Headache Specialists Research Articles

The impact of regular lifestyle behavior in migraine: a prevalence case-referent study.

Regular lifestyle behaviors (RLBs) of sleep, exercise, mealtime pattern and hydration status independently affect migraine occurrence. We aimed herein to evaluate the differences in migraine occurrence among participants who do and do not maintain the RLB triumvirate. Cases of chronic migraine (CM) and referents of episodic migraine (EM) ≥ aged 15 years with charts regularly documenting RLB notes were continuously enrolled from a retrospective case-referent cohort study performed on electronic chart review from January 1, 2014 to January 1, 2015 at the Stanford Headache and Facial Pain Program. Association between RLB prevalence and migraine occurrence was studied. 175 CM and 175 EM patients were enrolled (mean age 44.4 years, 22 % males). Migraine was diagnosed according to the ICHD-3 beta criteria, and was confirmed by a Headache Specialist attending the Clinic. The CM cohort (22 %) exhibited less RLB than the EM cohort (69 %), with crude odds ratio of 0.13 (95 % confidence interval or CI 0.08-0.21). The adjusted odds ratio and adjusted relative risk between RLB+, Meds+ (those taking medication) and CM were 0.67 (95 % CI 0.32-1.40) and 0.74 (95 % CI 0.43-1.28), indicating no significant effect modification. Engaging in regular lifestyle behavior helps quell chronic migraine.

A review study on recent advance of headache and facial pain disorders

Headache and facial pain disorders are prevalent, disabling, and largely treatable, but are under-recognized, underdiagnosed, and undertreated, and a burden, both to the individual and to the society. Headache and facial pain cuts across a diverse group of physicians, including neurologists, neurosurgeons, headache specialists, otolaryngologists, dental specialists, anesthesiologists, and pain specialists. This review discusses the relevant neuroanatomy, the updates in pathophysiology, and classification of headache and facial pain disorders. We will also introduce the art of history-taking in headache patients, as well as physical examination, investigation, and treatment of the most common disorders.

A pilot study of cognitive behavioural therapy and relaxation for migraine headache: a randomised controlled trial.

Headache is being viewed more commonly in a biopsychosocial framework, which introduces the possible utilisation of psychological treatment options, such as cognitive behavioural therapy and relaxation. No such treatments have been trialled in the UK. We conducted a randomised controlled pilot trial, comparing a brief guided self-help CBT and relaxation treatment with standard medical care (SMC), in a UK NHS setting. Participants were recruited from specialist headache clinics across London. Participants were randomised to receive either treatment or standard medical care. Our objective was to provide design information necessary for a future definitive trial of the SHE treatment, including, recruitment/retention rates, acceptability of randomisation, treatment fidelity and estimations of mean and variances of outcome measures. From the initial 275 patients identified, 73 were randomised. There was no difference in drop-out rates between SMC and treatment groups. Of the 36 participants randomised to receive treatment, 72 % attended all sessions. Findings show that a future definitive trial of the SHE treatment is feasible, with small modifications of protocol, within a UK NHS context.

Dr. Ninan T. Mathew--A "Tribute" (1937-2015).

Dr. Ninan T. Mathew--A "Tribute" (1937-2015).

Chronic migraine: treatability, refractoriness, pseudo-refractoriness.

