Headache Diary Research Articles

Statistical testing of association between menstruation and migraine.

To repair and refine a previously proposed method for statistical analysis of association between migraine and menstruation. Menstrually related migraine (MRM) affects about 20% of female migraineurs in the general population. The exact pathophysiological link from menstruation to migraine is hypothesized to be through fluctuations in female reproductive hormones, but the exact mechanisms remain unknown. Therefore, the main diagnostic criterion today is concurrency of migraine attacks with menstruation. Methods aiming to exclude spurious associations are wanted, so that further research into these mechanisms can be performed on a population with a true association. The statistical method is based on a simple two-parameter null model of MRM (which allows for simulation modeling), and Fisher's exact test (with mid-p correction) applied to standard 2 × 2 contingency tables derived from the patients' headache diaries. Our method is a corrected version of a previously published flawed framework. To our best knowledge, no other published methods for establishing a menstruation-migraine association by statistical means exist today. The probabilistic methodology shows good performance when subjected to receiver operator characteristic curve analysis. Quick reference cutoff values for the clinical setting were tabulated for assessing association given a patient's headache history. In this paper, we correct a proposed method for establishing association between menstruation and migraine by statistical methods. We conclude that the proposed standard of 3-cycle observations prior to setting an MRM diagnosis should be extended with at least one perimenstrual window to obtain sufficient information for statistical processing.

Migraine: is it related to hormonal disturbances or stress?

BackgroundCommon neurological syndrome (migraine without aura) is more common among women than men. Migraine is among the top 20 causes of disability. Menstruation is known to be a powerful trigger for migraine, and so is stress, but the presentation of headache is similar in both. Also, women are more vulnerable to stress as well as migraine, and this makes a complex relationship of menstruation, stress, and migraine.ObjectiveThis study was done to understand the association of hormonal fluctuation in menstruation and stress with common migraine.Materials and methodsA cross-sectional comparative study was conducted in 40 young adult females, of whom 20 participants were cases of migraine without aura (18–35 years old), and the remaining 20 participants were age-matched controls. The study was done in Maulana Azad Medical College, New Delhi. Study participants were selected on the basis of International Headache Society (ICHD-IIA1.1) (2004) classification. Study participants with neurological disorders, chronic diseases, and disease suggestive of any hormonal disturbances were excluded. Clinically diagnosed migraine cases were asked to maintain a headache diary and to fill in the Depression Anxiety Stress Scales questionnaire. Biochemical assessment of hormonal status for thyroid-stimulating hormone, triiodothyronine, thyroxine, estrogen, follicle-stimulating hormone, luteinizing hormone, and prolactin was also done on the second day of their menstrual cycle. We used the Mann–Whitney U test to compare hormonal levels and the χ2 test to compare anxiety- or depression-related stress among the migraine and nonmigraine groups.ResultsSignificantly higher values of prolactin were observed in cases (mean ± standard deviation, 152.7 mIU/L±30.5) compared to controls (76.1 mIU/L±8.7), with a P-value <0.001. There was no statistically significant difference observed in levels of thyroid-stimulating hormone (P=0.081), estrogen (P=0.086), luteinizing hormone (P=0.091), or follicle-stimulating hormone (P=0.478). Also, anxiety with stress or depression with stress was significantly higher among the migraine group than the controls (P=0.002). Odds of any stress in migraine were higher in the migraine group than in the nonmigraine group (odds ratio 12, 95% confidence interval 2.7–53.33).ConclusionMigraine, particularly without aura, in women is mainly associated with stress-related anxiety or depression, and are more susceptible to stress in the premenstrual period.

EHMTI-0276. A novel mobile health application for patients with chronic headache

Background Headache is the commonest presenting complaint to neurology clinics across Europe and the developed world. However, within publically funded healthcare systems such as the UK’s National Health Service (NHS), long term follow-up in specialist clinics is not currently possible for all patients with chronic headache disorders. One potential solution to this challenge is to develop mobile health (mHealth) applications to allow specialists to monitor larger numbers of patients than would be possible within existing service models. We therefore aimed to develop a novel mobile application based system to allow remote monitoring of patients with chronic headache. System design The system consists of separate interfaces for patients and clinicians. The patient interface, accessed through mobile devices, enables patients to keep headache diaries and assesses the impact of symptoms using quality of life scales. The web-based interface used by clinicians, charts patients responses in a user-friendly format. Longitudinal change in symptom severity is charted in relation to medication/lifestyle changes and other interventions. The treating clinician is also able to set alarm parameters for individual patients that would alert them that a patient needs review and if necessary expedite a clinic appointment. Conclusions

