Migraine days decline with duration of illness in adolescents with transformed migraine

The aim of this study was to assess the proportion of subjects with transformed migraine (TM) who have 15 or more migraine days per month as a function of duration of chronic daily headache (CDH) in an adolescent sample. CDH is a syndrome characterized by 15 or more headache days per month. In specialty care, TM is the most common type of CDH. Most adults who meet criteria for TM do not meet the International Headache Society (IHS) criteria for chronic migraine (CM). TM criteria require 15 or more headache days per month (not necessarily migraine), with a current or past history of migraine. CM requires 15 or more migraine days per month. As TM develops, attack frequency increases and the number of migraine features diminishes. If this observation is correct, individuals who meet criteria for TM but not CM may be at a later stage in the evolution of the disease, compared with those who meet criteria for CM. We reviewed charts of 267 adolescents (13-17 years) seen in a headache centre, to identify 117 with TM. We divide subjects with TM into those with recent onset (1 year) and examined the number of migraine days per month and demographic features. We modelled predictors of CM (>15 migraine days per month) using logistic regression. Of 117 adolescents with TM, 55 (47%) had recent-onset (<1 year) and 62 (53%) had long-duration TM. Those with recent-onset TM were much more likely also to meet criteria for CM (74.5% vs. 25.8%, P < 0.001). This was verified in the TM with medication overuse subgroup (recent onset 66.7%, vs. long duration 37%, P = 0.01) and in the TM without medication overuse subgroup (62.2% vs. 19.2%, P = 0.001). Modelling the dichotomous outcome of CM (>15 days of migraine/month) in logistic regression, CM was predicted by recent onset of CDH, recent onset of migraine (<36 months), and younger ages (相似文献   

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)     

Outcome of medication overuse headache after abrupt in-patient withdrawal

One hundred and one patients suffering from chronic daily headache (CDH) and medication overuse were treated, in an in-patient setting, with abrupt discontinuation of the medication overused, intravenous hydrating, and intravenous administration of benzodiazepines and ademetionine. The mean time to CDH resolution was 8.8 days. The in-patient withdrawal protocol used was effective, safe and well tolerated. There was a trend for a shorter time to CDH resolution in patients who overused triptans (P=0.062). There was no correlation between time to CDH resolution and either the type of initial primary headache or duration of medication abuse, whereas time to CDH resolution was related to daily drug intake (P=0.01). In multiple regression analysis, daily drug intake, age and type of medication overused were independent predictors of time to CDH resolution. At 3-months' follow-up, no patient had relapsed and was again overusing symptomatic medications.     

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.     

Management of Chronic Daily Headache: Challenges in Clinical Practice

Chronic daily headache (CHD) refers to a category of headache disorders that are characterized by headaches occurring on more than 15 days per month. This category is subdivided into long- and short-duration (>4 or <4 hours) CDH disorders based on the duration of individual headache attacks. Examples of long-duration CDH include transformed migraine (TM), chronic migraine (CM), new daily persistent headache (NDPH), acute medication overuse headache, and hemicrania continua (HC). The goal of this review is to enable clinicians to accurately diagnose and effectively manage patients with long-duration CDH. Patients with CDH often require an aggressive and comprehensive treatment approach that includes a combination of acute and preventive medications, as well as nondrug therapies.     

The classification of chronic daily headache in adolescents--a comparison between the second edition of the international classification of headache disorders and alternative diagnostic criteria

