Headstrong intervention for pediatric migraine headache: a randomized clinical trial

Background

The purpose of this study was to evaluate the efficacy of a self-guided CD-ROM program (“Headstrong”) containing cognitive-behavioral self-management strategies versus an educational CD-ROM program for treating headaches, headache-related disability, and quality of life.

Methods

Participants were 35 children ages 7–12 years with migraine recruited from one university medical center and two children’s hospital headache clinics. Participants were randomly assigned to complete the Headstrong or educational control CD-ROM program over a 4-week period. Data on headache frequency, duration, and severity, migraine-related disability, and quality of life (QOL) were obtained at baseline, post-intervention, and 3-months post-intervention.

Results

At post-intervention, Headstrong resulted in lower severity (on a 10-point scale) than the control group by child report (5.06 ± 1.50 SD vs. 6.25 ± 1.92 SD, p = 0.03, ES = 0.7). At 3-months post-intervention, parents reported less migraine-related disability (on the PedMIDAS) in the Headstrong group compared to the control group (1.36 ± 2.06 SD vs. 5.18 ± 6.40 SD; p = 0.04, ES = 0.8). There were no other group differences at post treatment or at 3-months post-intervention.

Conclusions

When compared to an educational control, Headstrong resulted in lower pain severity at post-treatment and less migraine-related disability at 3-months post-intervention, by child and parent report respectively. Headache frequency and quality of life did not change more for Headstrong versus control. Additional research is needed on the Headstrong Program to increase its efficacy and to test it with a larger sample recruited from multiple centers simultaneously.     

Treatment of primary headache in children: a multicenter hospital-based study in France

The aim of this 6-month, prospective, multicenter study of 398 children and adolescents with primary headaches was to collect data on headache treatment in neuropediatric departments. Treatments were compared before and after consultation. Prior to consultation, the acute treatments that had been prescribed most frequently were paracetamol (82.2% of children) and non-steroidal anti-inflammatory drugs treatment (53.5%); 10.3% had received a prophylactic treatment. No differences in either acute or prophylactic treatment with respect to headache diagnosis were observed. After the neuropediatric consultation, paracetamol was replaced by a non-steroidal anti-inflammatory drug in about three-quarters of cases and by triptan in about one-quarter of cases. The number of children prescribed a prophylactic treatment nearly doubled, whereas there was a 5-fold and 23-fold increase in psychotherapy and relaxation training, respectively, between pre-referral and referral. We conclude that specific treatments were underused for primary headache.     

High prevalence of headaches in patients with epilepsy

Background

To examine the association between headaches and epilepsy.

Methods

Consecutive adult epileptic patients who went to the outpatient clinic of the Epilepsy Center of PLA General Hospital between February 01, 2012, and May 10, 2013, were recruited into this study. A total of 1109 patients with epilepsy completed a questionnaire regarding headaches.

Results

Overall, 60.1% of the patients (male: 57.2%; female: 63.8%) reported headaches within the last year. The age-weighted prevalence of interictal migraine was 11.7% (male 8.9%, female 15.3%), which is higher than that reported in a large population-based study (8.5%, male 5.4%, female 11.6%) using the same screening questions. The prevalence of postictal headaches was 34.1% (males 32.7%, females 35.2%), and the presence of preictal headaches was 4.5% (males 4.3%, females 5.2%). The prevalence of headache yesterday in the general population was 4.8% (male 3.0%, female 6.6%). Thus, the prevalence of headaches, including migraine, is higher in epileptic patients in China.

Conclusions

The high prevalence of postictal headaches confirms the frequent triggering of a headache by a seizure. A much lower frequency of preictal headaches, a condition in which the real triggering effect of the headache on the seizure might be difficult to prove.     

Co-morbidity of migraine and epilepsy: a review of clinical features

Migraine and epilepsy are common neurological conditions that often co-exist. There are some common symptoms and in some patients there may be a diagnostic problem. The purpose of this study was to review the literature on the co-morbidity of migraine and epilepsy, and to differentiate their clinical characteristics. A search in Medline using the terms ‘migraine and epilepsy’ was conducted to identify articles published during the period 1963–1999. Articles describing co-morbidity of epilepsy and migraine have been reviewed. In the absence of convulsive episodes or a clearly migrainous profile (especially in children), confusion is most likely in patients affected by transient blindness, paroxysmal abdominal pain, unseen nocturnal events and “basilar” symptoms. Electroencephalographic abnormalities and response to an anticonvulsant may not clarify diagnosis. Although clinicians generally have little difficulty, rarely more investigations may be required for some patients. An isolated, single electroencephalogram may not provide definitive data unless an event is captured during the recording. Clinicians, therefore, have to rely mainly on the interpretation of the patient's history and clinical presentation. Received: 10 Juli 2000 / Accepted in revised form: 5 October 2000     