EHMTI-0156. Quantitative sensory testing in patients with headache attributed by idiopathic intracranial hypertension – a case-control study

Background In patients with idiopathic intracranial hypertension (IIH) headache often persist as a disabling symptom even after intracranial pressure (ICP) has normalized. Yet very little is known about the mechanisms of chronification. Aim To explore pain perception in patients with IIH in a controlled design at time of diagnosis and after 3 months of treatment. Materials and methods We explored pain perception in patients with newly diagnosed IIH by Quantitative Sensory Testing (QST) measuring cephalic and extra-cephalic supra-threshold pain ratings and pain thresholds for pressure and electrical stimulation. QST was performed at diagnosis and after one and three months. ICP was measured at baseline and at the 3-month follow-up. QST measurements from sex-matched controls were used for comparisons. Headache was assessed by monthly standardized interviews and headache diaries. Results At baseline IIH patients (n = 28) showed no consistent abnormalities in pain sensitivity or thresholds (p > 0.09 for all comparisons to healthy controls (n = 28). Although headache improved markedly and ICP normalized in 52%, there was no consistent change in pain sensitivity from baseline to follow-up (p > 0.09 for all variables). Patients with (54%) and without persistent chronic headache (46%) 3 months after diagnosis showed no different pain perception either at baseline or at the 3-month follow-up. Conclusions Although headache persisted as a chronic symptom in half of the patients we found no evidence of increased central pain sensitivity suggesting that headache chronification in IIH is caused by mechanisms other than central sensitization.

EHMTI-0317. Transcranial direct current stimulation in chronic migraine: a pilot trial combining cathodal visual and anodal dlpfc stimulation

Method We recruited 20 patients suffering from chronic migraine (n = 15) or medication overuse headache (n = 5)(ICHD-III beta 1.3 or 8.2).All had stable preventive treatment for at least 2 months. We applied anodal tDCS over F3 and cathodal over Oz: intensity 2 mA, duration 20min, daily for 8 weeks. Patients filled in headache diaries before (T0), during (T1) and after treatment (T2).We recorded CHEPS, QST, nBR and VEP at baseline (T0), immediately after (T1) and after 8 weeks (T2).

EHMTI-0228. A clinical interview versus prospective headache diaries in the diagnosis of menstrual migraine without aura

The International Classification of Headache Disorders (ICHD) II and III beta defines menstrual migraine as attacks of migraine without aura occurring on day 1±2 of the menstrual cycle in ≥2/3 menstruations. According to the ICHD III beta, a three month prospective headache diary is required in order to establish the diagnosis of MM.

EHMTI-0384. A double blind randomized placebo controlled trial for non-invasive dynamic trans-cutaneous electrical nerves stimulation in management of tension type headaches

Tension-type headaches (TTH) are the most common type of headaches, and new non-invasive modalities might improve their better management. Dynamic transcutaneous electrical nerves stimulation (dTENS) is one of them. We designed a protocol for a randomized double blind placebo controlled clinical trial to assess the effects of dTENS for patients with chronic TTH. dTENS is added to the standard management with no changes in routine practice. We invite for this study adolescents, adults and elderly patients who consented to participate. Specially designed headache diaries, HALT, HART indices and clinical interview are included as the major outcomes measures. The zones, intensity and duration for dTENS application were recommended and modified by physical therapist (L.G.) and acupuncture specialist (M.N.). They included the zones (on the head and neck) and dosage recommended by the manufacturer. The course of dTENS study consists of 10 procedures performed by clinicians (D.V. and G.R.) who were trained for this. All participants of the study are randomized into two groups using a computer-based software. Placebo-devices were made for this trial by the manufacturer (DENAS Corporation, Ekaterinburg, Russia). The sham-devices look and sound exactly as the active ones, but electrodes are not connected to the electrical stimulator. These compact devices for dTENS are approved for using in medical settings and at home, and this trial might add evidence for physicians when prescribing them to patients.