OBJECTIVES: To compare the second edition of the International Classification of Headache Disorders (ICHD-2) and the Silberstein-Lipton (S-L) criteria in the classification of adolescents with chronic daily headache (CDH). METHODS: We reviewed the clinical records and the headache diaries of 170 adolescents (13 to 17 years) seen between 1998 and 2003 at a headache center. Relevant information was transferred to a standardized form that included operational criteria for the ICHD-2. CDH subtypes were classified according the criteria proposed by S-L into transformed migraine (TM) with (TM+) and without medication overuse (TM-), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). RESULTS: From the 69 patients with TM- according the S-L criteria, most (71%) could be classified as chronic migraine (CM), while a minority of patients required a combination of diagnosis, mainly migraine and CTTH (14.4%). Of the patients with TM+, just 39.6% met the criteria for probable CM (PCM) with probable medication overuse (PMO). If instead of 15 migraine days per month, we considered 15 or more days of migraine or probable migraine, 84% of the subjects with TM- and 68.7% of those with TM+ could be classified. Of the 27 subjects classified as NDPH without medication overuse according to the S-L system, the majority (51.2%) were also classified as NDPH according the ICHD-2. Interestingly, three (11.1% of the subjects with NDPH without medication overuse) were classified as CM in the ICHD-2 because these patients had an abrupt onset of 15 or more days of migraine per month. All patients with NDPH with medication overuse according to the S-L criteria required a combination of diagnoses in the ICHD-2. All subjects with CTTH received a single diagnosis in both classification systems. CONCLUSIONS: (i) Among adolescents with TM, the majority (58.1%) could be classified as CM, according to the ICHD-2. These results were driven by TM without medication overuse. (ii) If the ICHD-2 criteria for CM are revised to require 15 days of migraine or probable migraine, the proportion of patients with TM- who meet the criteria for CM increases from 71% to 84%; for TM+, the proportion with probable chronic migraine and PMO increases from 30% to 68%. (iii) About half of the patients with NDPH according to the S-L criteria have too many migraine features to meet ICHD-2 criteria for NDPH.     

Chronic daily headaches: clinical profile in Indian patients

Chronic daily headache (CDH) remains a relatively unexplored entity in India. Misconceptions are common, unnecessary investigations often done and inappropriate therapy prescribed. Analgesic overuse is seldom recognized. The present report appears to be the first of its kind from India. CDH has been defined as headaches occurring more than 15 days per month for more than 3 months (secondary causes excluded). Over 2 years (1998-1999) 849 cases (49.6% of all primary headaches) were seen. More than 1 year's follow-up data were available in 205 subjects (M 34; F 171). The distribution of these was as follows: (i), chronic tension-type headache (CTH), 33 (16.1%); (ii), chronic/transformed migraine (TM), 169 (82.4%); (iii), new persistent CDH, 3 (1.5%). There were 169 cases of TM (M : F 1 : 4.7; age 26-58 years). History of past episodic migraine was present in all. Transformation had been gradual (89.4%) or acute (10.6%). Possible factors in transformation included psychological stress (44.4%), analgesic overuse (28.4%), ergot overuse (4.1%). HRT seemed to be implicated in three female subjects. Analgesic overuse was limited between intake of 600 and 2400 mg of aspirin equivalent per day (mean 735 mg). Ergot overuse varied between 1 and 3 mg/day of ergotamine for > or = 3 days/week. With medical therapy approximately 70% TM and 40% CTH patients noted significant improvement. About 80% of these relapsed on therapy withdrawal. CDH in India is not uncommon. Analgesic/ergot overuse needs to be recognized early. The average dose of analgesic implicated in CDH seems much less compared with that reported in the West.     

Transformed migraine and medication overuse in a tertiary headache centre--clinical characteristics and treatment outcomes

