Primary headaches in preschool age children: clinical study and follow-up in 163 patients

Although headache frequency is increasing in preschool age children, an extensive evaluation of the clinical features in affected patients has yet to be achieved. This retrospective study examined 243 patients who were separately analysed in two distinct groups according to the age of onset and the age of first clinical evaluation. Group 1 included preschool age children, while Group 2 consisted of pubertal age patients. In all the patients the importance of a positive family history for headache as a risk factor was confirmed. In addition, when compared with Group 2, Group 1 showed greater male gender prevalence and earlier onset of the attacks. Regarding clinical features, in Group 1, compared with Group 2, the attack duration was shorter with lower symptom association such as photo- or phonophobia, nausea and no pain increase during physical activity. In the same group, tension-type headache was the predominant diagnosis, in contrast to the high migraine prevalence of Group 2. This study also showed that the International Headache Society 1988 classification criteria are not fully adequate for juvenile headaches. In fact, the headaches of more than 10% of patients in Group 1 still remained unclassifiable, while those of all the subjects in Group 2 were properly classifiable.     

Migraine and tension headache in children under 6 years of age.

OBJECTIVE: To investigate the clinical features of idiopathic headache with early onset, whose presence is probably underestimated by parents and physicians and the influence of environmental and psychological factors on headache in children. METHODS: We report on a prospective longitudinal evaluation of 35 consecutive children referred to the Neuropsychiatry Departments of the Universities of Varese and Pavia (mean age at the first observation: 4 years and 7 months, range: 12 months-6 years; mean age at onset: 4 years and 2 months, range: 10 months-6 years) presenting with headache symptomatology. Mean duration of clinical follow-up: 9.5 months. The diagnosis based on the IHS criteria was then compared to the intuitive clinical diagnosis made in accordance with alternative case definitions. We examined our patients for the presence of early developmental disorders and interictal somatic disorders. We also studied the role of psychosocial factors at the onset and in the course of headache. RESULTS: Diagnosis: migraine without aura in two cases, episodic tension headache in four cases, migrainous disorders not fulfilling above criteria in eight cases, headache of the tension-type not fulfilling above criteria in 12 cases and headache not classifiable in nine cases. Clinical features of headache are described in the text. Early developmental disorders (0-2 years), such as eating difficulties and sleep disorders, were detected in 18/35 children. Among patients older than 2 years, we also detected interictal somatic disorders (20 cases) such as sleep disorders, eating difficulties, enuresis and idiopathic vomiting. In 14/35 subjects, we identified psychosocial components playing a significant role at the onset of, and during, the headache. CONCLUSIONS: A better clinical definition of the disorder would make it easier to identify very young affected children and consequently to plan more specific therapeutic interventions, taking into account environmental and psychological factors. A diagnosis of idiopathic headache becomes particularly significant: according to our cases, despite their being limited in number, migraine and tension headache can be considered also as indices of individual or family related problems requiring appropriate psychiatric or psychological intervention. This stresses the need for a multidisciplinary team of specialists that would include a psychologist/ psychiatrist or headache specialist with specific training in psychiatry.     

Osmophobia in primary headaches

This study evaluates osmophobia (defined as an unpleasant perception, during a headache attack, of odours that are non–aversive or even pleasurable outside the attacks) in connection with the diagnosis of primary headaches. We recruited 775 patients from our Headache Centre (566 females, 209 males; age 38±12 years), of whom 477 were migraineurs without aura (MO), 92 with aura (MA), 135 had episodic tension–type headache (ETTH), 44 episodic cluster headache (ECH), 2 chronic paroxysmal hemicrania (CPH) and 25 other primary headaches (OPHs: 12 primary stabbing headaches, 2 primary cough headaches, 3 primary exertional headaches, 2 primary headaches associated with sexual activity, 3 hypnic headaches, 2 primary thunderclap headaches and 1 hemicrania continua). Among them, 43% with MO (205/477), 39% with MA (36/92), and 7% with CH (3/44) reported osmophobia during the attacks; none of the 135 ETTH and 25 OPH patients suffered this symptom. We conclude that osmophobia is a very specific marker to discriminate adequately between migraine (MO and MA) and ETTH; moreover, from this limited series it seems to be a good discriminant also for OPHs, and for CH patients not sharing neurovegetative symptoms with migraine. Therefore, osmophobia should be considered a good candidate as a new criterion for the diagnosis of migraine.     

