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)     

Chronic daily headache in U.S. soldiers after concussion

(Headache 2012;52:732‐738) Objective.— To determine the prevalence and characteristics of, and factors associated with, chronic daily headache (CDH) in U.S. soldiers after a deployment‐related concussion. Methods.— A cross‐sectional, questionnaire‐based study was conducted with a cohort of 978 U.S. soldiers who screened positive for a deployment‐related concussion upon returning from Iraq or Afghanistan. All soldiers underwent a clinical evaluation at the Madigan Traumatic Brain Injury Program that included a history, physical examination, 13‐item self‐administered headache questionnaire, and a battery of cognitive and psychological assessments. Soldiers with CDH, defined as headaches occurring on 15 or more days per month for the previous 3 months, were compared to soldiers with episodic headaches occurring less than 15 days per month. Results.— One hundred ninety‐six of 978 soldiers (20%) with a history of deployment‐related concussion met criteria for CDH and 761 (78%) had episodic headache. Soldiers with CDH had a median of 27 headache days per month, and 46/196 (23%) reported headaches occurring every day. One hundred seven out of 196 (55%) soldiers with CDH had onset of headaches within 1 week of head trauma and thereby met the time criterion for posttraumatic headache (PTHA) compared to 253/761 (33%) soldiers with episodic headache. Ninety‐seven out of 196 (49%) soldiers with CDH used abortive medications to treat headache on 15 or more days per month for the previous 3 months. One hundred thirty out of 196 (66%) soldiers with CDH had headaches meeting criteria for migraine compared to 49% of soldiers with episodic headache. The number of concussions, blast exposures, and concussions with loss of consciousness was not significantly different between soldiers with and without CDH. Cognitive performance was also similar for soldiers with and without CDH. Soldiers with CDH had significantly higher average scores on the posttraumatic stress disorder (PTSD) checklist compared to soldiers with episodic headaches. Forty‐one percent of soldiers with CDH screened positive for PTSD compared to only 18% of soldiers with episodic headache. Conclusions.— The prevalence of CDH in returning U.S. soldiers after a deployment‐related concussion is 20%, or 4‐ to 5‐fold higher than that seen in the general U.S. population. CDH following a concussion usually resembles chronic migraine and is associated with onset of headaches within the first week after concussion. The mechanism and number of concussions are not specifically associated with CDH as compared to episodic headache. In contrast, PTSD symptoms are strongly associated with CDH, suggesting that traumatic stress may be an important mediator of headache chronification. These findings justify future studies examining strategies to prevent and treat CDH in military service members following a concussive injury.     

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.     

Which Patients With Headache Do Not Seek Medical Attention?

(Headache 2011;51:1279‐1284) Objectives.— To evaluate why patients do not discuss their headaches with their doctors and to compare these patients with those who seek medical assistance for headache. Method.— Cross‐sectional study. A total of 200 consecutive patients attended by family doctors had their complaints registered. Those with headaches were interviewed. A semi‐structured questionnaire, Headache Impact Test and Hospital Anxiety and Depression Scale were used. Results.— Fifty‐two percent had headaches. Ten percent sought medical assistance for headache, 11% already had received some form of medical assistance for headache. There was no association between headache disability and seeking a doctor for headache. Patients that did not seek a doctor for headache had a higher prevalence of tension‐type headache (59.6% vs 22.1%; P < .01), a lower prevalence of migraine with aura (32.3% vs 40.5%; P < .01), headache intensity (5.4 vs 6.8; P = .01) and frequency (4.2 × 7.4 days/month; P < .01). Fifty‐two percent of them needed preventive treatment. Most of them did not seek a doctor because their headaches were mild or received relief from painkillers. Conclusions.— Patients who did not seek medical assistance for headache had more tension‐type headache, less migraine with aura, lower headache intensity and frequency, but the same headache disability. Most of them needed preventive treatment and did not seek doctors because their headache was mild or received relief from painkillers.     