Studies suggest that a substantial proportion of headache sufferers presenting to headache clinics may overuse acute medications. In some cases, overuse may be responsible for the development or maintenance of a chronic daily headache (CDH) syndrome. The objectives of this study are to evaluate patterns of analgesic overuse in patients consulting a headache centre and to compare the outcomes in a group of patients who discontinued medication overuse to those of a group who continued the overuse, in patients with similar age, sex and psychological profile. We reviewed charts of 456 patients with transformed migraine (TM) and acute medication overuse defined by one of the following criteria: 1. Simple analgesic use (>1000 mg ASA/acetaminophen) > 5 days/week; 2. Combination analgesics use (caffeine and/or butalbital) > 3 tablets a day for > 3 days a week; 3. Opiate use > 1 tablet a day for > 2 days a week; 4. Ergotamine tartrate use: 1 mg PO or 0.5 mg PR for > 2 days a week. For triptans, we empirically considered overuse > 1 tablet per day for > 5 days per week. Patients who were able to undergo detoxification and did not overuse medication (based on the above definition) after one year of follow-up were considered to have successful detoxification (Group 1). Patients who were not able to discontinue offending agents, or returned to a pattern of medication overuse within one year were considered to have unsuccessful detoxification (Group 2). We compared the following outcomes after one year of follow-up: Number of days with headache per month; Intensity of headache; Duration of headache; Headache score (frequency x intensity). The majority of patients overused more than one type of medication. Numbers of tablets taken ranged from 1 to 30 each day (mean of 5.2). Forty-eight (10.5%) subjects took >10 tablets per day. Considering patients seen in the last 5 years, we found the following overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%. Of 456 patients, 318 (69.7%) were successfully detoxified (Group 1), and 138 (30.3%) were not (Group 2). The comparison between groups 1 and 2 after one year of follow-up showed a decrease in the frequency of headache of 73.7% in group 1 and only 17.2% in group 2 (P < 0.0001). Similarly, the duration of head pain was reduced by 61.2% in group 1 and 14.8% in group 2 (P < 0.0001). The headache score after one year was 18.8 in group 1 and 54 in group 2 (P < 0.0001). A total of 225 (70.7%) successfully detoxified subjects in Group 1 returned to an episodic pattern of migraine, compared to 21 (15.3%) in Group 2 (P < 0.001). More rigorous prescribing guidelines for patients with frequent headaches are urgently needed. Successful detoxification is necessary to ensure improvement in the headache status when treating patients who overuse acute medications.     

Chronic daily headache in children and adolescents

OBJECTIVE: To describe the clinical features of children with chronic daily headache (CDH) and examine the usefulness of the International Classification of Headache Disorders-II. BACKGROUND: Few data are available on chronic daily headache and analgesic overuse in children and adolescents and there are no specific criteria for headache in children. METHODS: We retrospectively reviewed all charts of 79 children and adolescents (<16 years) with headache on > or =15 days/month presenting to the outpatient clinic of the Department of Neurology of the Leiden University Medical Center between 1994 and 2001. We classified their headaches according to the International Classification of Headache Disorders-II. RESULTS: Fifty-seven (72%) children had chronic daily headache for more than 6 months, with a duration of more than 4 hours a day in 60% of them. Quality, severity, and location of pain varied. Sixty patients (76%) used analgesics, 10 patients more than one type. Thirteen patients (16%) used analgesics daily. In one-third of patients, headache led to frequent school absenteeism and sleeping problems. Twenty-eight (35%) patients could be classified, 17 patients (22%) as chronic tension-type headache, 5 patients (6%) as chronic migraine, and 6 patients (8%) as probable medication overuse headache. Fifteen patients (19%) did not fit into any category and 36 (46%) could not be classified due to insufficient data. CONCLUSIONS: Chronic daily headache in children is a serious disorder. A relatively large number of patients overuse medication and it leads to frequent school absenteeism and sleeping problems. It remains difficult to classify their headaches with the new criteria for headache disorders.     

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.     

Epidemiology of chronic daily headache

Daily or near-daily headache is a widespread problem in clinical practice. The general term of chronic daily headache (CDH) encompasses those primary headaches presenting more than 15 days per month and lasting more than 4 hours per day. CDH includes transformed migraine (TM), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). Around 40% of patients attending a specialized headache clinic meet CDH diagnostic criteria, of which 80% are women. In these clinics about 60% of patients suffer from TM, 20% from CTTH, and 20% meet NDPH criteria. Most, some 80%, overuse symptomatic medications. One should be very cautious on extrapolating these numbers to the general population. CDH prevalence in the general population seems to be around 4% to 5% (up to 8% to 9% for women). Regarding the prevalence of CDH subtypes, NDPH is rare (0.1%), whereas the prevalence of TM (1.5% to 2%) and CTTH (2.5% to 3%) is clearly higher. In contrast to data from specialized clinics, only around a quarter of CDH subjects in the general population overuse analgesics; the prevalence of CDH subjects with analgesic overuse being 1.1% to 1.9% of the general population. Most of these patients with analgesic overuse are TM patients.     

