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.     

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.     

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.     

Analysis of the patients attending a specialist UK headache clinic over a 3-year period

OBJECTIVE: This study analyzed the profile of patients who attended a specialist UK headache clinic over a 3-year period. METHODS: An audit was conducted of the clinical records of patients attending the specialist headache clinic at King's College, London, between January 1997 and January 2000. Data were collected for diagnoses given, current medications taken, medications prescribed and recommended, and investigations conducted. Results were calculated as numbers and proportions of patients for the 3-year period and for the 3 separate 12-month periods. RESULTS: A total of 458 patients were included in the audit. Most patients were diagnosed as having chronic daily headache (CDH, 60%) or migraine (33%). Prior to the clinic visit, most patients with CDH and migraine treated their headaches with analgesics, and there was little use of prophylactic medication. In the clinic, 74% of patients with CDH and 85% of migraineurs were prescribed prophylactic medication, and 81% of migraineurs were given triptans for acute treatment. Diagnostic testing was performed in 12% of the patients, and all results were normal or negative. CONCLUSIONS: CDH and migraine were the most common headache types encountered in this UK secondary-care clinic. Review of treatment patterns used prior to the initial clinic evaluation suggests that management of CDH and migraine in UK primary care is suboptimal, and educational initiatives are needed to improve headache management.     

New daily persistent headache in the paediatric population

We conducted a clinic-based study focusing on the clinical features of new-onset chronic daily headaches (CDH) in children and adolescents. The clinical records and headache diaries of 306 children and adolescents were reviewed, to identify 187 with CDH. Relevant information was transferred to a standardized form that included operational criteria for the diagnoses of the headaches. Since we were interested in describing the clinical features of these headaches, we followed the criteria A and B of the 2nd edn of the International Classification of Headache Disorders (ICHD-2) and refer to them as new daily persistent headaches (NDPH) regardless of the presence of migraine features (therefore, this is a modified version of the ICHD-2 criteria). From the 56 adolescents with NDPH, most (91.8%) did not overuse medications. Nearly half (48.1%) reported they could recall the month when their headaches started. NDPH was more common than chronic tension-type headache in both adolescents overusing and not overusing medication. Individuals with NDPH had headaches fulfilling criteria for migraine on an average of 18.5 days per month. On most days, they had migraine-associated symptoms (one of nausea, photophobia or phonophobia)). NDPH is common in children and adolescents with CDH. Most subjects do not overuse medication. Migraine features are common.     

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.     

Chronic daily headache in children and adolescents: a clinic based study from India

Chronic Daily Headache (CDH) is uncommon in Indian children compared to their adult counterpart. This is a retrospective study looking at the headache phenomenology of CDH in Indian children and adolescents. The validity of the case definitions of subtypes of chronic primary headaches mentioned in the IHS 2004 classification have been evaluated. 22 children (age range 8-15 years; M : F-16 : 6) diagnosed as having primary CDH using a modified definition seen between 2002 and 2003 have been studied. CDH has been defined as daily or near daily headaches > 15d/month for > 6 weeks. The rationale for this modified definition has been discussed. Majority of children (15/22) had a more or loss specified time of onset of regular headache spells resembling New Daily Persistent Headache (NDPH) but did not fulfil totally the diagnostic criteria of NDPH as laid down by IHS 2004. In all cases headache phenomenology included a significant vascular component. Headache phenomenology closely resembled Chronic Tension Type Headache (CTTH) in 4 patients and Chronic Migraine in 3 patients. However, in no patient in these groups, a history of evolution from the episodic forms of the diseases could be elicited. Heightened level of anxiety mostly related to academic stress and achievement was noted in the majority (19/22). Only a minority of patients (3/22) had anxiety and depression related to interpersonal relationships in the family. Medication overuse was not implicated in any patient. CDH in children in India is very much different from CDH in adults with the vast majority of patients exhibiting overlapping features of migraine and tension-type headache. There is need for a modified diagnostic criteria and terminology for chronic primary headaches in children.     

