Mild Head Trauma and Chronic Headaches in Returning US Soldiers

Objective.— To determine the incidence and types of head or neck trauma and headache characteristics among US Army soldiers evaluated for chronic headaches at a military neurology clinic following a combat tour in Iraq. Background.— Head or neck trauma and headaches are common in US soldiers deployed to Iraq. The temporal association between mild head trauma and headaches, as well as the clinical characteristics of headaches associated with mild head trauma, has not been systematically studied in US soldiers returning from Iraq. Methods.— A retrospective cohort study was conducted with 81 US Army soldiers from the same brigade who were evaluated at a single military neurology clinic for recurrent headaches after a 1‐year combat tour in Iraq. All subjects underwent a standardized interview and evaluation to determine the occurrence of head or neck trauma during deployment, mechanism and type of trauma, headache type, and headache characteristics. Results.— In total, 33 of 81 (41%) soldiers evaluated for headaches reported a history of head or neck trauma while deployed to Iraq. A total of 18 (22%) subjects had concussion without loss of consciousness and 15 (19%) had concussion with loss of consciousness. Ten subjects also had an accompanying traumatic neck injury. No subjects had moderate or severe traumatic brain injury. Exposure to blasts was the most common cause of trauma, accounting for 67% of head and neck injuries. Headaches began within one week after trauma in 12 of 33 (36%) soldiers with head or neck injury. Another 12 (36%) reported worsening of pre‐existing headaches after trauma. Headaches were classified as migraine type in 78% of soldiers with head or neck trauma. Headache types, frequency, severity, duration, and disability were similar for soldiers with and without a history of head or neck trauma. Conclusion.— A history of mild head trauma, usually caused by exposure to blasts, is found in almost half of returning US combat troops who receive specialized care for headaches. In many cases, head trauma was temporally associated with either the onset of headaches or the worsening of pre‐existing headaches, implicating trauma as a precipitating or exacerbating factor, respectively. Headaches in head trauma‐exposed soldiers are usually migraine type and are similar to nontraumatic headaches encountered at a military specialty clinic.     

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.     

Headache Disability Among Adolescents: A Student Population‐Based Study

(Headache 2010;50:210‐218) Objective.— To examine the extent and to identify the relevant predictors of headache disabilities in adolescents. Background.— Headaches are common in adolescents but their impact and related factors have not been extensively studied in adolescent communities. Method.— We recruited and surveyed 3963 students aged 13‐15 from 3 middle schools using self‐administered questionnaires. The questionnaires were used to make 3 assessments: (1) headaches were diagnosed using a validated headache questionnaire; (2) headache disabilities were valuated using the 6‐question Pediatric Migraine Disability Assessment; (3) depression was measured using the Adolescent Depression Inventory. Results.— The student response rate was 93%. In total, 484 students (12.2%) had migraines with or without auras, 444 (11.2%) had probable migraines, and 1092 (27.6%) had tension‐type headaches. The students with migraine had the highest Pediatric Migraine Disability Assessment scores (10.7 ± 20.0); whereas, the students with tension‐type headaches had the lowest scores (2.0 ± 4.4). Logistic regression analyses indicated that there were a number of independent predictors for moderate to severe headache‐related disability (Pediatric Migraine Disability Assessment score ≥31), including a migraine or probable migraine diagnosis, a higher depression score, severe headache intensity, and frequent headaches. Conclusions.— The Pediatric Migraine Disability Assessment provides a simple tool to measure the impact of headaches in adolescents. Adolescents with migraine headaches suffered the greatest level of disability. Higher depression scores were associated with more severe headache‐related disabilities in adolescents, independent of headache frequency and severity.     

Clinical Experience With Headaches in Preadolescent Children

We have reviewed the diagnoses of 654 children aged from 7 to 14 years who attended a neurologist for headache evaluation. Headaches beginning between the age of 7 and 14 represented a higher percentage (18.3%) than the proportion of preadolescent children in our health area (12.9%). Headaches were more common in girls; although cluster, posttraumatic, benign exertional headaches, and the only case of brainstem glioma were restricted to boys. Despite the female predominance, the proportion of males with migraine was significantly higher in the preadolescents than in the over 15 age group. Migraine accounted for the majority of diagnoses (609 - 93% of the total series), while tension-type headache (27 - 4%), and headache associated with sinus infection (7 - 1%) were the diagnoses which followed in frequency. There were only two headaches (0.3%) associated with intracranial masses.
Even though, in terms of frequency, headache is a very common reason for neurology consultation, the present results show that the majority of preadolescents consulting because of headache suffer from benign conditions.     