Juvenile myoclonic epilepsy presenting as a new daily persistent-like headache

New daily persistent headache (NDPH) is a recognized subtype of chronic daily headache with a unique presentation of a daily headache from onset typically in individuals with minimal or no prior headache history. Various secondary mimics of NDPH have now been documented but at present there has been no association made between primary epilepsy syndromes and new daily persistent-like headaches. A case patient is presented who developed a daily continuous headache from onset who 3 months after headache initiation had her first generalized tonic-clonic seizure. Further investigation into her history and her specific EEG pattern suggested a diagnosis of juvenile myoclonic epilepsy (JME). Her NDPH and seizures ceased with epilepsy treatment. Clinically relevant was that the headache was the primary persistent clinical symptom of her JME before the onset of generalized tonic-clonic seizures. The current case report adds another possible secondary cause of new daily persistent-like headaches to the medical literature and suggests another association between primary epilepsy syndromes and distinct headache syndromes.     

儿童头痛的脑电图分析

目的 通过分析头痛儿童脑电图变化,提高临床对儿童头痛脑电图癫痫的认识。方法 对120例发作性头痛患儿进行脑电图检查。结果 本组120例中常规描记111例,其中正常40例（36%）,非特异性异常68例（61%）,痫性放电3例（3%）;长程电脑图监测9例,其中正常2例（22%）,非特异性异常5例（56%）,痫性放电3例（3%）;长程脑电图监测9例,其中正常2例（22）,非特异性异常5例（56%）;痫性放电2例（22%）。结论 脑电图（或长程脑电图）检查对发作性头痛患儿诊断有一定意义。     

Topiramate in the prevention of pediatric migraine: literature review

Pediatric migraine is a disabling condition, which can cause a significant impact on quality of life. Currently, no drugs have been approved by the FDA for its preventive treatment. Our aim was to review the medical literature concerning the efficacy and tolerability of topiramate in the prophylactic treatment of migraine in children and adolescents. A total of five papers were reviewed: two randomized controlled trials (RCTs), a post-hoc subset analysis of adolescents who had been included in three RCTs carried out on adults and two open studies. Topiramate has been proven to reduce headache frequency and the accompanying disability. The frequency of side effects varied considerably among studies, the most frequent being weight loss, anorexia, abdominal pain, difficulties in concentrating, sedation and paresthesia. Since these adverse events, although often transitory, may be distressing for the child, we strongly recommend to assess the disability caused by the migraine episodes before deciding to initiate a prophylactic treatment. Nevertheless, dropout rates due to side effects in the studies were very low.     

Continuity of healthcare for headache patients: a problem of communication between headache specialists and general practitioners

The continuous care of headache patients, from headache centres to general practice, is a managerial problem that is still unsolved in Italy. In fact, if on the one hand patients do not usually go to headache centres because of poor information, on the other hand, if they do, they do not find their general practitioner (GP) sufficiently prepared to continue the management. In Sicily we have formed a dense network of headache centres that we will try to link on the Internet to deal with the problem of poor patients information and poor specialist consultation. We also have faced the problem of the continuous care, trying to overcome “the difficulties of comunication between specialists, GPs and patients” and “the difficulties of GPs in diagnostic work”, by simple instruments like the Italian version of ID–Migraine, a simple three–item questionnaire.     

Ictal epileptic headache: an old story with courses and appeals

The term “ictal epileptic headache” has been recently proposed to classify the clinical picture in which headache is the isolated ictal symptom of a seizure. There is emerging evidence from both basic and clinical neurosciences that cortical spreading depression and an epileptic focus may facilitate each other, although with a different degree of efficiency. This review address the long history which lead to the 'migralepsy' concept to the new emerging pathophysiological aspects, and clinical and electroencephalography evidences of ictal epileptic headache. Here, we review and discuss the common physiopathology mechanisms and the historical aspects underlying the link between headache and epilepsy. Either experimental or clinical measures are required to better understand this latter relationship: the development of animal models, molecular studies defining more precise genotype/phenotype correlations as well as multicenter clinical studies with revision of clinical criteria for headache-/epilepsy-related disorders represent the start of future research. Therefore, the definition of ictal epileptic headache should be used to classify the rare events in which headache is the only manifestation of a seizure. Finally, using our recently published criteria, we will be able to clarify if ictal epileptic headache represents an underestimated phenomenon or not.     