EHMTI-0327. Information and communication technology for improving the management of medication overuse headache: results of the comoestas multicentric, multinational study

Background The management of medication overuse headache (MOH) is rewarding but also challenging because effective treatment is frequently followed by relapses. Information and Communication Technology has recently been proposed as a valid aid to improve healthcare quality in chronic conditions. In this frame, we developed a headache diary associated with an alert/alarm logic for the interactive monitoring and the professional support of MOH patients after detoxification.

Medium-term effectiveness of online behavioral training in migraine self-management: A randomized trial controlled over 10 months.

This randomized, controlled trial examined the medium-term effectiveness of online behavioral training in migraine self-management (oBT; N = 195) versus waitlist control (WLC; N = 173) on attack frequency, indicators of self-management (primary outcomes), headache top intensity, use of rescue medications, quality of life and disability (secondary outcomes). An online headache diary following the ICHD-II and questionnaires were completed at baseline (T0), post-training (T1) and six months later (T2). Missing data (T1: 24%; T2: 37%) were handled by multiple imputation. We established effect sizes (ES) and tested between-group differences over time with linear mixed modelling techniques based on the intention-to-treat principle. At T2, attack frequency had improved significantly in oBT (-23%, ES = 0.66) but also in WLC (-19%; ES = 0.52). Self-efficacy, internal and external control in migraine management--and triptan use--improved only in oBT, however. This indicates different processes in both groups and could signify (the start of) active self-management in oBT. Also, only oBT improved migraine-specific quality of life to a sizable extent. oBT produced self-management gains but could not account for improved attack frequency, because WLC improved as well. The perspective that BT effects develop gradually, and that online delivery will boost BT outreach, justifies further research.

Commercially available mobile phone headache diary apps: a systematic review.

BackgroundHeadache diaries are often used by headache sufferers to self-monitor headaches. With advances in mobile technology, mobile electronic diary apps are becoming increasingly common.ObjectiveThis review aims to identify and evaluate all commercially available mobile headache diary apps for the two most popular mobile phone platforms, iOS and Android.MethodsThe authors developed a priori a set of 7 criteria that define an ideal headache diary app intended to help headache sufferers better understand and manage their headaches, while providing relevant data to health professionals. The app criteria were intended as minimum requirements for an acceptable headache diary app that could be prescribed by health care professionals. Each app was evaluated and scored against each criterion.ResultsOf the 38 apps identified, none of the apps met all 7 app criteria. The 3 highest scoring apps, meeting 5 of the app criteria, were iHeadache (developed by Better QOL), ecoHeadache (developed by ecoTouchMedia), and Headache Diary Pro (developed by Froggyware). Only 18% of the apps were created with scientific or clinical headache expertise and none of the apps reported on psychometric properties.ConclusionsDespite the growing market and demand, there is a concerning lack of scientific expertise and evidence base associated with headache diary apps.

Diagnosis and management of headache in children and adolescents: an overview

Background Headache is a common complaint in childhood with up to 75% of children reporting a notable headache by the age of 15 years. Pediatric migraine is the most frequent recurrent headache, occurring in up to 28% of older teenagers. Migraine can have a substantial effect on the life of the child, as well as their family, leading to lost school days and withdrawal from social interactions. The prevalence of non-migrainous headache is 10-25% in childhood and adolescence. Materials and methods The distinction of tension-type headache from migraine can be difficult. Although the International Classification of Headache Disorders criteria help, these criteria might be too restrictive to differentiate tension-type headache from migraine without aura in children. A headache diary is a useful method for the differentiation of headache types. The diagnosis of primary headache requires exclusion of secondary headache since many organic disorders can present as tension-type headache because disease-specific features are absent. Fever is the most common cause of benign paroxysmal headache. The basis of diagnosis is a systematic headache history, careful physical and neurological examination, including fundoscopy, and follow-up using a headache diary. If the results of neurological examination are normal in children with frequent headache neuroimaging is not routinely done. Results

Comparison of neurofeedback and transcutaneous electrical nerve stimulation efficacy on treatment of primary headaches: a randomized controlled clinical trial.