Chronic migraine (CM), a highly disabling condition affecting 2-3% of the general population, represents a difficult-to-treat disorder for its unclear pathophysiology, complex comorbidities, and disappointing response to available pharmacological treatments[1]. High quality evidence (≥2 RCTs) recommends the prophylactic use of onabotulinum toxin A (155-195 IU) and topiramate (100 mg) in CM, while lower quality evidence (1 RCT) supports the treatment with sodium valproate (800-1500 mg), gabapentin (2400 mg) and tizanidine (18 mg)[2]. Amitriptyline, memantine, zonisamide and pregabalin may also be of help in CM but their use has been suggested only in open studies[2]. CM patients may show poor or no response to preventative therapies. The consensus statement of the European Headache Federation (EHF) defines CM refractory to treatment (rCM) when it does not respond to adequate dosages of at least 3 drugs from the classes of beta-blockers, anticonvulsants, tricyclics, onabotulinum toxin A and others (e.g., flunarizine, candesartan) for at least 3 months each, in absence of medication overuse[3]. This rCM definition has been questioned by some authors who stressed the need of using drugs from different classes, not limited to 3, before making rCM diagnosis[4]. Labeling a patient as affected by rCM may profoundly modify his/her life with heavy psychological, social, work and medico-legal consequences, potentially leading to expensive and still unsatisfying surgical procedures such as occipital nerve stimulation[5]. We point out the risk that the current rCM EHF definition could indeed also include pseudo-refractory CM patients, due to potential bias: firstly, a significant proportion of CM patients may spontaneously reverse to episodic migraine, as clearly evidenced in population-based study[6]; secondly, rCM patients may present underlying psychiatric disturbances (e.g., personality disorders) not easily recognized, classified and treated by headache specialists; thirdly, rCM diagnosis could be biased by unproven evidence as current rCM criteria do not specify who should attest patient's previous headache history (theoretically self-reported or stated by unqualified physicians). We suggest that 1) rCM is probably more rare than presently stated; 2) before formulating a diagnosis of rCM, psychiatric disorders should be carefully ruled out by appropriate and thorough psychiatric investigations; 3) when assessing CM patient's past medical history, only clinical data coming from certified headache centers should be considered; 4) CM patients should be followed up for an adequate period of time before making a definite rCM diagnosis.

A proposal for a national registry on chronic migraines.

According to the existing classification chronic migraine (CM) is a primary headache that occurs on 15 or more days per month for more than 3 months and has the features of migraine on at least 8 days per month. In Europe, CM prevalence ranges from 2.7% to 4.7%. CM is an extremely disabling disorder associated with significant functional impairment. The 2010 Global Burden of Disease Survey conducted by the WHO listed migraine as the 7th cause of disability in the world, responsible for 2.9% of all years of life lost to disability. Unfortunately, however, in its current definition CM includes subgroups of patients with very different levels of severity and outcome. Failing to recognize them entails highly negative repercussions on research and clinical practice, with inadequate patient management and lack of cost-effectiveness. Therefore, it is essential that these subgroups of subjects be clearly identified to optimize clinical management, rationalize the allocation of economic resources, provide specific clinical and health care procedures, and clarify pathogenetic mechanisms. The clinical registry will include the data of all patients with CM, aged 18 or over, seen at the Headache Centres of Parma, Bologna, Rome, and Milan. The diagnosis of CM will be made by a headache specialist based on the diagnostic criteria of the ICHD-III beta (2013) and on the CM classification proposed by Manzoni et al[1]. The principal aim of the clinical registry will be to identify still undefined subgroups of subjects with CM through a specially designed clinical registry to be applied in a large number of outpatients. The registry will make it possible to collect: personal and social patient data, as well as data about their physiological conditions and non-essential habits; clinical features of headache (before and after its evolution to chronicity); any factors concomitant with the headache's evolution to chronicity (i.e., medication overuse, life events, hypertension); comorbidity and injuries; headache-related disability (MIDAS, WHO-DAS-II, MSQ); quality of life (SF36); symptomatic and preventive treatments; medication overuse; visits and hospitalizations for CM; and recognized sickness and invalidity allowances. The creation of a large-scale registry will make it possible to identify specific CM (i.e., refractory CM) subgroups, based on clinical and biological features. It will also make it possible to identify areas with lack of or inadequate health care provision and waste of resources (i.e., useless examinations or treatments), eventually helping to improve CM management and ensure health care procedures that are more appropriate.

Procedural Headache Medicine in Neurology Residency Training: A Survey of US Program Directors.

