International Headache Society Diagnostic Criteria Research Articles

A study of acromegaly-associated headache with somatostatin analgesia.

To characterise somatostatin analogue responsive headache in acromegaly, hitherto not systematically documented in a significant cohort. Using the UK pituitary network, we have clinically characterised a cohort of 18 patients suffering from acromegaly-related headache with a clear response to somatostatin analogues. The majority of patients had chronic migraine (78%) as defined by the International Headache Society diagnostic criteria. Headache was present at the time of acromegaly presentation and clearly associated temporally with disease activity in all cases. Short-acting somatostatin analogues uniquely resolved pain within minutes and the mean duration of analgesia was 1-6 hours. Patients on long-acting analogues required less short-acting injections (mean 3.7 vs. 10.4 injections per day, p=0.005). 94% used somatostatin analogues to control ongoing headache pain. All patients presented with macroadenoma, most had incomplete resection (94%) and headache was ipsilateral to remnant tissue (94%). Although biochemical control was achieved in 78% of patients, headache remained in 71% of them. Patients selected for this study had ongoing headache post-treatment (mean duration 16 years after diagnosis); only 4 patients reached headache remission 26 years (mean, range 14-33) after the diagnosis. Headache in acromegaly patients can be persistent, severe, unrelieved by surgery, long-lasting and uncoupled from biochemical control. We show here that long-acting analogues allow a decrease in the number of short-acting analogue injections for headache relief. Further studies are needed to understand the mechanisms, markers and tumour tissue characteristics of acromegaly-related headache. Until then, this publication serves to provide the clinical characteristics as a reference point for further study.

The profile of headaches and migraine amongst medical students and its association to stress level, disability and self-management practices.

Migraine is the most common headache affecting young people that impairs their functional ability. This study aimed to determine the frequency of migraines among Malaysian medical students, the association between migraines, stress level, and functional disability among these students, and describe their self-management practices. A cross-sectional study was conducted among medical students in a private medical school in Penang state. All medical students in the study site were screened for the presence of headache symptoms and the diagnosis of migraine using a self-administered questionnaire comprising International Headache Society (IHS) diagnostic criteria. Other domains that were assessed were perceived stress level and functional disability, which were measured using the Perceived Stress Scale and the Headache Impact Test-6 (HIT-6), respectively. The students' selfmanagement practices for their headaches were determined using a descriptive survey. A total of 374 medical students participated in this study and 157 (42%) students reported experiencing headaches. More than half (n=97, 61.8%) of those with headaches fulfilled the IHS criteria for migraines. Migraines were significantly associated with functional disability compared with non-migraine headaches (p<0.001); however, no significant difference in stress levels were reported between the two groups. During migraine attacks, sleep (n=73, 60.33%) and self-medication (n=56, 69.14%) were the most common self-management practices. Only 11.46% of the 157 students with headaches consulted a doctor. A high proportion of medical students suffered from headaches and more than half of them had migraines. Migraine headaches were associated with significant functional disability. Very few students sought medical consultation and most students chose to self-manage their headaches.

The Association between Migraine And Sleep Quality

Objective: Migraine and sleep disorders are common health problems in the community and cause loss of labor. There are studies showing that there is a relationship between migraine and sleep quality and these two conditions worsen each other.&#x0D; Method: This is a case-control type cross-sectional study consisting of a total of 454 participants, included migraine patients, patients with non-migraine headaches and patients without headache complaint admitted to Family Medicine outpatient clinics between October 2017 and March 2018. Sociodemographic data form, Identity Migraine test, International Headache Society diagnostic criteria questionnaire, Pittsburgh sleep quality scale (PSQI) and Epworth day sleepiness scale (Epw) were applied to the participants by face to face interviews.&#x0D; Results: The total PSQI score was 6.5 ± 3.1, and significantly different between the groups. Patients with diagnosis of migraine had a higher PSQI score and poor sleep quality rate than the control groups. There was no correlation between the frequency of migraine attacks and PSQI scores. Extreme sleepiness in day time for the migraine group (30.7%) was higher than the control groups and there was no correlation between the frequency of migraine attacks and Epw scores.&#x0D; Conclusion: Poor sleep quality and daytime sleepiness rates in migraine patients were higher than those with non-migraine headache patients and patients without headache complaints. This may be due to the fact that migraine is a specific problem affecting sleep or the frequency and severity of headache in the migraine patients are greater than that of the non-migraine headache patients and headache-free participants.