Background:Headache is one of the most prevalent investigated complaints in the neurology clinics and is the most common pain-related complaint worldwide. Stress is a significant factor that causes and triggers headaches. Since healthcare practitioners experience a lot of stress in their careers, they are more prone to headaches.Objectives:This study was designed to evaluate and compares the efficacy of neurofeedback behavioural therapy (NFB) and transcutaneous electrical nerve stimulation (TENS) in the treatment of primary headaches in healthcare providers.Patients and Methods:The current study was a clinical trial, performed in Teheran, IR Iran, with two experimental groups and a control group. Convenient sampling method was used to recruit patients. Independent variables were NFB and TENS and dependent variables were frequency, severity, and duration of headache. Blanchard headache diary was used for assessment. Hence, 45 healthcare providers with primary headache were selected and randomly allocated to one of the NFB, TENS, and control groups by block random assignment method. All three groups completed the headache diary during one week before and after the treatment period as pretest and posttests, respectively. The NFB group was treated in the period between pretest and posttest with fifteen 30-minute treatment sessions three times a week and the TENS group was treated with fifteen 20-minute daily sessions. The control group received none of these treatments.Results:The results from the analysis of covariance showed that treatment with NFB and TENS had caused significant decrease in the frequency, severity, and duration of headache in experimental groups. The results of the LSD post-hoc test indicated that there were significant differences in the frequency, severity, and duration of pain among experimental groups and the control group. Moreover, there were significant differences between pain frequencies in experimental groups.Conclusions:According to the results and given the significant reductions in the frequency, severity, and duration of headaches, it seems that NFB and TENS might have an effective role in reducing primary headaches of healthcare providers. In addition, comparing the two methods, treatment with NFB was more effective in reducing headache frequency and severity.

The course of headache in idiopathic intracranial hypertension: a 12-month prospective follow-up study.

Our aim was to prospectively describe the course of headache during the first year of idiopathic intracranial hypertension (IIH). Patients with newly diagnosed IIH were consecutively included from December 2010 to June 2013. Treatment according to standard guidelines was initiated. Headache history was obtained by headache diaries and standardized interviews performed at baseline and after 1, 2, 3 and 12months. Parallel changes in papilledema were assessed by optical coherence tomography (OCT). All patients had comprehensive neuro-ophthalmological examinations including automated perimetry. Forty-four patients were included. Thirty-five patients completed the 12-month follow-up. Dramatic improvement in headache occurred within the first weeks after diagnosis. After 1year, 15 patients reported no or only infrequent headache. However, 15 of the remaining 20 patients reported sustained chronic headache. Early age of onset and high diagnostic intracranial pressure (ICP) were associated with better headache outcome (≤1 headache days/month) after a year. Papilledema decreased rapidly within the first 2months of diagnosis. After 1year, OCT measures had normalized. Visual outcome was excellent in most patients. Although headache in 43% of patients responded well to ICP management, sustained long-term headache was seen in the remaining patients, despite resolution of papilledema. Headache in IIH may thus be attributed to more complex mechanisms than ICP elevation alone. High ICP and young age were associated with better headache outcome. Early treatment according to standard guidelines seems sufficient to ensure excellent visual outcome in the vast majority of patients.

Specific Headache Factors Predict Sleep Disturbances Among Youth With Migraine

BackgroundThere is a paucity of pediatric data addressing the complex relationship between primary headaches and sleep disturbances. Our study objective was to explore headache-related factors that predict sleep disturbance and to compare sleep complaints with other forms of headache-related disability among youth with migraines. MethodsA prospective cohort study was conducted in patients 10-18 years old with migraine or probable migraine and without daily sleep complaints. The patients completed a 90-day internet-based headache diary. On headache days, patients rated headache intensity, answered Pediatric Migraine Disability Assessment-based questions modified for daily scoring, and reported sleep disturbances that resulted as a direct effect of proximate headaches. ResultsFifty-two patients generated 4680 diary entries, 984 patients (21%) involved headaches. Headache intensity (P = 0.009) and timing of headache onset (P < 0.001) were predictive of sleep disturbances. Three Pediatric Migraine Disability Assessment-based items were also associated with sleep disturbances: partial school-day absence (P = 0.04), recreational activities prevented (P < 0.001), and decreased functioning during recreational activities (P < 0.001). Sleep disturbances correlated positively and significantly with daily headache disability scores (rpb = 0.35; P < 0.01). ConclusionWe conclude that specific headache factors predict sleep disturbances among youth with primary headaches.

