Patient satisfaction with a neurological specialist consultation for headache

Objective - To evaluate patient satisfaction with a specialist consultation for headache and thus identify subgroups of headache patients more satisfied than others. Design - A survey of consecutive patients referred to a neurologist for headache. Setting - Neurological outpatient clinics in North Norway. Patients - We included 889 consecutive patients referred to a specialist centre for headache during a period of 2 years. Using a questionnaire, we recorded patients' satisfaction with the potential treatment initiated by the specialist. Results - Sixty-three percent of migraine patients (95% CI, 0.58 to 0.68) were satisfied with the consultation, compared to 44% of patients with non-migrainous headache (95% CI, 0.40 to 0.70), (p =0.01). Altogether 481 patients had some kind of measure recommended by the neurologist, and 317 of these (66%) were satisfied (95% CI, 0.62 to 0.70). Patients with tension-type headache and those who were not prescribed specific treatment modalities were less satisfied. Conclusion - The study confirms that patients with headache are satisfied with a neurological specialist consideration, especially in the case of migraine.     

Patient satisfaction with a neurological specialist consultation for headache

OBJECTIVE: To evaluate patient satisfaction with a specialist consultation for headache and thus identify subgroups of headache patients more satisfied than others. DESIGN: A survey of consecutive patients referred to a neurologist for headache. SETTING: Neurological outpatient clinics in North Norway. PATIENTS: We included 889 consecutive patients referred to a specialist centre for headache during a period of 2 years. Using a questionnaire, we recorded patients' satisfaction with the potential treatment initiated by the specialist. RESULTS: Sixty-three percent of migraine patients (95% CI, 0.58 to 0.68) were satisfied with the consultation, compared to 44% of patients with non-migrainous headache (95% CI, 0.40 to 0.70), (p = 0.01). Altogether 481 patients had some kind of measure recommended by the neurologist, and 317 of these (66%) were satisfied (95% CI, 0.62 to 0.70). Patients with tension-type headache and those who were not prescribed specific treatment modalities were less satisfied. CONCLUSION: The study confirms that patients with headache are satisfied with a neurological specialist consideration, especially in the case of migraine.     

The burden of headache disorders in India: methodology and questionnaire validation for a community-based survey in Karnataka State

Primary headache disorders are a major public-health problem globally and, possibly more so, in low- and middle-income countries. No methodologically sound studies of prevalence and burden of headache in the adult Indian population have been published previously. The present study was a door-to-door cold-calling survey in urban and rural areas in and around Bangalore, Karnataka State. From 2,714 households contacted, 2,514 biologically unrelated individuals were eligible for the survey and 2,329 (92.9 %) participated (1,103 [48 %] rural; 1,226 [52 %] urban; 1,141 [49 %] male; 1,188 [51 %] female; mean age 38.0 years). The focus was on primary headache (migraine and tension-type headache [TTH]) and medication-overuse headache. A structured questionnaire administered by trained lay interviewers was the instrument both for diagnosis (algorithmically determined from responses) and burden estimation. The screening question enquired into headache in the last year. The validation study compared questionnaire-based diagnoses with those obtained soon after through personal interview by a neurologist in a random sub-sample of participants (n = 381; 16 %). It showed high values (>80 %) for sensitivity, specificity and predictive values for any headache, and for specificity and negative predictive value for migraine and TTH. Kappa values for diagnostic agreement were good for any headache (0.69 [95 % CI 0.61–0.76]), moderate (0.46 [0.35–0.56]) for migraine and fair (0.39 [0.29–0.49]) for TTH.The survey methodology, including identification of and access to participants, proved feasible. The questionnaire proved effective in the survey population. The study will give reliable estimates of the prevalence and burden of headache, and of migraine and TTH specifically, in urban and rural Karnataka.     

Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: Results of the German Headache Consortium study

