Pediatric Migraine: Abortive Management in the Emergency Department

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.     

Headache in an Italian pediatric emergency department

The objective of this study was to assess epidemiology, diagnostic work-up, treatment and follow-up of children presenting to emergency department (ED) with headache. Records of visits for non-traumatic headache to the ED of a pediatric hospital over a period of 12 months were retrospectively reviewed. Headache center charts were analyzed one year after. Five-hundred and fifty patients (1% of all ED visits) were included. Spectrum of diagnoses was: primary headache (56.7%), with 9.6% of migraine; secondary headache (42%); unclassified headache (1.3%). Viral illnesses accounted for 90.5% of secondary headaches. A serious disorder was found in 4% of patients. Forty-four patients (8%) underwent neuroimaging studies, with 25% of abnormal findings. Only 223 patients (40.5%) received pharmacological treatment. On discharge, 212 patients (38.5%) were referred to headache center and 114 (20.7% of all patients) attended it. ED diagnosis was confirmed in 74.6% of cases. Most of ED repeated visits (82.6%) occurred in patients not referred to headache center at discharge from first ED visit. The most frequent diagnosis was primary headache; viral illnesses represented the majority of secondary headaches. Underlying serious disorders were associated with neurological signs, limiting the need of diagnostic investigations. Well structured prospective studies are needed to evaluate appropriate diagnostic tools, as well as correct therapeutic approach of pediatric headache in emergency. Collaboration with headache center might limit repeated visits and provide a correct diagnostic definition.     

Biofeedback Therapy for Pediatric Headache: Factors Associated With Response

Objectives.— The goal of this study was to measure the effect of biofeedback therapy on pediatric headache and to identify factors associated with response to biofeedback therapy. Background.— In the United States, 17% of children have frequent or severe headaches. Biofeedback therapy (BFT) appears to be an effective treatment for headaches in adults and is often recommended for children with headaches, but there are few data in the pediatric population. It is also not clear which patients are most likely to benefit from biofeedback therapy. Methods.— We examined the records of patients, aged 8 to 18 years old, who were referred to a pediatric BFT clinic for management of headache between 2004 and 2008. We extracted data regarding patient and headache characteristics, medication use, family history, and measures of depression, anxiety, and somatization. Chronic headache was defined as ≥4 headache days/week. Positive response to biofeedback was defined as a 50% reduction in number of headache days/week or hours/week, or ≥3‐point decrease in severity (0‐10 scale) between first and last visits. We analyzed the responder rate for those with episodic and chronic headaches and performed multivariable analysis to determine what factors were associated with headache response to biofeedback therapy. Results.— We analyzed records from 132 children who attended ≥2 biofeedback sessions. Median headache frequency dropped from 3.5 to 2 headache days/week between the first and last visits. The response rate was 58% overall; 48% for chronic headaches and 73% episodic headaches. In multivariate analysis, ability to raise hand temperature by >3°F at the last visit and use of selective serotonin reuptake inhibitors (SSRIs) were associated with a positive response, and preventive medication use was associated with nonresponse. Anxiety, depression, and somatization were not significantly associated with response to biofeedback therapy. Conclusions.— Biofeedback therapy appears to be an effective treatment for children and adolescents with both episodic and chronic headaches. Further study is warranted to compare biofeedback with other treatments for chronic pediatric headache. Use of SSRIs appears to be associated with a positive response to biofeedback therapy, but the reasons for this relationship are unclear and merit further study.     

Use of the Emergency Department for Severe Headache. A Population-Based Study

Background.— Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache. Methods.— As part of the American Migraine Prevalence and Prevention study, a validated self‐administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, “frequent” ED use was defined as a particpant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology. Results.— Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension‐type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache. Conclusions.— Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.     