Managing chronic headaches in the clinic

Chronic daily headache (CDH), which is often linked to a history of migraine, tension-type headache and the abuse of headache medications, and cluster headache are the best known of the chronic headaches. These headaches may not be well recognised or well treated in primary care. This article outlines the development of management algorithms for these headache subtypes, designed for use by the primary care physician with an interest in headache. Principles of care for chronic headaches include implementation of screening procedures, differential diagnosis, tailoring of management to the individual's needs, proactive follow-up and a team approach to care. These principles can be customised to the headache subtype by the selection of appropriate therapies. The optimal treatments for CDH include physical therapy to the neck if there is any stiffness there, withdrawal of abused medications and treatment of any subsequent withdrawal symptoms and headache prophylaxis, together with the provision of acute medications as rescue therapy. Optimal treatments for cluster headache include short- and long-term prophylaxis to prevent the headaches developing and acute medications for use as rescue. If treatment is ineffective, alternative medications can be provided at follow-up, with the possibility of referral for refractory patients.     

Indicators of a major depressive episode in primary care patients with a chief complaint of headache

OBJECTIVE: To identify the indicators of major depressive episode (MDE) in primary care patients with a chief complaint of headache. BACKGROUND: MDE is very frequent among headache patients in primary care. However, primary care physicians often fail to recognize the coexistence of MDE. METHODS: A total of 177 consecutive new adult patients who visited 19 primary care clinics from January 2002 to December 2002 with a chief complaint of headache were enrolled in the study. All subjects completed a self-report questionnaire that included questions regarding the duration and severity of their headaches, changes in headache severity, and other symptoms. The questionnaire also identified distressed high utilizers (patients who consulted different doctors for the same episode of an illness, without being referred). MDE was diagnosed using a module of the mini international neuropsychiatric interview (MINI). To identify potential indicators of depression, both univariate analysis and multiple logistic regression analysis were performed. RESULTS: Forty-five of 177 patients (25.4%) fulfilled the diagnostic criteria for MDE. Univariate analysis revealed that severe headache, longer duration of headaches, multiple somatic symptoms, and being a distressed high utilizer were associated with MDE. Multiple logistic regression analysis revealed that patients with headaches lasting 6 months or longer and those with multiple somatic symptoms were more likely to be suffering from MDE (adjusted odds ratios: 3.1, 95% CI: 1.7-10.6; and 3.9, 95% CI: 1.2-8.1, respectively). CONCLUSIONS: MDE is highly prevalent in headache patients visiting a primary care setting. Multiple somatic symptoms and longer duration (> or =6 months) of headaches are particularly useful indicators of MDE.     

Chronic daily headache with analgesics overuse in professional women breath-hold divers

Objective.— The object of this study is to investigate the prevalence and characteristics of headache in Korean professional women breath-hold divers, including their overuse of analgesics.
Background.— Headache is a common problem encountered in clinical practice, and undersea divers exhibit unique causes of headache in addition to other common primary headaches. Many scuba divers are known to use various types of drugs to overcome dive-related symptoms or to enhance their underwater performance.
Methods.— The target population of this study was women divers in the northern district of Jeju Island who were registered in the divers' union. Data were collected using telephone interviews with a structured questionnaire. Headache was diagnosed and classified according to criteria of the International Headache Society.
Results.— Nine hundred and eleven (80.3%) divers responded to the telephone interview. The prevalence rates of headache were 21.4% for tension-type headache and 9.1% for migraine. One hundred and four divers (11.4%) fulfilled the criteria for chronic daily headache (CDH). Overuse of combination analgesics was reported by 70.7% of divers. Women divers with CDH were significantly older and they complained more of tinnitus and dizziness, and had a greater history of hypertension than divers without headache.
Conclusion.— The prevalence of CDH is high in Korean professional women breath-hold divers, with many of them being combination-analgesics overusers.     

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.     

