Allergy and Immunotherapy: Are They Related to Migraine Headache?

(Headache 2011;51:8‐20) Introduction.— Several studies have reported that migraine headaches are more common in patients with allergic rhinitis and that immunotherapy decreases the frequency of headache in atopic headache sufferers. Objective.— To determine if the degree of allergic sensitization and the administration of immunotherapy are associated with the prevalence, frequency, and disability of migraine headache in patients with allergic rhinitis. Methods.— Consecutive patients between the ages of 18‐65 presenting to an allergy practice that received a diagnosis of an allergic rhinitis subtype (eg, allergic or mixed rhinitis) were enrolled in this study. All participants underwent allergy testing as well as a structured verbal headache diagnostic interview to ascertain the clinical characteristics of each headache type. Those reporting headaches were later assigned a headache diagnosis by a headache specialist blinded to the rhinitis diagnosis based on 2004 International Classification Headache Disorders‐2 (ICHD‐2) diagnostic criteria. Migraine prevalence was defined as the percentage of patients with a diagnosis of migraine headache (ICHD‐2 diagnoses 1.1‐1.5). Migraine frequency represented the number of days per month with migraine headache self‐reported during the headache interview and migraine disability was the number of days with disability obtained from the Migraine Disability Assessment questionnaire. Generalized linear models were used to analyze the migraine prevalence, frequency, and disability with the degree of allergic sensitization (percentage of positive allergy tests) and administration of immunotherapy as covariates. Patients were categorized into high (> 45% positiveallergy tests) and low (≤45% positive allergy tests) atopic groups based on the number of allergy tests that were positive for the frequency and disability analyses. Results.— A total of 536 patients (60% female, mean age 40.9 years) participated in the study. The prevalence of migraine was not associated with the degree of allergic sensitization, but there was a significant age/immunotherapy interaction (P < .02). Migraine headaches were less prevalent in the immunotherapy group than the nonimmunotherapy at ages <40 years and more prevalent in the immunotherapy group at ages ≥40 years of age. In subjects ≤45 years of age, increasing percentages of allergic sensitization were associated with a decreased frequency and disability of migraine headache in the low atopic group (risk ratios [RRs] of 0.80 [95% CI; 0.65, 0.99] and 0.81[95% CI; 0.68, 0.97]) while increasing percentages were associated with an increased frequency (not disability) in the high atopic group (RR = 1.60; [95% CI; 1.11, 2.29]). In subjects ≤45 years of age, immunotherapy was associated with decreased migraine frequency and disability (RRs of 0.48 [95% CI; 0.28, 0.83] and 0.55 [95% CI; 0.35, 0.87]). In those >45 years of age, there was no effect of degree of allergic sensitization or immunotherapy on the frequency and disability of migraine headache. Conclusions.— Our study suggests that the association of allergy with migraine headaches depends upon age, degree of allergic sensitization, administration of immunotherapy, and the type of headache outcome measure that are studied. Lower “degrees of atopy” are associated with less frequent and disabling migraine headaches in younger subjects while higher degrees were associated with more frequent migraines. The administration of immunotherapy is associated with a decreased prevalence, frequency, and disability of migraine headache in younger subjects.     

Migraine Disability Awareness Campaign in Asia: Migraine Assessment for Prophylaxis