Laser acupuncture in children with headache: a double-blind, randomized, bicenter, placebo-controlled trial

To investigate whether laser acupuncture is efficacious in children with headache and if active laser treatment is superior to placebo laser treatment in a prospective, randomized, double-blind, placebo-controlled trial of low level laser acupuncture in 43 children (mean age (SD) 12.3 (+/-2.6) years) with headache (either migraine (22 patients) or tension type headache (21 patients)). Patients were randomized to receive a course of 4 treatments over 4 weeks with either active or placebo laser. The treatment was highly individualised based on criteria of Traditional Chinese medicine (TCM). The primary outcome measure was a difference in numbers of headache days between baseline and the 4 months after randomization. Secondary outcome measures included a change in headache severity using a 10 cm Visual Analogue Scale (VAS) for pain and a change in monthly hours with headache. Measurements were taken during 4 weeks before randomization (baseline), at weeks 1-4, 5-8, 9-12 and 13-16 from baseline. The mean number of headaches per month decreased significantly by 6.4 days in the treated group (p<0.001) and by 1.0 days in the placebo group (p=0.22). Secondary outcome measures headache severity and monthly hours with headache decreased as well significantly at all time points compared to baseline (p<0.001) and were as well significantly lower than those of the placebo group at all time points (p<0.001). We conclude that laser acupuncture can provide a significant benefit for children with headache with active laser treatment being clearly more effective than placebo laser treatment.     

Placebo and other psychological interactions in headache treatment

We present a theory according which a headache treatment acts through a specific biological effect (when it exists), a placebo effect linked to both expectancy and repetition of its administration (conditioning), and a non-specific psychological effect. The respective part of these components varies with the treatments and the clinical situations. During antiquity, suggestions and beliefs were the mainstays of headache treatment. The word placebo appeared at the beginning of the eighteenth century. Controversies about its effect came from an excessive interpretation due to methodological bias, inadequate consideration of the variation of the measure (regression to the mean) and of the natural course of the disease. Several powerful studies on placebo effect showed that the nature of the treatment, the associated announce, the patients’ expectancy, and the repetition of the procedures are of paramount importance. The placebo expectancy is associated with an activation of pre-frontal, anterior cingular, accumbens, and periacqueducal grey opioidergic neurons possibly triggered by the dopaminergic meso-limbic system. In randomized control trials, several arms design could theoretically give information concerning the respective part of the different component of the outcome and control the natural course of the disease. However, for migraine and tension type headache attacks treatment, no three arm (verum, placebo, and natural course) trial is available in the literature. Indirect evidence of a placebo effect in migraine attack treatment, comes from the high amplitude of the improvement observed in the placebo arms (28% of the patients). This figure is lower (6%) when using the harder criterium of pain free at 2 h. But these data disregard the effect of the natural course. For prophylactic treatment with oral medication, the trials performed in the last decades report an improvement in 21% of the patients in the placebo arms. However, in these studies the duration of administration was limited, the control of attacks uncertain as well as the evolution of the co-morbid psycho-pathology. Considering the reviews and meta-analysis of complex prophylactic procedures, it must be concluded that their effect is mostly linked to a placebo and non-specific psychological effects. Acupuncture may have a slight specific effect on tension type headache, but not on migraine. Manual therapy studies do not exhibit difference between manipulation, mobilization, and controls; touch has no proven specific effect. A comprehensive efficacy review of biofeedback studies concludes to a small specific effect on tension type headache but not on migraine. A review of behavioral treatment conclude to an interesting mean improvement but did not demonstrated a specific effect with the exception of a four arm study including a pseudo meditation control group. Expectation-linked placebo, conditioning, and non-specific psychological effects vary according clinical situations and psychological context; likely low in RCT, high after anempathic medical contact, and at its maximum with a desired charismatic healer. The announcements of doctors strongly influence the beliefs of patients, and in consequence their pain and anxiety sensibilities; this modulates the amplitude of the placebo and the non-specific psychological effects and is therefore a major determinant of the therapeutic success. Furthermore, any repetitive contact, even through a placebo, may interfere positively with the psychopathological co-morbidity. One has to keep in mind that the non-specific psychological interactions play a major role in the improvement of the majority of the headache sufferers.     