Prevalence and socio-demographic and clinical correlation of migraine in depressive disorder – A cross sectional study

Introduction: Studies have shown an association between migraine and psychiatric disorders like depression where a bidirectional etiology exists. Aim: To study the prevalence of migraine among depressed patients and to correlate the severity of migraine and depression. Methodology: The included 152 outpatients who were diagnosed with depressive disorder and recurrent depressive disorder using the ICD 10 diagnostic criteria. They were then given the Hamilton Depression Rating Scale (HAM-D). Migraine was diagnosed using the International Headache Society (IHS) diagnostic criteria of migraine and rated using the Migraine Disability Assessment Score (MIDAS). Data were analyzed using chi-square test, independent sample t test and Pearson’s correlation. Results: The study included 152 patients with depression. There is a 35.5% prevalence of migraine was seen in depressed patients. In 75.9% of cases, migraine was previously un-diagnosed. There was a significant association between presence of migraine and female sex (?2= 5.32, p=0.02), student status (?2 =; 1.5 p

Risk of Postdural Puncture Headache in Adolescents and Adults.

Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years. After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria. A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch. The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.

Evaluation of anxiety, depression and marital relationships in patients with migraine.

The aim of this study was to evaluate the frequency and characteristics of attacks in patients with migraine, to determine the effects of anxiety or depressive symptoms, and to evaluate the marital relationships of patients with migraine. Thirty patients who were admitted to the neurology outpatient clinic of our hospital between July 2018 and October 2018 and were diagnosed with migraine according to the 2013 International Headache Society (IHS) diagnostic criteria were included in this cross-sectional study. Age, sex, headache frequency and severity, depressive traits, marital satisfaction and anxiety status were examined. We used the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Maudsley Marital Questionnaire (MMQ) and Visual Analogue Scale (VAS) for measuring relevant parameters. The mean severity of migraine pain according to VAS scale was 6.93 ± 1.41 and the mean number of migraine attacks was 4.50 ± 4.24. The mean BDI score of the patients was 12.66 ± 8.98, the mean MMQ-M score was 19.80 ± 12.52, the mean MMQ-S score was 13.20 ± 9.53, the mean STAI-state score was 39.93 ± 10.87 and the mean STAI-trait score was 45.73 ± 8.96. No significant correlation was found between age, number of migraine attacks, migraine duration, migraine headache intensity, and BDI, STAI and MMQ scores (p>0.05). But there was a positive correlation between MMQ-S and scores obtained from the BDI and STAI-state scales (p<0.05). In this study more than half of the migraine patients had mild, moderate or severe depression. A positive correlation was found between sexual dissatisfaction and scale scores of depression and anxiety.

Prevalencia de migraña y caracterización de una población estudiantil universitaria, Medellín, 2014

Objective: To determine the prevalence of migraine and the clinical and epidemiological characteristics of a representative subset of university students from Medellin in 2014. Methods: Descriptive, cross-sectional study. Data was collected from a private university student subset. All participants were over 18 (legal age in Colombia) and were enrolled in different university programs. They all verbally agreed to participate before submitting their personal data to the study. Data was collected using a survey developed by researchers and was based on the 2013 International Headache Society (IHS) diagnostic criteria (beta version) and other variables of interest to the study, such as sociodemographic data, comorbidities, family disease history, and treatment methods. Results: A total of 650 students completed and submitted the survey. The median age was 21 years (interquartile range: 19-23 years), and 427 students (65.7%) were female participants. Migraine prevalence was determined to be 27.7%. Among students who met migraine diagnostic criteria (n=180), irritable bowel syndrome (24.4%) and depressive disorders (8.9%) were the two most common conditions in their medical records. A total of 103 (57.2%) students had a family history of migraine, and only 51% of those who met migraine diagnostic criteria had already been diagnosed by a qualified physician. The most common migraine episode triggers identified included long periods of fasting (71.3%), sleep deprivation (69.1%), and university testing (63.8%). Of the participants, 168 (93.3%) expressed that they use analgesics to treat their migraine episodes, but only 44.6% were using analgesic therapy prescribed by a qualified physician. The most common medications used as a prophylactic approach were naproxen (19.6%) and propranolol (12,3%). The most common medications used as a therapeutic approach were acetaminophen (70.8%) and ibuprofen (44.4%). Conclusions: A greater migraine prevalence was observed than that which was reported in the general population and the presence of factors traditionally described with this pathology.

Predictive Factors of Headache Resolution After Chiari Type 1 Malformation Surgery.