Objectives.— This study aimed to survey the headache diagnoses and consequences among outpatients attending neurological services in 8 Asian countries. Methods.— This survey recruited patients who consulted neurologists for the first time with the chief complaint of headache. Patients suffering from headaches for 15 or more days per month were excluded. Patients answered a self‐administered questionnaire, and their physicians independently completed a separate questionnaire. In this study, the migraine diagnosis given by the neurologists was used for analysis. The headache symptoms collected in the physician questionnaire were based on the diagnostic criteria of migraine proposed by the International Classification of Headache Disorders, second edition (ICHD‐2). Results.— A total of 2782 patients (72% females; mean age 38.1 ± 15.1 years) finished the study. Of them, 66.6% of patients were diagnosed by the neurologists to have migraine, ranging from 50.9% to 85.8% across different countries. Taken as a group, 41.4% of those patients diagnosed with migraine had not been previously diagnosed to have migraine prior to this consultation. On average, patients with migraine had 4.9 severe headaches per month with 65% of patients missing school, work, or household chores. Most (87.5%) patients with migraine took medications for acute treatment. Thirty‐six percent of the patients had at least one emergency room consultation within one year. Only 29.2% were on prophylactic medications. Neurologists recommended pharmacological prophylaxis in 68.2% of patients not on preventive treatment. In comparison, migraine prevalence was the highest with ICHD‐2 “any migraine” (ie, migraine with or without migraine and probable migraine) (73.3%) followed by neurologist‐diagnosed migraine (66.6%) and ICHD‐2 “strict migraine” (ie, migraine with or without aura only) (51.3%). About 88.6% patients with neurologist‐diagnosed migraine fulfilled ICHD‐2 any migraine but only 67.1% fulfilled the criteria of ICHD‐2 strict migraine. Conclusions.— Migraine is the most common headache diagnosis in neurological services in Asia. The prevalence of migraine was higher in countries with higher referral rates of patients to neurological services. Migraine remains under‐diagnosed and under‐treated in this region even though a high disability was found in patients with migraine. Probable migraine was adopted into the migraine diagnostic spectrum by neurologists in this study.     

Characteristics of the first 1000 headaches in an outpatient headache clinic registry

(Headache 2011;51:226‐231) Objective.— To analyze the incidence and characteristics of the first 1000 headaches in an outpatient clinic. Background.— Headache is a common cause of medical consultation, both in primary care and in specialist neurology outpatient clinics. The International Classification of Headache Disorders, 2nd Edition (ICHD‐II), enables headaches to be classified in a precise and reproducible manner. Methods.— In January 2008, an outpatient headache clinic was set up in Hospital Clínico Universitario, a tertiary hospital in Valladolid, Spain. Headaches were classified prospectively in accordance with ICHD‐II criteria. In each case we recorded age and sex, duration of headache, ancillary tests required, and previous symptomatic or prophylactic therapies. Results.— In January 2010, the registry included 1000 headaches in 682 patients. The women/men ratio was 2.46/1 and the mean age of the patients was 43.19 ± 17.1 years (range: 14‐94 years). Patients were referred from primary care (53.4%), general neurology clinics (36.6%), and other specialist clinics (9%). The headaches were grouped (ICHD‐II classification) as follows: group 1 (Migraine), 51.4%; group 2 (Tension‐type headache), 16%; group 3 (Trigeminal autonomic cephalalgias), 2.6%; group 4 (Other primary headaches) and group 13 (Cranial neuralgias), 3.4%. The diagnostic criteria of chronic migraine were satisfied in 8.5% of migraines. Regarding secondary headaches, 1.1% of all cases were included in group 5 (Headaches attributed to trauma) and 8.3% in group 8 (Headaches attributed to a substance or its withdrawal). Only 3.4% of headaches were classified in group 14 (Unspecified or not elsewhere classified), and 5.2% were included in the groups listed in the ICHD‐II research appendix. Conclusion.— This registry outlines the characteristics of patients seen in an outpatient headache clinic in a tertiary hospital; our results are similar to those previously reported for this type of outpatient clinic. Migraine was the most common diagnosis. Most headaches can be classified using ICHD‐II criteria.     

