Coexistence of cervicogenic headache and migraine without aura (?)

It is well known that migraine with aura may coexist with various unilateral headaches, like cluster headache and chronic paroxysmal hemicrania. It may also coexist with cervicogenic headache. The diagnosis of migraine without aura ("common migraine") poses greater problems than the diagnosis of migraine with aura. Cervicogenic headache diagnosis also poses problems when these two headaches coexist, since they have symptoms in common. Therefore, the scientific demonstration of coexistence of migraine without aura and cervicogenic headache is bound to be a difficult task. In the present study, migraine without aura and cervicogenic headache seemed to coexist in 4 patients (3 F and 1 M, mean age 50). Attacks with migraine characteristics fulfilled the IHS and IASP migraine criteria. Out of a maximum of 13 migraine characteristics based on the IHS/IASP migraine criteria, such as unilaterality, aggravation on minor physical activity, etc., none of the patients presented less than 11, as opposed to a mean of < or = 4 of these criteria in the cervicogenic type attacks. A similar system, based on criteria such as: reduction of range of motion in the neck, mechanical precipitation of attacks, etc., was also developed for cervicogenic headache. The mean number of cervicogenic headache criteria was 4.3 (out of a total of 5) in the "cervicogenic part of the picture", as opposed to 1.5 (1.8 if laterality is considered, see text) in the "migraine part of the picture". Drug regimens and anaesthetic blocks also showed different results in the two different headaches in the same patient. All in all, this study seems to support a coexistence of the two headache types.     

Prevalence and clinical characteristics of migraine in France

OBJECTIVE: To determine the prevalence and clinical features of migraine and related headache types in France. METHODS: The authors recruited a population of subjects with headache representative of the national population using a stratified sampling method. They screened 10,585 subjects aged 15 and older who were representative of the general population. They identified 1,486 of these as having headaches, and these subjects were subsequently interviewed for information on clinical features, natural history, and functional impact of headache. The authors categorized subjects based on the International Headache Society (IHS) classification and assessed disability using the MIDAS questionnaire. RESULTS: The authors found a standardized prevalence for migraine (IHS categories 1.1 and 1.2) of 7.9% (11.2% for women and 4.0% for men) and 9.1% for migrainous disorder (IHS category 1.7). Migraine attacks were associated with a considerable degree of handicap in activities of daily living, with a MIDAS grade distribution of 74.7% (grade 1), 13.3% (grade 2), 7.7% (grade 3), and 4.3% (grade 4). The prevalence of migraine with MIDAS grade 3 or 4 was 1.6%. CONCLUSIONS: The prevalence of migraine (IHS categories 1.1 and 1.2) in France is 7.9%, and that of total migraine is 17.0%; this does not seem to have evolved over the past 10 years.     

Prevalence of headache in an elderly population: attack frequency, disability, and use of medication

OBJECTIVES: To assess the 1 year prevalence of tension-type headache (TTH), migraine headache (MH), and chronic daily headache (CDH), as well as of headache in general in a rural elderly population. METHODS: A door to door two phase survey was carried out on all elderly (>/=65 years) residents in three villages in central Italy. Participants completed a standardised headache questionnaire and underwent a clinical evaluation by a neurologist. Headache diagnosis was made according to the classification of the International Headache Society, with minor modifications for the classification of patients with MH with>/=15 attacks/month. RESULTS: Eight hundred and thirty three (72.6%) of the 1147 eligible persons completed the study protocol. One year prevalence rates were respectively 44.5% for TTH, 11.0% for MH, 2.2% for symptomatic headaches, and 0.7% for the remaining types of headache. The prevalence of headache in general was 51.0% because 62 residents had both TTH and MH attacks. Prevalence rates of patients with headache were higher in women than men (62.1% and 36.6% respectively) and decreased steadily with age for the 65-74, 75-84, and 85-96 age groups (56.7%, 45.2% and 26.1% respectively). Prevalence rates were 20.4% for patients with moderate to severe attacks, 18.0% for those with >/=1 attacks a month, and 4.4% for those with CDH. Of the 425 with headache 52 (12.2%) had not taken any drugs for their attacks in the previous year, 195 (45.9%) had taken them regularly, and 178 (41.9%) had taken them only when the headache pain interfered with activities that could not be postponed. Medication overuse was reported by 37.8% of patients with CDH with higher proportions for transformed migraine than for patients with chronic TTH (69.2% and 23.8% respectively, p=0.009) CONCLUSIONS: A consistent proportion of elderly people have primary headaches and consultation with a specialist is particularly recommended for patients with moderate or severe attacks, or with CDH.     