To survey neurology residency program directors (PDs) on trainee exposure, supervision, and credentialing in procedures widely utilized in headache medicine. Clinic-based procedures have assumed a prominent role in headache therapy. Headache fellows obtain procedural competence, but reliance on fellowship-trained neurologists cannot match the population eligible for treatments. The inclusion of educational modules and mechanisms for credentialing trainees pursuing procedural competence in residency curricula at individual programs is not known. A web-based survey of US neurology residency PDs was designed by the American Headache Society (AHS) procedural special interest section in collaboration with AHS and American Academy of Neurology's Headache and Facial Pain section leadership. The survey addressed exposure, training, and credentialing in: (1) onabotulinumtoxinA (onabotA) injections, (2) extracranial peripheral nerve blocks (PNBs), and (3) trigger point injections (TPIs). Fifty-five PDs (42.6%) completed the survey. Compared to noncompleters, survey completers were more likely to feature headache fellowships at their institutions (38.2% vs 10.8%, P=0.0002). High exposure (onabotA=90.9%, PNBs=80.0%, TPIs=70.9%) usually featured hands-on patient instruction (66.2%) and lectures (55.7%). Supervised performance rates were high (onabotA=65.5%, PNBs=60.0%, TPIs=52.7%), usually in continuity clinic (60.0%) or headache elective (50.9%). Headache specialists (69.1%) or general neurology (32.7%) faculty most commonly trained residents. Formal credentialing was uncommon (16.4-18.2%), mostly by documenting supervised procedures (25.5%). Only 27.3% of programs permitted trainees to perform procedures independently. Most PDs felt procedural exposure (80.0-90.9%) and competence (50.9-56.4%) by all trainees was important. Resident exposure to procedures for headache is high, but credentialing mechanisms, while desired by most PDs, are not generally in place. Implementation of a credentialing process may ensure trainees enter practice with the ability to perform procedures safely and effectively.

Therapeutic Monoclonal Antibodies: What Headache Specialists Need to Know.

Monoclonal antibodies (mAbs) are now an important part of the treatment armamentarium for a wide range of conditions including cancer, autoimmune diseases, inflammatory diseases of the joint and bowel, transplant rejection, and multiple sclerosis. Significant progress over the last 30 years in the development of therapeutic mAbs has resulted in improved efficacy and safety. Monoclonal antibodies approved for the treatment of neurological illnesses so far are limited to use in multiple sclerosis. Several therapeutic mAbs have completed phase 2 clinical trials for migraine prevention, and there are phase 3 trials underway for migraine prophylaxis and for cluster headache at the time of this writing. The purpose of this review is to discuss the characteristics of mAbs, including their mechanism of action and safety profile, and briefly describe the mAbs being evaluated for the prevention of migraine and cluster headaches. Monoclonal antibodies have several features that distinguish them from small molecules, including very high selectivity, relatively long half-life that generally allows for once or twice monthly dosing, and significantly reduced potential for drug-drug interactions or other nontarget related toxicities. The clinical development of mAbs that target calcitonin gene-related peptide and its receptor is underway and will evaluate this promising new drug class for the prevention of migraine and cluster headache.

Pilot Randomized Controlled Trial of Internet-Delivered Cognitive-Behavioral Treatment for Pediatric Headache.