An epidemiological study of headache in Florianopolis, Brazil

The aim of this study was to estimate the 1-year prevalence of headache, migraine, tension-type headache (TTH) and chronic daily headache (CDH), and the degree of association of migraine with some sociodemographic characteristics of the population of Florianopolis, Brazil. This is a cross-sectional, door-to-door, population-based study. In 300 randomly selected households, 625 subjects, aged 15-64 years, responded to a structured questionnaire. The 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4%. Migraine and CDH were significantly more prevalent in females than in males. Migraine was significantly associated with the following variables: low household income, low electricity consumption, and divorced or widowed marital status. We have shown high prevalences of migraine and CDH in Florianopolis, close to the higher rates of previous studies. There was a preponderance of migraine in females, divorced or widowed, with a low socioeconomic level.     

Chronic daily headache: correlation between the 2004 and the 1988 International Headache Society diagnostic criteria

BACKGROUND: In a previous study, we compared the 1988 International Headache Society (IHS) criteria and the Silberstein-Lipton criteria (S-L) in a subspeciality clinic sample of 638 patients with chronic daily headache (CDH) assessed both clinically and with headache diaries. Both systems allowed for the classification of most patients with CDH. The 1988 IHS classification required multiple diagnoses and was more complex to apply. OBJECTIVES: The aim of this study was to revisit the same database, now comparing the prior classification systems with the new 2004 IHS classification. In contrast with the 1st edition, the 2nd edition includes criteria for chronic migraine (CM), new daily persistent headache (NDPH), and hemicrania continua (HC). METHODS: We reviewed the clinical records and the headache diaries of 638 patients seen between 1980 and 2001 at a headache center. All patients had primary CDH according to the S-L criteria. RESULTS: Using the S-L criteria as a reference, of the 158 patients with transformed migraine (TM) without medication overuse, just 9 (5.6%) met 2004 IHS criteria for CM. Most of the subjects were classified using combinations of migraine and CTTH diagnoses, much like the 1988 IHS classification. Similarly, using the new IHS system, just 41/399 (10.2%) subjects with TM with medication overuse were classified as probable CM with probable medication overuse. Most patients with NDPH without overuse were easily classified using the 2004 criteria (95.8%). Regarding NDPH with medication overuse, the diagnostic groups were much like results for the 1st edition. All patients with chronic tension-type headache (CTTH) and hemicrania continua (HC) according to the S-L system were easily classified using the 2004 IHS criteria. CONCLUSIONS: We conclude that the 2004 IHS criteria facilitate the classification of NDPH without medication overuse and HC. For subjects with TM according to the S-L system, the new IHS criteria are complex to use and require multiple diagnoses. Very few patients with TM in the S-L system could be classified with a single diagnosis in the 2004 IHS classification. In fact, CM was so rare that it would be virtually impossible to conduct clinical trials of this entity using the 2004 IHS criteria. Clinical trials of this entity should therefore be conducted using the S-L criteria. Finally, we propose that in the 3rd edition of the IHS classification, the diagnosis of NDPH be revised so as not to exclude migraine features.     

Chronic headaches: from research to clinical practice

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 4–5% of the population. It can be subdivided into headaches of short duration (<4 h/attack) like chronic cluster headache, and disorders of long duration (>4 h/attack). Primary CDH of long duration includes transformed migraine, chronic tension–type headache, and new daily persistent headache and hemicrania continua. Analgesics, ergots and triptan overuse are frequent in all types of CDH. We revise recent insights into the epidemiology, pathophysiology, clinical characteristics and prognosis of CDH.     

Hemicrania Continua and Symptomatic Medication Overuse

SYNOPSIS
Hemicrania continua (HC) is a rare, strictly unilateral, non-paroxysmal headache disorder characterized by its absolute responsiveness to indomethacin. The pain is usually moderate in intensity and frequently associated with a superimposed"jabs and jolts" headache.
We report two cases of HC which presented as chronic daily headache (CDH) with abortive medication overuse.
CDH can be due to transformed migraine (TM), new daily persistent headache (NDPH), chronic tension-type headache, and HC. All can be unilateral, and all can be associated with medication overuse. Our two cases meet the criteria for HC based on indomethacin responsiveness. One meets the criteria for TM, the other NDPH. Is HC a distinct disorder, or a subset of these other disorders? CDH with medication overuse includes in its differential diagnosis HC.     