The objective of this study was to evaluate the association between low and frequent low back pain and chronic migraine (CM) and chronic tension-type headache (CTTH) in a large, German population-based sample. Headaches were diagnosed according to International Classification of Headache Disorders-2 criteria and categorized according to frequency (episodic 1–14 days/month or chronic ?15 days/month) and headache type (migraine or TTH). We defined frequent low back pain as self-reported low back pain on ?15 days/month. We calculated odds ratios and 95% confidence intervals (CI) using logistic regression analyses, adjusting for sociodemographic covariates. There were 5605 respondents who reported headache in the previous year, of whom 255 (4.5%) had Chronic Headache. Migraine was diagnosed in 2933 respondents, of whom 182 (6.2%) had CM. TTH was diagnosed in 1253 respondents, of whom 50 (4.0%) had CTTH. Among 9944 respondents, 6030 reported low back pain, of whom 1267 (21.0%) reported frequent low back pain. In adjusted models, the odds of having frequent low back pain were between 2.1 (95% CI 1.7-2.6) and 2.7 (95% CI 2.3-3.2) times higher in all episodic headache subtypes when compared to No Headache. The odds of having frequent low back pain were between 13.7 (95% CI 7.4-25.3) and 18.3 (95% CI 11.9-28.0) times higher in all chronic headache subtypes when compared to No Headache. Low and frequent low back pain was associated with CM and CTTH. Multiple explanations may contribute to the association of headache and back pain, including the notion that the neurobiology of chronic headache, independent of primary headache type, not only involves the trigeminal pain pathway, but is also a part of abnormal general pain processing.     

Kaplan Award 1998. Epidemiology of chronic daily headache in the general population

Background and Objectives.—Although chronic daily headache, mainly transformed migraine, is an important reason for consultation in headache clinics, its actual prevalence is unknown. This study analyzes the prevalence of the different types of chronic daily headache in an unselected population.
Methods.—A questionnaire exploring headache frequency was distributed to 2252 unselected subjects. Those having headache 10 or more days per month were given a headache diary and were seen by a neurologist who classified their headaches. The varieties of chronic daily headache were classified according to the second revision of IHS criteria proposed by Silberstein et al published in Neurology 1996;47:871.
Results.—The questionnaire was returned by 1883 subjects (83.5%). One hundred thirty-five admitted to headache 10 or more days per month. Chronic daily headache criteria were fulfilled by 89 individuals (4.7%). Eighty were women. Forty-two (47.2% of subjects with chronic daily headache and 2.2% of all subjects) had chronic tension-type headache. Analgesic overuse was found in 8 (17%). Transformed migraine was diagnosed in 45 (50.6% of subjects with chronic daily headache and 2.4% of all subjects). Fourteen (31.1%) individuals with this form of chronic daily headache overused ergots or analgesics. The remaining 2 cases in this series met the criteria of new daily persistent headache. No one was diagnosed as having hemicrania continua.
Conclusions.—Almost 5% of the general population (9% of women) suffers from chronic daily headache, the proportion of chronic tension-type headache and transformed migraine being quite similar. Less than one third overuse analgesics. The prevalence of chronic daily headache subtypes shown here differs from data obtained from headache clinics, emphasizing that caution is needed in extrapolating data from specialized units to the general population.     

Polymorphism in apolipoprotein E among migraineurs and tension-type headache subjects

Nitric oxide plays an important role in the pathogenesis of migraine as well as tension-type headache. Studies suggest that the expression of molecules involved in the pathogenesis of headache, i.e., nitric oxide and interleukin, is influenced by apolipoprotein E (APOE) and is gene specific. Hence, we hypothesized that APOE polymorphism may be associated with migraine as well as tension-type headache.The study sample comprised of three groups: migraineurs, tension-type headache subjects as well as a healthy control group. A total of 50 subjects in each group were included after screening for the inclusion and exclusion criteria. None of the subjects was a blood relative of any other subject included in the present study. Their venous blood was drawn and stored at −20°C. Genomic DNA extraction was performed with a commercial kit and simple sequence-specific primer PCR was performed to assess the APOE polymorphism. Data were analyzed with the help of SPSS V11.0 for Windows. χ² test and logistic regression analysis were run. The results of the study showed that APOE ε2 gene increases the risk of migraine as compared to the control group and the tension-type headache group (OR = 4.85; 95% CI = 1.92–12.72; P < 0.001 and OR = 2.31; 95% CI = 1.08–4.94; P = 0.01, respectively). Interestingly, APOE ε4 gene was protective against migraine as well as tension-type headache. This study shows that APOE ε2 gene increases the risk of migraine, while APOE ε4 gene is protective against migraine and tension-type headache. Further research is required to confirm the findings of the present study in a larger sample and to elucidate the role of APOE polymorphism in headache.     