Relationship between insomnia and headache in community-based middle-aged Hong Kong Chinese women

Limited studies have investigated the prevalence of insomnia symptoms among individuals with different headache diagnoses and the association between insomnia and headache in subjects with comorbid anxiety and depression. A total of 310 community-dwelling Hong Kong Chinese women aged 40–60 years completed a self-administered questionnaire on headache, sleep difficulties, mood disturbances, and functional impairment. About 31% of the sample complained of recurrent headache unrelated to influenza and the common cold in the past 12 months. The percentages of women diagnosed to have migraine, tension-type headache (TTH), and headache unspecified were 8.4, 15.5 and 7.1%, respectively. The most frequent insomnia complaint was “problem waking up too early” (29.4%), followed by “difficulty staying asleep” (28.0%) and “difficulty falling asleep” (24.4%). Women with headaches were significantly more likely to report insomnia symptoms than those without headaches. There were no significant differences among women with migraine, TTH, and headache unspecified in the prevalence of insomnia symptoms. Logistic regression analysis showed that women with insomnia disorder as defined by an insomnia severity index total score ≥8 had 2.2-fold increased risk of reporting recurrent headache, 3.2-fold increased risk of migraine, and 2.3-fold increased risk of TTH, after adjusting for anxiety and depression. Individual insomnia symptoms were not independent predictors. The association between insomnia and headache was stronger in subjects with more frequent headaches. Our findings suggest that insomnia and the associated distress, but not insomnia symptoms alone, is an independent risk factor for recurrent headache in middle-aged women with mixed anxiety, depression and sleep disturbances.     

Patient satisfaction with a neurological specialist consultation for headache

Objective - To evaluate patient satisfaction with a specialist consultation for headache and thus identify subgroups of headache patients more satisfied than others. Design - A survey of consecutive patients referred to a neurologist for headache. Setting - Neurological outpatient clinics in North Norway. Patients - We included 889 consecutive patients referred to a specialist centre for headache during a period of 2 years. Using a questionnaire, we recorded patients' satisfaction with the potential treatment initiated by the specialist. Results - Sixty-three percent of migraine patients (95% CI, 0.58 to 0.68) were satisfied with the consultation, compared to 44% of patients with non-migrainous headache (95% CI, 0.40 to 0.70), (p =0.01). Altogether 481 patients had some kind of measure recommended by the neurologist, and 317 of these (66%) were satisfied (95% CI, 0.62 to 0.70). Patients with tension-type headache and those who were not prescribed specific treatment modalities were less satisfied. Conclusion - The study confirms that patients with headache are satisfied with a neurological specialist consideration, especially in the case of migraine.     

Comorbidity in Finnish migraine families

The objective of the study was to investigate comorbidity of migraine in Finnish migraine families. One thousand consecutive participants in the Finnish Migraine Gene Project reported their medical illnesses in addition to migraine and headache. Migraine patients (n=678) reported significantly more hypotension (OR 1.43, CI 95% 1.02–2.01), allergy (OR 1.83, CI 95% 1.34–2.51) and psychiatric disorders (OR 4.09, CI 95% 2.11–7.92) compared to their family members without migraine (n=322). Subgroup analyses demonstrated that especially women and the group fulfilling the criteria for both migraine with and without aura were likely to have additional disorders besides their migraine. Interestingly, male migraineurs with aura reported a significant association with stroke and epilepsy. Familial migraine is comorbid with hypotension, allergy and psychiatric disorders. The association between migraine with aura and stroke and epilepsy among men of the studied families warrants further study. Clinical, pathophysiological and genetic implications of these results are discussed.     

Association between blood pressure measures and recurrent headache in adolescents: cross-sectional data from the HUNT-Youth study

The relationship between blood pressure and headache in youth has not been explored and the objective of the present study was to provide data on this association in an adolescent population. Cross-sectional data from a large population-based survey, the Young-HUNT study, on 5,847 adolescents were used to evaluate the association between blood pressure (systolic, diastolic, mean arterial and pulse pressure) and recurrent headache, including migraine and tension-type headache. Increasing pulse pressure was inversely related to recurrent headache prevalence, and both tension-type headache and migraine. For systolic blood pressure such an inverse relationship was present for recurrent headache and tension-type headache prevalence. For migraine, the results were not significant, although there was a tendency in the same direction (p = 0.05). High-pulse pressure has previously been found to be inversely related to the prevalence of migraine and tension-type headache in an adult population. This inverse relationship has now been demonstrated to be present among adolescents also, supporting the results from a previous study in adults, that blood pressure regulation may be linked to the pathophysiology of headache.     