To evaluate the feasibility and preliminary effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention for adolescents with chronic headache. Headache is among the most common pain complaints of childhood. Cognitive-behavioral interventions are efficacious for improving pain among youth with headache. However, many youth do not receive psychological treatment for headache due to poor access, which has led to consideration of alternative delivery modalities such as the Internet. We used a parallel arm randomized controlled trial design to evaluate the feasibility and preliminary effectiveness of an Internet-delivered family-based CBT intervention, Web-based management of adolescent pain. Adolescents were eligible for the trial if they were a new patient being evaluated in a specialized headache clinic, between 11 and 17 years of age, and had recurrent headache for 3 months or more as diagnosed by a pediatric neurologist. Eighty-three youths were enrolled in the trial. An online random number generator was used to randomly assign participants to receive Internet CBT adjunctive to specialized headache treatment (n = 44) or specialized headache treatment alone (n = 39). The primary treatment outcome was headache days. Youth and parents in the Internet CBT group demonstrated high levels of engagement with the web program and reported satisfaction with the intervention. Multilevel modelling (MLM) was used to conduct hypothesis testing for continuous outcomes. For our primary treatment outcome of headache days, adolescents reported a statistically significant reduction in headache days from baseline to post-treatment and baseline to 3-month follow-up in both treatment conditions (main effect for time F(2, 136) = 19.70, P < .001). However, there was no statistically significant difference between the Internet CBT group and the specialized headache treatment group at post-treatment or follow-up (group × time interaction F(2, 134) = 0.94, P = .395). For our secondary treatment outcomes, findings from MLM showed that adolescents in both groups demonstrated statistically significant improvement headache pain intensity, activity limitations, depressive symptoms, and parent protective behaviors from baseline to post-treatment and these gains were maintained at 3-month follow-up. Adolescent anxiety symptoms and sleep did not change during the study period for either group. There were no statistically significant group differences on any secondary outcomes at post-treatment or follow-up (P > .05 for all outcomes). No adverse events were reported. Although adjunctive Internet CBT did not lead to additional benefit in this population, future research should evaluate whether it is an effective intervention for adolescents with headache who are unable to access specialized headache treatment.

Survey of Opioid and Barbiturate Prescriptions in Patients Attending a Tertiary Care Headache Center.

To educate physicians about appropriate acute migraine treatment guidelines by determining (1) where headache patients were first prescribed opioids and barbiturates, and (2) the characteristics of the patient population who had been prescribed opioids and barbiturates. Several specialty societies issued recommendations that caution against the indiscriminate use of opioids or barbiturate containing medications for the treatment of migraine. These medications are still being prescribed in various medical settings and could put headache specialists in a difficult position when patients request these agents. Patients presenting to a headache center comprised of eight physicians were asked to complete a survey that assessed headache types, comorbid conditions, and whether they had ever been prescribed opioids or barbiturates. If they responded affirmatively to the latter question, they were asked about the prescribing doctor, medication effectiveness, and whether they were currently on the medication. Data collection took place over a one month period. Two hundred forty-four patients were given the survey and 218 of these patients completed it. The predominant diagnosis was migraine (83.9%). More than half of the patients reported having been prescribed an opioid (54.8%) or a barbiturate (56.7%). About one fifth were on opioids (19.4%) or barbiturates (20.7%) at the time of completing the survey. Most patients reported being on opioids for more than 2 years (24.6%) or less than one week (32.1%). The reasons most frequently cited for stopping opioids were that the medications did not help (30.9%) or that they saw a new doctor who would not prescribe them (29.4%). Among patients who had previously been on barbiturates, 32.2% had been on these for over 2 years. Most patients (61.8%) stopped barbiturates because they did not find the medication helpful, while 17.6% said they saw a new doctor who would not prescribe them. The physician specialty most frequently cited as being the first prescriber for opioids was emergency medicine (20.2%) with family doctors and general neurologists the next groups at 17.7% each. General neurologists were the most frequent (37.8%) first prescribers of barbiturates. Approximately 20% of patients presenting to a headache center reported current use of opioids and/or barbiturates. ED physicians were reported to be the most frequent first prescribers of opioids and general neurologists were the most frequent first prescribers of barbiturates. Taken as a whole, these data provide a useful snapshot of the wide variety of physician specialties that might benefit from additional education on the appropriate use of opioids and barbiturate-containing medications in patients with headaches.

New Investigator and Trainee Task Force Survey on the Recruitment and Retention of Headache Specialists.