Headache is the main and often isolated symptom of patients with Chiari type 1 malformation (CM1). Classically described as occipital and exacerbated by cough, headaches may be poorly characterized, making it difficult to establish CM1 as the underlying cause. Current guidelines for surgical posterior fossa decompression are undefined. The challenge is to distinguish headaches related to CM1 from headaches coincidentally coexisting with CM1. We aimed to determine predictive factors of headache resolution after surgery and applied to our cohort the Chiari Severity Index, a recently developed predictive prognostic score. This retrospective study enrolled 49 patients with CM1 and preoperative headache. Standardized telephone interviews regarding headaches before and after surgery were conducted by the same neurologist; magnetic resonance imaging morphometric analyses were performed by an independent neuroradiologist. Headache resolution was defined as ≥50% reduction in frequency of headache days. Preoperative factors of headache resolution after multivariate analysis were attack duration <5 minutes (P= 0.001), triggering by Valsalva maneuvers (P= 0.003), severe intensity of attack (P= 0.05), occipital location (P= 0.05), and greater number of headache days per month (P= 0.04). These characteristics are part of International Headache Society diagnostic criteria for headache attributed to CM1. No radiologic predictive factor was demonstrated. Postoperative improvement was inversely correlated with Chiari Severity Index. This study confirms the relevance of International Headache Society criteria to identify headaches related to CM1. We propose their systematic use in a preoperative questionnaire.

Psoriasis and migraine.

Psoriasis and migraine share several pathogenetic mechanisms due to systemic inflammation, which increase the risk of developing cardiovascular disease. Our aim was to investigate the prevalence of migraine with (MA) and without aura (MO) in the psoriatic population, investigating a possible new comorbidity of the psoriatic disease. We referred 68 psoriatic patients to a nine questions survey formulated on the basis of the International Headache Society (IHS) diagnostic criteria for migraine. Then, in the case of MA, the mean monthly number of migraine crises was assessed. Data of psoriatic patients were then compared with those of a psoriasis-free control group composed of 235 migraine patients (with and without aura). A clinical diagnosis of migraine was performed in 32 psoriasis patients with a great prevalence in women (F: 87.50% - M: 12.5%). Moreover, we found a much higher prevalence (62.5%) of MA, with the remaining 37.5% diagnosed with MO. Comparing the prevalence of MA between psoriasis + migraine patients and the control group we observed a statistical significative difference (P < 0.0001); furthermore, the number of MA crises was significantly higher (P < 0.0001) in patients with psoriasis with respect to the MA control group. We showed a significant association between psoriasis and migraine, especially MA, probably due to common pathogenetic mechanisms, but further studies are needed to assess their interplay in developing cardiovascular diseases.

Aspirin for acute treatment of episodic tension-type headache in adults.

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (two to 14 headache days per month), and chronic TTH (15 headache days per month or more). Aspirin is one of a number of analgesics suggested for acute treatment of episodic TTH. To assess the efficacy and safety of aspirin for acute treatment of episodic tension-type headache (TTH) in adults compared with placebo or any active comparator. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Oxford Pain Relief Database from inception to September 2016, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites. We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral aspirin for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm. Two review authors independently assessed studies for inclusion and extracted data. For various outcomes (predominantly those recommended by the International Headache Society (IHS)), we calculated the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT), one additional harmful outcome (NNH), or to prevent one event (NNTp) for oral aspirin compared to placebo or an active intervention.We assessed the evidence using GRADE and created a 'Summary of findings' table. We included five studies enrolling adults with frequent episodic TTH; 1812 participants took medication, of which 767 were included in comparisons of aspirin 1000 mg with placebo, and 405 in comparisons of aspirin 500 mg or 650 mg with placebo. Not all of these participants provided data for outcomes of interest in this review. Four studies specified using IHS diagnostic criteria; one predated commonly recognised criteria, but described comparable characteristics and excluded migraine. All participants treated headaches of at least moderate pain intensity.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged one study to be at high risk of bias due to small size.There were no data for aspirin at any dose for the IHS preferred outcome of being pain free at two hours, or for being pain free at any other time, and only one study provided data equivalent to having no or mild pain at two hours (very low quality evidence). Use of rescue medication was lower with aspirin 1000 mg than with placebo (2 studies, 397 participants); 14% of participants used rescue medication with aspirin 1000 mg compared with 31% with placebo (NNTp 6.0, 95% confidence interval (CI) 4.1 to 12) (low quality evidence). Two studies (397 participants) reported a Patient Global Evaluation at the end of the study; we combined the top two categories for both studies to determine the number of participants who were 'satisfied' with treatment. Aspirin 1000 mg produced more satisfied participants (55%) than did placebo (37%) (NNT 5.7, 95% CI 3.7 to 12) (very low quality evidence).Adverse events were not different between aspirin 1000 mg and placebo (RR 1.1, 95% CI 0.8 to 1.5), or aspirin 500 mg or 650 mg and placebo (RR 1.3, 95% CI 0.8 to 2.0) (low quality evidence). Studies reported no serious adverse events.The quality of the evidence using GRADE comparing aspirin doses between 500 mg and 1000 mg with placebo was low or very low. Evidence was downgraded because of the small number of studies and events, and because the most important measures of efficacy were not reported.There were insufficient data to compare aspirin with any active comparator (paracetamol alone, paracetamol plus codeine, peppermint oil, or metamizole) at any of the doses tested. A single dose of aspirin between 500 mg and 1000 mg provided some benefit in terms of less frequent use of rescue medication and more participants satisfied with treatment compared with placebo in adults with frequent episodic TTH who have an acute headache of moderate or severe intensity. There was no difference between a single dose of aspirin and placebo for the number of people experiencing adverse events. The amount and quality of the evidence was very limited and should be interpreted with caution.