Relationship between insomnia and headache in community-based middle-aged Hong Kong Chinese women

Limited studies have investigated the prevalence of insomnia symptoms among individuals with different headache diagnoses and the association between insomnia and headache in subjects with comorbid anxiety and depression. A total of 310 community-dwelling Hong Kong Chinese women aged 40–60 years completed a self-administered questionnaire on headache, sleep difficulties, mood disturbances, and functional impairment. About 31% of the sample complained of recurrent headache unrelated to influenza and the common cold in the past 12 months. The percentages of women diagnosed to have migraine, tension-type headache (TTH), and headache unspecified were 8.4, 15.5 and 7.1%, respectively. The most frequent insomnia complaint was “problem waking up too early” (29.4%), followed by “difficulty staying asleep” (28.0%) and “difficulty falling asleep” (24.4%). Women with headaches were significantly more likely to report insomnia symptoms than those without headaches. There were no significant differences among women with migraine, TTH, and headache unspecified in the prevalence of insomnia symptoms. Logistic regression analysis showed that women with insomnia disorder as defined by an insomnia severity index total score ≥8 had 2.2-fold increased risk of reporting recurrent headache, 3.2-fold increased risk of migraine, and 2.3-fold increased risk of TTH, after adjusting for anxiety and depression. Individual insomnia symptoms were not independent predictors. The association between insomnia and headache was stronger in subjects with more frequent headaches. Our findings suggest that insomnia and the associated distress, but not insomnia symptoms alone, is an independent risk factor for recurrent headache in middle-aged women with mixed anxiety, depression and sleep disturbances.     

Prevalence of primary headaches in Germany: results of the German Headache Consortium Study

We investigated the prevalence of migraine (MIG), tension-type headache (TTH), and chronic headache in a population-based sample in Germany. A total of 18,000 subjects aged between 18 and 65 years were screened from 2003 until 2005 using a validated questionnaire. Overall 9,944 participants (55.2%) responded (mean age 43 ± 13.1 years, 52.7% women). Headache frequency <15 days/month was reported by 5,350 (55.5%) subjects of whom 1,601 (16.6%, [95% confidence interval (95% CI): 15.9–17.4]) reported episodic MIG, 1,202 (12.5%, 95% CI 11.8–13.1) episodic TTH, and 1,150 (11.9%, [11.3–12.6]) episodic MIG + episodic TTH, 1,396 (14.5%, [13.8–15.2]) unclassifiable headache. In women, episodic MIG peaked between 36 and 40 years, episodic MIG + TTH between 18 and 35 years and episodic TTH between 56 and 66 years. In men, episodic MIG was predominant between 36 and 45 years, episodic MIG + TTH between 26 and 35 years and episodic TTH showed comparable frequency between 36 and 66 years. Headache ≥15 days/month was reported by 2.6% (n = 255, [95% CI 2.3–3]). Chronic MIG was reported by 1.1% (n = 108, [0.91–1.33]), chronic TTH (n = 50, [95% CI 0.4–0.7]), chronic MIG + TTH 0.8% (n = 74, 95% CI 0.6–0.9) and unclassifiable headache 0.2% (n = 23, [95% CI 0.1–0.3]). Chronic headache was more frequent in women compared to men with the highest prevalence between 46 and 65 years. It is of note that the number of subjects with chronic headache is small in all age groups. The results of our large, population-based study provide reliable, age- and sex-specific estimates of the prevalence of primary headache disorders in Germany. The prevalence with respect to episodic and chronic primary headache disorders in Germany is comparable to other European countries and the USA.     

Prevalences of migraine and tension-type headache in adolescent girls of Shiraz (southern Iran)

OBJECTIVE: To determine the prevalences of migraine and tension-type headache in teenaged girls attending schools in Shiraz (southern Iran). BACKGROUND: Studies of headache prevalence are numerous, and findings have varied according to the specific population and region involved. No data are available regarding headache prevalence among Iranian teenagers. METHODS: A random sample of 1868 teenaged girls (aged 11 to 18 years) was evaluated, and 507 subjects reported headache. The headache disorders were classified on the basis of a clinical interview, general physical and neurologic examinations, and the diagnostic criteria of the International Headache Society. Logistic regression was used for data analysis. RESULTS: Overall prevalence rate for migraine was 6.1% (95% CI, 5.0 to 7.2) and for tension-type headache, 12.1% (95% CI, 10.6 to 13.6). Migraine and tension-type headache were significantly associated. CONCLUSIONS: It is concluded that exposition of subjects to sunlight, type of food, and a family history of headache had most significant effects on occurrence of migraine and tension-type headaches.     