Frequency of Headaches in Children is Influenced by Headache Status in the Mother

(Headache 2010;50:973‐980) Background.— Migraine aggregates within families. Nonetheless the familial aggregation of chronic daily headaches (CDH) and of episodic headaches of different frequencies has been very poorly studied. Accordingly herein we test the hypothesis that frequency of primary headaches aggregates in the family. Methods.— Sample consisted of 1994 children (5‐12 years) identified in the population. Validated questionnaires were used to interview the parents. Crude and adjusted prevalences of low‐frequency (1‐4 headache days/month), intermediate‐frequency (5‐9 days/month), high‐frequency (10‐14 headache days/month), and CDH (15 or more headache days/month) in children were calculated as a function of headaches in the mother. Results.— Frequency of headaches in the mother predicted frequency of headaches in the children; when the mother had low frequency headaches, the children had an increased chance to have low or intermediate headache frequency (relative risk = 1.4, 1.2‐1.6) but not CDH. When the mother had CDH, risk of CDH in the children was increased by almost 13‐fold, but the risk of infrequent headaches was not increased. In multivariate models, headaches in the children were independently predicted by headaches in the mother (P < .001); headache frequency in the children was also predicted by frequency in the mother (P < .001). Conclusions.— Frequency of headaches in children is influenced by frequency of headaches in the mother and seems to aggregate in families. Future studies should focus on the determinants of headache aggregation, including genetic and non‐genetic factors.     

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.     

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)     

A History of Cigarette Smoking Is Associated With the Development of Cranial Autonomic Symptoms With Migraine Headaches

(Headache 2011;51:85‐91) Objective.— To look at the smoking history of migraine patients and to determine if a history of cigarette smoking is associated with the development of cranial autonomic symptoms with migraine headaches. Background.— It has recently been noted that a significant number of migraine patients may develop autonomic symptoms during their attacks of headache. Why some headache patients activate the trigeminal autonomic reflex and develop cranial autonomic symptoms while others do not is unknown. Cluster headache occurs more often in patients with a history of cigarette smoking, suggesting a link between tobacco exposure and cluster headache pathogenesis. Could cigarette smoking in some manner lead to activation of the trigeminal‐autonomic reflex in headache patients? If cigarette smoking does lower the threshold for activation of the trigeminal autonomic reflex then do migraine patients who have a history of cigarette smoking more often develop cranial autonomic symptoms than migraineurs who have never smoked? Methods.— Consecutive patients diagnosed with migraine (episodic or chronic) who were seen over a 7‐month time period at a newly established headache center were asked about the presence of cranial autonomic symptoms during an attack of head pain. Patients were deemed to have positive autonomic symptoms along with headache if they experienced at least one of the following symptoms: eyelid ptosis or droop, eyelid or orbital swelling, conjunctival injection, lacrimation, or nasal congestion/rhinorrhea. A smoking history was determined for each patient including was the patient a current smoker, past smoker, or had never smoked. Patients were deemed to have a positive history of cigarette smoking if they had smoked continuously during their lifetime for at least at 1 year. Results.— A total of 117 migraine patients were included in the analysis (96 female, 21 male). Forty‐six patients had a positive smoking history, while 71 patients had no smoking history. Some 70% (32/46) of migraineurs with a positive history of cigarette smoking had cranial autonomic symptoms along with their headaches, while only 42% (30/71) of the nonsmoking patients experienced at least 1 autonomic symptom along with headaches and this was a statistically significant difference (P < .005). In total, 74% of current smokers had autonomic symptoms with their headaches compared with 61% of past smokers and this was not a statistically significant difference. There was a statistically significant difference between the number of current smokers who had autonomic symptoms with their headaches compared with the number of patients who never smoked and had autonomic symptoms (P < .05). Overall, 52% of the studied migraineurs had autonomic symptoms. There was a statistically significant difference between autonomic symptom occurrence in male and female smokers vs male and female nonsmokers. Each subtype of cranial autonomic symptoms was all more frequent in smokers. Conclusion.— A history of cigarette smoking appears to be associated with the development of cranial autonomic symptoms with migraine headaches.     