Chronic Headache and Comorbibities: A Two‐Phase,Population‐Based,Cross‐Sectional Study

Background.— Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.— To estimate the 1‐year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.— This was a cross‐sectional, population‐based, 2‐phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD‐2). Medication overuse headache was diagnosed, as per the ICHD‐2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM‐IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.— A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension‐type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.— The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;50:1306‐1312)     

Headache Triggers in the US Military

(Headache 2010;50:790‐794) Background.— Headaches can be triggered by a variety of factors. Military service members have a high prevalence of headache but the factors triggering headaches in military troops have not been identified. Objective.— The objective of this study is to determine headache triggers in soldiers and military beneficiaries seeking specialty care for headaches. Methods.— A total of 172 consecutive US Army soldiers and military dependents (civilians) evaluated at the headache clinics of 2 US Army Medical Centers completed a standardized questionnaire about their headache triggers. Results.— A total of 150 (87%) patients were active‐duty military members and 22 (13%) patients were civilians. In total, 77% of subjects had migraine; 89% of patients reported at least one headache trigger with a mean of 8.3 triggers per patient. A wide variety of headache triggers was seen with the most common categories being environmental factors (74%), stress (67%), consumption‐related factors (60%), and fatigue‐related factors (57%). The types of headache triggers identified in active‐duty service members were similar to those seen in civilians. Stress‐related triggers were significantly more common in soldiers. There were no significant differences in trigger types between soldiers with and without a history of head trauma. Conclusion.— Headaches in military service members are triggered mostly by the same factors as in civilians with stress being the most common trigger. Knowledge of headache triggers may be useful for developing strategies that reduce headache occurrence in the military.     

3‐Year follow‐up of secondary chronic headaches: The Akershus study of chronic headache

The objective was to investigate the 3‐year course of secondary chronic headaches (≥15 days per month for at least 3 months) in the general population. An age and gender stratified random sample of 30,000 persons aged 30–44 years from the general population received a mailed questionnaire. All with self‐reported chronic headache, 517 in total, were interviewed by neurological residents. The questionnaire response rate was 71%. The rate of participation in the initial and follow‐up interview was 74% (633/852) and 87% (83/95) respectively. The International Classification of Headache Disorders was used, and then in the next step the Cervicogenic Headache International Study Group and American Academy of Otolaryngology criteria were used in relation to cervicogenic headache (CEH) and headache attributed to chronic rhinosinusitis (HACRS). Of those followed‐up, 40 had headache attributed to head and/or neck trauma (chronic posttraumatic headache), 0 had CEH and 0 had HACRS according to the ICHD‐II criteria, while 18 had CEH according to the Cervicogenic Headache International Study Group's criteria, and 37 had HACRS according to the criteria of the American Academy of Otolaryngology. The headache index (frequency×intensity×duration) was significantly reduced from baseline to follow‐up in chronic posttraumatic headache and HACRS, but not in CEH. We conclude that secondary chronic headaches seem to have various course dependent of subtype. Recognizing the different types of secondary chronic headaches is of importance because it might have management implications.     

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)     

Refractory headache: classification and nomenclature

There are a number of reasons to attempt to define and classify refractory headache disorders. Particularly important are the potential benefits in the areas of research, treatment, and medical cost reimbursement. There are challenges in attempting to classify refractory forms of headaches, including the lack of biological or other objective markers and a lack of consensus among practitioners as to what qualifies as refractoriness, or even if a separate category for refractory migraine and other refractory headaches needs to be established. A definition of refractory migraine has been proposed by Schulman et al in this issue ("Defining Refractory Migraine [RM] and Refractory Chronic Migraine [RCM]: Proposed Criteria for the Refractory Headache Special Interests Section of the American Headache Society"), which should be tested for validity and usefulness. It seems reasonable to consider adding this defined syndrome to the International Classification of Headache Disorders, second edition (ICHD-II). In this article, options for adding refractory headache syndromes to the ICHD are discussed with pros and cons for each. Two "best" options for adding the disorder "refractory migraine" to the ICHD are presented along with an illustrative case example.     

Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study

(Headache 2011;51:932‐944) Background.— The effectiveness of medical therapies for chronic post‐traumatic headaches (PTHs) attributable to mild head trauma in military troops has not been established. Objective.— To determine the treatment outcomes of acute and prophylactic medical therapies prescribed for chronic PTHs after mild head trauma in US Army soldiers. Methods.— A retrospective cohort study was conducted with 100 soldiers undergoing treatment for chronic PTH at a single US Army neurology clinic. Headache frequency and Migraine Disability Assessment (MIDAS) scores were determined at the initial clinic visit and then again by phone 3 months after starting headache prophylactic medication. Response rates of headache abortive medications were also determined. Treatment outcomes were compared between subjects with blast‐related PTH and non‐blast PTH. Results.— Ninety‐nine of 100 subjects were male. Seventy‐seven of 100 subjects had blast PTH and 23/100 subjects had non‐blast PTH. Headache characteristics were similar for blast PTH and non‐blast PTH with 96% and 95%, respectively, resembling migraine. Headache frequency among all PTH subjects decreased from 17.1 days/month at baseline to 14.5 days/month at follow‐up (P = .009). Headache frequency decreased by 41% among non‐blast PTH compared to 9% among blast PTH. Fifty‐seven percent of non‐blast PTH subjects had a 50% or greater decline in headache frequency compared to 29% of blast PTH subjects (P = .023). A significant decline in headache frequency occurred in subjects treated with topiramate (n = 29, ?23%, P = .02) but not among those treated with a low‐dose tricyclic antidepressant (n = 48, ?12%, P = .23). Seventy percent of PTH subjects who used a triptan class medication experienced reliable headache relief within 2 hours compared to 42% of subjects using other headache abortive medications (P = .01). Triptan medications were effective for both blast PTH and non‐blast PTH (66% response rate vs 86% response rate, respectively; P = .20). Headache‐related disability, as measured by mean MIDAS scores, declined by 57% among all PTH subjects with no significant difference between blast PTH (?56%) and non‐blast PTH (?61%). Conclusions.— Triptan class medications are usually effective for aborting headaches in military troops with chronic PTH attributed to a concussion from a blast injury or non‐blast injury. Topiramate appears to be an effective headache prophylactic therapy in military troops with chronic PTH, whereas low doses of tricyclic antidepressants appear to have little efficacy. Chronic PTH triggered by a blast injury may be less responsive to commonly prescribed headache prophylactic medications compared to non‐blast PTH. These conclusions require validation by prospective, controlled clinical trials.     

The prevalence and characteristics of different types of headache in patients with Behçet's disease, a case-control study

Background.— Headache is one of the most common neurologic symptoms of Behçet's disease (BD) that may be due to migraine, tension‐type headache, uveitis, or direct consequence of neuro‐Behçet's disease (NBD) or other causes. Objective.— To study the prevalence and characteristics of different types of headache in patients with BD. Method.— Subjects were recruited as consecutive patients who referred to Behçet's Clinic at the Nemazee Hospital, Shiraz, Southern Iran, from March 2004 to March 2006. All patients fulfilled the International Study Group criteria for BD. Each patient was interviewed for history of BD and headache. Neurological examinations and, if necessary, ancillary investigations were performed for each patient. Control group was an age‐ and sex‐matched population. Headache entities fulfilled the International Headache Society criteria. Results.— In total, 35% (63/180) of patients had no headache. Migraine with and without aura was the cause of headache in 1.7% (3/180) and 25.6% (46/180) of patients, respectively. Tension‐type headache was found in 23.9% (43/180) of patients. In 8.3% (15/180) of patients, headache could be justified by NBD. Headache due to uveitis was observed in 3.3% (6/180) of patients and 4 patients (2.2%) had other causes of headache. Migraine was significantly more common in patients than the control group (OR: 2.9, P < .0001). Considering the effect of gender, migraine was also significantly more frequent in patients than in the control group both in females (OR: 3.1, P < .0001) and males (OR: 3.2, P = .006). Conclusion.— Migraine and tension‐type headaches are the most prevalent types of headaches in Behçet's patients. NBD must be meticulously investigated in patients with BD who presented with headache.     