The burden of headache in China: validation of diagnostic questionnaire for a population-based survey

The objective of this study was to test the validity, in the Chinese population, of the Lifting The Burden diagnostic questionnaire for the purpose of a population-based survey of the burden of headache in China. From all regions of China, a population-based sample of 417 respondents had completed the structured questionnaire in a door-to-door survey conducted by neurologists from local hospitals calling unannounced. They were contacted for re-interview by telephone by headache specialists who were unaware of the questionnaire diagnoses. A screening question ascertained whether headache had occurred in the last year. If they had, the specialists applied their expertise and ICHD-II diagnostic criteria to make independent diagnoses which, as the gold standard, were later compared with the questionnaire diagnoses. There were 18 refusals; 399 interviews were conducted in 202 women and 197 men aged 18-65 years (mean age 44.4±12.6 years). In comparison to the specialists' diagnoses, the sensitivity, specificity, positive predictive value, negative predictive value and Cohen's kappa (95% CI) of the questionnaire for the diagnosis of migraine were 0.83, 0.99, 0.83, 0.99 and 0.82 (0.71-0.93), respectively; for the diagnosis of tension-type headache (TTH), they were 0.51, 0.99, 0.86, 0.92 and 0.59 (0.46-0.72), respectively. In conclusion, the questionnaire was accurate and reliable in diagnosing migraine (agreement level excellent), less so, but adequate, for TTH (sensitivity relatively low, false negative rate relatively high and agreement level fair to good). The non-specific features of TTH do not lend themselves well to diagnosis by questionnaire.     

A community-based study of headache diagnosis and prevalence in Singapore

We present the results of a community survey based on the diagnostic criteria of the International Headache Society (IHS) describing headache prevalence and symptomatology in the Singapore population. A questionnaire administered by trained personnel was completed by 2096 individuals from a randomized sample of 1400 households. The overall lifetime prevalence of headache was 82.7%. The migraine prevalence was 2.4% in males and 3.6% in females; for episodic tension-type headache and chronic tension-type headache the corresponding figures were 11.1%/11.8% and 0.9%/1.8%, respectively. Inclusion of borderline cases (IHS codes 1.7 and 2.3) resulted in prevalences of 9.3% for migraine, 39.9% for episodic tension headache and 2.4% for chronic tension headache. Headaches described by 31.2% of the respondents were unclassifiable. The different premonitory symptoms, precipitants and aggravating factors in migraine and tension-type headache in our study population suggest that they represent two distinct syndromes rather than opposite ends of a clinical spectrum.     

Prevalence of migraine, tension-type headache, and other headaches in Hong Kong

OBJECTIVE: To assess the prevalence of migraine and other headaches in Hong Kong in 1998. BACKGROUND: A community-based prevalence survey of headache was carried out from July 1992 to March 1993, and the prevalence rates were 1% for migraine, 2% for tension-type headache, and 1% for other headaches. A similar survey was carried out in May and June 1998 to interview individuals aged 15 years or older. Recurrent headache was defined as having two or more headaches unrelated either to influenza or a common cold within the past 12 months. METHODS: Respondents with recurrent headache were offered a personal interview for clinical validation. Of 3156 randomly selected individuals, 1436 responded. RESULTS: Headache was due to influenza or a common cold in 270 (18.8%) respondents; recurrent headache affected 533 (37.1%) respondents. The overall prevalence rates were 4.7% for migraine, 26.9% for tension-type headache, and 5.5% for other headaches. Clinical validation was available for 72 respondents. After adjustment for possible misclassification, the estimated prevalence rates became 12.5% for migraine, 18.7% for tension-type headache, and 6.0% for other headaches. There was a female preponderance for all types of headache with a peak in the 25- to 34-year-age group for tension-type headache. CONCLUSIONS: All types of headache were more common in the 1998 study, and the prevalence rates were closer to those of Western communities.     

A face-to-face interview of participants in HUNT 3: the impact of the screening question on headache prevalence

The aim of this study was to evaluate the effect of the screening question phrasing on the 1-year prevalence figures of headache disorders, including migraine. Of a random sample of 563 invited participants in the Nord-Trøndelag Health Survey 2006–2008 in Norway, 297 (53%) met to a face-to-face interview. There were 74.1% that reported having had headache during the last year, whereas only 31.0% stated that they had suffered from headache in the same period. The 1-year prevalence of migraine was 17.2% and of tension-type headache (TTH) 51.9%. Migraine was ten times more likely (OR = 9.96, 95% CI 4.75–20.91) among those who stated that they were headache sufferers than among those who were not. Only headache sufferers had chronic TTH or medication-overuse headache. Thus “Have you suffered from headache?” can be a useful screening question in population-based questionnaire studies if the goal is to identify most migraineurs and almost all individuals with chronic headache.     