Frequent migraine and migraine status without tension-type headaches: an unusual presentation of rebound headaches

Rebound headaches usually present as daily or almost daily, prolonged, generalized tension-type headaches with superimposed migraine-like attacks. The latter are more frequent, more intense, and longer than any episodic migraine that the patient might have experienced prior to the development of the chronic daily headaches. Rebound presenting as migraine without tension-type pain has been mentioned in a few previous articles on chronic daily headache, but there have been no previous articles stressing that frequent migraine might relate to the analgesics that are being used. These case histories are presented to illustrate that frequent migraine and migraine status without tension-type headaches may be manifestations of rebound and improve when the offending analgesic agents are stopped. If the clinician fails to recognize this unusual presentation of rebound headache, the patient might be placed on unnecessary and often ineffective medications for prophylaxis instead of stopping the offending pain relief medications.     

Primary headaches and painful spontaneous cervical artery dissection

The relation between primary headaches (PH) and pain related to spontaneous cervical artery dissection (SCAD) is still unclear, as well as the progress of PH after dissection. To investigate this relation, the characteristics of pain related to SCAD and changes in PH patterns after SCAD, we evaluated 54 consecutive patients. Thirty-five (65%) had previous PH. Painful SCAD occurred in 39 (72%). Frontal and parietal localizations were significantly associated with internal carotid artery dissection (p=0.013 and p=0.010, respectively), whereas occipital and nuchal pain, with vertebral artery dissection (p=0.047 and p<0.001, respectively). Previous PH did not influence the presence of pain at SCAD onset. Twenty-six (74%) patients with PH reported improvement in PH pattern after a mean follow-up of 32 months. These results suggest that mechanisms underlying PH do not modulate dissection-related pain. Disruption of perivascular afferents may be involved in improvement of PH patterns after SCAD.     

Short-lasting headaches in children

Short-lasting headaches have been studied infrequently in children and it is not known if the main categories of primary headaches of this type in adults are applicable to children. We report our experience with a group of 20 children with a brief headache. Two patients had a secondary headache. One patient had a headache with some clinical characteristics of paroxysmal hemicrania. The remaining 17 had a very brief headache. They were in many aspects comparable to others from previous studies on idiopathic stabbing headache in children: no associated symptoms, no other associated headache, frequent family history of migraine. They differed, however, in the younger age of the patients and the more frequent extratrigeminal location of the pain. Extratrigeminal ice-pick pain may be a variant of idiopathic stabbing headache, more prevalent in young children.     

Transformed migraine is a cause of chronic daily headaches

Chronic daily headaches (CDH) consist of episodes of head pain occurring daily; more than 15 days each month; often associated with a history of migraine, with or without aura; or with a history of tension-type headaches occurring alone or both occurring together. Chronic daily headaches are frequently associated with rebound headaches after ergotamine, barbiturate, caffeine, and analgesic abuse. We previously reported that migraineurs with typical intermittent headaches exhibited excessive cerebral cortical vasodilation after oral acetazolamide which usually precipitated and reproduced their typical headaches. In the present study, cerebral vasodilator responses were tested by measuring changes in local cerebral blood flow (ΔLCBF) utilizing xenon-contrasted CT scanning, before and after oral administration of 14.3 mg/kg of acetazolamide, in 11 patients with CDH. The results were compared with 12 age-matched typical migraineurs, with and without aura, who had a history of migraine attacks occurring at intervals of 1 month or longer. Global and subcortical gray and white matter ΔLCBFs were quantitated and compared between both groups. After acetazolamide, ΔLCBF increased in cortical gray matter by 11.8% among patients with CDH and by 16.7% among migraineurs, with no significant differences between groups. Typical migraine attacks were provoked by acetazolamide in 9 patients (82%) with CDH and in 11 (92%) migraineurs with intermittent headaches. These observations are taken as evidence that at least 82% of patients with CDH have transformed migraine as judged by the provocation by acetazolamide of typical migraine attacks associated with excessive ΔLCBF increases. Serotonin agonists should be considered in the treatment of CDH to avoid ergotamine, caffeine, barbiturate, and analgesic abuse.     

