266 intracerebral hemorrhages (ICH). Clinical and biochemical inflammatory markers were predictors of subsequent early neurologic deterioration, whereas early ICH growth, intraventricular bleeding, and high systolic blood pressure within 48 hours were factors associated with early neurologic deterioration in spontaneous ICH. see page 461 Yablon et al. determined the prevalence and risk factors for deep vein thrombosis (DVT) after brain injury. Admission duplex ultrasonography revealed thigh DVT in 11% of 709 consecutive neurorehabilitation patients. Prevalence was higher with brain tumor (21%) and hemorrhage (16%) vs trauma (6.7%). DVT risk was multifactorial, and influenced by the type of brain injury. see page 485 In this double-blind, placebo-controlled trial, Rio et al. compare …

Sleeping behaviour and headache attacks in cases of primary headache. Possible pathological mechanisms

Headache is connected with sleep quality, e.g. hypnic headache and chronic paroxysmal headache attacks occur preferentially during REM sleep; this is possibly also true for cluster headache and migraine. REM sleep is typically characterized by the occurrence of ponto-geniculo-occipital spikes (PGOs). These PGOs should be able to trigger cortical spreading depression (CSD), which, although often clinically silent, is assumed to be an essential element of a migraine attack and possibly also of other forms of headache. CSDs are considered a correlate of migraine aura. They could lead to the secondary activation of trigeminovascular afferences, which would then induce a headache. Interestingly, illnesses that are comorbid with migraine cause an increase in the amount of REM sleep; conversely, various drugs administered prophylactically for these illnesses reduce the quantity of REM sleep.

Cerebral venous sinus thrombosis: A great masquerader

Cerebral venous sinus thrombosis (CVST) and cortical venous thrombosis (CVT) leading to ischemia and infarction of the brain are being increasingly detected in recent times with the advent of greater awareness amongst the clinicians and greater availability of non-invasive radiodiagnostic modalities like magnetic resonance imaging (MRI) and MR venography. Patients often present with protean neurological manifestations in the form of focal neurological deficits, seizures, headache and other features of raised intracranial tension, leading to misdiagnosis and delay in treatment. The clinical presentation may be with features suggestive of transient ischemic attack (TIA) or at times an intracranial space-occupying lesion (ICSOL). High index of suspicion is required in appropriate clinical settings to diagnose this entity at the earliest and ensure prompt treatment with anticoagulants, which can result in almost complete neurological recovery. We report three such cases, which presented to us with varying manifestations, and briefly discuss this entity.

Medication overuse headache

The current literature on medication overuse headache will be reviewed with regard to clinical presentation, pathophysiology, therapy and prognosis in the light of the new headache classification. Medication overuse headache is a widely unrecognized medical condition, which according to recent epidemiological studies has evolved to the third most frequent form of headache after tension-type headache and migraine. The first classification of headache disorders from 1988 defined medication overuse headache (formerly called 'drug-induced headache') on the bases of drugs that were available in the 1980s. For the most important anti-headache drugs, including triptans, new data on specific clinical features and more important mean critical monthly dosages and mean critical monthly intake frequencies are now available. Furthermore, recent prospectively conducted studies have revealed rates and predictors of relapse after successful withdrawal. The newly available data on medication overuse headache may provide the basis for future consensus guidelines for the management of this condition.

Benign Angiopathy of the Central Nervous System

Apparent central nervous system vasculitis could have a benign course in a subset of patients and is referred to as benign angiopathy of the central nervous system (BACNS). This is mostly is seen in young women and presents with acute onset of neurologic symptoms, usually in the form of severe headache and/or a focal neurologic event. Cerebrospinal fluid analysis could be normal or nearly normal. Brain angiogram typically shows segmental narrowing, ectasia, or beading in multiple vascular territories on brain angiogram. Like in all cases of CNS vasculitis, exclusion of other systemic diseases or its mimickers associated with cerebral involvement is important.BACNS could respond favorably to treatment with corticosteroids alone or in combination with a calcium channel blocker, thereby avoiding unnecessary and prolonged treatment with other immunosuppressants like cyclophosphamide with their side effects. Little is published in the literature about BACNS, but is a rapidly emerging concept. It is thus important to recognize. We report a patient with classic presentation of BACNS to highlight the significance of distinguishing benign angiopathy from the more aggressive form of CNS vasculitis, because the treatment and response varies in these 2 entities.