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

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

From migraine to chronic daily headache: the biological basis of headache transformation

Migraine headache carries the potential of transforming into chronic daily headache (CDH) over a period of time. Although several risk factors for migraine progression to CDH have been identified, the biological basis of this transformation is unknown. In this review, the consequences of stressful life events and medication overuse, 2 risk factors associated with the development of CDH, on brain processes involved in headache are examined. The extensive overlap in both neural circuitry and cellular events that occur with stress, medication overuse, and migraine provide insight into potential mechanisms that may lead to CDH. Particular attention is devoted to the effect of stress and medication overuse on peripheral and central neuroimmune interactions that can facilitate pain signaling. These interactions include the degranulation of mast cells in the dura, causing the sensitization of primary afferent neurons, as well as the activation of glial cells in the brain that can lead to central sensitization. It is hypothesized that the biological processes involved in migraine headache are directly impacted by stress, medication overuse, and other risk factors, resulting in a reduced threshold for induction of headache and transformation of episodic migraine to CDH.     

Chronic daily headaches in children

Chronic daily headache (CDH) is increasingly recognized as a problem in pediatrics and tertiary pediatric headache care. It is estimated that up to 4% of the adult population has CDH. Many of these are chronic migraine (CM). The fraction of the pediatric population with CDH appears to be lower, although the prevalence has not been adequately determined. The simplest definition of CDH is more than 15 headache days per month. In the International Classification of Headache Disorders, Second Edition (ICHD-II), several types of CDH have been identified. These criteria have been contrasted with the Silberstein-Lipton criteria, with revisions suggested. The diagnosis of CDH is further complicated and may be initiated by the overuse of analgesic medications (medication overuse headache) and requires the resolution of this issue before a final diagnosis can be established. In children, most CDH appears to have migraine features, although it may not completely meet the ICHD-II criteria for migraine or CM. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the secondary headaches or headaches directly attributed to a secondary cause. Treatment and management involve a multidisciplinary approach, including acute therapy for when the headache severity increases (while avoiding medication overuse), preventative therapy to reduce the frequency and impact of the CDH, and biobehavioral therapy to assist with long-term outcome.     

Repetitive intravenous prochlorperazine treatment of patients with refractory chronic daily headache

OBJECTIVES: To investigate the efficacy and long-term outcome of intravenous prochlorperazine for the treatment of refractory chronic daily headache. BACKGROUND: Unlike dihydroergotamine, the treatment results of intravenous neuroleptics as first-line agents for refractory chronic daily headache have rarely been reported. METHODS: We retrospectively analyzed the data of inpatients with refractory chronic daily headache who received intravenous repetitive prochlorperazine treatment from November 1996 to March 1999. A semistructured telephone follow-up interview was done in September 1999. RESULTS: A total of 135 patients (44 men, 91 women) were recruited, including 95 (70%) with analgesic overuse. After intravenous prochlorperazine treatment, 121 (90%) achieved a 50% or greater reduction of headache intensity, including 85 (63%) who became headache-free. The mean hospital stay was 6.2 +/- 2.7 days, and mean total prochlorperazine used was 98 +/- 48 mg. Acute extrapyramidal symptoms occurred in 21 patients (16%). One hundred twenty-four patients (92%) were successfully followed up, with a mean duration of 14.3 +/- 7.5 months. Compared with pretreatment status, 93 patients (75%) considered their headache intensity decreased, and 86 patients (69%) considered their headache frequency decreased, although 40 (32%) still had a daily headache. Of the 87 patients with analgesic overuse who could be followed, 61 (70%) no longer overused analgesics. Poor response to prochlorperazine treatment (relative risk, 1.8) and presence of major depression (relative risk, 1.8) were predictors of persistent chronic daily headache at follow-up. CONCLUSIONS: Prochlorperazine was effective and safe in the treatment of patients with refractory chronic daily headache with or without analgesic overuse. Compared with dihydroergotamine, prochlorperazine seemed less effective at achieving "freedom from headache" during hospitalization, but had a similar outcome at follow-up.