Prevalence and clinical characteristics of primary headaches among school children in South Korea: a nationwide survey

Objectives.— To determine the 1‐year prevalence of headache and clinical characteristics of primary headaches among school children in South Korea. Background.— Many population‐based studies have estimated the 1‐year prevalence of headache, migraine, and tension‐type headache (TTH). The results of those studies vary in terms of race and region. There have been few epidemiological population‐based studies of headache in children and adolescents in Korea. Methods.— We conducted a cross‐sectional school‐based study of a randomized and proportional sample of 5360 boys and girls. All 180 sampled schools participated in this study. The questionnaires collected demographic data in addition to specific questions about headache according to the International Classification of Headache Disorder criteria, 2nd Edition. Valid questionnaires were returned by 94.1% of the sample population. Modified criteria changed the “duration” of migraine (>1 hour instead of 4 hours). Results.— The prevalence of headache among school children was 29.1% (1465/5039) in South Korea. The prevalence of headache in girls (33.4%) was significantly higher than in boys (24.4%) (P < .001). The mean age of students with headaches (14.02 ± 3.03) was significantly higher than students without headaches (12.73 ± 3.36) (P < .001). The prevalence of headache according to region was 30.7% among students in urban, 31.2% in suburban, and 21.6% in rural areas. The prevalence of headache according to age was 20.8% among students ～6‐12 years, 32.0% ～13‐15 years, and 38.2% ～16‐18 years. The prevalence according to headache types was 8.7% (boys 7.0%, girls 10.3%) in migraine, 13.7% (boys 10.7%, girls 16.3%) in TTH, and 6.7% in others. The mean frequency, severity of headache, and duration of symptoms were significantly higher in girls than in boys (P < .001). Conclusions.— Recurrent primary headaches are quite prevalent among school‐aged children and adolescents in South Korea, and the prevalence rates are similar to those reported elsewhere. TTH was more common than migraine. The prevalence of migraine headache increased with age. The prevalence rate of headache in students in urban and suburban areas was significantly higher than the rate of students in rural areas.     

Somatic symptoms in headache patients: the influence of headache diagnosis, frequency, and comorbidity

BACKGROUND: Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. METHODS: Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME-MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow-up data were obtained 6 months after consultation. RESULTS: Clinical diagnoses and PRIME-MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P<.001) and chronic daily headache (CDH) (6.3, P=.008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to 2 days per week had significantly higher somatic counts (P=.01). Six-month follow-up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P=.01 and 0.8, P=.003, respectively). CONCLUSION: Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.     

Osmophobia in primary headaches

This study evaluates osmophobia (defined as an unpleasant perception, during a headache attack, of odours that are non–aversive or even pleasurable outside the attacks) in connection with the diagnosis of primary headaches. We recruited 775 patients from our Headache Centre (566 females, 209 males; age 38±12 years), of whom 477 were migraineurs without aura (MO), 92 with aura (MA), 135 had episodic tension–type headache (ETTH), 44 episodic cluster headache (ECH), 2 chronic paroxysmal hemicrania (CPH) and 25 other primary headaches (OPHs: 12 primary stabbing headaches, 2 primary cough headaches, 3 primary exertional headaches, 2 primary headaches associated with sexual activity, 3 hypnic headaches, 2 primary thunderclap headaches and 1 hemicrania continua). Among them, 43% with MO (205/477), 39% with MA (36/92), and 7% with CH (3/44) reported osmophobia during the attacks; none of the 135 ETTH and 25 OPH patients suffered this symptom. We conclude that osmophobia is a very specific marker to discriminate adequately between migraine (MO and MA) and ETTH; moreover, from this limited series it seems to be a good discriminant also for OPHs, and for CH patients not sharing neurovegetative symptoms with migraine. Therefore, osmophobia should be considered a good candidate as a new criterion for the diagnosis of migraine.     

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.     

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.     

Relationship Between Childhood Physical Maltreatment and Migraine in Adolescents

(Headache 2010;50:761‐768) Objective.— To study the relationship between childhood physical abuse and migraine in adolescents. Background.— Childhood maltreatment might lead to an increased probability of migraine among adults. Nevertheless, the relationship between migraine and childhood abuse is unknown in adolescents. Methods.— We enrolled 3955 students, ages 13‐15, from 3 middle schools. Each participant completed a valided headache questionnaire for headache diagnosis and the Adolescent Depression Inventory (ADI). A classification of physical maltreatment was given to students who reported they had been beaten by parents or elder family members. Results.— A total of 926 (23.4%) students were diagnosed with migraine or probable migraine occurring within the 3 months prior to the survey. Physical maltreatment was reported by 945 (23.9%) students, including a frequency of “rarely” in 762 (19.3%) students and “sometimes or often” in 183 (4.6%). The students reporting physical maltreatment were more likely to suffer migraine or probable migraine compared with those who reported no physical maltreatment (30.3% vs 21.3%, odds ratios = 1.6, 95%, CI: 1.4‐1.9, P < .001). A higher frequency of physical maltreatment was associated with a higher likelihood of migraine diagnosis (21.3% vs 28.3%, vs 38.3%, “never” vs “rarely” vs “sometimes or often maltreated,” respectively, P < .001). In addition, among the students diagnosed with migraine, those reporting physical maltreatment had higher mean ADI scores, a higher frequency of headaches, and a greater proportion of severe headaches. Conclusions.— The results suggest that physical maltreatment is associated with migraine in adolescents and that physical maltreatment may be related to an increase in the frequency and intensity of headaches in adolescents with migraines. A history of physical maltreatment may be helpful in the treatment of adolescents suffering from migraine.     