The Momentary Relationship Between Stress and Headaches in Adolescent Girls

Objective.— The objective of this study was to compare the relationship between repeated momentary reports of stress and headaches in female adolescents with varying degrees of headache frequency. Background.— Headaches are the most common form of pain reported by adolescents affecting more than a third of all adolescents. High levels of stress during adolescence may predispose an adolescent to experience headaches in adulthood. Randomized, momentary data collection of stress and headaches provides the most accurate data regarding the adolescent experience of these variables. Methods.— The research methodology, ecological momentary assessment, is a valid approach to better understand the relationship between stress and headaches in adolescence. Data were obtained by each participant's use of an electronic diary (ED), which captured repeated momentary reports of perceived stress, head pain, and stress‐related symptoms in female adolescents with varying degrees of recurrent headache. Seven times per day for the 21‐day study period, teen girls responded to ED questions about their current stress levels, head pain, and stress‐related symptoms. Based on participants' momentary reports of headaches, Low Headache, Moderate Headache, and Chronic Headache groups were created. General estimating equation models were used to analyze the relationship between momentary variables as well as the lag effect between stress and head pain. Results.— Thirty‐one participants, aged 14‐18 years, completed 2841 randomized ED reports and reported 674 occurrences of headache. The Chronic Headache and Moderate Headache groups reported significantly increased levels of stress, head pain, and headaches. The relationship between momentary stress and head pain was significantly strong both within and across participants. The strength of this relationship increased with increased headache activity. A significant lag effect was found between stress and headaches; however, the effect of depression as a moderator of the stress and headache relationship remains unclear. Conclusion.— Perceived stress and head pain was highly correlated in these female adolescents. Given the large population of teens affected by headaches, a plausible next step would be to validate these results in other samples and to determine methods with which to identify teens who may be at risk for a pattern of increasing stress and headaches.     

Behavioral dependence in patients with medication overuse headache: a cross-sectional study in consulting patients using the DSM-IV criteria

Objective.— The aim of this study was to assess behavioral dependence on migraine abortive drugs in medication‐overuse headache (MOH) patients and identify the predisposing factors. Background.— It is common occurrence that MOH patients relapse after medication withdrawal. Behavioral determinants of medication overuse should therefore be identified in MOH patients. Methods.— This was a cross‐sectional, multicenter study that included 247 MOH patients (according to International Classification of Headache Disorders, 2nd edition criteria) consulting in French headache specialty centers. Face‐to‐face interviews were conducted by senior neurologists using a structured questionnaire including the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV) criteria for the evaluation of dependence, Hospital Anxiety and Depression Scale for the evaluation of anxiety and depression, and 6‐item short‐form Headache Impact Test scale for the determination of functional impact. Results.— Most MOH patients had pre‐existing primary migraine (87.4%) and current migraine‐type headaches (83.0%). Treatments overused included triptans (45.8%), opioid analgesics alone or in combination (43.3% of patients), and analgesics (27.9%). Nonmigraine abortive substances (tobacco, caffeine, sedatives/anxiolytics) were overused by 13.8% of patients. Two‐thirds of MOH patients (66.8%) were considered dependent on acute treatments of headaches according to the DSM‐IV criteria. Most dependent MOH patients had migraine as pre‐existing primary headache (85.7%) and current migraine‐type headaches (87.9%), and most of them overused opioid analgesics. More dependent than nondependent MOH patients were dependent on psychoactive substances (17.6% vs 6.1%). Multivariate logistic analysis indicated that risk factors of dependence on acute treatments of headaches pertained both to the underlying disease (history of migraine, unilateral headaches) and to drug addiction (opioid overuse, previous withdrawal). Affective symptoms did not appear among the predictive factors of dependence. Conclusion.— In some cases, MOH thus appears to belong to the spectrum of addictive behaviors. In clinical practice, behavioral management of MOH should be undertaken besides pharmacological management.     

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)     

Migraine Education Improves Quality of Life in a Primary Care Setting

(Headache 2010;50:600‐612) Objective.— The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine‐related disability and quality of life, worry about headaches, self‐efficacy for managing migraines, emergency room (ER) visits for headache, and satisfaction with headache care. Background.— Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been performed to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (for example, self‐efficacy for managing headaches, worry about headaches). Methods.— In this open‐label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills‐based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache‐related disability (as measured by the Headache Impact Test‐6 (HIT‐6), migraine‐specific quality of life (MSQ), worry about headaches, self‐efficacy for managing headaches, ER visits for headaches, and satisfaction with care at 4 time points over 12 months (baseline, 3 months, 6 months, 12 months). Results.— Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT‐6 and MSQ (all P < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in “worry about headaches,”“self‐efficacy for managing headaches,” and “satisfaction with headache care.” Conclusion.— The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly evaluate the effects of education and skill development on headache characteristics and the emotional and cognitive factors that influence headache.     