Familial migraine with and without aura: clinical characteristics and co-occurrence

Migraine with aura (MwA) and migraine without aura (MwoA) are the two common forms of migraine. Many migraine patients suffer from both kinds of attacks. In a questionnaire-based study using the current International Headache Society (IHS) criteria we determined the clinical characteristics and occurrence of MwA + MwoA in 1000 migraine patients belonging to 210 Finnish migraine families. Nine hundred and six patients were able to indicate whether they suffered from MwA (but not MwoA), migraine aura without headache (migraine equivalent) (but not MwA) or MwA and MwoA. Of these patients, 3.2% had experienced MwoA, 11.1% MwA, 40.6% MwA + MwoA, 23.5% MwoA and 20.3% MwA-like symptoms not meeting the IHS criteria. The high prevalence of MwA attacks in the families studied supports the belief that aura has a strong hereditary component. The MwA + MwoA patients had significantly more severe attacks, more typical headache and more prodromal symptoms than the MwA and MwoA subjects. Therefore, it is possible that there is a continuum with pure MwA at the neural and pure MwoA at the headache end of the spectrum, and MwA + MwoA lying in between the two. The MwA + MwoA patients would thus be liable to both types of migraine, making their attacks more characteristic and more severe. This would also explain why the co-occurrence of MwA and MwoA is more common in the clinic compared with population based epidemiological studies. These findings have consequences for future research on liability genes for migraine.     

Chronic daily headache: a rational approach to a challenging problem

Chronic daily headache (CDH) is a significant public health problem with 3 to 5% of the population worldwide experiencing daily or near-daily headaches. Patients with CDH can be particularly challenging, and clinicians require a systematic approach to help guide investigations and management. The revised 2004 International Headache Society Classification Criteria introduces formalized criteria for several CDH disorders including chronic migraine and medication overuse headache as well as new daily persistent headache, hemicrania continua, hypnic headache, and SUNCT syndrome. Medication overuse is common in patients with CDH who present to physicians. Familiarity and comfort with drug-withdrawal and detoxification strategies is therefore essential. Patients with chronic migraine and chronic cluster experience significant disability and diminished quality of life. The ability to manage these patients effectively is a rewarding clinical experience.     

Headaches in a rheumatology clinic: when one pain leads to another

Chronic daily headaches (CDH) affect between 3 and 4% of the Western population and is one of the most common problems seen in the neurology clinic. It is often difficult to delineate where CDH began and medication overuse headache (MOH) supervenes. The current study analyses the development of MOH in people taking regular analgesia for reasons other than headache, namely patients attending rheumatology clinics. The aim of this study was to assess, for the first time in an Irish population of patients, whether CDH was more common in such patients as previously reported. We also wanted to see how often rheumatology patients were taking non-prescribed analgesics. The results show that, in a cohort of 114 rheumatology patients, 32% reported that they suffer from headaches regularly. Of these, 38% fulfilled criteria for CDH (or 12% of the whole cohort). Of the 14 patients with CDH, 11 also fulfilled the International Classification of Headache Disorders criteria for MOH. Seventy per cent of the patients fell under the category of medication overuse (>15 days a month for >3months) but only 9% fulfil criteria for MOH. Contrary to the previous work in this area, we found a very low (<2%) incidence of previous migraine in our patients with CDH. We conclude that headaches (both CDH and MOH) are common in this patient population. We suggest that here should be greater awareness amongst all doctors caring for these patients of the potential for creating a second chronic problem when using excessive analgesia to treat the first.     