The prevalence of migraine and probable migraine in a Brazilian favela: results of a community survey

(Headache 2011;51:971‐979) Objectives.— The objectives of the present study were to estimate the 1‐year prevalence of primary headaches and the role of select socio‐demographic aspects in a representative sample of adults living in a Brazilian shanty town. Background.— Some socio‐demographic factors, such as marital status, income, education, and job status have been described in studies with contentious results. Nevertheless, few studies have assessed the prevalence of headache and the role of socio‐demographic aspects in very low‐income communities. Methods.— A cross‐sectional, population‐based study was undertaken. Door‐to‐door interviews with 383 people were conducted. Individuals were aged greater than 18 years, randomly selected from the “Paraisopolis” shanty town in São Paulo, Brazil. The degree of the association was calculated through prevalence ratios and adjusted with backward logistic regression by gender, age, and some socio‐demographic factors, including living conditions. Results.— The estimated 1‐year prevalence of headache, migraine, chronic migraine, and tension‐type headache were 47% (CI 95%: 39.5‐52.6%), 20.4% (CI 95%: 16.6‐24.9%), 8.4% (CI 95%: 6.1‐12.0%), and 6.2% (CI 95%: 3.3‐9.8%), respectively. Migraine was more prevalent in women and among employed people. No other relationship was found. The overall prevalence of migraine and chronic migraine in this very low‐income community were high and migraine was associated with gender and job status. Conclusion.— The overall prevalence of migraine and chronic migraine in this very low‐income community were high and tension‐type headache was low. A paradox was noted in the employment status and income association, one would expect higher levels of migraine in a low‐income population, but higher numbers were found in those employed vs unemployed. These findings will need to be replicated in other population samples.     

Childhood Maltreatment and Migraine (Part II). Emotional Abuse as a Risk Factor for Headache Chronification

(Headache 2010;50:32‐41) Objectives.— To assess in a headache clinic population the relationship of childhood abuse and neglect with migraine characteristics, including type, frequency, disability, allodynia, and age of migraine onset. Background.— Childhood maltreatment is highly prevalent and has been associated with recurrent headache. Maltreatment is associated with many of the same risk factors for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity. Methods.— Electronic surveys were completed by patients seeking treatment in headache clinics at 11 centers across the United States and Canada. Physician‐determined data for all participants included the primary headache diagnoses based on the International Classification of Headache Disorders‐2 criteria, average monthly headache frequency, whether headaches transformed from episodic to chronic, and if headaches were continuous. Analysis includes all persons with migraine with aura, and migraine without aura. Questionnaire collected information on demographics, social history, age at onset of headaches, migraine‐associated allodynic symptoms, headache‐related disability (The Headache Impact Test‐6), current depression (The Patient Health Questionnaire‐9), and current anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire. Results.— A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (≥15 days/month) was reported by 34%. Transformation from episodic to chronic was reported by 26%. Prevalence of current depression was 28% and anxiety was 56%. Childhood maltreatment was reported as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. In univariate analyses, physical abuse and emotional abuse and neglect were significantly associated with chronic migraine and transformed migraine. Emotional abuse was also associated with continuous daily headache, severe headache‐related disability, and migraine‐associated allodynia. After adjusting for sociodemographic factors and current depression and anxiety, there remained an association between emotional abuse in childhood and both chronic (odds ratio [OR] = 1.77, 95% confidence intervals [CI]: 1.19‐2.62) and transformed migraine (OR = 1.89, 95% CI: 1.25‐2.85). Childhood emotional abuse was also associated with younger median age of headache onset (16 years vs 19 years, P = .0002). Conclusion.— Our findings suggest that physical abuse, emotional abuse, and emotional neglect may be risk factors for development of chronic headache, including transformed migraine. The association of maltreatment and headache frequency appears to be independent of depression and anxiety, which are related to both childhood abuse and chronic daily headache. The finding that emotional abuse was associated with an earlier age of migraine onset may have implications for the role of stress responses in migraine pathophysiology.     