Headache After Traumatic Brain Injury: A National Survey of Clinical Practices and Treatment Approaches

BackgroundIndividuals with headache after traumatic brain injury (TBI) receive care in a wide variety of clinical locations by physicians trained in multiple specialties. ObjectiveTo understand current practice patterns and perceptions of treatment issues among clinicians managing headache after TBI. DesignNational survey of current clinical practice using a 20-item questionnaire developed by the authors. ParticipantsSurvey respondents were members of the Central Nervous System Council list survey of the American Academy of Physical Medicine and Rehabilitation (N = 1782) and the American Headache Society membership (N = 1260). MethodsThe survey was sent electronically to potential participants and was followed by 2 biweekly reminders. The survey queried the physicians' clinical setting; their use of headache classification systems, headache diaries, checklists, and diagnostic procedures; the pharmacologic and nonpharmacologic treatments prescribed; and headache chronicity and associated symptoms and disorders among their patients with TBI. ResultsCompleted surveys were received from 193 respondents. The use of standardized classification systems and checklists was commonly reported. Respondents used nonpharmacologic and pharmacologic treatment approaches with similar frequency and modest perceived success rates. A high frequency of headache-associated new sleep and mood disorders was reported. When response differences occurred between practice settings, they reflected a focus on headache diagnosis, classification, and pharmacologic treatment among neurology and specialty headache clinics, whereas a nonpharmacologic approach to management among TBI specialty and general rehabilitation clinicians was more commonly reported. ConclusionManagement strategies for treating headache after TBI vary widely among general and specialty clinical practices. This suggests that additional research is needed that would lead to an increase in the use of established headache classification and the development of standardized management approaches so that all practitioners who care for patients after TBI can provide consistent effective care.

Olfactory hallucination in childhood primary headaches: case series.

Although olfactory hallucination (OH) has been reported in patients with primary headaches, olfactory aura has not been recognised by the International Classification of Headache Disorders (ICHD-2). In this study, we examined the frequency and characteristics of OH among children and adolescents with primary headaches. 839 neurologically normal patients with primary headaches (537 migraine) were eligible for the assessment of olfactory hallucination. Headache diagnosis was based on the ICHD. Data were prospectively collected during clinic sessions and using headache diaries. Olfactory hallucination was reported exclusively during headache attacks by 21/839 (2.5%) patients, all of whom had migraine. The prevalence of olfactory hallucination was 3.9% among migraineurs (6.5% among those with migraine aura). Olfactory hallucination shortly followed the onset of headaches and lasted from 15 to 50 minutes. Of those with MA, 10 patients had visual aura; two had somatosensory aura; one had motor aura; and two had a combination of visual and somatosensory aura. Using the ICHD-2, both OH and migraine aura occurred in the same headache attacks. In 12/15 patients, OH occurred simultaneously with migraine aura, whereas in 3/12 patients, it preceded aura. Our findings show that olfactory hallucination occurs in migraine and it has similarities to migraine aura.

Clopidogrel as prophylactic treatment for migraine: a pilot randomised, controlled study.

Anecdotal reports suggest that clopidogrel may prevent migraine attacks. We undertook a pilot randomised trial. We randomised consecutive migraineurs with four to 15 headache days per 28-day month to receive clopidogrel 75 mg or placebo daily for three months. Headache was primarily assessed with a headache diary. There were no statistically significant treatment effects. The number of headache days fell by 1.9 on clopidogrel and 1.6 on placebo (adjusted difference 0.02, CI -2.07 to 2.12). Headache severity rose by 0.14 points (out of 10) on clopidogrel, and fell by 0.63 on placebo; treatment effect 0.7 points (CI -0.11 to 1.57). The main treatment effect did not depend on the presence or absence of migraine with aura at baseline, a patent foramen ovale (PFO) or atrial septal aneurysm. The evidence is inconclusive, but a multicentre trial would be feasible recruiting from primary care.

Onabotulinumtoxin A for prophylaxis in chronic migraine: preliminary data from Headache Regional Centre of Aosta Valley.