Behaviour during attacks and assessment of intensity in primary headaches of children and adolescents

Assessment of attack intensity in primary headaches of paediatric age has not received great attention in the literature to date and in the international classification the criteria to define pain intensity are also not specified. The purpose of this research was to evaluate whether behaviour during attacks, reported by the child or a parent, can be used as a measure of attack disability, and so as an indirect measure of attack intensity in primary headaches of children and adolescents. The subjects were 320 patients aged between 3 and 14 years (mean age 9.9 years, SD 2.6 years) affected by primary recurrent headaches and first seen at a headache clinic. Twelve variables taken from their history were considered and sequentially analysed with multiple correspondence analysis and cluster analysis. Five types of behaviour during attacks were identified: (i) the child (or the parent) is unable to answer the questions or the child has no limitation in activities; (ii) the child may have some activity limitation, but only in lively games; (iii) the child has limitations in daily life with regard also to quiet activities; (iv) at least during some attacks the child lies down with closed eyes or in the dark; (v) during each attack the child lies down with closed eyes or in the dark. The least important variables for the identification of the five behaviour types were studying at school and absence from school. There are some limitations in considering child's behaviour as a measure of attack intensity/disability; one of these is the fact that it was found to be related to the educational level of the mother. However, behaviour during attacks, reported by the child or the parent, provides useful information independently of child's age and, together with the score of pain, when this is given, it can be used as measure of attack intensity.     

Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons. The Akershus study of chronic headache

We studied secondary chronic headaches (≥ 15 days/month for at least 3 months) in a random sample of 30 000 persons aged 30–44 years. They received a mailed questionnaire. Those with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. The criteria of the International Classification of Headache Disorders (ICHD-II) were applied. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Of the 633 participants, 298 had a secondary chronic headache. The 1-year prevalence of secondary chronic headache was 2.14%, i.e. chronic posttraumatic headache 0.21%, chronic headache attributed to whiplash injury 0.17%, post-craniotomy headache 0.02%, medication-overuse headache (MOH) 1.72%, cervicogenic headache 0.17%, headache attributed to chronic rhinosinusitis 0.33% and miscellaneous headaches 0.04%. The majority of those with ICHD-II-defined secondary chronic headache had MOH, while about one-third had other secondary headaches often in combination with MOH.     

Effectiveness of amitriptyline in the prophylactic management of childhood headaches

OBJECTIVE: To study the effectiveness of a standardized dose of amitriptyline, 1 mg/kg, for childhood headaches. BACKGROUND: Amitriptyline has been shown to be effective for the prophylaxis of migraine in adults. Studies in children, however, have been quite limited. In adults, the suggested effective dose range is 10 to 150 mg. In children, a standardized dosage is often not used, resulting in a dosage range in clinical practice that often varies from a very low dose to a dose equivalent to that used in adults. METHODS: Children with more than three headaches per month were treated with amitriptyline, slowly increasing the dose to 1 mg/kg per day. The frequency, severity, and duration of their headaches were initially evaluated and subsequently measured at each follow-up evaluation. Two hundred seventy-nine children had headaches occurring frequently enough to indicate prophylactic treatment. Of these children, 192 (68.8%) were treated with amitriptyline. The average age at presentation was 12.0 (+/- 3.0) years. The ratio of boys to girls was 1:1.74. The average frequency of headaches was 17.1 (+/- 10.1) days per month. The average severity was 6.84 (+/- 1.67) on a 10-point pain scale. The average duration was 11.5 (+/- 15.0) hours. The most frequent diagnoses using International Headache Society criteria were migraine (60.6%), migraine with aura (7.9%), and tension-type headache (10.4%). Of these children, 146 have been seen for at least one follow-up examination, occurring on average 67.3 (+/- 32.3) days after beginning prophylactic treatment. RESULTS: A total of 84.2% of the children reported an overall perception of being better, while 11.6% reported being the same. The frequency of headaches improved to 9.2 (+/- 10.0) days per month. The average severity was reduced to 5.1 (+/- 2.1), and the average duration was reduced to 6.3 (+/- 11.1) hours. If daily or continuous headaches were excluded, the improvements were more marked. Minimal side effects were reported from these children and their families. Long-term evaluation (156 to 415 days) showed continued sustained improvement. CONCLUSIONS: Amitriptyline is an effective prophylactic medication for children with frequent headaches. A standardized dosing regimen results in a significant number of children responding with minimal side effects. The children are able to tolerate this dosing scheme and demonstrate good adherence to a dosing schedule of once a day.     