Characterization of chronic daily headaches in children in a multidisciplinary headache center

BACKGROUND: Chronic daily headaches (CDH) occur in >4% of the adult population. The criteria for CDH, however, are controversial. In children, the characterization of frequent headaches and CDH is limited. METHODS: A Headache Center to characterize headaches in children (3 to 18 years old) was established. Over 34 months, 577 children have been evaluated. With use of a definition of > or =15 headaches per month, 200 (34.6%) children had CDH. RESULTS: The average age at the first headache in these children was 9.3 +/- 3.6 years, whereas the average age at presentation to the Headache Center was 12.5 +/- 3.1 years. Sixty-eight percent were girls, 88% were Caucasian, and 11% were African American. Ninety-two percent clinically had migraine headaches, whereas 60.5% met the International Headache Society migraine criteria. The pain was pulsatile in 79%, 63.5% had nausea with or without vomiting, and 59.5% had photophobia and phonophobia. Three subcategories emerged, with 37% having frequent headaches but not daily, 43.5% having episodic daily headaches, and 19.5% having a continuous headache. CONCLUSION: The features of CDH in children most closely match those of migraine. A clear division of these children using frequency identifies three groups: frequent headaches (15 to 29), daily intermittent, and daily continuous. The daily continuous group is the most unique; however, the nature of these headaches continues to remain migrainous.     

Epidemiology and clinical characteristics of chronic daily headache in a clinic-based cohort of Iranian population

Although CDH is a major health care problem encountered in headache clinics, our knowledge about the epidemiological features of CDH is limited in developing countries. The objective of this study was to survey the frequency and clinical features of chronic daily headache (CDH) and its subtypes among Iranian population presenting to a referral tertiary Headache clinic in a University Hospital. This cross-sectional survey was carried out between September 2011 and March 2012. Data of patients with CDH including their age, sex, educational level, and marital status were recorded using structured face-to-face interview. Subtypes of the CDH were determined by history, physical examination and appropriated laboratory or imaging findings. A total number of 177 cases (32.71 %) fulfilled the CDH criteria. The frequency of CDH was higher in 40–49 age groups (n = 54) and among women with a female to male ratio of 2.12/1. Chronic migraine was the most common subtype of CDH in 75 cases (44.4 %). Chronic tension-type headache and secondary causes were second and third frequent subtypes of CDH in 27.8 and 20.1 % of cases, respectively. Cervicogenic headaches (10.7 %) and medication overuse headache (4.1 %) were the most common causes of secondary headaches. The present study confirmed previous findings which showed a high prevalence of CDH and chronic migraine in clinic setting, with preponderance for women. In addition, we found the highest prevalence of cervicogenic headaches among secondary causes of CDH.     

Clinical characteristics of adolescent headache

We evaluate clinical characteristics of headache in a group of subjects > 12 years to assess the sensitivity and specificity of the IHS criteria. We consider whether age at onset may influence the clinical features. We used a semi-structured questionnaire to examine 136 patients consecutively referred to our division. We considered the following subdiagnoses: IHS 1.1, 1.2, 1.7, 2.1, 2.2, 2.3. Migrainous disorders were found to be more common than non-migrainous headaches. A definite diagnosis was established in 68.1% of the migrainous group and in 86.6% of the tension-type headache group. Unilateral location, severe intensity of pain, the presence of nausea, vomiting, phonophobia and photophobia were features which differed between migrainous and non-migrainous subjects. No difference was found regarding aggravation of the headache by physical activity. On the basis of the criterion duration of attacks < 2 hours, IHS 1.7 was found to differ significantly from other migraine types. With the exception of the presence of vomiting in migrainous patients, the age at onset was not found to be a factor influencing the characteristics of the headache. Diagnostic criteria for migraine were highly specific but poorly sensitive, and those for tension-type headaches highly sensitive but less specific. The sensitivity/specificity of the IHS criteria in adolescent migraine can be influenced by the heterogeneity of the clinical characteristics. In fact, the intensity, the location and the quality of pain were similar to those found in childhood migraine, while the concomitant symptoms were less frequent than in childhood and in adult migraine. Further studies are needed to define the degree of severity of the clinical features in adolescent headache and to address the question of the validity of the IHS criteria.     