We sought to survey the New Investigators and Trainees Section (NITS) members of the American Headache Society (AHS) to better understand their exposure to headache medicine during training and to determine their perceptions and attitudes about the field and the future of headache medicine. Despite the high prevalence of headache disorders in the general population, only about 2% of neurology residents pursue headache medicine fellowships. Furthermore, there is a paucity of United Council of Neurologic Subspecialties headache specialists in the country to meet the population demands. Thus, there needs to be a focus on how to recruit and retain more headache specialists. A survey was distributed via SurveyMonkey to the NITS listserv. It remained online for 60 days, during which reminder emails were sent to members of the listserv. In addition, the survey was available on laptops at NITS-related events at an annual AHS meeting. Descriptive analyses were then conducted using SurveyMonkey and Excel. Of the 93 members of NITS, 64 of the 96 (68.8%) clicked to initiate the survey and 52.7% successfully completed it. Attendings made up the majority of respondents (62.5%), followed by fellows (10.9%), and residents (7.8%). Key highlights of the survey included the following: just under 10% reported no exposure to a headache center during any time in their training (medical school, residency, or fellowship); less than 2% had exposure to a headache center during medical school; less than half of participants reported exposure to a headache center in residency (45.3%) and during fellowship (43.4%). Having a mentor in the field, liking the patient population, and working in a headache center, 64.7%, 52.9%, and 41.2%, respectively, were the top ways in which participants became interested in headache. The journal Headache (56.9%), attendings (56.3%), and the AHS/American Academy of Neurology guidelines for migraine management (52.0%) are the resources cited as being used all/most of the time. About 82.4% strongly agree that there needs to be improved headache education for physicians of all specialties (primary care, emergency department, psychiatry); 84.4% feel that they are appreciated by their patients; 68.6% feel that there is strong support in their departments for headache; 56.9% believe that their work schedule leaves enough time for personal and family life; and 60.8% agreed that their professional life will improve in years to come. Participants agreed/strongly agreed that they like to treat the following diseases/symptoms: migraine headache (98.0%), cluster headache (92%), chronic daily headache (84%), and post-concussive syndrome (71.4%). Participants disagreed/strongly disagreed that they like to treat the following comorbid conditions/symptoms: low back pain (66.6%), dizziness (42.9%), sleep apnea (36.7%), depression (32.0%), and anxiety (32.0%). In this detailed survey on the recruitment and retention of headache specialists, the following themes emerged: mentorship and exposure to a headache center are key foundations in the young investigator/trainee experience. Young headache specialists appear positive about their field of medicine. These specialists like to treat various headache types but not necessarily some of the related comorbidities (sleep disorders, depression, anxiety, back pain, and dizziness). Finally, there was strong agreement that there needs to be improved headache education for physicians of other medical specialties.

The Alice in Wonderland Syndrome: A Case of Aura Accompanying Cluster Headache.

Cluster headache (CH) is a primary headache which has highly specific and sensitive criteria, and notpresence of an aura. It has been recently reported that CH may not presence with aura more than ever and this condition will be identified by headache specialists as a new form of CH. As there is no report to our knowledge on Alice in Wonderland syndrome (AIWS) manifested as CH aura in the literature, we present a case of a 35-year-old man having AIWS as CH aura. Clinically, AIWS is not uncommon and is likely to be underestimated as a diagnostic entity. Valproate may be preferred for treatment in CH patients with AIWS aura.

Post-craniotomy headache: a clinical view with a focus on the persistent form.

Post-craniotomy headache is a frequent complication of neurosurgical procedures and is often a challenge for neurosurgeons, neurologists, and headache specialists. This was a narrative review. Surgical trauma, adherence of the musculature to the dura mater, peripheral nerve injury, development of neurinomas in the surgical scar, and central sensitization may be involved in the genesis of such headaches. Performing smaller craniotomies, replacement of the bone (craniotomy), performing cranioplasty, and infiltration of the surgical site with local anesthesia at the end of the surgical procedure are strategies used to prevent such headaches. Among the most frequent characteristics of post-craniotomy headaches are that they start on the first days after the operation, are located on the same side as and at the site of the surgical scar, and improve with the passage of time. Depression, anxiety, and temporomandibular disorders are frequently associated with these headaches. Abortive treatment such as opioids, ordinary analgesics, non-hormonal anti-inflammatory drugs, and triptans can be administered. There have been reports of improvements using sodium divalproex, verapamil, and local anesthetics. Post-craniotomy headaches can have significant repercussions on patients' quality of life. There is a need for clinical trials evaluating therapeutic options for treatment of this type of headache.