Prevalence of Migraine in Patients With Celiac Disease and Inflammatory Bowel Disease

Objective.— To assess the prevalence of headache in clinic and support group patients with celiac disease and inflammatory bowel disease (IBD) compared with a sample of healthy controls. Background.— European studies have demonstrated increased prevalence of headache of patients with celiac disease compared with controls. Methods.— Subjects took a self‐administered survey containing clinical, demographic, and dietary data, as well as questions about headache type and frequency. The ID‐Migraine screening tool and the Headache Impact Test (HIT‐6) were also used. Results.— Five hundred and two subjects who met exclusion criteria were analyzed – 188 with celiac disease, 111 with IBD, 25 with gluten sensitivity (GS), and 178 controls (C). Chronic headaches were reported by 30% of celiac disease, 56% of GS, 23% of IBD, and 14% of control subjects (P < .0001). On multivariate logistic regression, celiac disease (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.78‐8.10), GS (OR 9.53, 95%CI 3.24‐28.09), and IBD (OR 2.66, 95%CI 1.08‐6.54) subjects all had significantly higher prevalence of migraine headaches compared with controls. Female sex (P = .01), depression, and anxiety (P = .0059) were independent predictors of migraine headaches, whereas age >65 was protective (P = .0345). Seventy‐two percent of celiac disease subjects graded their migraine as severe in impact, compared with 30% of IBD, 60% of GS, and 50% of C subjects (P = .0919). There was no correlation between years on gluten‐free diet and migraine severity. Conclusions.— Migraine was more prevalent in celiac disease and IBD subjects than in controls. Future studies should include screening migraine patients for celiac disease and assessing the effects of gluten‐free diet on migraines in celiac disease.     

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 burden of headaches as assessed by the health family program

Background.— Unified health systems often have Family Health Programs (FHPs) as a core component of their preventive and early curative strategies. In Brazil, the FHP is established to proactively identify diseases such as diabetes and hypertension. Objective.— To use the FHP in order to assess the prevalence of primary headaches, as per the Second Edition of the International Classification of Headache Disorders in a Brazilian city covered by the program, and to document the burden of migraine and tension‐type headache (TTH) in this population. Methods.— FHP agents were trained on how to apply questionnaires that screened for the occurrence of headaches in the past year. Screening method had been previously validated. Respondents that screened positively were interviewed by a headache specialist, and all their headache types were classified. Additionally, disability (Migraine Disability Assessment Scale and Headache Impact Test) and health‐related quality of life were assessed. Results.— The 1‐year prevalence of migraine was 18.2% [95% confidence interval = 13.7; 23.5]. TTH occurred in 22.9% [18.0%; 28.6%]. Other primary headaches occurred in 10.8% of the participants. Idiopathic stabbing headache was significantly more common in individuals with migraine relative to those without migraine (44.7% vs 10.3%, P < .001). Contrasting with TTH, migraineurs had a mean of 3.1 headache types vs 1.9 in TTH (P < .001). Secondary headaches occurred in 21.7% of the participants over a 1‐year period [16.9%; 27.3%]. Most cases were headaches attributed to infection (mostly respiratory). The impact of migraine was bimodal. Most sufferers had little impact, but a sizable minority was severely impaired. Conclusions.— The FHP can be effectively used to bring individuals with headache to the attention of providers. Future investigations should assess whether this increased attention translates into improved outcomes. [Correction added after online publication 21‐Feb‐2012: The original publication contained an incorrect abstract. The above content replaces the abstract found in the originally published article.] (Headache 2012;52:483‐490)     

Headache among patients with HIV disease: prevalence, characteristics, and associations