A review of nonvalidated and complementary therapies for cluster headache.

Cluster headache is arguably the most disabling form of primary headache. There is a great deal of information available about alternative therapy for migraine, but very little regarding alternative therapy for cluster headaches. This article reviews the popular and scientific print and electronic sources of information about alternative and complementary treatments for cluster headache dietary supplements, herbal modalities, folk remedies, physical and manual therapies, and unlabeled use of prescription drugs such as botulinum toxin, baclofen, and methylphenidate.

PEDIATRIC HEADACHE

Fusco C, Pisani F, Faienza C. Idiopathic stabbing headache: clinical characteristics of children and adolescents. Brain Dev. 2003;25:237‐240. Very few cases of short‐lasting headaches have been reported in children and adolescents. The aim of this study is to describe a group of patients in the pediatric age group with short attacks of head pain and to demonstrate that they are not easily classified according to existing criteria for adults. We describe 23 subjects in retrospect, 12 males and 11 females, with brief attacks of headache, stabbing in nature, self‐limited, lasting from a few seconds to 15 min. This sample was taken from a total population of 548 children and adolescents referred to our Pediatric Headache Unit during the years 1995‐1999. Mean age at onset of symptomatology was 9 years. The localization of the headache was bilateral in 60% of the patients and unilateral in 40%. The pain was either unifocal at the orbit or temple (60%) or multifocal (40%). In 24% of the children, the interictal awake EEG showed infrequent posterior slow‐waves. In 12 patients we used paracetamol with a good response. Although these painful episodes shared some aspects with the adult form of idiopathic stabbing headache, they had different durations of attack, and other primary headache syndromes did not accompany them either at the time of presentation or during the following 2 years. Short attacks of headache are present in the pediatric age group and are not easily classified according to the International Headache Society criteria. Their nature and correlation with migraine remains unclear. We propose follow‐up of these subjects to obtain a better description of the natural history of these forms of headache in the pediatric age group. Comment: An additional question: will all indomethacin‐responsive syndromes be clinically different in children? SJT

Therapeutic Effect of the Patients with Chronic Migraine in Pain Clinic

Background: Chronic daily headache (CDH) is surprisingly common and is defined by headaches that occur for 4 hours a day on 15 days a month over a 3 month period. Indeed, CDH is a group of headache disorders that includes chronic migraine (CM). Despite the personal and societal impact of this disorder, CM continues to be misdiagnosed and under-treated even though there are well-established diagnostic criteria as well as safe and effective treatments. The inappropriate use of medication for treating the headache episodes might contribute to the development of CDH, which is refractory to medical and non-medical treatments. A nerve block has been used to treat diverse headaches for a long time even though there is some controversy regarding its effectiveness. A study on the clinical characteristics of CM was performed. Here we report the therapeutic results of conservative treatment modalities as well as nerve block in a pain clinic. Methods: Prospective study and research on the clinical characteristics of CM was performed. The Silberstein and Lipton criteria (S-L criteria) were used to classify CDH, and the effectiveness of treatment including drug therapy and nerve block was evaluated after 3 months. Results: Most of the CDH were CM with a female predominance. Several psychopathological factors (e.g. psychiatric comorbidity, personality traits) were frequent in the CM patients. The overuse of medication (abortive drugs for migraine) might favor chronicity. After treatment for 3 months, significant improvement in the visual analogue scale for pain and the patient's satisfaction were obtained in most cases. Conclusions: CDH usually occurs in the form of an episodic headache, which was migraine in most cases. In addition to conventional treatment, a neural blockade appears to be effective in treating CM and medication overuse headache (MOH), but controlled studies will be needed to confirm these preliminary findings.

Cervicogenic headache: practical approaches to therapy.

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. The estimated prevalence of the disorder varies considerably, ranging from 0.7% to 13.8%. Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. Frequent coexistence of a history of head traumas suggests these also play an important role. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group. Positive response after an appropriate nerve block is an essential diagnostic feature of the disorder. Differential diagnoses of cervicogenic headache include hemicrania continua, chronic paroxysmal hemicrania, occipital neuralgia, migraine and tension headache. Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. This review evaluates use of drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies for the treatment of cervicogenic headache. A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available. In the meantime, limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach. The surgical approach, which includes decompression and radiofrequency lesions of the involved nerve structures, may also provide physicians with further options for refractory cervicogenic headache patients. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

Diagnostic delays and mis-management in cluster headache.

