Headache Medication Research Articles

Prevalence of chronic headache with and without medication overuse: Associations with socioeconomic position and physical and mental health status

Near-daily intake of acute symptomatic medication for frequent headache increases the risk for medication-overuse headache (MOH). Chronic headache (CH) and MOH prevalences are inversely related to socioeconomic position (SEP). It is not known how SEP influences the health status of people with these headaches. This cross-sectional study examined the prevalence of CH in Denmark; possible associations between CH and education, work status, and income; and the health status of people with CH across socioeconomic strata. A total of 129,150 individuals aged ⩾16years were invited to the 2010 Danish National Health Survey. Data on SEP indicators and purchases of prescription drugs in 2009 were retrieved from national registers. Respondents with headache ⩾15days per month over 3months were classified as having CH. Those with concurrent over-the-counter analgesic intake of ⩾15days per month or prescription medication overuse (⩾20 or ⩾30 defined daily doses per month depending on the drug or drugs) were classified as having MOH. Associations between headache and SEP were analyzed by logistic regression, and associations between headache and health status scores, by linear regression. Physical and mental health composite scores (SF-12) were summarized per headache group, stratified by SEP, and compared to the sample mean. Analyses were adjusted for stratified sampling and nonresponse. The response rate was 53.1%. CH prevalence was 3.3% with 53.0% of cases having concurrent medication overuse (MOH prevalence 1.8%). CH was more prevalent among those individuals with low SEP. Health status scores were significantly lower among persons with CH in all SEP categories. The burden of CH can be reduced by preventing and treating MOH.

Medication-overuse headache: a review.

Medication-overuse headache (MOH) is a worldwide health problem with a prevalence of 1%–2%. It is a severe form of headache where the patients often have a long history of headache and of unsuccessful treatments. MOH is characterized by chronic headache and overuse of different headache medications. Through the years, withdrawal of the overused medication has been recognized as the treatment of choice. However, currently, there is no clear consensus regarding the optimal strategy for management of MOH. Treatment approaches are based on expert opinion rather than scientific evidence. This review focuses on aspects of epidemiology, diagnosis, pathogenesis, prevention, and treatment of MOH. We suggest that information and education about the risk of MOH is important since the condition is preventable. Most patients experience reduction of headache days and intensity after successful treatment. The first step in the treatment of MOH should be carried out in primary care and focus primarily on withdrawal, leaving prophylactic medication to those who do not manage primary detoxification. For most patients, a general practitioner can perform the follow-up after detoxification. More complicated cases should be referred to neurologists and headache clinics. Patients suffering with MOH have much to gain by an earlier treatment-focused approach, since the condition is both preventable and treatable.

Medication overuse headache: self-perceived and actual knowledge among pharmacy staff.

The aim of this study was to investigate knowledge about medication overuse headache (MOH) among pharmacy staff. MOH is a public health problem both in Sweden and in many other countries. Persons with MOH have limited contact with health care, and medications used are to large extent over-the-counter (OTC) medications. Therefore, pharmacists have an important role in, eg, advising these individuals about their medication use. Little is, however, known about the actual level of knowledge about MOH among pharmacy staff, which determines the quality of their advice to MOH sufferers. A total of 326 questionnaires were distributed to 44 pharmacies in Gothenburg, Sweden. The questionnaire included background questions, questions about advice on headache treatment, source of knowledge about MOH, and questions on self-perceived and actual knowledge on MOH. The response rate was 70%. A majority of the pharmacy staff (90.6%) considered themselves to have knowledge about MOH to some or a greater extent. Almost half had learned about MOH through their university/vocational education. Only 8.6% knew that all 5 headache medications listed in the questionnaire can cause development of MOH, but 40% responded correctly on which treatment advice one can give a person with MOH. Actual knowledge on treatment advice differed significantly between groups of self-perceived knowledge. The knowledge on MOH is insufficient among pharmacy staff, but with the proper knowledge, pharmacy staff is well positioned to effect both primary and secondary prevention of MOH. We suggest not only increasing educational efforts about MOH within pharmacy programs but also continuing education at the pharmacies for all staff. Further, it is also important to increase knowledge among pharmacy customers.