Refractory headache: historical perspective, need, and purposes for an operational definition

The study of migraine has yielded many benefits for headache patients. Little research, however, has been performed on refractory migraine (RM) headache, a term often used interchangeably with intractable migraine. This may be a consequence of a lack of a well-accepted definition. In a survey performed by the Refractory Headache Special Interest Section (RHSIS) on the American Headache Society (AHS) in 2006, 58% of the members agreed that a definition for refractory headache should be added to the International Classification of Headache Disorders-2. A PubMed search identified 21 articles that defined refractory or intractable headache/migraine. Sixteen (76%) defined the term "refractory" and 5 (24%) defined the term "intractable." Many of these definitions did not address the need for an adequate trial of a preventive medicine, disability, and medication overuse. An operational definition will allow us to better characterize the disorder, address unmet medical needs, and identify the most effective treatments. RHSIS of the AHS has proposed a definition of RM. It is our hope that this definition will spur interest in this entity and will lead to further research in the area.     

Posttraumatic Headache: Classification by Symptom‐Based Clinical Profiles

There are currently no accepted therapies for posttraumatic headache (PTH). In order to meet the urgent need for effective therapies for PTH, we must continue to address fundamental gaps in our understanding of the clinical course and impact of PTH. Here we examine the existing schema used to characterize the clinical characteristics of PTH, including the International Classification of Headache Disorders (ICHD). There remain unresolved questions about whether to classify patients based on the extent of brain injury or on clinical symptom profiles. There also remain problematic issues of definition such as continuous headache, and chronic daily headache with features of “embedded” migraine‐type within these headaches, which will need to be studied further. We make the case that a symptom‐based classification is needed to begin an examination of these unresolved questions, and to establish clinically relevant endpoints for research and clinical trials for effective therapies.     

Not tonight, I have a headache?

OBJECTIVE: The present study examined the relationship between the diagnosis of migraine and self-reported sexual desire. BACKGROUND: There is evidence for a complex relationship between sexual activity and headache, particularly migraine. The current headache diagnostic criteria even distinguish between several types of primary headaches associated with sexual activity. METHODS: Members of the community or students at the Illinois Institute of Technology (N = 68) were administered the Brief Headache Diagnostic Interview and the Sexual Desire Inventory (SDI). Based on the revised diagnostic criteria established by the International Headache Society (ICHD-II), participants were placed in 1 of the 2 headache diagnostic groups: migraine (n = 23) or tension-type (n = 36). RESULTS: Migraine subjects reported higher SDI scores, and rated their own perceived level of desire higher than those suffering from tension-type headache. The presence of the symptom "headache aggravated by routine physical activity" significantly predicted an elevated SDI score. CONCLUSIONS: Migraine headaches and sexual desire both appear to be at least partially modulated by serotonin (5-HT). The metabolism of 5-HT has been shown to covary with the onset of a migraine attack, and migraineurs appear to have chronically low systemic 5-HT. As sexual desire also has been linked to serotonin levels, the results are consistent with the hypothesis that migraine and sexual desire both may be modulated by similar serotonergic phenomena.     

Defining Refractory Migraine: Results of the RHSIS Survey of American Headache Society Members

Objectives.— To gauge consensus regarding a proposed definition for refractory migraine proposed by Refractory Headache Special Interest Section, and where its use would be most appropriate. Background.— Headache experts have long recognized that a subgroup of headache sufferers remains refractory to treatment. Although different groups have proposed criteria to define refractory migraine, the definition remains controversial. The Refractory Headache Special Interest Section of the American Headache Society developed a definition through a consensus process, assisted by a literature review and initial membership survey. Design.— A 12‐item questionnaire was distributed at the American Headache Society meeting in 2007 during a platform session and at the Refractory Headache Special Interest Section symposium. The same questionnaire was subsequently sent to all American Headache Society members via e‐mail. A total of 151 responses from AHS members form the basis of this report. The survey instrument was designed using Survey Monkey. Frequencies and percentages of the survey were used to describe survey responses. Results.— American Headache Society members agreed that a definition for refractory migraine is needed (91%) that it should be added to the International Classification of Headache Disorders‐2 (86%), and that refractory forms of non‐migraine headache disorders should be defined (87%). Responders believed a refractory migraine definition would be of greatest value in selecting patients for clinical drug trials. The current refractory migraine definition requires a diagnosis of migraine, interference with function or quality of life despite modification of lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. The proposed criteria for the refractory migraine definition require failing 2 preventive medications to meet the threshold for failure. Although 42% of respondents agreed with the working definition of refractory migraine, 43% favored increasing the number to 3 (50%) or 4 (26%) preventive treatment failures. When respondents were asked if they felt that the proposed definition was appropriate to select patients for invasive procedures (patent foramen ovale repair or stimulators) only 44% agreed. Conclusions.— There is a consensus for a need for a definition for refractory migraine and that it should be added to the International Classification of Headache Disorder‐2. There was also general agreement by the responders that refractory forms of non‐migraine headache disorders should be defined.     