Ketoprofen for episodic tension-type headache in adults.

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache day per month), frequent episodic TTH (2 to 14 headache days per month), and chronic TTH (15 headache days a month or more). Ketoprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH. To assess the efficacy and safety of ketoprofen for treatment of episodic TTH in adults compared with placebo or any active comparator. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Oxford Pain Relief Database up to May 2016, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites. We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral ketoprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm. Two review authors independently assessed studies for inclusion and extracted data. We used the numbers of participants achieving each outcome to calculate the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT) or one additional harmful outcome (NNH) for oral ketoprofen compared to placebo or an active intervention for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).We assessed the evidence using GRADE and created a 'Summary of findings' table. We included four studies, all of which enrolled adults with frequent episodic TTH. They all specified using the IHS diagnostic criteria and reported mean baseline pain of at least moderate intensity. While 1253 people with TTH participated in these studies, the numbers available for any analysis were lower than this because outcomes were inconsistently reported and because many participants received active comparators.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged one study to be at high risk of bias due to small size.Useful information was available only for ketoprofen 25 mg. For the IHS preferred outcome of being pain-free at two hours the NNT for ketoprofen 25 mg compared with placebo was 9.0 (95% confidence interval (CI) 4.8 to 72) in two studies (272 participants; low quality evidence). The NNT was 3.7 (95% CI 2.6 to 6.3) for pain-free or mild pain at two hours in two studies (272 participants; moderate quality evidence). Fewer people needed rescue medication with ketoprofen 25 mg than with placebo, with a number needed to treat to prevent one event (NNTp) of 6.2 (95% CI 4.3 to 11) in three studies (605 participants; moderate quality evidence). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than placebo (NNH 15, (95% CI 8.7 to 45)) in three studies (651 participants with 66 events; low quality evidence). Most events were of mild to moderate intensity.Ketoprofen 25 mg was not different from paracetamol 1000 mg in two studies with 276 participants for any efficacy outcomes (low to moderate quality evidence); the RR for pain-free at two hours was 1.3 (95% CI 0.9 to 2.0). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than with paracetamol (NNH 17, 95% CI 8.9 to 130)) in two studies (582 participants, 68 events; low quality evidence).Studies reported no serious adverse events.We judged the quality of the evidence comparing ketoprofen 25 mg with placebo or paracetamol 1000 mg as moderate to very low. Where evidence was downgraded it was because of the small number of studies and events. Ketoprofen 25 mg provided a small benefit compared with placebo in terms of being pain-free at two hours or having mild or no pain at two hours for people with frequent episodic TTH who have an acute headache of moderate or severe intensity. Its use was associated with more people experiencing adverse events. Ketoprofen 25 mg was not superior to paracetamol 1000 mg for any efficacy outcome.

Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults.