The associations between headaches and psychopathology: a survey in school children

(Headache 2010;50:1537‐1548) Background.— Headaches are common in childhood and significantly impact children's quality of life. On the contrary to the adolescent and adult population, there are few data on the associations between headaches and psychopathology in young children. Objective.— The aim of this study was to examine the relationships between child headaches, emotional and behavioral difficulties in children aged 6‐11 years old. Methods.— A cross‐sectional survey was conducted in 2004 in 100 primary schools from a large French region, with 2341 children aged 6‐11 years old randomly selected. Child headache status, comorbid physical conditions, and socioeconomic characteristics were collected in parent‐administered questionnaires. Child psychopathology outcomes were assessed using child‐ and parent‐reported standardized instruments: respectively, the Dominic Interactive and the Strengths and the Difficulties Questionnaire. Associations were estimated using logistic regression models. Results.— Response rates to the parent questionnaire and the Dominic Interactive were 57.4% and 95.1%, respectively. The final sample size was 1308 children. Eleven percent of the children already experienced frequent headaches in their lifetime, with no difference by age or gender. Headaches were associated with parent‐reported emotional problems (OR = 1.76; 95% CI: 1.03‐3.01) and self‐reported general anxiety disorder (OR = 1.99; 1.13‐3.52). Comorbid physical conditions ≥2 appeared as an independent factor significantly associated with headaches (OR = 1.75; 95% CI: 1.13‐2.73). Inversely, low parental punitive behaviors were less frequently associated with headaches (OR = 0.41; 95% CI: 0.18‐0.94). Conclusion.— Our results suggest some associations between headaches, emotional disorders, and comorbid physical conditions in young children aged 6‐11 years old. Those results should be considered in the treatment approaches of childhood headaches and from the etiological aspect.     

Vagus nerve stimulation relieves chronic refractory migraine and cluster headaches

Anticonvulsant and antidepressant medications have demonstrated efficacy in migraine treatment. Vagus nerve stimulation (VNS) is an effective treatment for drug-refractory epilepsy and possibly depression and it also has documented analgesic effects. These observations suggested a possible role for VNS in treating severe refractory headaches, and led to a trial of VNS in patients with such headaches. VNS was implanted in four men and two women with disabling chronic cluster and migraine headaches. In one man and one woman with chronic migraines VNS produced dramatic improvement with restoration of ability to work. Two patients with chronic cluster headaches had significant improvement of their headaches. VNS was well tolerated in five patients, while one developed nausea even at the lowest current strength. In conclusion, VNS may be an effective therapy for intractable chronic migraine and cluster headaches and deserves further trials.     

Lack of association between antiphospholipid antibodies and migraine in children

Anticardiolipin antibodies are found frequently in those suffering from migraine, but it is not clear if this association is real or coincidental. Moreover, there are no data on the prevalence of anticardiolipin antibodies in children. In this study, 40 patients were divided into two groups according to the type of migraine: group I included 22 cases (15 females and 7 males, mean age+/-SD 13.7+/-8.9 years) suffering from migraine with and without aura; group II consisted of 18 children (10 females and 8 males, age 14.7+/-6.9 years) having migraine with prolonged aura or migrainous infarction, also called complicated migraine. We studied two groups of children as controls: a group of 35 children (25 females and 10 males, mean age 13.9+/-7.1 years) with juvenile chronic arthritis (group III) and a group of 40 healthy sex- and age-matched children who did not suffer from migraine or any other neurological disease (group IV). No statistically significant differences in levels of anticardiolipin antibodies were found between group I and II and controls. Our data demonstrate that, in children with migraine, anticardiolipin antibodies are not more frequent than in healthy controls, and suggest that anticardiolipin antibodies are not implicated in the pathogenesis of migraine.     