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

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

Headache and Migraine in Children with Sickle Cell Disease Are Associated with Lower Hemoglobin and Higher Pain Event Rates But Not Silent Cerebral Infarction

To identify risk factors for headache and migraine in children with sickle cell disease and test the hypothesis that either or both are independently associated with silent cerebral infarcts. In this cross-sectional study, we evaluated the health history, laboratory values, and brain magnetic resonance imaging findings of participants with sickle cell disease (hemoglobinSS or hemoglobinSβ°-thalassemia) with no history of overt stroke or seizures. Participants characterized headache severity and quality. Migraine was defined by International Headache Society criteria modified for increased sensitivity in children. Neuroradiology and neurology committees adjudicated the presence of silent cerebral infarction by review of magnetic resonance imaging and standardized examination by pediatric neurologists. The cohort included 872 children (51.1% males), ranging in age from 5 to 15 years (mean age, 9.1 years). Of these children, 317 (36.4%) reported recurrent headaches, and 132 (15.1%) reported migraines. In multivariable logistic regression analyses, both were associated with lower steady-state hemoglobin (P = .01 for headaches; P < .01 for migraines) and higher pain rate (P < .01 for headaches; P < .01 for migraines), defined as the number of admissions requiring opioids in the previous 3 years. The presence of silent cerebral infarction was not associated with recurrent headaches or migraines. Only 1.9% (6 of 317) of children with recurrent headaches received medication for headache prophylaxis. Recurrent headaches and migraines are common and undertreated in children with sickle cell disease. Low hemoglobin levels and high pain rates are associated with recurrent headaches and migraines; whereas, silent cerebral infarction is not.

Medication-overuse headache: epidemiology, diagnosis and treatment.

Medication-overuse headache (MOH) is one of the most common chronic headache disorders and a public health problem with a worldwide prevalence of 1-2%. It is a condition characterized by chronic headache and overuse of different headache medications, and withdrawal of the overused medication is recognised as the treatment of choice. However, the strategy for achieving withdrawal is, at present, based on expert opinion rather than scientific evidence, partly due to the lack of randomised controlled studies. This narrative review investigates different aspects of epidemiology, diagnosis, risk factors and pathogenesis as well as management for MOH. We suggest that the first step in the treatment of MOH should be carried out in general practice and should focus primarily on detoxification. For most patients, both prevention and follow up after detoxification can also be performed in general practice, thus freeing resources for referral of more complicated cases to headache clinics and neurologists. These suffering patients have much to gain by an earlier treatment-focused approach lower down on the treatment ladder.

Disability, anxiety and depression associated with medication-overuse headache can be considerably reduced by detoxification and prophylactic treatment. Results from a multicentre, multinational study (COMOESTAS project)

The objective of this article is to investigate whether headache-related disability, depression and anxiety can be reduced by detoxification and prophylactic treatment in patients with medication-overuse headache (MOH). Patients with MOH were included from six centres in Europe and Latin America in a seven-month cohort study. Before and six months after treatment, the degree of disability was measured by the Migraine Disability Assessment (MIDAS) questionnaire, while anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS). A total of 694 patients with MOH were included, of whom 492 completed the study. Headache days were reduced by 58.4% from 23.6 to 9.8 days per month at six months ( P < 0.001). The MIDAS score was reduced by 57.1% from baseline 59.9 to 25.7 ( P < 0.001). Number of patients with depression was reduced by 50.7% from 195 to 96 and number of those with anxiety was reduced by 27.1% from 284 to 207 (both P < 0.001). Disability, depression and anxiety were considerably reduced in patients with MOH by detoxification and prophylactic treatment. This emphasises the urgent need for increased awareness about avoiding overuse of headache medications and demonstrates that not only headache frequency but also disability are remarkably improved by adequate intervention.