Intravenous lignocaine (lidocaine) infusion for the treatment of chronic daily headache with substantial medication overuse

Patients with chronic daily headache with medication overuse are difficult to treat, especially when the doses of analgesia are substantial. We have previously shown that intravenous lignocaine (lidocaine) infusion is useful in maintaining pain control while the offending analgesic agent is withdrawn in these patients. The published data on long-term efficacy of this treatment is limited. We undertook a retrospective survey of 71 consecutive patients admitted for lignocaine infusion (mean 8.7 days) for treatment of chronic daily headache, with substantial analgesic abuse. Ninety percent of patients had a history of migraine headaches. In 80% of patients codeine was the predominant agent implicated in the analgesic rebound headaches (mean 1053 mg/week) and 24% used ergotamine-containing medications (mean 16 mg/week). Thirty-one percent frequently used injected narcotics. At completion 90% reported that their daily headache was absent or improved, and the analgesic agent was withdrawn successfully in 97%. At six month follow-up, 70% of patients reported that their daily headache was absent or improved and 72% of patients remained free of the offending analgesic agent. Intravenous lignocaine is a useful treatment in the management of chronic daily headache with substantial medication overuse. The benefits of the program last for at least six months.     

Amitriptyline in the prophylactic treatment of migraine and chronic daily headache

(Headache 2011;51:33‐51) Objective and Background.— Amitriptyline is one of the most commonly used medications in migraine prophylaxis. There have been relatively few placebo‐controlled studies of amitriptyline in migraine prophylaxis or in treatment of chronic daily headache (CDH). This report deals with a large placebo‐controlled trial of amitriptyline vs placebo of 20 weeks duration that included subjects with intermittent migraine (IM) as well as CDH. The study was carried out between 1976 and 1979; however, results have never been fully reported. Methods.— Patients with a history of migraine as defined by the 1962 Ad Hoc Committee report were recruited for this study. Subjects had at least 2 headaches per month, and no limit was placed on the number of headaches per month that could be experienced. The study format included a 4‐week baseline period (Period A) in which all subjects received placebo in a dose of 2 pills per day for one week, 3 pills per day for one week and then 4 pills per day for 2 weeks. Subjects with at least 2 migraine headaches in this period were then entered into Period B and randomized into either amitriptyline or placebo tracks. Medication consisted of identical tablets containing either 25 mg amitriptyline or placebo. Period B was 4 weeks in duration with dose titration identical to Period A. The dose could be reduced if necessary to reduce side effects. The minimum dose was one pill per day. Period C was a 12‐week maintenance or stabilization period in which the patient continued the dose established by week 8 with visits at weeks 12, 16, and 20. Patients kept a headache calendar that was used for data collection. Headache frequency (per month), severity, and duration (hours) were the primary measurement parameters employed for data analysis. Results.— For the entire group, 391 subjects were entered into Period A, 338 were randomized into Period B, 317 (81%) subjects completed the first post‐randomization visit (8 weeks), 255 (65%) completed week 12, 210 (54%) completed week 16, and 186 (48%) completed week 20. Using headache frequency and evaluating parameters of (a) improvement, (b) no change, or (c) worsening relative to baseline, there was a significant improvement in headache frequency for amitriptyline over placebo at 8 weeks (P = .018) but not at 12, 16, or 20 weeks. When amitriptyline and placebo patients were compared for headache frequency at 8, 12, 16, and 20 weeks to their own placebo stabilization period at 4 weeks, statistically significant improvement vs worsening was seen in headache frequency at each evaluation point for both amitriptyline and placebo groups (P ≤ .01) reaching 50% reporting a decrease in frequency in each group and approximately 10% reporting worsening by week 20. There were no significant differences in headache severity or duration between amitriptyline and placebo groups at anytime during the study. Within the study sample, there were 36 amitriptyline and 22 placebo subjects who had headaches ≥17 days/month that fit the current definition of CDH by the Silberstein‐Lipton criteria. These were analyzed separately as a subgroup for comparison of amitriptyline vs placebo using a metric of (1) no change or worsening; (2) up to a 50% improvement; and (3) ≥50% improvement in headache frequency. Amitriptyline was superior to placebo in number with improvement in frequency of ≥50% at 8 weeks (25% vs 5% [P = .031]) and at 16 weeks (46% vs 9% [P = .043]). There was a trend for amitriptyline to be superior to placebo at 12 and 20 weeks but this did not reach significance. Conclusions.— In this study, using headache frequency as the primary metric, for the entire group, amitriptyline was superior to placebo in migraine prophylaxis at 8 weeks but, because of a robust placebo response, not at subsequent time points. For the subgroup with CDH, amitriptyline was statistically significantly superior to placebo at 8 weeks and 16 weeks with a similar but nonsignificant trend at 12 and 20 weeks. Compared with placebo amitriptyline is effective in CDH. Amitriptyline was also significantly effective in IM compared intragroup to its own baseline; however, placebo was equally effective in the same analysis. The reason for the robust placebo response in the IM group is not clear, but has been occasionally reported.     