Prevalence and treatment of headaches in veterans with mild traumatic brain injury

(Headache 2011;51:1112‐1121) Objectives.— To report the prevalence and characteristics of headaches in veterans with mild traumatic brain injury (TBI) and to describe most common treatment strategies after neurological evaluation. Methods.— We conducted a retrospective cohort study. The setting was a United States Veterans Healthcare Administration Polytrauma Network Site. The study participants consisted of 246 veterans with confirmed diagnosis of mild TBI. The main outcome measures were: Self‐reported head pain occurring 30 days prior to initial mild TBI screening; headache severity measured by the Neurobehavioral Symptom Inventory; headache characteristics; and treatment prescribed by neurologists. Results.— The majority (74%) of veterans with a confirmed diagnosis of mild TBI (N = 246), due largely to blast exposure, reported headaches in the 30 days preceding the initial mild TBI evaluation. Thirty‐three percent of these veterans (N = 81) were referred to neurology for persistent headaches. Of the 56 veterans attending the neurology evaluation, 45% were diagnosed with migraine headaches and 20% with chronic daily headaches. The most commonly used abortive agents were triptans (68%) and the most common preventive medications were anticonvulsants (55%) and tricyclics (40%). Conclusion.— There was an increased prevalence of headaches in veterans with mild TBI. Most of the TBI veterans in our study group were exposed to blast injury and findings indicate that the nature of head trauma may be contributing to headaches. Findings highlight the need for developing effective headache prevention and treatment strategies for all persons with mild TBI and in particular for veterans with blast‐related mild TBI.     

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow‐up ranged from 18 to 42 months. Results.— Eighty‐two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension‐type headache, 6% chronic post‐traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty‐two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP. Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.     

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.     

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.     

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.     

Headaches in a pediatric emergency department: etiology, imaging, and treatment

OBJECTIVE: To assess the spectrum of diagnoses, the use of CT scans of the brain, and pharmacological treatments in patients presenting to a pediatric emergency department with headaches as the chief complaint. METHODS: A 1-year retrospective chart review of all children who presented to the emergency department with a headache as the chief complaint. RESULTS: One hundred thirty patients (0.7% of all pediatric emergency department visits, mean age = 9.3 years) were included in the study. Primary headaches included 11 migraine (8.5%) and 2 tension headaches (1.5%). Most of the secondary nonneurological headaches were associated with viral and respiratory illnesses (n=37, 28.5%), while the majority of the secondary neurological headaches included 26 posttraumatic (20%), 15 possible ventriculoperitoneal shunt malfunctions (11.5%), and 3 cases of aseptic meningitis (2.3%). The neurological etiology in 9 of these children (6.9%) was found to be serious (subdural hematoma, epidural hematoma, proven ventriculoperitoneal shunt malfunction, brain abscess, pseudotumor cerebri, and aseptic meningitis). Fifteen patients could not be etiologically classified, either because no specific etiology was found or their discharge diagnoses could not clearly explain the headache. Approximately 10% (5/53) of the CT scans of the head that were performed showed new abnormal findings including hydrocephalus secondary to ventriculoperitoneal shunt malfunction (2), subdural hematoma (1), epidural hematoma (1), and skull fracture (1). Forty-two patients (32%) were treated pharmacologically. Thirty-nine of the 42 treated patients (93%) were given over-the-counter analgesics, and 9 (21%) were given prescribed analgesics. CONCLUSIONS: The majority of the headaches in the pediatric emergency department were secondary to concurrent illness and minor head trauma, and required no pharmacological treatment or only treatment with minor analgesics. In a small minority of patients, headaches were secondary to serious neurological conditions, which required immediate medical attention. Computed tomography scans showed new abnormalities in a minority of patients and should be reserved for those with neurological diagnoses such as head trauma and ventriculoperitoneal shunt, as well as for those patients with recent onset of headaches with no clear etiological explanation, and for those with high-risk medical conditions, such as hypocoagulabilities. Future prospective studies are needed to assess the efficacy of the various pharmacological treatments in this population.     

Headaches After Concussion in US Soldiers Returning From Iraq or Afghanistan

(Headache 2010;50:1262‐1272) Objectives.— To determine the prevalence, characteristics, impact, and treatment patterns of headaches after concussion in US Army soldiers returning from a deployment to Iraq or Afghanistan. Methods.— A cross‐sectional study was conducted with a cohort of soldiers undergoing postdeployment evaluation during a 5‐month period at the Madigan Traumatic Brain Injury Program at Ft. Lewis, WA. All soldiers screening positive for a deployment‐related concussion were given a 13‐item headache questionnaire. Results.— A total of 1033 (19.6%) of 5270 returning soldiers met criteria for a deployment‐related concussion. Among those with a concussion, 957 (97.8%) reported having headaches during the final 3 months of deployment. Posttraumatic headaches, defined as headaches beginning within 1 week after a concussion, were present in 361 (37%) soldiers. In total, 58% of posttraumatic headaches were classified as migraine. Posttraumatic headaches had a higher attack frequency than nontraumatic headaches, averaging 10 days per month. Chronic daily headache was present in 27% of soldiers with posttraumatic headache compared with 14% of soldiers with nontraumatic headache. Posttraumatic headaches interfered with duty performance in 37% of cases and caused more sick call visits compared with nontraumatic headache. In total, 78% of soldiers with posttraumatic headache used abortive medications, predominantly over‐the‐counter analgesics, and most perceived medication as effective. Conclusions.— More than 1 in 3 returning military troops who have sustained a deployment‐related concussion have headaches that meet criteria for posttraumatic headache. Migraine is the predominant headache phenotype precipitated by a concussion during military deployment. Compared with headaches not directly attributable to head trauma, posttraumatic headaches are associated with a higher frequency of headache attacks and an increased prevalence of chronic daily headache.     