Migraine Diagnosis and Clinical Symptomatology

Migraine is a very common phenomenon. Eighteen percent of women in this country and 6% of men have migraine. The old classification for headaches and diagnostic criteria were published in 1962, more than a quarter of a century ago. In 1988, the International Headache Society published a new classification and diagnostic criteria for all headache disorders, cranial neuralgias, and facial pain. The International Headache Society classification divides migraine, as it had been divided in the past, into two major categories: migraine without aura (formerly called common migraine) and migraine with aura (formerly called classical migraine). These criteria are rather complex and simpler criteria are proposed for clinical practice. The typical patient with migraine is a woman whose headaches began in adolescence or young adult life. There usually is a family history of migraine. Migraine is almost always more than just a headache. Virtually anything in the external environment and many things in the internal milieu may provoke migraine in a susceptible individual. There are many potential manifestations of the aura of migraine, but 90% are visual phenomena. Migraine in children is a little different than in adults. When the onset is below the age of puberty, the ratio of females to males is equal, but after puberty there is a striking predominance of women over men in a ratio of 3:1. Whenever the history of migraine is not typical or if something unexpected is found on examination, imaging studies are warranted.     

A Prospective Comparison Between ICHD‐II and Probability Menstrual Migraine Diagnostic Criteria

Objective.— To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems. Methods.— Female migraineurs self‐reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD‐II) criteria and a probability model called Probability MM. Results.— Three months of pretreatment prospective diaries were completed by 126 women. ICHD‐II menstrually related migraine was diagnosed in 73.8% with pure MM in 7.1%. ICHD‐II and Probability diagnoses agreed for all cases of ICHD‐II non‐MM and pure MM, with disagreement among women diagnosed with ICHD‐II menstrually related migraine, only half of whom were identified as having a relationship with menses greater than chance alone using the Probability model. Interestingly, 20% of those women self‐reporting a substantial relationship between migraine and menses were not prospectively diagnosed with MM using either diagnostic system. Differences in menstrual vs nonmenstrual headaches were greater when using the Probability model. Conclusions.— Prospective headache diaries are needed to diagnose MM. A probability‐based method, which considers the chance occurrence of headaches during the menstrual cycle, identifies fewer women as having menstrually related migraine compared with the diary‐based methods recommended by the current ICHD‐II candidate criteria. (Headache 2010;50:539‐550)     

Diagnosis and classification of headache

Headache is the most common neurologic complaint. Migraine is by far the most frequent headache type seen by office-based physicians.Migraine remains under-recognized, under-diagnosed, and therefore under-treated in everyday medical practice. With time severely restricted in primary care day-to-day practice, a user friendly approach to assessment of headaches and differentiation into the broad types of "worrisome headache," migraine, tension-type, and others is necessary. A consensus-based, practical, rapid, six essential-question screening technique is outlined.     