Increased frequency of migraine in narcoleptic patients

We explored the relationship between narcolepsy and different types of headaches. We interviewed 68 patients with idiopathic narcolepsy for the presence of headache symptoms based on the criteria of the International Headache Society (IHS). Eighty-one percent of the patients reported headaches that warranted an IHS headache diagnosis. Fifty-four percent of the patients (64% women, 35% men) had migraine with all IHS criteria fulfilled.     

Prise en charge des céphalées chroniques quotidiennes chez l’enfant et l’adolescent

Chronic daily headache (CDH) affects 2 to 4% of adolescent females and 0,8 to 2% of adolescent males. CDH is diagnosed when headaches occur more than 4 hours a day, for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent headaches, that are migraine-like, as well as a chronic baseline headache. Silberstein and Lipton divided patients into four diagnostic categories: transformed migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. The second edition of the International Classification of Headache Disorders did not comprise any CDH category as such, but provided criteria for all four types of CDH: chronic migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Children and adolescents with CDH frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache and a psychiatric comorbidity (anxiety and mood disorders). CDH frequently results in school absence. CDH management plan is dictated by CDH subtype, the presence or absence of medication overuse, functional disability and presence of attacks of full-migraine superimposed. Reassuring, explaining, and educating the patient and family, starting prophylactic therapy and limiting aborting medications are the mainstay of treatment. It includes pharmacologic (acute and prophylactic therapy) and nonpharmacologic measures (biobehavioral management, biofeedback-assisted relaxation therapy, and psychologic or psychiatric intervention). Part of the teaching process must incorporate life-style changes, such as regulation of sleep and eating habits, regular exercise, avoidance of identified triggering factors and stress management. Emphasis must be placed on preventive measures rather than on analgesic or abortive strategies. Stressing the reintegration of the patient into school and family activities and assessing prognosis are other issues to address during the first visit. There are limited data evaluating the outcome of CDH in children and adolescents.     

Chronic daily headache

The term chronic daily headache (CDH) identifies a heterogeneous group of headaches characterized by the presence of daily or near-daily headache, including forms associated with medication overuse. This group includes chronic (transformed) migraine, chronic tension-type headache, new daily-persistent headache and hemicrania continua. According to population studies, CDH affects 4-5% of the general population worldwide, making it a significant social problem. CDH evolves from an episodic form of headache or, more rarely, is daily from onset. The classification of CDH continues to be debated, even though the recent revision of the diagnostic criteria for several primary headache forms seems to have resolved some of the nosographical difficulties. To date, no specific therapies have been approved for CDH and there have been few large-scale controlled trials of treatments in this area. This article reviews various aspects of CDH: classification issues, pathophysiological hypotheses and therapeutic (pharmacological and nonpharmacological) approaches.     

Parental satisfaction with sumatriptan nasal spray in childhood migraine

Migraine headaches are a frequently encountered neurologic problem in children. The utility of the triptans has not been as clearly documented in this population, although it is well delineated in acute migraine attacks in adults. We conducted a retrospective chart review of our experience with using sumatriptan nasal spray in children aged 5 to 12 years from our headache clinic population with migraine headaches. The nasal spray formulation is used frequently in our clinic population with patients who have failed over-the-counter therapy with ibuprofen or acetaminophen. None of the triptans are approved by the US Food and Drug Administration for use in children or adolescents (12 years and older). One hundred of these patients were identified, and their parents or guardians completed a standardized questionnaire regarding their child's response to sumatriptan nasal spray in acute migraine. Fifty-seven of 100 families completed the questionnaire, and 44 of 57 families (77%) reported good to excellent relief of their child's migraine attacks with sumatriptan nasal spray. In our cohort of pediatric patients, sumatriptan nasal spray was effective and well tolerated when used for abortive therapy of acute migraine attacks.     