Chronic migraine (CM) is a complex neurological disorder associated with substantial disability that affects approximately 2 % of general population. Onabotulinumtoxin A is employed for patients suffering from CM refractory to common therapeutic prophylaxis. Since May 2013, we have selected 22 patients referring to our headache centre with a history of CM which meets the diagnostic criteria of ICHD-3 beta (2013). The patients have been treated with onabotulinumtoxin A injection in 31 sites according to the protocol of the PREEMPT study at the total dosage of 155 U/treatment every 3 months. So far, eight patients have been subjected to three treatment sessions, five patients to two treatments and nine patients to one treatment. Three patients dropped for low compliance, but there were no serious adverse events. The frequency of headache days, the intensity of headache and the headache disability have been measured using headache diary, migraine disability assessment (MIDAS) questionnaire and headache impact test (HIT)-6 score. Data concerning the 13 patients who have been submitted to at least two treatment sessions have already shown a decrease of headache days of 20.64 % after the first treatment; MIDAS and HIT-6 scores have been significantly improved with a reduction of the scores, respectively, of 38.45 % for MIDAS and of 6.95 % for HIT-6. These are preliminary results because the observation time, the number of treatment sessions and the number of patients treated are still few.

PedMIDAS‐Based Scoring Underestimates Migraine Disability on Non‐School Days

The aim of this study is to compare daily Pediatric Migraine Disability Assessment (PedMIDAS)-based scores for headaches occurring on school days vs non-school days and during the school year vs the summer holiday. The PedMIDAS is the only instrument validated to assess migraine disability among school-aged children. However, the PedMIDAS may underestimate disability during prolonged school holidays. In a prospective cohort study, migraine patients aged 10-18 years completed a 90-day Internet-based headache diary. For each headache day, they answered PedMIDAS-based questions and rated their headache intensity (scale 1-10). PedMIDAS-based scores, headache intensity ratings, and relative headache frequencies were compared for school days vs non-school days and for the school year vs the summer holiday. Fifty-two patients completed 4680 diary entries comprising 984 headache days. The headache frequencies and intensity ratings did not differ between time periods. However, the mean headache disability scores (as measured from PedMIDAS-based questions) were significantly different for school days (0.85) compared to non-school days (0.45), P < .001, and for the school year (0.73) compared to the summer holiday (0.46), P < .016. Given similar headache intensities and frequencies, daily PedMIDAS-based scores significantly underestimate headache disability on non-school days. Accordingly, PedMIDAS scoring during the school year may not be comparable to assessments done during the summer holiday. These potential differences must be considered when using the instrument as an outcome measure for clinical trials.

Mindfulness-based Cognitive Therapy for the Treatment of Headache Pain

This pilot study reports the findings of a randomized controlled trial (RCT) investigating the feasibility, tolerability, acceptability, and initial estimates of efficacy of mindfulness-based cognitive therapy (MBCT) compared to a delayed treatment (DT) control for headache pain. It was hypothesized that MBCT would be a viable treatment approach and that compared to DT, would elicit significant improvement in primary headache pain-related outcomes and secondary cognitive-related outcomes. RCT methodology was employed and multivariate analysis of variance models were conducted on daily headache diary data and preassessment and postassessment data for the intent-to-treat sample (N=36), and on the completer sample (N=24). Patient flow data and standardized measures found MBCT for headache pain to be feasible, tolerable, and acceptable to participants. Intent-to-treat analyses showed that compared to DT, MBCT patients reported significantly greater improvement in self-efficacy (P=0.02, d=0.82) and pain acceptance (P=0.02, d=0.82). Results of the completer analyses produced a similar pattern of findings; additionally, compared to DT, MBCT completers reported significantly improved pain interference (P<0.01, d=-1.29) and pain catastrophizing (P=0.03, d=-0.94). Change in daily headache diary outcomes was not significantly different between groups (P's>0.05, d's≤-0.24). This study empirically examined MBCT for the treatment of headache pain. Results indicated that MBCT is a feasible, tolerable, acceptable, and potentially efficacious intervention for patients with headache pain. This study provides a research base for future RCTs comparing MBCT to attention control, and future comparative effectiveness studies of MBCT and cognitive-behavioral therapy.