Choosing Wisely in Headache Medicine: The American Headache Society's List of Five Things Physicians and Patients Should Question

In an effort to draw attention to tests and procedures associated with low-value care in headache medicine, the American Headache Society (AHS) joined the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. The AHS president appointed an ad hoc "Choosing Wisely" task force of the AHS. The committee surveyed AHS members to develop a candidate list of items for the AHS "Top 5" list of low-value care in headache medicine. Through a process of literature review and consensus, the final list of five items was chosen. Draft recommendations went through several rounds of revision and a process of outside review. The AHS Board of Directors approved the final list of "Five Things." The five recommendations approved by the AHS Board of Directors are: (1) don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine; (2) don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings; (3) don't recommend surgical deactivation of migraine trigger points outside of a clinical trial; (4) don't prescribe opioid- or butalbital-containing medications as a first-line treatment for recurrent headache disorders; and (5) don't recommend prolonged or frequent use of over-the-counter pain medications for headache. We recommend that headache medicine specialists and other physicians who evaluate and treat headache disorders should use this list when discussing care with patients.

Sleep-Related Headache and its Management

Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. Though our understanding of sleep and headache relationship has improved over the years with expanding knowledge in both fields and assessment tools such as polysomnography, it is still poorly understood. Headache and sleep have an interdependent relationship. Headache may be intrinsically related to sleep (migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicrania), may cause sleep disturbance (chronic migraine, chronic tension-type headache, and medication overuse headache) or a manifestation of a sleep disorder like obstructive sleep apnea. Headache and sleep disorder may be a common manifestation of systemic dysfunction-like anemia and hypoxemia. Headaches may occur during sleep, after sleep, and in relation to different sleep stages. Lack of sleep and excessive sleep are both considered triggers for migraine. Insomnia is more common among chronic headache patients. Experimental data suggest that there is a common anatomic and physiologic substrate. There is overwhelming evidence that cluster headache and hypnic headaches are chronobiological disorders with strong association with sleep and involvement of hypothalamus. Cluster headache shows a circadian and circannual rhythmicity while hypnic headache shows an alarm clock pattern. There is also a preferential occurrence of cluster headache, hypnic headache, and paroxysmal hemicrania during REM sleep. Silencing of anti-nociceptive network of periaqueductal grey (PAG), locus ceruleus and dorsal raphe nucleus doing REM sleep may explain the preferential pattern. Sleep related headaches can be classified into (1) headaches with high association with obstructive sleep apnea, which includes cluster headache, hypnic headache, and headache related to obstructive sleep apnea; and (2) headaches with high prevalence of insomnia, medication overuse, and psychiatric comorbidity including chronic migraine and chronic tension-type headache. The initial step in the management of sleep related headache is proper diagnosis with exclusion of secondary headaches. Screening for sleep disorders with the use of proper tests including polysomnography and referral to sleep clinic, when appropriate is very helpful. Control of individual episode in less than 2hours should be the initial goal using measures to abort and prevent a relapse. Cluster headache responds very well to injectable Imitrex and oxygen. Verapamil, steroids and lithium are used for preventive treatment of cluster headache. Intractable cluster headache patients have responded to hypothalamic deep brain stimulation. Hypnic headache patients respond to nightly caffeine, indomethacin, and lithium. Paroxysmal hemicrania responds very well to indomethacin. Early morning headaches associated with obstructive sleep apnea respond to CPAP or BiPAP with complete resolution of headache within a month. Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.

Cluster headache associated with acute maxillary sinusitis

BackgroundCluster headache is a primary headache by definition not caused by any known underlying structural pathology. However, symptomatic cases have been described, for example tumours, particularly pituitary adenomas, malformations, and infections/inflammations. The evaluation of cluster headache is an issue unresolved.Case descriptionI present a case of a 24-year-old patient who presented with a 4-week history of side-locked attacks of pain located in the left orbit. He satisfied the revised International Classification of Headache Disorders criteria for cluster headache. His medical and family histories were unremarkable. There was no history of headache. A diagnosis of cluster headache was made. The patient responded to symptomatic treatment. Low-dose computer tomography scan after 2 weeks displayed a left-sided acute maxillary sinusitis. The headache attacks resolved completely after treatment with antibiotics and sinus puncture.Discussion and evaluationAlthough I cannot exclude an unintentional comorbidity, in my opinion, the co-occurrence of an acute maxillary sinusitis with unilateral headache, in a hitherto headache-free man, points toward the fact that in this case the cluster headache was caused or triggered by the sinusitis. The headache attacks resolved completely after the treatment and the patient also remained headache free at the follow-up. The response of the headache to sumatriptan and other typical cluster headache medications does not exclude a secondary form. Symptomatic cluster headaches responsive to this therapy have been described. Associated cranial lesions such as infections have been reported in cluster headache patients and the attacks may be clinically indistinguishable from the primary form.ConclusionsNeuroimaging, preferably contrast-enhanced magnetic resonance imaging including sinuses should always be considered in patients with cluster headache despite normal neurological examination. Acute maxillary sinusitis can present as cluster headache.