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (two to 14 headaches per month), and chronic TTH (15 headache days a month or more). Paracetamol (acetaminophen) is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH. To assess the efficacy and safety of paracetamol for the acute treatment of frequent episodic TTH in adults. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (CRSO), MEDLINE, EMBASE, and the Oxford Pain Relief Database to October 2015, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites. We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral paracetamol for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm. Two review authors independently assessed studies for inclusion and extracted data. We used the numbers of participants achieving each outcome to calculate the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT) or one additional harmful outcome (NNH) for oral paracetamol compared to placebo or an active intervention for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. We included 23 studies, all of which enrolled adults with frequent episodic TTH. Twelve studies used the IHS diagnostic criteria or similar, six used the older classification of the Ad Hoc Committee, and five did not describe specific diagnostic criteria but generally excluded participants with migraines. Participants had moderate or severe pain at the start of treatment. While 8079 people with TTH participated in these studies, the numbers available for any analysis were lower than this because outcomes were inconsistently reported and because many participants received active comparators.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged five studies to be at high risk of bias for incomplete outcome reporting, and seven due to small size.For the IHS preferred outcome of being pain free at two hours the NNT for paracetamol 1000 mg compared with placebo was 22 (95% confidence interval (CI) 15 to 40) in eight studies (5890 participants; high quality evidence), with no significant difference from placebo at one hour. The NNT was 10 (7.9 to 14) for pain-free or mild pain at two hours in five studies (5238 participants; high quality evidence). The use of rescue medication was lower with paracetamol 1000 mg than with placebo, with an NNTp to prevent an event of 7.8 (6.0 to 11) in six studies (1856 participants; moderate quality evidence). On limited data, the efficacy of paracetamol 500 mg to 650 mg was not superior to placebo, and paracetamol 1000 mg was not different from either ketoprofen 25 mg or ibuprofen 400 mg (low quality evidence).Adverse events were not different between paracetamol 1000 mg and placebo (RR 1.1 (0.94 to 1.3); 5605 participants; 11 studies; high quality evidence). Studies reported no serious adverse events.The quality of the evidence using GRADE comparing paracetamol 1000 mg with placebo was moderate to high. Where evidence was downgraded it was because a minority of studies reported the outcome. For comparisons of paracetamol 500 mg to 650 mg with placebo, and of paracetamol 1000 mg with active comparators, we downgraded the evidence to low quality or very low quality because of the small number of studies and events. Paracetamol 1000 mg provided a small benefit in terms of being pain free at two hours for people with frequent episodic TTH who have an acute headache of moderate or severe intensity.

Shared Genetic Factors Underlie Migraine and Depression.

Migraine frequently co-occurs with depression. Using a large sample of Australian twin pairs, we aimed to characterize the extent to which shared genetic factors underlie these two disorders. Migraine was classified using three diagnostic measures, including self-reported migraine, the ID migraine™ screening tool, or migraine without aura (MO) and migraine with aura (MA) based on International Headache Society (IHS) diagnostic criteria. Major depressive disorder (MDD) and minor depressive disorder (MiDD) were classified using the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. Univariate and bivariate twin models, with and without sex-limitation, were constructed to estimate the univariate and bivariate variance components and genetic correlation for migraine and depression. The univariate heritability of broad migraine (self-reported, ID migraine, or IHS MO/MA) and broad depression (MiDD or MDD) was estimated at 56% (95% confidence interval [CI]: 53-60%) and 42% (95% CI: 37-46%), respectively. A significant additive genetic correlation (r G = 0.36, 95% CI: 0.29-0.43) and bivariate heritability (h 2 = 5.5%, 95% CI: 3.6-7.8%) was observed between broad migraine and depression using the bivariate Cholesky model. Notably, both the bivariate h 2 (13.3%, 95% CI: 7.0-24.5%) and r G (0.51, 95% CI: 0.37-0.69) estimates significantly increased when analyzing the more narrow clinically accepted diagnoses of IHS MO/MA and MDD. Our results indicate that for both broad and narrow definitions, the observed comorbidity between migraine and depression can be explained almost entirely by shared underlying genetically determined disease mechanisms.

Management of headache and associated factors among undergraduate medicine and health science students of University of Gondar, North West Ethiopia.

BackgroundThe headache disorders, namely, migraine and tension type headache and the associated analgesic consumption is badly underestimated and thus makes a major current public health problem. The objective of this study was to determine the prevalence of migraine and tension type headaches and the associated management options used among undergraduate students of College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.MethodInstitution based cross sectional study was conducted among 720 students in May, 2014. Pretested and structured self-administered questionnaires were used as data collecting tool followed by short interview to diagnose the type of headache based on the International Headache Society diagnostic criteria. SPSS version 20 was also used to analyse the data descriptively as well as inferentially using logistic regression models to investigate factors associated with presence of headache and analgesic use.ResultThe prevalence of lifetime headache and headache in the last 12 months was 81.11 and 67.22 %, respectively. Migraine and tension type headache were having 94 (13.06 %) and 481 (66.81 %) prevalence, respectively. Prevalence of life time headache was significant among females, students with family history of headache and lack of adequate vacation time. Similarly, lifetime prevalence of analgesic use for headache was 72.45 % and it had statistical association with sex, age, type of headache, lack of adequate vacation time and family history of headache. Majority of the students, migraineurs (54.65 %) and the tension type headache sufferers (66.17 %) commonly used paracetamol.ConclusionHigh prevalence without adequate medical care seeking behaviour and the associated significant analgesic consumption necessitate the designing of all rounded strategies to improve the quality of life of individuals with such neurologic disorders.