The diagnosis and treatment of chronic migraine.

Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.

Cervical 10 kHz spinal cord stimulation in the management of chronic, medically refractory migraine: A prospective, open-label, exploratory study.

A significant minority of chronic migraine (CM) subjects fail conventional medical treatment (rCM), becoming highly disabled. Implantation of an occipital nerve stimulator is a therapeutic option for these subjects. Paresthesia-free cervical 10 kHz spinal cord stimulation (HF10 SCS) may provide an alternative. We report the results of a prospective, open-label, exploratory study assessing the long-term safety, tolerability and efficacy of cervical HF10 SCS in cohort of rCM subjects. Included subjects were diagnosed with CM by an experienced headache specialist with the aid of an hourly headache diary. They were refractory to conventional medical treatments including onabotulinumtoxin-A injections. Medication overuse headache was not an exclusion criteria. Enrolled subjects underwent a 2- to 4-week tunnelled cervical HF10 SCS trial followed by a permanent system implant if a significant, subjective reduction in headache intensity/episodes was reported during the trial. Subjects were evaluated at baseline and 6 months after implantation with the aid of monthly diaries and headache-specific questionnaires. Seventeen subjects underwent a trial of cervical HF10 SCS; 14 were still implanted at 6 months (one trial failure, one trial infection, one implant site infection). Seven of the 14 subjects had >30% reduction in headache days. The average reduction in headache days was 6.9 for the overall population and 12.9 among the responders. Three subjects reported tenderness over the IPG/connection site, and one had a lead migration that required surgical revision. Paresthesia-free cervical HF10 SCS may be a safe and effective therapeutic option for chronic migraineurs refractory to conventional treatments.

Characteristics of the first 2000 patients registered in a specialist headache clinic

ObjectivesHeadache is a common cause of medical consultations. We aim to analyse demographic characteristics of the first 2000 patients in our register, and the incidence of their different headaches coded according to the International Classification of Headache Disorders, second edition (ICHD-II) Patients and methodsIn January 2008, a headache outpatient clinic was established in a tertiary hospital. Patients could be referred by general practitioners according to criteria established by prior consensus, as well as by general neurology or other specialty clinics. The following variables were prospectively collected for all patients; age, sex, referral source, complementary tests required, and the previously prescribed symptomatic or prophylactic therapies. All headaches were classified according to ICHD-II. When a patient fulfilled criteria for more than one type of headache, all of them were diagnosed and classified. ResultsIn October 2012, 2000 patients (ratio women/men 2.59/1) had been seen in our headache clinic. The median age was 42 years (range, 11-94), 55.3% were referred from primary care, and 68.1% did not require complementary tests. A total of 3095 headaches were recorded in these 2000 patients, of which 2222 (71.8%) were considered primary headaches, 382 (12.3%) secondary headaches including 117 (3.8%) corresponding to cranial neuralgias, 136 (4.3%) were unclassified headaches, and 238 (7.7%) were included in the Appendix to the ICHD-II. The most represented group was group 1 (migraine) accounting for 53% of all headaches. ConclusionsThe characteristics of the first 2000 patients in our register were comparable to those previously described in other types of outpatient headache clinics. Migraine was the most frequent diagnosis, and secondary headaches were not as frequent in our series. Most headaches could be coded according to ICHD-II criteria.

Headache research and medical practice in Brazil: an historical overview.