Psychological and neuropsychological correlates of dependence-related behaviour in Medication Overuse Headaches: a one year follow-up study

BackgroundMedication Overuse Headache (MOH) can be related in some patients to dependence-related behaviour characterised by craving, a deficit in controlling substance intake, which is associated to orbitofrontal cortex (OFC) dysfunction. The aim of this study was to explore the psychological correlates in MOH patients and the functioning of the OFC through neuropsychological assessment (Iowa Gambling Task: IGT) and to relate it to prognosis at a one year follow-up point.FindingsSeventeen subjects suffering from probable MOH were included and compared to 19 migraineurs and to 17 controls. The results show significant between group differences for behavioural dependence, depression, anxiety, catastrophizing. There were no between group differences for impulsivity. Mean IGT score did not allow differentiation of MOH patients from the other groups, whereas the score was significantly different between opiate abusers and other medication abusers (45 +/−5.7 versus 57.1 +/−8.2, p = 0.019). Among the clinical variables rated at inclusion, the amount of acute headache medication taken per month was the only one predicting the prognosis (RR = 1.05, 95% CI = 1-1.06, p = 0.04). A slight increase in risk of relapse at 1 year was observed in patients with poorer IGT scores (RR = 0.92, 95% CI = 0.85-1, p = 0.05) and higher behavioural-dependence scores (RR = 1.07, 95% CI = 1–1.14, p = 0.05). None of the other psychological variables predicted relapse risk.ConclusionsThese results must be interpreted with caution due to the low number of subjects. They showed a deficit in decision making processes in MOH patients who overuse medications containing psychoactive substances like opiates. Moreover dependence-related variables are related to the prognosis.

Prescription Headache Medication in OEF/OIF Veterans: Results From the Women Veterans Cohort Study

To examine differences in male and female veterans of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) period of service in taking prescription headache medication, and associations between taking prescription headache medication and mental health status, psychiatric symptoms, and rates of traumatic events. Headaches are common among active service members and are associated with impairment in quality of life. Little is known about headaches in OEF/OIF veterans. Veterans participating in the Women Veterans Cohort Study responded to a cross-sectional survey to assess taking prescription headache medication, mental health status (Post Deployment Health Assessment), psychiatric symptoms (portions of the Brief Patient Health Questionnaire and the Posttraumatic Stress Disorder Checklist), and traumatic events (the Traumatic Life Events Questionnaire and queries regarding military trauma). Gender differences among taking prescription headache medication, health status, psychiatric symptoms, and traumatic events were examined. Regression analyses were used to examine the influence of gender on the associations between taking prescription headache medication and health status, psychiatric symptoms, and traumatic events. 139/551 (25.2%) participants reported taking prescription headache medication in the past year. A higher proportion of women veterans (29.1%) reported taking prescription medication for headache in the last year compared with men (19.7%). Taking prescription headache medication was associated with poorer perceived mental health status, higher anxiety and posttraumatic stress disorder symptoms, and higher rates of traumatic events. The association between prescription headache medication use and perceived mental health status, and with the association between prescription headache medication use and posttraumatic stress disorder symptoms, was stronger for men than for women. Among OEF/OIF veterans, the prevalence of clinically relevant headache is high, particularly among women veterans. Taking prescription headache medication is associated with poor mental health status, higher rates of psychiatric symptoms, and higher rates of traumatic events; however, these variables did not appear to meaningfully account for gender differences in prevalence of taking prescription headache medication. Future research should endeavor to identify factors that might account for the observed differences.