Cluster headache is a stereotyped form of primary headache that while common in terms of neurologic illnesses is much less common as a cause of disabling headache than migraine. We directly interviewed 230 patients with cluster headache. National support groups contributed 76% and 24% came from the National Hospital for Neurology and Neurosurgery Headache Clinic. Seventy-two percent were men and 28% women, giving a male to female (M:F) ratio of 2.5:1. Episodic cluster headache (ECH) was recorded in 79% while 21% had chronic cluster headache (CCH). The mean time to diagnosis has dropped from 22 years in the 1960s to 2.6 years in the 1990s, although the mean number of GPs seen before a diagnosis was made remains at three. While there has been improvement in the time to diagnosis for cluster headache, a number of physicians will be consulted, and better education is likely to reduce the overall patient suffering.

Diagnosis, epidemiology, and impact of tension-type headache.

Although tension-type headache is the most prevalent headache and affects 78% of the general population, the substantial societal and individual burden associated with this primary headache has been overlooked. In contrast to migraine headache, there has been limited focus on tension-type headache. Most patients with the chronic form of tension-type headache, which affects 3% of the population, are left virtually without any specific treatment. Chronic tension-type headache differs from the episodic form in frequency, lack of effect to most treatment strategies, more medication overuse, and more loss of quality of life. Daily or near daily headaches also constitute a major diagnostic and therapeutic problem and distinguishing chronic tension-type headache from migraine headache and from medication-induced headache is a substantial diagnostic challenge because management strategies are completely different. Considerable benefits for the society can be gained by specific strategies leading to reductions in the amount of sickness absence and impaired working abilities. The burden on the affected patients' and their families' quality of life also may be improved by a general acceptance of the disorder and by the development of a specific treatment strategy.

Cluster Headache and Cluster Variants.

Patients must be cognizant of the time course of the cluster headache periods to optimally tailor their therapy. Steroids provide the fastest onset of prophylactic effect. Once steroids are initiated, it remains difficult to wean patients off of them, and that is why it is always recommended to associate another prophylactic agent from the onset with the steroids. All triptans can be considered; however, only injectable sumatriptan and zolmitriptan have been the subject of controlled studies, and the former remains the gold standard because of its speed of action. Lithium, although not a first-line therapy, remains mainly efficacious for the chronic form of cluster headache. There does not seem a significant tendency for analgesic rebound-withdrawal headache with cluster headache compared with migraine. Scientific studies of the treatment of cluster headache are inherently difficult because of the rarity of the syndrome, the short duration of attacks, and the relatively short duration of the cluster period, along with the presence of spontaneous remissions. Moreover, still a significant proportion of the available evidence on this subject is uncontrolled. Active, rather than placebo, control individuals are recommended. As far as surgical procedures are concerned, although only recently introduced and less documented, gamma-knife radiosurgery should be preferred to the procedures associated with craniotomy, which are inherently associated with a higher complication potential risk.

Localization of a Gene for Migraine without Aura to Chromosome 4q21

Migraine is a common form of headache and has a significant genetic component. Here, we report linkage results from a study in Iceland of migraine without aura (MO). The study group comprised patients with migraine recruited by neurologists and from the registry of the Icelandic Migraine Society, as well as through the use of a questionnaire sent to a random sample of 20,000 Icelanders. Migraine diagnoses were made and confirmed using diagnostic criteria established by the International Headache Society. A genome-wide scan with multipoint allele-sharing methods was performed on 289 patients suffering from MO. Linkage was observed to a locus on chromosome 4q21 (LOD=2.05; P=.001). The locus reported here overlaps a locus (MGR1) reported elsewhere for patients with migraine with aura (MA) in the Finnish population. This replication of the MGR1 locus in families with MO indicates that the gene we have mapped may contribute to both MA and MO. Further analysis indicates that the linkage evidence improves for affected females and, especially, with a slightly relaxed definition of MO (LOD=4.08; P=7.2 x 10(-6)).