Effects of Coriandrum sativum Syrup on Migraine: A Randomized, Triple-Blind, Placebo-Controlled Trial

Background:Migraine is one of the most common and debilitating neurological problems. Although numerous preventive drugs are used to treat migraine, their complications are unavoidable. Application of herbal medicine, especially well-known medicinal plants, to treatment of chronic diseases, like migraine, could be effective. Coriandrum sativum L. (C. sativum) fruit is one of the most commonly prescribed herbs in Persian medicine, which has been used to treat headache.Objectives:This study was designed to evaluate the effects of C. sativum syrup on duration, severity and frequency of migraine.Patients and Methods:A total of 68 migraineurs, who had the eligibility criteria, according to international headache society diagnostic criteria, were randomly assigned to intervention group (n = 34) or control group (n = 34). In addition to 500 mg of sodium valproate per day, in intervention group, they received 15 mL of Coriander fruit syrup and 15 mL of placebo syrup, in control group, three times a day, during a month. The subjects were followed for clinical efficacy at weeks 1, 2, 3 and 4. The number of migraine attacks per week, as well as the duration and severity of attacks, were evaluated.Results:Of 68 patients randomized, 66 were included in analysis. The generalized estimating equations analysis showed that the Coriander fruit syrup decreased duration, severity and frequency of migraine, in the intervention group (P < 0.001). To be more precise, the mean migraine duration, severity and frequency, in the intervention group, were 5.7 hours, 3.65 units and about 50% less than control group, respectively.Conclusions:Results of this study showed that C. sativum fruit is efficient in reduction of the duration and frequency of migraine attacks and in diminishing pain degree.

Ibuprofen for acute treatment of episodic tension-type headache in adults.

Tension-type headache (TTH) affects about one person in five worldwide. It is divided into infrequent episodic TTH (fewer than one headache per month), frequent episodic TTH (1 to 14 headaches per month), and chronic TTH (15 headaches a month or more). Ibuprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH. To assess the efficacy and safety of oral ibuprofen for treatment of acute episodic TTH in adults. We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and our own in-house database to January 2015. We sought unpublished studies by asking personal contacts and searching on-line clinical trial registers and manufacturers' websites. We included randomised, placebo-controlled studies (parallel-group or cross-over) using oral ibuprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective and include at least 10 participants per treatment arm. Two review authors independently assessed studies for inclusion, and extracted data. Numbers of participants achieving each outcome were used to calculate risk ratio (RR) and number needed to treat for an additional beneficial outcome (NNT) or number needed to treat for an additional harmful outcome (NNH) of oral ibuprofen compared to placebo for a range of outcomes, predominantly those recommended by the International Headache Society (IHS). We included 12 studies, all of which enrolled adult participants with frequent episodic TTH. Nine used the IHS diagnostic criteria, but two used the older classification of the Ad Hoc Committee, and one did not describe diagnostic criteria but excluded participants with migraines. While 3094 people with TTH participated in these studies, the numbers available for any form of analysis were lower than this; placebo was taken by 733, standard ibuprofen 200 mg by 127, standard ibuprofen 400 mg by 892, and fast-acting ibuprofen 400 mg by 230. Participants had moderate or severe pain at the start of treatment. Other participants were either in studies not reporting outcomes we could analyse, or were given one of several active comparators in single studies.For the IHS-preferred outcome of being pain free at 2 hours the NNT for ibuprofen 400 mg (all formulations) compared with placebo was 14 (95% confidence interval (CI), 8.4 to 47) in four studies, with no significant difference from placebo at 1 hour (moderate quality evidence). The NNT was 5.9 (4.2 to 9.5) for the global evaluation of 'very good' or 'excellent' in three studies (moderate quality evidence). No study reported the number of participants experiencing no worse than mild pain at 1 or 2 hours. The use of rescue medication was lower with ibuprofen 400 mg than with placebo, with the number needed to treat to prevent one event (NNTp) of 8.9 (5.6 to 21) in two studies (low quality evidence).Adverse events were not different between ibuprofen 400 mg and placebo; RR 1.1 (0.64 to 1.7) (high-quality evidence). No serious adverse events were reported. Ibuprofen 400 mg provides an important benefit in terms of being pain free at 2 hours for a small number of people with frequent episodic tension-type headache who have an acute headache with moderate or severe initial pain. There is no information about the lesser benefit of no worse than mild pain at 2 hours.