The interrelations of migraine, vertigo, and migrainous vertigo

OBJECTIVE: To assess the prevalence of migrainous vertigo in patients with migraine and in patients with vertigo according to explicit diagnostic criteria that are presented for discussion. METHODS: The authors prospectively evaluated 200 consecutive patients from a dizziness clinic and 200 patients from a migraine clinic for migrainous vertigo based on the following criteria: 1) recurrent vestibular symptoms (rotatory/positional vertigo, other illusory self or object motion, head motion intolerance); 2) migraine according to the criteria of the International Headache Society (IHS); 3) at least one of the following migrainous symptoms during at least two vertiginous attacks: migrainous headache, photophobia, phonophobia, visual or other auras; and 4) other causes ruled out by appropriate investigations. In addition, the authors compared the prevalence of migraine according to the IHS criteria in the dizziness clinic group with a sex- and age-matched control group of 200 orthopedic patients. RESULTS: The prevalence of migraine according to the IHS criteria was higher in the dizziness clinic group (38%) compared with the age- and sex-matched control group (24%, p < 0.01). The prevalence of migrainous vertigo was 7% in the dizziness clinic group, and 9% in the migraine clinic group. In 15 of 33 patients with migrainous vertigo, vertigo was regularly associated with migrainous headache. In 16 patients, vertigo occurred both with and without headache, and in two patients headache and vertigo never occurred together. The duration of attacks varied from minutes to days. CONCLUSION: These results substantiate the epidemiologic association between migraine and vertigo and indicate that migrainous vertigo affects a significant proportion of patients both in dizziness and headache clinics.     

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy resulting in stroke in an 11-year-old male

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is caused by mutations in the Notch3 gene on chromosome 19. The condition manifests itself clinically typically in the third to fifth decade with migraine and recurrent episodes of stroke or transient ischaemic attacks. We report the case of an 11-year-old male with CADASIL resulting in stroke with right hemiparesis and dysphasia. Acute magnetic resonance imaging suggested infarction in the left hemisphere; magnetic resonance angiography revealed calibre variation of the intracerebral arteries. The patient suffered from common migraine with five to six attacks per month for 3 years 6 months before the stroke. Attacks occurred early in the morning with severe one-sided headache, photophobia, nausea, and vomiting. Antimigraine medications had no effect. The family history revealed more cases of CADASIL, with an autosomal dominant pattern. The diagnosis of CADASIL was confirmed by the finding of the known mutation of the Notch3 gene running in the family. With treatment in a neurorehabilitation centre the patient recovered most of his functions with only discrete fine-motor and cognitive sequelae. Our case report highlights the need for paediatricians to consider CADASIL in childhood stroke as well as in migraine patients.     

Chronic daily headache

Chronic daily headache (CDH) is a heterogeneous group of headaches that includes primary and secondary varieties. Primary CDH is a frequent entity that probably affects 4% to 5% of the population. It can be subdivided into headaches of short duration (less than 4 hours per attack), like chronic cluster headache, and disorders of long duration (greater than 4 hours per attack). Primary CDH of long duration includes transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. Analgesic or ergot overuse is frequent in all types of CDH. We review recent insights into the proposed classification, epidemiology, pathophysiology, clinical characteristics, and treatment of CDH.     

Epidemiology of headache

Previous classifications of headache have lacked accuracy. In 1988, the Headache Classification Committee of the International Headache Society (IHS) introduced operational diagnostic criteria for all headache disorders. Since then, epidemiological headache research has been substantially made easily. Although the use of uniform and specific diagnostic criteria may reduce diagnostic variability, several other methodologic problems remain: episodicity, coexisting headaches, measurement techniques, sample source, may explain the differences among studies. All these difficulties overlap and explain the wide range of overall prevalence from 35p.100 to 100 p. 100. Information on migraine epidemiology are available: a one-year prevalence of migraine in America and Western Europe in adults is about 10 à 15 p.100. In France, Henry et al. found a prevalence of 12.1 p.100 (6.1 p.100 for men and 17.6 p.100 for women) for migraine. The aura symptoms are extremely difficult to describe, explaining the heterogeneity of prevalence for migraine with aura. Sex and age distribution as well as the relationship with sociodemographic factors and associated pathologies (stroke, epilepsia.) are now well-known. Epidemiology of tension-type headaches has received less attention. This headache varies both in frequency and severity; this fact make epidemiologic studies more difficult. Cluster headache is better defined by IHS criteria, but its prevalence remains debated. Different methodological approaches could explain these difficulties, rather real differencies in frequency among various population. Cluster Headache prevalence varies from 0.006 p.100 in China to 0.07 p.100 of the population in the republic of San Marino and 0.24 p.100 in the general population of the United states. In conclusion, the development of IHS criteria has made possible the progress of epidemiologic research. Additional studies are required to better define the risk factors and conditions that act as co-morbidity factors.     