The prevalence and burden of primary headaches in China: a population-based door-to-door survey

Objectives.— In the absence of reliable data on the prevalence and burden of primary headache disorders in the mainland of China, a population‐based survey was initiated by Lifting The Burden: the Global Campaign against Headache. Methods.— Throughout all regions of China, 5041 non‐related adult respondents aged 18‐65 years were randomly sampled from the general population according to the expanded programme on immunization method established by World Health Organization. They were visited by door‐to‐door calling and surveyed using the structured questionnaire developed by Lifting The Burden, translated into Chinese and adapted to Chinese culture after a pilot study. Results.— The responder rate was 94.1%. The estimated 1‐year prevalence of primary headache disorders was 23.8% (95% confidence interval 22.6‐25.0%), of migraine 9.3% (95% confidence interval 8.5‐10.1%), of tension‐type headache (TTH) 10.8% (9.9‐11.6%), and of chronic daily headache (CDH) 1.0% (0.7‐1.2%). Of respondents with migraine, TTH, and CDH, moderate or severe impact and therefore high need for effective medical care were reported by 38.0%, 23.1%, and 47.9%, respectively. The World Health Organization quality of life‐8 questionnaire showed that all 3 types of headache reduced life quality. The total estimated annual cost of primary headache disorders, including migraine, TTH, and CDH was CNY 672.7 billion, accounting for 2.24% of gross domestic product (GDP) (direct cost: CNY 108.8 billion, 0.36% of GDP; indirect cost: CNY 563.9 billion, 1.88% of GDP). Conclusion.— The prevalence of primary headaches is high in China and not dissimilar from the world average. These headaches cause disability, impair work, study and daily activities, decrease life quality, and bring about a heavy and hitherto unrecognized socioeconomic burden.     

Improvement of chronic headache after treatment of unruptured intracranial aneurysms

OBJECTIVE: The objective of this study is to determine the incidence, character, and outcome of headache in patients with unruptured intracranial aneurysms who had been treated to avoid the risk of rupture. BACKGROUND: There are a variety of clinical manifestations associated with unruptured intracranial aneurysms. Among them, chronic headache is the most common presenting and/or accompanying symptom. METHODS: Among the 137 patients with unruptured aneurysms who had been treated, we collected 81 patients excluding 30 on the basis of inclusion criteria. Twenty-six patients were lost to follow-up. We collected data by medical record review and a telephone survey. Included in the information collected was the analysis of presenting symptom, location and size of each aneurysm, location, quality, intensity and duration of headaches, associated symptoms, triggering and alleviating factors, and precipitating events. RESULTS: Forty-nine patients (60.5%) of 81 had chronic headaches before the diagnosis of unruptured intracranial aneurysm. Forty-four patients (89.8%) answered that their headaches were improved slightly (12 patients) or markedly (32 patients) (P <.05). The clinical pattern of the headache worsened in only 1 patient and did not change in 4 patients. When the surgical group (40 patients) and the coil embolization group (41 patients) were compared, there was no significant difference observed in outcome (P >.05). CONCLUSION: Either by employing the technique of clipping or by coil embolization, treatment of unruptured intracranial aneurysms resulted in relief of headaches in majority of patients who had headaches pre-operatively.     

Nontraumatic Headaches in the Emergency Department: Evaluation of a Clinical Pathway

Objective.— To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED). Background.— Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence‐based operative protocol are lacking. Methods.— A before–after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6‐month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED. Results.— A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: ?11.3%, 95% confidence intervals [CI]: ?18.7% to ?3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: ?5.7%, 95% CI: ?10.6% to ?0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: ?3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 ± 102 minutes vs 180.5 ± 105 minutes, difference: ?9.8 minutes, 95% CI: ?20.3 to 5.7; P = .09). A 6‐month follow‐up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: ?0.33%, 95% CI: ?2.1% to 0.9%; P = .5). Conclusions.— Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.     

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.