宁波地区6岁以下儿童意外死亡原因分析及防范探讨

目的 了解宁波地区6岁以下儿童意外死亡原因及相关因素。方法 按国际疾病分类（ICD-9）进行死因分类,将1991-1999年间宁波市江东区（26例）和鄞县（233例）259例6岁以下儿童意外死亡资料进行分析。结果 儿童意外死亡前4位主要原因为溺水、意外窒息、车祸、意外附落。儿童意外死亡率排在首位农村为溺水城区为车祸。1岁以内意外死亡多见下意外窒息,死于溺水、车祸及意外坠落多见于2岁以上儿童,结论 意外损伤事故危及儿童生命。应针对危险因素采取防范措施。     

Prevalence of primary headaches and cranial neuralgias in men and women aged 55-94 years (Bruneck Study)

The aim of the current study was to estimate the prevalence of all primary headaches and cranial neuralgias in the general community. As part of the population-based Bruneck Study, 574 men and women aged 55–94 years underwent extensive neurological and laboratory examinations involving a standardized headache interview. In the Bruneck Study population the lifetime prevalence of all primary headaches combined and of cranial neuralgias was 51.7 and 1.6%, respectively. Tension-type headache (40.9%) and migraine (19.3%) emerged as the most common types of headache. In men and women aged 55–94 years the 1-year prevalence of primary headaches was high at 40.5%. In this age range headaches caused significant impairment of health-related quality of life. The Bruneck Study has confirmed the high lifetime prevalence of primary headaches and cranial neuralgias in the general population and provided first valid prevalence data for all primary headaches based on International Classification of Headache Disorders, 2nd edition criteria.     

Prevalence and predictors of headaches in US adolescents

OBJECTIVES: To examine the prevalence of headaches among US adolescents; to explore the differences in prevalence by sex, race, and age; and to test the nature of the association between headaches and depression, self-esteem, and insomnia. METHODS: This longitudinal study used a nationally representative sample of adolescents (n = 6072) who were interviewed in 1995 (wave 1) and then interviewed a year later in 1996 (wave 2). Path analyses were used to test for the relationships among headaches, insomnia, depression, and self-esteem. RESULTS: More than 90% of subjects had experienced one or more headaches during the past 12 months. Of that 90%, about 30% reported recurrent headaches occurring weekly or more frequently. Girls tended to report more recurrent headaches (37.6%) than boys (21.3%). American Indians experienced the highest rate (35. 6%) of recurrent headaches followed by white adolescents (32.1%). Depression and low self-esteem in wave 1 were found to precede the headaches in wave 2 in girls, but not in boys. No causal relationship was found between insomnia and headaches. CONCLUSIONS: Headaches are prevalent among US adolescents, especially in girls and American Indians. This study suggests the existence of different paths involving different factors in headache-presenting behavior for boys and girls. Further studies are needed to illustrate the different mechanisms of headache in the two sexes.     

Vessel-wall MRI in primary headaches: The role of neurogenic inflammation

Objective

The purpose of this study was to investigate if vessel-wall magnetic resonance imaging (VW-MRI) could differentiate among primary headaches disorders, such as migraine and cluster headache (CH), and detect the presence of neurogenic inflammation.

Background

The pathophysiology of primary headaches disorders is complex and not completely clarified. The activation of nociceptive trigeminal afferents through the release of vasoactive neuropeptides, termed “neurogenic inflammation,” has been hypothesized. VW-MRI can identify vessel wall changes, reflecting the inflammatory remodeling of the vessel walls despite different etiologies.

Methods

In this case series, we enrolled seven patients with migraine and eight patients with CH. They underwent a VW-MRI study before and after the intravenous administration of contrast medium, during and outside a migraine attack or cluster period. Two expert neuroradiologists analyzed the magnetic resonance imaging (MRI) studies to identify the presence of vessel wall enhancement or other vascular abnormalities.

