Comprehensive Inpatient Treatment of Refractory Chronic Daily Headache

Objective.— (1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors. Background.— An evidence‐based assessment (2004) concluded that many refractory headache patients appear to benefit from inpatient treatment, underscoring the need for more research, including outcome predictors. Methods.— The authors completed a retrospective chart review of 283 consecutive admissions over 6 months. The inpatient program (mean length of stay = 13.0 days) included intravenous and oral medication protocols, drug withdrawal when indicated, cognitive‐behavior therapy, and other services when needed, including anesthesiological intervention. Patient‐reported pain levels and consensus of medical staff determined outcome status. Results.— The 267 completers (94%) included 212 women and 55 men (mean age = 40.3 years, range = 13‐74) from 43 states and Canada. The modal diagnosis was intractable, chronic daily headache (85%), predominantly migraine. Most (59%) had medication overuse headache (MOH), involving opioids (48%), triptans (16%), or butalbital‐containing analgesics (10%). Psychiatric diagnoses included stress‐related headache (82%), mood disorders (70%), anxiety disorders (49%), and personality disorders (PD, 26%). More patients with a PD (62%) had opioid‐related MOH than those with no PD (38%), P < .005. Of the completers, 78% had moderate to significant pain reduction, with comparable improvement in mood, function, and behavior. Clinical factors predicting moderate‐significant headache improvement were limited to MOH (84% vs 69%, P < .007) and presence of a PD (68% vs 81%, P < .03). Conclusions.— Most patients (78%) improved following aggressive, comprehensive inpatient treatment. Maintenance of improvement is likely to depend on multiple post‐discharge factors, including continuity of care, compliance, and home or work environment.     

Refractory Migraine – A Review

Refractory migraine has long been a challenge to all headache specialists. This subgroup of migraine patients experience disability and impaired quality of life, despite optimal treatment. This article reviews the proposed definitions and epidemiology of refractory migraine, as well as the pathophysiology that may contribute to the genesis of this disorder. Aspects of treatment, including pharmacological, complementary/adjunct, and invasive approaches, are reviewed. Comorbid factors, medication overuse, potential pitfalls to treatment, and areas for future investigation are highlighted.     

Medications associated with probable medication overuse headache reported in a tertiary care headache center over a 15-year period

OBJECTIVES: To evaluate the substances associated with medication overuse headache (MOH) in a headache center, over the course of the past 15 years. BACKGROUND: The acute treatment of migraine has substantially changed over the past 15 years, and therefore, the substances associated with MOH may have changed as well. METHODS: We randomly reviewed charts of subjects seen during the years of 2005, 2000, 1995, and 1990, to identify substances associated with MOH. Since the criteria proposed by the second edition of the International Classification of Headache Disorders require causal attribution, demonstrated by improvement after withdrawal (and this was not assessed in this study), herein we refer to probable MOH (PMOH). We contrasted the substances associated with PMOH over the studied years. RESULTS: Our sample consists of 1200 individuals, 300 per year of interest. The proportions of subjects with a diagnosis of PMOH remained stable over the years, varying from 64% of all cases seen in the center in 1990, to 59.3% in 2005. We found a significant decrease in the relative frequency of probable ergotamine overuse headache (from 18.6% to 0%, P < .0001), and in probable combination analgesic overuse headache (from 42.2% to 13.6%, P < .0001). The differences were not significant for opioid overuse headache. The relative frequency increased significantly for the triptans (from 0% to 21.6%, P < .0001), simple analgesics (from 8.8% to 31.8%, P < .05), and for combinations of acute medications (from 9.8% to 22.7%, P = .01). CONCLUSION: While overuse of acute medications remains an important problem in the tertiary care arena, the substances associated with the overuse have dramatically changed over the past 15 years. Educational initiatives should emphasize that the newer specific acute migraine medications (triptans) may also be associated with PMOH.     

Unique Case of “Post‐Lumbar Puncture Headache”

Lumbar puncture (LP) is associated with complications that include post‐LP orthostatic headache, local bleeding, and subdural hematoma. We report a unique case of a spontaneous frontal epidural hematoma following a therapeutic lumbar puncture in a patient with a history of idiopathic intracranial hypertension. This case highlights the importance of symptomatology in patients following LPs by revealing a rare intracranial presentation that would be devastating if not discovered promptly and appropriately managed.     

The “Repeater” Phenomenon in Migraine Patients: A Clinical and Psychometric study

(Headache 2010;50:348‐356) Background.— Headache is one of the most common symptoms in an emergency department (ED), while migraine is the most frequently observed headache in this setting. The aim of our study was to evaluate the influence of clinical and psychometric variables on the repeater phenomenon, ie, patients who make at least 3 visits to the ED at least 1 week apart during a 6‐month period. Methods.— According to the International Classification of Headache Disorders, 2nd edition (ICHD‐II) criteria, we consecutively recruited Italian‐speaking migraine subjects who came to the ED or outpatient service. All the patients underwent the Migraine Disability Assessment Scale for the evaluation of migraine disability. We also administered the Beck Depression Inventory, State and Trait Anxiety Inventory, and Toronto Alexithymia Scale‐20 for the evaluation of depressive, anxiety, and alexithymic symptoms, respectively. A personality profile was also obtained by means of the Tridimensional Personality Questionnaire (TPQ). Results.— We consecutively enrolled 465 migraine patients, diagnosed according to the ICHD‐II criteria. Seventy (15%) of these patients met the repeater definition. The repeater group had more severe disability and was affected to a greater degree by chronic migraine, regardless of symptomatic drug overuse, than the non‐repeater group. As regards the psychometric variables, repeaters were more alexithymic, anxious, and depressed than non‐repeaters. The personality profile, as measured by the TPQ, revealed that the repeater patients scored higher on the harm avoidance scale and their subscales than the non‐repeater patients. Conclusions.— According to the findings of our study, the repeater migraineur is typically triptan‐naïve, more alexithymic, and more depressed than the non‐repeater migraineur. A clinical and psychometric evaluation of repeater patients who go to the ED because of migraine attacks may help to understand this epidemiological and clinical phenomenon. From a clinical point of view, these psychometric findings may not only shed light on the epidemiology of migraine in the ED, but may also help to design a specific therapeutic protocol for this subgroup of migraine patients.     

Terminology Matters: Patient Understanding of “Opioids” and “Narcotics”

Background: The terms “opioid” and “narcotic” are often used interchangeably by healthcare providers. The purpose of this study was to compare understanding “narcotics” vs. “opioids.” Methods: A convenience sample of English‐speaking women (n = 188), aged 21–45 years, seeking care at a primary care clinic were asked (1) “What is an opioid/narcotic?” (2) “Give an example of an opioid/narcotic?” (3) “Why does someone take an opioid/narcotic?” and (4) “What happens when someone takes an opioid/narcotic for a long time?” Responses were recorded verbatim by a research assistant and then coded independently by two investigators. Results: More than half of respondents (55.9%) responded “don’t know” to all 4 opioid questions, while just 3.2% responded “don’t know” to all 4 narcotic questions (P < 0.01). Most women were unfamiliar with the term opioid (76.3%) and did not know why someone would take an opioid (68.8%). About two‐thirds of respondents were able to give an example of a narcotic (64.2%) and knew the consequences of long‐term narcotic use (63.2%). Conclusions: While more women were more familiar with narcotic, many identified negative connotations with this term. Future research should explore how to improve patient understanding and attitudes regarding both the terms opioids and narcotics.