Promethazine Plus Sumatriptan in the Treatment of Migraine: A Randomized Clinical Trial

This study was performed to evaluate the efficacy and safety of the combination of sumatriptan (50 mg) plus promethazine (SPr) (25 mg) compared with sumatriptan (50 mg) plus placebo in patients with migraine attacks. Migraine is a chronic, disabling disorder with an estimated worldwide prevalence of 10% in adults imposing substantial social and economic impact. Efficient treatment of migraine attacks could benefit patients by reducing their disability and the need for health care resources, and improving economic productivity. This was a multicenter, randomized, double-blind trial conducted at 5 university-affiliated research centers in Iran. Between January 2013 and April 2013, 350 individuals with a history of migraine were evaluated. Patients were diagnosed with migraine, with or without aura, as defined by the International Headache Society diagnostic criteria. The 242 patients meeting the eligibility criteria were randomly assigned to SPr group (n = 121) or the sumatriptan plus placebo (SP) group (n = 121). The study medications were taken on an outpatient basis during the moderate to severe phase of migraine attack. Patients recorded details of the treated migraine on a diary card and rated pain severity immediately before dosing and 30 minutes, 1 hour, 2 hours, and 4 hours after dosing using a 4-point scale (0 = none to 3 = severe). Of 242 patients randomized, 216 were included in the intention-to-treat efficacy analysis. In the SPr group, 39.6% of subjects experienced 2-hour headache-free response (primary outcome), which was significantly more effective than SP treatment (26.3%, odds ratio: 1.83, 95% confidence interval: 1.03-3.26, P = .038). Significantly more patients receiving SPr treatment (62.2%) had headache improvement compared with SP treatment (37.2%) at 2 hours (odds ratio: 2.77, 95% confidence interval: 1.60-4.81, P < .001). A similar pattern of between-group differences was observed for 4-hour headache-free response (P = .006) and headache improvement response (P = .003). The incidence of headache recurrence within 2-48 hours after treatment was lowest in the SPr group (15.0%) compared with SP group (26.6%, P = .041). The only significant drug-related adverse events reported in ≥15% of patients in any treatment group were somnolence (32.2% and 7% in the SPr and SP groups, respectively, P < .001), extrapyramidal symptoms (4.3% and 0%, P = .05), and nausea (1% and 8%, P = .03). This is the first prospective clinical trial to demonstrate that multimechanism therapy for migraine, combining a triptan and an antiemetic agent, is well tolerated and offers improved clinical benefits compared with monotherapy.

Diagnostic value of combinations of symptoms of migraine and tension-type headache included in the diagnostic criteria for children and adolescents in the international classification of headache disorders 2nd edition

To suggest diagnostic combinations of symptoms for migraine and tension type headache (TTH), and for differentiation of overlapping headache (classified as either migraine or TTH) through evaluation of the diagnostic value of combinations of characteristics included in the International Headache Society diagnostic criteria for migraine and TTH in children and adolescents. The study comprised an epidemiological school-based study (412 of 1029 pupils with chronic/recurrent headache) and a clinical study conducted in the Pediatric Neurology Ward and outpatient clinic at Plovdiv Medical University Hospital (203 patients with chronic/recurrent headache). An inclusion criterion was at least two episodes of headache during the last year. Exclusion criteria were: headache occurring only during acute infections; withdrawal of informed consent. Headache was classified according to the International Classification of Headache Disorders 2nd edition (ICHD-II) The diagnostic value of all combinations of items in criteria C and D for migraine and TTH was measured by sensitivity, specificity, and odds ratio. The combination "unilateral location, severe intensity, aggravation by physical activity" had 100% specificity for migraine. The combination "bilateral location, pressing-tightening quality, mild intensity, no aggravation by physical activity" had 100% specificity for TTH. The combinations: "migrainous location, severe intensity, aggravation by physical activity", "severe intensity, nausea", "pulsating quality, nausea", "pulsating quality, migrainous location, aggravation by physical activity" seemed to pose the greatest risk for developing migraine. These combinations--"no nausea, no photophobia", "bilateral location, mild intensity and either no aggravation by physical activity or pressing-tightening quality, or no nausea or no photophobia" increased the most the TTH risk. Using these combinations as additional criteria for overlapping headache we classified 50% of overlapping headache as TTH and 8.3% as migraine. Some combinations of symptoms clarify the diagnosis of migraine and TTH. More than 50% of overlapping headache could be differentiated as TTH or MWA by the proposed combinations.