Genetics of tension-type headache

Abstract The objective of this study was to investigate the importance of genetics in tension-type headache. A MEDLINE search from 1966 to December 2006 was performed for “tension-type headache and prevalence” and “tension-type headache and genetics”. The prevalence of tensiontype headache varies from 11 to 93%, with a slight female preponderance. Co-occurrence of migraine increases the frequency of tension-type headache. A family study of chronic tension-type headache suggests that genetic factors are important. A twin study analysing tension-type headache in migraineurs found that genetic factors play a minor role in episodic tension-type headache. Another twin study analysing twin pairs without co-occurrence of migraine showed a significantly higher concordance rate among monozygotic than same-gender dizygotic twin pairs with no or frequent episodic tension-type headache, while the difference was minor in twin pairs with infrequent episodic tensiontype headache. Frequent episodic and chronic tension-type headache is caused by a combination of genetic and environmental factors, while infrequent episodic tensiontype headache is caused primarily by environmental factors. 1 This is a “Springer Open Choice” article. Unrestricted non-commercial use, distribution, and reproduction in any medium is permitted, provided the original author and source are credited.     

American Headache Society members' assessment of headache diagnostic criteria

OBJECTIVE: We assessed the views of physicians interested in headache as to the diagnosis of the most commonly occurring and currently controversial headaches. BACKGROUND: The International Headache Society (IHS) classification system has received wide professional endorsement and considerable empirical support, but in the United States, their adoption by clinicians may be proceeding more slowly. Questions remain, including what diagnostic criteria for migraine and tension-type headache clinicians may continue to favor over those outlined by the IHS, to what extent is the "transformed migraine" diagnosis used in clinical practice, and how is analgesic rebound headache diagnosed with regard to the various quantitative measures of analgesic use. METHODS: Members of the American Headache Society rated the importance of IHS and non-IHS diagnostic criteria for migraine and tension-type headache and for analgesic rebound headache. Respondents also described their use of the proposed transformed migraine diagnosis. RESULTS: Two-thirds (67.3%) of the respondents reported use of the IHS criteria or the IHS criteria in conjunction with clinical judgment. For migraine and tension-type headache, IHS criteria were rated with high importance, but some respondents reported using additional non-IHS diagnostic criteria and de-emphasizing certain IHS criteria. For chronic headache, almost two-thirds (63%) of respondents reported using the transformed migraine diagnosis. For analgesic rebound headache, respondents preferred to make the diagnosis based on medication consumption that is lower than amounts stipulated in the IHS classification system. CONCLUSIONS: There remains a number of physicians interested in headache who do not use the IHS classification system, who modify the IHS criteria in practice, and who use the "transformed migraine" diagnosis for patients with chronic daily headache.     

Lifetime prevalence and characteristics of recurrent primary headaches in a population-based sample of Swedish twins

OBJECTIVE: To examine the lifetime prevalence and other characteristics of recurrent primary headaches in twins. BACKGROUND: The twin model may provide insights into the role of genetic and environmental influences in headache disorders. However, assumptions as to whether twins are representative of the general population, and whether monozygotic and dizygotic twins are similar have rarely been addressed. METHODS: The study population consisted of a random sample of 17- to 82-year-old twins from the Swedish Twin Registry (n = 1329). Structured interviews on the telephone by lay personnel and the International Headache Society criteria were used for assessment and diagnosis of recurrent primary headaches. Prevalence data of the general population for migraine and tension-type headache was obtained from various published reports. RESULTS: A total of 372 subjects (29%) had ever had recurrent headaches. In total, 241 recurrent headache sufferers fulfilled the criteria for migraine or tension-type headache, and the lifetime prevalence was 7.1% for migraine without aura, 1.4% for migraine always with aura, 1.9% for migraine occasionally with aura, 9.4% for episodic tension-type headache, and 1.3% for chronic tension-type headache. The lifetime prevalence of all migraine and all tension-type headache, including another 84 subjects fulfilling all but one of the criteria for migraine or tension-type headache, was 13.8% and 13.5%, respectively. The corresponding prevalence risk for women was 2.4 (95% confidence interval [CI] 1.7, 3.4) and 1.5 (95% CI 1.1, 2.1), respectively. Zygosity was not a significant predictor for migraine. In tension-type headache, the prevalence risk for dizygotic twins and unlike-sexed twins as compared with monozygotic twins was 1.9 (95% CI: 1.2, 3.1) and 1.8 (95% CI: 1.1, 2.9), respectively. CONCLUSION: There is no twin-singleton or monozygotic-dizygotic difference for the risk of migraine. In tension-type headache, twins seem to have a lower risk than singletons, and this is especially true for monozygotic twins.     