Since the creation of the Brazilian Headache Society in 1978, substantial developments have taken place in both research and clinical practice in the field of headache medicine in Brazil. The Society now has almost 300 members throughout the country, actively working to improve the health of the general population and, in particular, diagnose and treat headache disorders. In addition, in a few large cities, such as São Paulo, Rio de Janeiro, Recife, Ribeirão Preto, Curitiba, and Porto Alegre, headache specialists have come together to promote research projects and increase knowledge in the field through MSc, PhD, and postdoctoral programs. Furthermore, scientific journals have emerged and books have been published to record and disseminate Brazilian scientific production in headache medicine. In this narrative review, we will briefly describe some important aspects of headache medicine in Brazil from prehistoric times to the present day, discuss the origin of headache medicine as a specialty in Brazil, the principal publications dealing with headache disorders, the use of plants and other unconventional forms of treatment used by faith healers, the main training centers, and the research produced to date by Brazilians. In conclusion, in recent years enormous progress has been made in headache medicine in Brazil stimulating us to review and expand our role in an increasingly international scenario.

Central Integration of Canal and Otolith Signals is Abnormal in Vestibular Migraine: A Commentary.

Central Integration of Canal and Otolith Signals is Abnormal in Vestibular Migraine: A Commentary.

Prevalence and clinical hallmarks of primary exercise headache in middle-aged Japanese on health check-up.

Objective We examined the prevalence and clinical features of primary exercise headache (PEH) in middle-aged Japanese population. Methods A headache specialist interviewed middle-aged subjects serially on health check-up. The primary headaches were diagnosed according to the International Classification of Headache Disorders (ICHD-III beta). Cardiovascular disease (CVD) risk and radiological findings were analyzed. Prevalence of PEH and clinical features were assessed. Results Among 2,546 subjects (1,588 men and 958 women), thirty subjects (13 men and 17 women) were diagnosed with PEH. The prevalence of PEH was 1.19%, 0.82% in men and 1.77% in women. The mean age [standard deviation (SD)] of the subjects was 44.3 (8.8) years and their mean duration (SD) of PEH was 4.5 (7.0) months. Headache occurred bilaterally (23 patients) or unilaterally (7 patients), and in the occipital (16 patients), frontal (10 patients) or diffuse region (4 patients). The persistent headache time ranged from 5 minutes to 12 hours. The degree of headache severity was classified as mild (13 patients), moderate (5 patients) or severe degree (12 patients). PEH was triggered by gym training (16 patients), swimming (6 patients), running (6 patient) and skiing (2 patients). All patients were exercise beginners or played a sport occasionally. No patients visited physicians for headache consultation. Other primary headaches coexisted in 20 patients (67%). Twenty patients had migraine without aura (MO). Seven patients had headache associated with sexual activity. Five patients had cough headache. Two patients had CVD risk factors. Conclusion The present study of PEH indicated the prevalence of 1.2% and the female/male ratio of 2.1 in middle-aged Japanese. The comorbidity rate of MO was high. PEH may not be an uncommon headache in middle-aged MO sufferers and sport beginners.

Investigation of obsessive-compulsive symptoms in patients with migraine

A migraine is not just a headache. Migraines are characterized by the co-occurrence of various systemic changes and known to be associated with many psychiatric disorders in the interictal period, especially major depression and anxiety disorders. Obsessive-compulsive disorder (OCD) in patients with migraines is relatively less studied. Obsessive-compulsive symptoms were investigated in consecutive patients with a diagnosis of migraine and compared with that of a control group of healthy individuals. The relationship of these symptoms with the defined clinical features of migraine was analyzed. 74 patients and 36 controls were included in this study. Patients were chosen from those admitted with headache complaints to the Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Headache Outpatient Clinics between December 2010-March 2012. A headache specialist diagnosed all patients with migraine using the International Headache Society criteria.. The Yale Brown Obsessive and Compulsive Scale (Y-BOCS) was used to score OCD symptoms in all participants. In comparing Y-BOCS total scores between the migraine patients and the control group, we found a statistically significant difference (z(109)= -3.100, p<0.05). Furthermore, both the Y-BOCS obsession and compulsion sub-scores were significantly different between the groups. The duration, frequency and side of migraine did not have any correlation with our findings. In conclusion, our study suggested that migraine sufferers tend to have higher obsessive and compulsive symptoms. These findings could be based on genetic changes and/or functional differences in the brain.