Prevalence and burden of chronic migraine in adolescents: results of the chronic daily headache in adolescents study (C-dAS)

(Headache 2011;51:693‐706) Objective.— To estimate the prevalence of chronic migraine (CM) among adolescents and to describe the epidemiologic profile, headache characteristics, disability, and healthcare utilization of adolescents with CM in the USA. Background.— Chronic daily headache (CDH) and CM occur in children and adolescents, but are poorly understood in these populations because their presentation is different from that in adults. It may be difficult to assign a definitive diagnosis to young people suffering from CDH because symptoms may fail to meet the criteria for one of the CDH subtypes. Methods.— A large sample of households with at least one resident aged 12 to 19 years was selected in balance with the US Census. Data were collected in 3 phases: (1) mailed questionnaire; (2) telephone interview; and (3) 30‐day interactive voice response system diary. CM prevalence was estimated by adapting the second edition of the International Classification of Headache Disorders criteria for CM to include pediatric migraine diagnostic criteria. The population was stratified for medication overuse. Medication overuse was defined as 15 or more days per month of acute medication use. Included in the study were measures of headache characteristics, headache impact (Headache Impact Test), disability (Pediatric Migraine Disability Assessment), and healthcare and medication use. Data are reported on subjects 12 to 17 years of age only. Results.— The US adolescent (12‐17 years) prevalence rate for CM was 0.79% (0.00‐1.70) excluding those with medication overuse and 1.75% (0.62‐2.89) when adolescents with medication overuse were included. The majority of adolescents with CM had Headache Impact Test scores greater than or equal to 60, indicating severe headache impact, and mean Pediatric Migraine Disability Assessment scores greater than 17, indicating severe headache and disability. The majority of adolescents with CM (approximately 60%) had not visited a healthcare provider in the previous year and less than one in 5 reported taking medications to prevent headaches during the last month. Conclusions.— Results suggest that CM occurs less frequently in adolescents than adults, but like adults, adolescents are severely burdened by the disorder. Data support an unmet medical need; however, the development of optimal criteria for diagnosing adolescents with CM is critical to fully understanding how medical needs can be met within this complex population.     

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.     

A pivotal moment in 50 years of headache history: the first American Migraine Study

Objective.— To describe the magnitude and distribution of the public health problem posed by migraine in the United States by examining migraine prevalence, attack frequency, and attack‐related disability by gender, age, race, household income, geographic region, and urban vs rural residence. Design.— In 1989, a self‐administered questionnaire was sent to a sample of 15,000 households. A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. Setting.— A sample of households selected from a panel to be representative of the US population in terms of age, gender, household size, and geographic area. Participants.— After a single mailing, 20,468 subjects (63.4% response rate) between 12 and 80 Years of age responded to the survey. Respondents and nonrespondents did not differ by gender, household income, region of the country, or urban vs rural status. Whites and the elderly were more likely to respond. Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. Results.— In total, 17.6% of females and 5.7% of males were found to have 1 or more migraine headaches per year. The prevalence of migraine varied considerably by age and was highest in both men and women between the ages of 35 to 45 years. Migraine prevalence was strongly associated with household income; prevalence in the lowest‐income group (less than $10,000) was more than 60% higher than in the 2 highest‐income groups (greater than or equal to $30,000). The proportion of migraine sufferers who experienced moderate to severe disability was not related to gender, age, income, urban vs rural residence, or region of the country. In contrast, the frequency of headaches was lower in higher‐income groups. Attack frequency was inversely related to disability. Conclusions.— A projection to the US population suggests that 8.7 million females and 2.6 million males suffer from migraine headache with moderate to severe disability. Of these, 3.4 million females and 1.1 million males experience 1 or more attacks per month. Females between ages 30 and 49 years from lower‐income households are at especially high risk of having migraines and are more likely than other groups to use emergency care services for their acute condition.     

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.