Efficacy of MAP0004 evaluated by combined relief from migraine pain and freedom from nausea, photophobia and phonophobia in subjects with episodic migraines

Migraine is a disabling condition affecting approximately 30 million people in the USA. Most clinical trials evaluating the efficacy of the acute treatment of migraine use endpoints measuring relief of pain over time. Associated symptoms, such as nausea, photophobia and phonophobia are included in the International Headache Society diagnostic criteria for migraine and relief of these symptoms are usually also included as clinical trial endpoints. MAP0004, an investigational product which delivers dihydroergotamine via a breath-synchronized metered dose inhaler (TEMPO®), was shown to be superior to placebo in effectively relieving migraine pain at 30 minutes, 2, 4, 24 and 48 hours in a large randomized double-blind placebo-controlled Phase 3 trial. In an effort to evaluate a more robust measure of efficacy, this post-hoc analysis assessed the combined relief from migraine pain (defined as pain reduction from moderate or severe to mild or none) and freedom from nausea, photophobia and phonophobia at several time points post-treatment without the use of rescue medication prior to those time points. Additionally, the sustainability of this effect 2-24 hours without the use of rescue medication was assessed. 794 subjects treated a qualifying migraine and had at least one post-dose efficacy assessment. Significantly higher percentage of MAP0004-treated subjects achieved combined relief from migraine pain and freedom from associated symptoms compared to placebo at: 1 hour (20.9% vs. 14.1%; p=0.0131), 2 hours (36.8% vs. 19.4%, p<0.0001), 4 hours (45.8% vs. 23.9%, p<0.0001), 24 hours (49.6% vs. 31.7%, p<0.0001) and 48 hours (41.1% vs. 28.5%, p=0.0002) post-treatment. This combined efficacy endpoint was sustained 2-24 hours in a significantly higher percentage of subjects treated with MAP004 than with placebo (28% vs. 11.3%, p<0.0001). The most common adverse events during the double-blind period in ≥ 2% of MAP0004-treated subjects and > placebo were medication aftertaste (6.1%), nausea (4.4%) and cough (2.4%). Migraine is a disabling condition affecting approximately 30 million people in the USA. Most clinical trials evaluating the efficacy of the acute treatment of migraine use endpoints measuring relief of pain over time. Associated symptoms, such as nausea, photophobia and phonophobia are included in the International Headache Society diagnostic criteria for migraine and relief of these symptoms are usually also included as clinical trial endpoints. MAP0004, an investigational product which delivers dihydroergotamine via a breath-synchronized metered dose inhaler (TEMPO®), was shown to be superior to placebo in effectively relieving migraine pain at 30 minutes, 2, 4, 24 and 48 hours in a large randomized double-blind placebo-controlled Phase 3 trial. In an effort to evaluate a more robust measure of efficacy, this post-hoc analysis assessed the combined relief from migraine pain (defined as pain reduction from moderate or severe to mild or none) and freedom from nausea, photophobia and phonophobia at several time points post-treatment without the use of rescue medication prior to those time points. Additionally, the sustainability of this effect 2-24 hours without the use of rescue medication was assessed. 794 subjects treated a qualifying migraine and had at least one post-dose efficacy assessment. Significantly higher percentage of MAP0004-treated subjects achieved combined relief from migraine pain and freedom from associated symptoms compared to placebo at: 1 hour (20.9% vs. 14.1%; p=0.0131), 2 hours (36.8% vs. 19.4%, p<0.0001), 4 hours (45.8% vs. 23.9%, p<0.0001), 24 hours (49.6% vs. 31.7%, p<0.0001) and 48 hours (41.1% vs. 28.5%, p=0.0002) post-treatment. This combined efficacy endpoint was sustained 2-24 hours in a significantly higher percentage of subjects treated with MAP004 than with placebo (28% vs. 11.3%, p<0.0001). The most common adverse events during the double-blind period in ≥ 2% of MAP0004-treated subjects and > placebo were medication aftertaste (6.1%), nausea (4.4%) and cough (2.4%).

Brief migraine episodes in children and adolescents-a modification to International Headache Society pediatric migraine (without aura) diagnostic criteria.

The international Headache Society (I H S) diagnostic criteria (International classification of headache disorders edition 2- ICHD 2) for headache in children and adults improved the accuracy of migraine diagnoses. However many short duration headaches in children, receive an atypical migraine diagnosis. This study is to diagnose children and adolescents who presented with such atypical migraines of less than one hour duration. 1402 children and adolescents aged 5 to 15 years who presented with recurrent brief activity affected head pain, were studied. Known and common migraine triggers and family history of migraine were recorded in all. All the children studied had moderate to severe headache lasting 5 to 45 minutes which forced them motionless during the attacks (thus fulfilling 2 diagnostic pain features). At least one of the ICHD2 pediatric migraine diagnostic symptoms (nausea / vomiting / photophobia / phonophobia) were present in all. Two additional features were diagnostic of brief migraines in all of them- one of the parents or siblings was a migrainer and one of the common migraine triggers as a precipitating factor. This study concludes that if duration of head pain is less than one hour ,two additional features to be included to diagnose definitive migraine in children and adolescents - one migraine parent or sibling and one of the migraine triggers precipitating the head pain.