Characteristics,impact and treatment of 6000 headache attacks: The PAMINA study

The aim of this study was to prospectively evaluate the characteristics of headache attacks, their impact on daily activities as well as the type and efficacy of acute medication in patients with migraine. We included 281 patients with episodic migraine (87% females, aged 41.2±12.1). All patients kept a headache diary for 3 months covering headache characteristics, therapy and questions adopted from the Headache Impact Test (HIT‐6) for rating the impact of each single headache attack (HIT‐6 s). For evaluating the efficacy of acute medication we compared triptans with other compounds using headache duration as outcome parameter. Of 6051 headache attacks 52.8% fulfilled the ICHD‐II criteria of migraine. The HIT‐6 s score was 2.4±2.2 (range 0–6). It was lowest in untreated headaches (2.0±2.1) and highest in those treated with a combination of triptans and other compounds (4.1±2.0, p <0.001). Patients used triptans on 8.0% of all headache days, other compounds on 33.1%, a combination of both on 1.5% and no medication on 57.3% of the headache days. Migraine attacks of moderate or severe intensity treated with triptans alone lasted significantly shorter than those treated with other compounds (5.1±3.6 vs. 6.9±5.3 h, p <0.001). In conclusion, almost 50% of the headaches occurring in patients with migraine do not fulfill migraine criteria. Use of triptans is associated with a shorter duration of moderate and severe migraine attacks compared to use of other compounds.     

Peripheral neurostimulation for the treatment of chronic,disabling transformed migraine

BACKGROUND: Up to 5% of the general population suffers from transformed migraine. This study analyzes clinical responses of transformed migraine to cervical peripheral nerve stimulation. METHODS: Headache frequency, severity, and disability (Migraine Disability Assessment [MIDAS] scores) were independently measured in an uncontrolled consecutive case series of 25 patients with transformed migraine implanted with C1 through C3 peripheral nerve stimulation. All patients met International Headache Society (IHS) criteria for episodic migraine, as well as suggested criteria for transformed migraine, and had been refractory to conventional treatment for at least 6 months. Responses to C1 through C3 peripheral nerve stimulation were recorded. RESULTS: Prior to stimulation, all patients experienced severe disability (grade IV on the MIDAS) with 75.56 headache days (average severity, 9.32; average MIDAS score, 121) over a 3-month period. Following stimulation, 15 patients reported little or no disability (grade I), 1 reported mild disability (grade II), 4 reported moderate disability (grade III), and 5 continued with severe disability (grade IV), with 37.45 headache days (average severity, 5.72; average MIDAS score, 15). The average improvement in the MIDAS score was 88.7%, with all patients reporting their headaches well controlled after stimulation. CONCLUSIONS: These results raise the possibility that C1 through C3 peripheral nerve stimulation can help improve transformed migraine symptoms and disability. A controlled study is required to confirm these results.     

The Comparison of Patients Suffering from Temporo-mandibular Disorders and a General Headache Population

SYNOPSIS
The purpose of this study was to examine the possible association of signs and symptoms of temporomandibular disorders relative to headache. Fifty-six sequential patients referred to the Headache Institute of Minnesota for evaluation and treatment of migraine and tension headaches were examined for signs and symptoms of temporomandibular disorders. The results of the examination of headache patients were compared to patients suffering from myofascial pain dysfunction and/or TMJ internal derangements from the TMJ and Craniofacial Pain Clinic at the University of Minnesota. Finally the migraine and tension headache patients were compared to each other and an asymptomatic population.
Results indicate that patients with temporomandibular disorders exhibit significantly more jaw dysfunction and pericranial muscle tenderness than migraine and tension headache patients. ^Migraine and tension headache patients were found to have similar amounts of pericranial muscle tenderness. Migraine and tension headache patients exhibited significantly more pericranial and neck muscle tenderness than a general population.     

Migraine and tension-type headaches: the questionable validity of current classification systems.