Chronic daily headache and the revised international headache society classification

Chronic daily headache (CDH) is surprisingly common. It is best defined as a primary headache disorder with head pain on most days. There are a number of possible secondary causes of persistent headache, including traumatic, vascular, neoplastic, and infectious processes, all of which must be ruled out when the patient with frequent headache is evaluated. However, most patients with CDH seem to have a primary neurophysiologic disorder. This category of primary CDH does not seem to be a homogeneous disorder, but rather one with important subtypes. Several authors have proposed subdivisions of primary CDH such as chronic migraine, evolved migraine, transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. The International Headache Society (IHS) Classification published in 1988 did not address CDH other than to define a category “chronic tension-type headache.rd The revised IHS Classification (ICHD II) attempts to characterize CDH more thoroughly with the addition of chronic migraine and new daily persistent headache diagnoses, but this complex issue continues to defy easy categorization. This article provides a review of thinking about the nature of primary CDH and how ICHD II attempts to organize this category for much needed research purposes.     

Validation of a german language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias

BACKGROUND: To develop a German language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias. OBJECTIVE: Aim of the study was to develop a German language self-administered headache questionnaire for screening for migraine (MIG), tension-type headache (TTH), and trigeminal-autonomic cephalgias (TAC). METHODS: Questionnaire-based diagnoses were blindly compared with those of headache experts. RESULTS: Overall 278 headache patients (MIG = 97, TTH = 60, TAC = 98, MIG plus TTH = 23) as well as 42 patients with low back pain without headache and 47 healthy subjects were studied. The Cohen's kappa for 7 headache syndromes including all combination diagnoses was 0.64 (95% CI 0.58-0.70). Sensitivity and specificity for migraine were 0.73 and 0.96, for TTH 0.85 and 0.98, for TAC 0.63 and 0.99, and for MIG plus TTH 0.62 and 0.97, respectively. Ignoring all combination diagnoses, the kappa-coefficient for the monodiagnoses MIG, TTH, and TAC (193 out of 278 patients) was 0.93 (CI 0.83-1.0). The retest-reliability (4 weeks later) was 0.95. CONCLUSION: We present the first questionnaire in German language including 3 most common primary headaches for use in epidemiological research.     

Determinants of tension-type headache in children

The objective of this study was to study the prevalence, characteristics and predisposing factors of tension-type headache in children. An unselected population-based questionnaire study was carried out in 1409 Finnish schoolchildren aged 12 years. Of them, 1135 (81%) returned an acceptably completed questionnaire. The prevalence of episodic tension-type headache in children was 12% (138 of 1135). Children with episodic tension-type headache also often reported characteristics of pain typical for migraine. Children with frequent and persistent episodic tension-type headache reported stabbing and severe occipital pain, phonophobia and abdominal pain significantly more often than children with infrequent episodic tension-type headache. Neck-shoulder symptoms, symptoms of depression and oromandibular dysfunction were each independently associated with episodic tension-type headache. The father's occupation of a lower-level white-collar worker put the child at a four-fold risk for episodic tension-type headache. We conclude that episodic tension-type headache is as common as migraine in children. It can be associated with depression, oromandibular dysfunction and muscular stress. Especially children with frequent and persistent episodic tension-type headache report characteristics of pain typical for migraine.     

Chronic daily headache in a paediatric headache centre

The prevalence and the clinical features of chronic daily headache (CDH) were studied in 968 children and adolescents observed during a period of one year in the Headache Centre of the Anna Meyer Paediatric Hospital of Florence. Nine hundred and fortyfour patients (97.52%) had primary headache according to ICHD-II, 24 subjects had secondary headache and 56 patients had CDH (5.93% of primary headaches). The mean age of subjects with CDH was higher than general (13.5 vs. 11.5 years), with a female preponderance (69.6% vs. 30.4%). According to the ICHD-II, headaches were classified as chronic migraine in 10 patients (1.5.2 ICHD-II), chronic tension-type headache in 36 (2.3 ICHD-II), new daily persistent headache in 8 (4.8 ICHD-II) and 2 patients reported mixed pattern (chronic migraine+chronic tension type headache). Medication overuse was not implicated in our patients.