Results

Fourteen out of 15 patients had no enhancement. One out of 15, with migraine, showed a focal parietal enhancement in the intracranial portion of a vertebral artery, unmodified during and outside the attack, thus attributable to atherosclerosis. No contrast enhancement attributable to neurogenic inflammation was observed in VW-MRI, both during and outside the attack/cluster in all patients. Moreover, MRI angiography registered slight diffuse vasoconstriction in one of seven patients with migraine during the attack and in one of eight patients with cluster headache during the cluster period; both patients had taken triptans as symptomatic therapy for pain.

Conclusions

These preliminary results suggest that VW-MRI studies are negative in patients with primary headache disorders even during migraine attacks or cluster periods. The VW-MRI studies did not detect signs of neurogenic inflammation in the intracranial intradural vessels of patients with migraine or CH.     

Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: A randomized trial

Omega-3 and n-6 fatty acids are biosynthetic precursors to lipid mediators with antinociceptive and pronociceptive properties. We conducted a randomized, single-blinded, parallel-group clinical trial to assess clinical and biochemical effects of targeted alteration in dietary n-3 and n-6 fatty acids for treatment of chronic headaches. After a 4-week preintervention phase, ambulatory patients with chronic daily headache undergoing usual care were randomized to 1 of 2 intensive, food-based 12-week dietary interventions: a high n-3 plus low n-6 (H3-L6) intervention, or a low n-6 (L6) intervention. Clinical outcomes included the Headache Impact Test (HIT-6, primary clinical outcome), Headache Days per month, and Headache Hours per day. Biochemical outcomes included the erythrocyte n-6 in highly unsaturated fatty acids (HUFA) score (primary biochemical outcome) and bioactive n-3 and n-6 derivatives. Fifty-six of 67 patients completed the intervention. Both groups achieved targeted intakes of n-3 and n-6 fatty acids. In intention-to-treat analysis, the H3-L6 intervention produced significantly greater improvement in the HIT-6 score (−7.5 vs −2.1; P < 0.001) and the number of Headache Days per month (−8.8 vs −4.0; P = 0.02), compared to the L6 group. The H3-L6 intervention also produced significantly greater reductions in Headache Hours per day (−4.6 vs −1.2; P = 0.01) and the n-6 in HUFA score (−21.0 vs −4.0%; P < 0.001), and greater increases in antinociceptive n-3 pathway markers 18-hydroxy-eicosapentaenoic acid (+118.4 vs +61.1%; P < 0.001) and 17-hydroxy-docosahexaenoic acid (+170.2 vs +27.2; P < 0.001). A dietary intervention increasing n-3 and reducing n-6 fatty acids reduced headache pain, altered antinociceptive lipid mediators, and improved quality-of-life in this population.     

Self-reported headache frequency and features associated with frequent headaches in Canadian young adolescents

OBJECTIVE: To explore the associated factors for frequent headache among young adolescent Canadians. METHODS: We analyzed the self-administered questionnaire microdata files of the National Longitudinal Survey of Children and Youth (NLSCY: 1996 to 1997). Two thousand and ninety respondents representing 793,100 Canadian youth aged 12 to 13 years were asked how often they had headaches in the previous 6 months. RESULTS: Of the 2090 adolescents, 1998 (96%) responded. Frequent headaches of "about once a week" or more often were reported by 26.6% of them aged 12 to 13 years (95% CI: 24.2, 28.6). Frequent headaches appear to be associated with a plethora of risk factors germane to the life experience of these young adolescents. All factors were significant at P <.0001 by chi-square analysis and can be loosely categorized as school-related, lifestyle-related, or involving mental health. A multivariate Classification and Regression Tree (CART) analysis models frequent headaches on a depression scale, a self-esteem scale, and ever having smoked, with 60% sensitivity, and 65% specificity. CONCLUSIONS: The NLSCY reveals a remarkable insight into headache frequency and the life experience of Canada's young adolescents with frequent headaches.     

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.