Background.— Headache is one of the most common medical complaints reported by individuals suffering from human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), but limited and conflicting data exist regarding their prevalence, prototypical characteristics, and relationship to HIV disease variables in the current era of highly active antiretroviral therapy (HAART). Objectives.— The aims of the present cross‐sectional study were to characterize headache symptoms among patients with HIV/AIDS and to assess relations between headache and HIV/AIDS disease variables. Methods.— Two hundred HIV/AIDS patients (49% female; mean age = 43.22 ± 12.30 years; 74% African American) from an internal medicine clinic and an AIDS outreach clinic were administered a structured headache diagnostic interview to assess headache characteristics and features consistent with International Classification of Headache Disorders (ICHD)‐II diagnostic semiologies. They also completed 2 measures of headache‐related disability. Prescribed medications, most recent cluster of differentiation (CD4) cell count, date of HIV diagnosis, possible causes of secondary headache, and other relevant medical history were obtained via review of patient medical records. Results.— One hundred seven patients (53.5%) reported headache symptoms, the large majority of which were consistent with characteristics of primary headache disorders after excluding 4 cases attributable to secondary causes. Among those who met criteria for a primary headache disorder, 88 (85.44%) met criteria for migraine, most of which fulfilled ICHD‐II appendix diagnostic criteria for chronic migraine. Fifteen patients (14.56%) met criteria for episodic or chronic tension‐type headache. Severity of HIV (as indicated by CD4 cell counts), but not duration of HIV or number of prescribed antiretroviral medications, was strongly associated with headache severity, frequency, and disability and also distinguished migraine from TTH. Conclusions.— Problematic headache is highly prevalent among patients with HIV/AIDS, most of which conform to the semiology of chronic migraine, although with some atypical features such as bilateral location and pressing/tightening quality. A low frequency of identifiable secondary causes is likely attributable to reduced frequency of opportunistic infections in the current era of HAART. Disease severity is strongly predictive of headache, highlighting the importance of physician attention to headache symptoms and of patient adherence to treatment. (Headache 2012;52:455‐466)     

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.     

Migraine and Its Relation with Lifestyle in Women

Migraine is a very common primary headache disorder with no underlying identifiable pathological cause. It has a profound effect on the well‐being and general functioning of its victims. Migraine is best understood as a chronic disorder with episodic manifestations, progressive in some individuals, having dramatic social and economic costs. Migraine causes stress in patients and their families, changes the roles and lifestyles and disturbs the social interactions between family members. Being more common in women, migraine is a significant women's health concern. The low rate of headaches with identifiable organic causes suggests that individual and environmental factors are determinants of migraine. Therefore, studying lifestyle and its relation with migraine is very important. This study examines the relation between migraine headaches and lifestyle in women refereed to university clinics in Iran. Methods: This is a case‐control study of 170 patients selected randomly using Poisson sampling. The study population included female patients suffering from headache referred to the neurology clinics and health centers in Iran (with neurologist‐diagnosed migraine according to the criteria of the International Society of Headache). The study population for the control group included women without migraine headache whose life conditions were similar to the migraine group and who were living in the same area. Data were collected by interview and a questionnaire which was tested for reliability and validity using content validity and retest methodologies. Results: Findings showed a significant relation between some dimensions of lifestyle, such as diet eating habits (P = 0.001), resting and sleeping habits (P = 0.012), and drug usage patterns (P = 0.001) with migraine headaches. But there were no significant relationships noted between smoking, exercise or stress levels with migraine headaches. Discussion: Lifestyle habits, including rest and sleep, diet and drug usage, are important factors in migraine attacks. It is important to emphasize changing habits, such as improper use of analgesics, to decrease side effects in migraine victims. The health centers should consider promoting healthy habits and behaviors as a priority in their services.     