Optimal Use of Acute Headache Medication: A Qualitative Examination of Behaviors and Barriers to Their Performance

This study aims to qualitatively examine the behaviors required to optimally use acute headache medication and the barriers to successful performance of these behaviors. The efficacy of drug treatment is partly determined by medication adherence. The adherence literature has focused almost exclusively on the behaviors required to optimally use medications that are taken on a fixed schedule, as opposed to medications taken on an as needed basis to treat acute episodes of symptoms, such as headaches. Twenty-one people with headache and 15 health care providers participated in qualitative phenomenological interviews that were transcribed and coded by a multidisciplinary research team using phenomenological analysis. Interviews revealed 8 behaviors required to optimally use acute headache medication, including cross-episode behaviors that people with headache regularly perform to ensure optimal acute headache medication use, and episode-specific behaviors used to treat an individual headache episode. Interviews further revealed 9 barriers that hinder successful performance of these behaviors. Behaviors required to optimally use acute headache medication were numerous, often embedded in a larger chain of behaviors, and were susceptible to disruption by numerous barriers.

OnabotulinumtoxinA for treatment of chronic migraine: PREEMPT 24-week pooled subgroup analysis of patients who had acute headache medication overuse at baseline

Acute headache medication overuse (MO) is common in patients with chronic migraine (CM). We evaluated safety and efficacy of onabotulinumtoxinA as preventive treatment of headache in CM patients with baseline MO (CM+MO) in a planned secondary analysis from two similarly designed, randomized, placebo-controlled, parallel, Phase III trials. Patients were randomized to treatment groups (155–195U of onabotulinumtoxinA or placebo) using MO (patient-reported and diary-captured frequency of intake) as a stratifying variable. Of 1384 patients, 65.3% (n=904) met MO criteria (onabotulinumtoxinA: n=445, placebo: n=459). For the CM+MO subgroup at Week 24, statistically significant between-treatment group mean changes from baseline favoring onabotulinumtoxinA versus placebo were observed for headache days (primary endpoint: −8.2 vs. −6.2; p<0.001) and other secondary endpoints: frequencies of migraine days (p<0.001), moderate/severe headache days (p<0.001), cumulative headache hours on headache days (p<0.001), headache episodes (p=0.028), and migraine episodes (p=0.018) and the percentage of patients with severe Headache Impact Test-6 category (p<0.001). At Week 24, change from baseline in frequency of acute headache medication intakes (secondary endpoint) was not statistically significant (p=0.210) between groups, except for triptan intakes (p<0.001), where the onabotulinumtoxinA-treated group was favored. OnabotulinumtoxinA was effective and well tolerated as headache prophylaxis in CM+MO patients.

Headaches During Pregnancy

Headache is a common symptom in pregnant women. Although most headaches seen in women are primary headache disorders (migraine, tension-type headache), complications or conditions associated with pregnancy can present with a secondary headache. Headaches are common symptoms in idiopathic intracranial hypertension, eclampsia, and reversible cerebral vascular syndrome. Migraines may begin or worsen during pregnancy, but pregnancy tends to reduce migraine frequency and severity. Although it is desirable to avoid medications for headaches during pregnancy, treatment should be considered when headaches are severe and cause significant disability. Being aware of possible treatments for migraine and headaches during pregnancy is essential.

A sample of headache incidence in post concussive patients

ObjectiveHeadache is one of the most common and debilitating symptoms after traumatic brain injury (TBI) and may persist months to years after the initial injury. The purpose of this pilot...

The Experience of Headaches in Health Care Workers: Opportunity for Care Improvement

This study assessed the relationship between health care workers' self-reported experience of headaches/migraines, their overall quality of life, and treatment outcomes. The study sample consisted of adults employed by a self-insured hospital system located in the Southeast United States. Study participants responded to a web-based survey disseminated via work email accounts. The survey measured headache medication use, health care service utilization, and impacts on quality of life and treatment optimization using standardized instruments. We received responses from 2453 employees (response rate 33.8%), of which 84.4% reported headaches, suggesting that those with headaches were more likely to complete the survey. Forty percent of respondents reported mild to severe disability due to headaches, and approximately 65% used prescription or over-the-counter medications to treat headaches. Approximately 45% of participants taking headache medications reported unsatisfactory treatment. Among all respondents, those with mild, moderate, or severe migraine disability were 2.35, 1.7, or 2.08 times more likely to take headache medications than those with little or no migraine disability. Among those taking headache medications for treatment, respondents with nonclinical job titles, presenting better physical health status, or reporting little or no migraine disability were more likely to achieve treatment optimization. Recognizing the potential over response by employees who have headaches, our study remains suggestive of a care improvement opportunity in the health care workforce.