Headache is the most common symptom patients present to their doctors. Current systems classify the most common recurring headaches as either migraine or tension-type. Review of the literature brings into question this traditional approach to headache classification. These two "types" of headache patterns appear, instead, to be different expressions of the same pathophysiological process, having overlapping symptomatic presentations with certain features emphasized to a greater or lesser extent. Additionally, the same therapies have been demonstrated to be effective for patients traditionally classified in either headache group. This article reviews the overlap of clinical symptoms, pathophysiology, and effective treatments for headaches traditionally diagnosed as migraine and tension-type. An alternative continuum classification model is suggested.     

The International Classification of Headache Disorders, 3rd Edition (ICHD III) – Changes and Challenges

In order to effectively study and manage headache disorders, diagnosis is essential. In both research and clinical arenas, separating secondary causes from primary headache disorders is a crucial first step, followed by further specificity within these broader categories. Historical approaches to classifying headache disorders culminated in the International Classification of Headache Disorders (ICHD), completed and published in 1988. This was revised as the International Classification of Headache Disorders, 2nd Edition (ICHD II) in 2004. The International Headache Society's Subcommittee on Classification began work on the 3rd edition in 2010, and has just published this online and in the journal Cephalalgia. The diagnostic criteria for more than 200 causes of headaches are based upon evidence when available, and fortunately, recent research in the field of headache medicine has produced data applicable to the refinement of classification of a number of primary and secondary headache disorders. Some areas, however, await further study, making classification more challenging. This article will attempt to provide an overview of the rationale behind the ICHD, a guide to its use, and a summary of important diagnostic features of the primary and secondary headaches, particularly where these have changed significantly in the ICHD III from ICHD II.     

Prevalence and clinical characteristics of headache in a rural community in Oman

OBJECTIVES: To perform a prospective epidemiological study of headache in a rural community in Oman, assessing prevalence, symptom profile, and health care utilization pattern. METHODS: Using a door-to-door survey prevalence estimates were based on a detailed structured headache assessment questionnaire performed in 1158 subjects. Migraine and tension-type headache were diagnosed according to the International Headache Society criteria. RESULTS: The crude lifetime and last-year prevalence of headache were 83.6% and 78.8%, respectively, with a female preponderance. The last-year prevalence of migraine and tension headache was 10.1% and 11.2%, respectively. There was no significant gender difference in migraine prevalence (4.5% in male and 5.6% in female), but tension-type headache was 2.6 times more common in females (3.1% in male and 8.1% in female). Last-year prevalence of frequent headaches was 5.4%. Forty eight percent of respondents sought medical assistance for their headaches and 79% were using medication, 40% of them used self-medication. CONCLUSIONS: This prospective study shows that headache is also highly prevalent in this community. Migraine and tension-type headache have the same prevalence, but the sex distribution for migraine is different from that observed in the Western world. Tension-type headache prevalence was substantially lower than that observed in other parts of the world. Frequent headaches were as common as in other population-based studies worldwide. Analgesic use/overuse probably also coexisted with headache, because self-medication was quite common.     

The Epidemiology of Migraine in Medical Students

The purpose of this study was to investigate the prevalence of migraine in medical students, as well as its clinical aspects and impact. All 595 medical students of Santa Casa School of Medicine of São Paulo, Brazil were asked if they had experienced any kind of headache in the past year. Those who responded positively were further investigated by an appropriate questionnaire. Diagnosis of migraine was based on the International Headache Society criteria of 1988. Forty percent of students suffered from some kind of headache; 40.2% of these headaches were migraine. The prevalence of migraine was 54.4% in women and 28.3% in men. Migraine headaches were unilateral in 24.2%, had a gradual onset in 69%, and were of a throbbing type in 88.3%. Migraine was considered incapacitating by 53.9% of students. Migraine with aura caused more disability than migraine without aura. Women experienced more intense migraine than men, and migraine with aura was especially more severe than migraine without aura. Photophobia, phonophobia, and nausea were more commonly encountered in migraine with aura. Despite the high prevalence, the high rate of disability, and the need for analgesic medication, only 7.1% of students with migraine had sought medical treatment.