Description and validation of an Italian ICHD-II-based questionnaire for use in epidemiological research

Background.— In the absence of biological markers, the diagnosis of primary headache in epidemiological studies rests on clinical findings, as reported through ad‐hoc interviews. Objectives.— The aim of this study was to validate a specially designed headache questionnaire to be administered by a physician for the diagnosis of primary headaches or of probable medication overuse headache in the general population according to the 2004 International Classification of Headache Disorders, 2nd edition (ICHD‐II). Methods.— The questionnaire comprises 76 questions based on the ICHD‐II diagnostic criteria for migraine (codes 1.1, 1.2.1, 1.2.2, 1.2.3, 1.5.1, and 1.6), tension‐type headache (codes 2.1, 2.2, 2.3, and 2.4), primary stabbing headache (code 4.1), and probable medication‐overuse headache (code 8.2.7), as well as on other clinical features (eg, age at onset, relation between headache and pregnancy, etc). The answers to each question could be of the following types: (1) numbers (ie, age at onset); (2) “Yes” or “No” (eg, as in reply to “Do you have nausea during headache?”); and (3) predefined answers (eg, quality of pain). We assessed the validity and reliability of the questionnaire and its sensitivity and specificity for migraine and tension‐type headache. Results.— The study population consisted of 50 patients (37 women and 13 men) aged 18‐76 years (mean, 40.7) seen for the first time on a consecutive basis at the University of Parma Headache Centre. The questionnaire was administered independently by 2 trained physicians (E1 and E2) prior to the visit performed by a headache specialist taken as the gold standard (GS). GS, E1, and E2 were blind to the diagnosis made by each others. If appropriate, more than 1 headache type were considered. When present, we defined the 2 different headache types in the same subject as Diagnosis 1 and Diagnosis 2. Questionnaire‐based diagnosis was compared with the diagnosis established by GS. For Diagnosis 1 (n = 50), we found an agreement rate of 98% (K‐value: 0.96; 95% confidence interval [CI]: 0.88‐1.00) between E1 and GS and between E2 and GS, and of 96% (K‐value: 0.91; 95% CI: 0.80‐1.00) between E1 and E2. For Diagnosis 2 (n = 24), we found an agreement rate of 83.3% (K‐value: 0.80; 95% CI: 0.63‐0.98) between E1 and GS, of 62.5% (K‐value: 0.62; 95% CI: 0.41‐0.82) between E2 and GS, and of 70.8% (K‐value: 0.66; 95% CI: 0.45‐0.87) between E1 and E2. Sensitivity and specificity were 100% and 93.3%, respectively, for migraine without aura (code 1.1) and 100% for frequent episodic tension‐type headache (code 2.2). Conclusion.— Our findings support the use of this questionnaire as a valid and reliable tool for diagnosis of headaches in epidemiological studies.     

Validation of the Portuguese Version of ID‐Migraine™

(Headache 2010;50:396‐402) Background.— Migraine is a highly prevalent disorder that imposes an important burden of disability to patients and has social and economic impact in developed countries. A good screening tool for migraine diagnosis is useful to improve disease identification and therapeutic approaches, hopefully reducing the burden of migraine. Although Portuguese is currently the sixth most spoken language in the world, no migraine screening instrument exists in Portuguese. Objective.— To validate the Portuguese version of ID‐Migraine?. Methods.— Consecutive adults of 2 headache outpatient clinics in Lisbon, Portugal fulfilled the Portuguese version of ID‐Migraine? before evaluation by a trained neurologist in clinic, blinded to the questionnaire's results. The gold standard was the neurologists' clinical diagnosis, according to the International Classification of Headache Disorders, 2nd edition. A subset of patients was randomly selected to revaluation, in order to determine test–retest reliability. The validity measures of the test were calculated. Results.— A total of 142 patients were included, 83.8% of which women, with an age average of 39.2 years. Clinical diagnosis of migraine was made in 63.4% of the patients. The Portuguese version of ID‐Migraine? presented a sensitivity of 0.94 (95% CI 0.87‐0.97), specificity of 0.60 (95% CI 0.46‐0.73) and a positive predictive value of 0.80 (95% CI 0.71‐0.87). Calculated Cronbachs' alpha was 0.78 and kappa coefficient 0.60. Conclusions.— The Portuguese version of ID‐Migraine? was of easy and rapid application and well accepted by patients. Its validity measures were identical to the 3 other versions of the same questionnaire – English (original), Italian, and Turkish. The Portuguese version of ID‐Migraine? is a valid screening tool for migraine, the first that can be used in Portuguese speaking communities although the low literacy rates in some of these countries may prevent its generalized application throughout the world.