Rates and reasons for discontinuation of triptans and opioids in episodic migraine: Results from the American Migraine Prevalence and Prevention (AMPP) study

BackgroundPersons with migraine use acute medications to manage headache pain and associated symptoms. Several studies have reported reasons why patients select specific medications; however, little is known about why patients discontinue acute medications. This study assesses reasons for discontinuation of two commonly used classes of medication—triptans and opioids. MethodsThis study uses data from the 2008 and 2009 AMPP surveys. Eligible subjects had episodic migraine in both 2008 and 2009 and provided data on acute treatment use in both years. The AMPP survey also assessed reasons for discontinuing migraine medications. ResultsOf 3,334 eligible migraineurs, 714 triptan users in 2008, 247 (34.6%) had discontinued triptans by 2009. In 2008 there were 417 opioid users, of whom 246 (59.0%) had discontinued the drug by the 2009 survey. Ordinal regression comparing the pattern of headache-related disability (MIDAS scores) revealed a decrease in headache-related disability among triptan discontinuers (21.4% moderate to severe disability) compared to opioid discontinuers (33.0% moderate to severe disability [p=.004]). Triptan discontinuers were 48% less likely to discontinue because of pain recurrence than those discontinuing opioids (p=.006), 51% less likely to discontinue due to chest pain (p=.018), and 57% less likely to discontinue due to neck pain (p=.004) compared to opioid discontinuers. Triptan discontinuers were 47% less likely to discontinue headache medication because of concern about interactions with other medications (p=.013) and 42% less likely due to concern about effects to the stomach compared to opioid users (p=.029). No differences in reasons for discontinuation were noted for efficacy of pain relief or side effects. DiscussionThis study shows that opioid use is associated with an increased risk of medication discontinuation compared to triptans. Reasons for medication discontinuation included return of migraine pain, concerns regarding drug interactions, and stomach upset, among others. Physicians managing patients using opioids may need to frequently assess the patient's risk of discontinuing their treatment plan, or physicians may need to be proactive and modify the treatment plan to better suite the patient's needs, which may change over time. Further studies are warranted that evaluate rates and reasons of discontinuation of other classes of acute migraine medications.

Contraception and Headache

Most women have used at least 1 method of contraception during their reproductive years, with the majority favoring combined oral contraceptives. Women are often concerned about the safety of their method of choice and also ask about likely effects on their pre-existing headache or migraine and restrictions on using their headache medication. While there should be no restriction to the use of combined hormonal contraceptives by women with migraine without aura, the balance of risks vs benefits for women with aura are debatable. Migraine with aura, but not migraine without aura, is associated with a twofold increased risk of ischemic stroke, although the absolute risk is very low in healthy, nonsmoking women. Although ethinylestradiol has been associated with increased risk of ischemic stroke, the risk is dose-dependent. Low-dose pills currently used are considerably safer than pills containing higher doses of ethinylestradiol but they are not risk-free. This review examines the evidence available regarding the effect that different methods of contraception have on headache and migraine and identifies strategies available to minimize risk and to manage specific triggers such as estrogen "withdrawal" headache and migraine associated with combined hormonal contraceptives. The independent risks of ischemic stroke associated with migraine and with hormonal contraceptives are reviewed, and guidelines for use of contraception by women with migraine are discussed in light of the current evidence.

Usefulness and applicability of web-based headache diagnostic software

Headache diagnostic software (HDS), developed by Headache center, Neurology Clinic in Belgrade integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient’s headache have been collected. Purpose The aim of this pilot study was to test its diagnostic accuracy, the usefulness and applicability in the diagnosis of primary headache disorders and medication overuse headache (MOH).