Anti-epileptic drugs in the preventive treatment of migraine headache: a brief review

Anti-epileptic drugs are employed for the prophylactic treatment of migraine. Valproic acid and its sodium salt (divalproex) have been shown to be effective in preventing migraine in double-blind placebo-controlled studies. Gabapentin and lamotrigine have also been proposed for migraine prophylaxis, but more extensive studies are needed to confirm their efficacies. The main mechanism of action of anti-epileptic drugs in the inhibition of the sodium channel to induce a depolarization, preventing the high, frequent action potentials typically excited by convulsive attacks. Moreover, valproate and gabapentin increase brain concentrations of GABA and, probably, inhibit the degradation of GABA. Other proposed mechanisms of action for valproate are a direct effect on neuronal membranes and a reduction of excitatory transmission by aspartate. Valproate, at the recommended dose of 500 mg twice daily, is well tolerated. The more frequent unwanted effects associated with almost all drugs of this class are weight gain, drowsiness, dizziness and tremor. Topiramate has recently been proposed for the treatment of unresponsive, high frequency migraine, taking into account both the GABA and glutamatergic mechanisms of action. Received: 13 November 2000 / Accepted in revised form: 5 April 2001     

Prevalence of headache in Europe: a review for the Eurolight project

The main aim of the present study was to do an update on studies on headache epidemiology as a preparation for the multinational European study on the prevalence and burden of headache and investigate the impact of different methodological issues on the results. The study was based on a previous study, and a systematic literature search was performed to identify the newest studies. More than 50% of adults indicate that they suffer from headache in general during the last year or less, but when asked specifically about tension-type headache, the prevalence was 60%. Migraine occurs in 15%, chronic headache in about 4% and possible medication overuse headache in 1–2%. Cluster headache has a lifetime prevalence of 0.2–0.3%. Most headaches are more prevalent in women, and somewhat less prevalent in children and youth. Some studies indicate that the headache prevalence is increasing during the last decades in Europe. As to methodological issues, lifetime prevalences are in general higher than 1-year prevalences, but the exact time frame of headache (1 year, 6 or 3 months, or no time frame stated) seems to be of less importance. Studies using personal interviews seem to give somewhat higher prevalences than those using questionnaires.     

Extracephalic tenderness and pressure pain threshold in children with headache

Background Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non‐headache pains and interictal pericranial muscular tenderness more often than headache‐free children. Objective To study if children with different types of headache report non‐headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache‐free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. Design A population‐based sample of 13‐year‐old children with migraine (n = 48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non‐headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. Results Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. Conclusions Children with migraine experience more non‐headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.     

High dietary caffeine consumption is associated with a modest increase in headache prevalence: results from the Head-HUNT Study

The aim of this study was to investigate the association between caffeine consumption and headache type and frequency in the general adult population. The results were based on cross-sectional data from 50,483 (55%) out of 92,566 invited inhabitants aged ≥20 years who participated in the Nord-Trøndelag Health Survey. In the multivariate analyses, adjusting for age, gender, smoking, and level of education as confounding factors, a weak but significant association (OR = 1.16, 95% CI 1.09–1.23) was found between high caffeine consumption and prevalence of infrequent headache. In contrast, headache >14 days/month was less likely among individuals with high caffeine consumption compared to those with low caffeine consumption. The results may indicate that high caffeine consumption changes chronic headache into infrequent headache due to the analgesic properties of caffeine. Alternatively, chronic headache sufferers tend to avoid intake of caffeine to not aggravate their headaches, whereas individuals with infrequent headache are less aware that high caffeine use can be a cause.     

Migraine-like headache as the presenting symptom of basilar artery occlusion

If migraine or a migrainelike headache and stroke occur together, it is difficult to determine whether migraine is the cause of the stroke or stroke is the cause of symptomatic migraine. We report the case of a 19-year-old woman without a history of migraine who presented with a migraine-like headache, nausea and desire for tranquility and dimmed lighting. Initial neurological examination, computed tomography and cerebrospinal fluid analysis were normal, leading to the presumptive diagnosis of first manifestation of migraine. Persistence of dizziness and transient diplopia, however, prompted a magnetic resonance imaging examination, which revealed major stroke in the posterior circulation due to occlusion of the basilar artery. The symptoms resolved spontaneously and treatment with antiplatelet inhibitor was prescribed. Smoking and use of oral contraceptives were identified as vascular risk factors. Stroke in the posterior circulation due to occlusion of the basilar artery may show rather inconspicuous symptoms and provoke migrainous headache. Received: 19 August 2002, Accepted in revised form: 2 December 2002 Correspondence to J.G. Heckmann