A Canadian population survey on the clinical, epidemiologic and societal impact of migraine and tension-type headache.

Trained telephone interviewers contacted 1,573 adults across Canada about the nature and frequency of headaches suffered by them or by others in their households. Using a table of pain symptoms and other characteristics abstracted from the International Headache Society (IHS) classification, the headaches were assigned to migraine headache, tension-type headache or other diagnostic groups. Of the households sampled, 59% had at least one headache sufferer in residence. The proportion of headache sufferers with migraine was 14%; with tension-type, 36%; and with both, 14%. Migraine headache caused more disability than tension-type headache, with nearly 20% of migraine sufferers taking time off work and disability lasting for a mean of 1 day. It is concluded that the current prevalences of migraine and tension-type headache in Canada fall around the mean of previous studies, that the IHS criteria can form a basis for diagnostic classification and that the functional impact of migraine has been seriously underestimated in the past.     

Classification of primary headaches

Given the range of disorders that produce headache, a systematic approach to classification and diagnosis is an essential prelude to clinical management. For the last 15 years, the diagnostic criteria of the International Headache Society (IHS) have been the accepted standard. The second edition of The International Classification of Headache Disorders (January 2004) reflects our improved understanding of some disorders and the identification of new disorders. Neurologists who treat headache should become familiar with the revised criteria. Like its predecessor, the second edition of the IHS classification separates headache into primary and secondary disorders. The four categories of primary headaches include migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalalgias, and other primary headaches. There are eight categories of secondary headache. Important changes in the second edition include a restructuring of these criteria for migraine, a new subclassification of tension-type headache, introduction of the concept of trigeminal autonomic cephalalgias, and addition of previously unclassified primary headaches. Several disorders were eliminated or reclassified. In this article, the authors present an overview of the revised IHS classification, highlighting the primary headache disorders and their diagnostic criteria. They conclude by presenting an approach to headache diagnosis based upon these criteria.     

Chronic daily headache in Chinese elderly: prevalence, risk factors, and biannual follow-up

OBJECTIVE: To investigate the prevalence, risk factors, and prognosis of chronic daily headache (CDH) in a population of elderly Chinese subjects. METHODS: A community-based survey of registered residents > or =65 years old (n = 2,003) in two townships of Kinmen Island in 1993. A neurologist used a structured questionnaire and clinical interview to make the diagnosis of headache. Subjects who had headaches > or =15 days/month for > or =6 months in the previous year were considered to have CDH. CDH was further classified into chronic tension-type headache (CTTH), CDH with migrainous features (CDH/MF), and other CDH. Person-to-person biannual follow-up of the subjects with CDH was done in June 1995 and August 1997. RESULTS: A total of 1,533 people (77%) participated in our prevalence study. Sixty subjects (3.9%) fulfilled the criteria for CDH, with a higher prevalence in women (F/M: 5.6%/1.8%, p < 0.001). Of these subjects, 42 (70%) had CTTH, 15 (25%) had CDH/MF, and 3 (5%) had other CDH. Only 23% of those with CDH had consulted physicians for their headaches in the previous year. Multivariate logistic regression revealed the significant risk factors for CDH to be analgesic overuse (OR = 79), a history of migraine (OR = 6.6), and a Geriatric Depression Scale-Short Form score of > or =8 (OR = 2.6). The follow-up results in 1995 and 1997 showed that about two-thirds of the subjects still had CDH. Analgesic overuse (relative risk = 1.6) in 1993 was a significant predictor of persistent CDH at follow-up. CONCLUSIONS: A total of 3.9% of this elderly population had CDH, with CTTH being the most common subtype. Almost two-thirds of those with CDH had persistent frequent headaches at follow-up. Analgesic overuse was a significant predictor of a poor outcome.