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.     

Melatonin as adjunctive therapy in the prophylaxis of cluster headache: a pilot study

BACKGROUND: The periodicity of cluster headache suggests involvement of the suprachiasmatic nucleus of the hypothalamus, the biological clock. The secretion of melatonin, a hormone produced by the pineal gland and regulated by the suprachiasmatic nucleus, is altered in patients with cluster headache. Melatonin shifts circadian rhythms. A previous study of melatonin for primary prophylaxis of cluster headache demonstrated a 50% response rate. OBJECTIVE: To evaluate the use of melatonin as adjunctive therapy in patients with cluster headache who have incomplete relief of their headaches on conventional therapy. METHODS: Nine patients participated in the study, six with chronic cluster headache and three with episodic cluster headache. Patients with chronic cluster headache completed a baseline diary for 1 month, followed by 1 month of melatonin treatment, then 1 month of placebo. Patients with episodic cluster headache received placebo for 1 month, then melatonin for 1 month. Patients continued their usual prophylactic and abortive treatments during the study. Headache frequency, intensity, and use of analgesics were recorded. The primary endpoint of the study was the mean number of headaches per day, with mean daily analgesic consumption and percentage of mild, moderate, and severe headaches as secondary endpoints. RESULTS: There were no significant differences between means on analysis of variance and t testing for the melatonin, placebo, and baseline months for all primary and secondary endpoints. There were no side effects reported. CONCLUSIONS: Patients with chronic cluster headache or patients with episodic cluster headache whose headaches are uncontrolled on conventional therapy do not appear to gain therapeutically from the addition of melatonin to their usual treatment regimens. It is perhaps the phase-shifting properties of melatonin that mediate its effect in patients with episodic cluster headache, and it may be necessary to treat from the beginning of the cluster bout to reset the circadian pacemaker, thus producing a more positive outcome.     

Treatment of chronic daily posttraumatic headache with divalproex sodium

OBJECTIVE: To determine the effectiveness of divalproex sodium in the treatment of chronic daily posttraumatic headaches. BACKGROUND: Divalproex sodium has been found to be useful for the treatment of migraine and chronic daily headache. No studies have been done to evaluate effectiveness in posttraumatic headache. METHODS: A retrospective review was done of 100 patients treated with divalproex for chronic daily posttraumatic headache of 2 months or longer. RESULTS: Sixty percent of patients with chronic posttraumatic headache had mild to moderate improvement in their headaches after at least 1 month of divalproex sodium. Forty percent either showed no response (26%) or discontinued treatment because of side effects (14%). Fifty-eight percent of patients showing improvement had a change in headache pattern from daily to episodic. CONCLUSIONS: Divalproex sodium appears to be safe and effective for treatment of patients with persistent, chronic daily posttraumatic headaches.     

Traumatic stressors and post-traumatic stress disorder symptoms in headache patients

OBJECTIVE: The aim of this study was to assess the prevalence of significant traumatic stressors and post-traumatic stress disorder (PTSD) symptoms in a headache population. BACKGROUND: Several recent publications have emphasized the relationship between life stressors and/or daily hassles and recurrent headaches. However, little is known about the prevalence and impact of major traumatic stressors in patients with recurrent headaches. METHODS: Eighty patients with either migraine or tension-type headache completed a PTSD checklist. Data were compared with those from patients with chronic masticatory muscle pain of similar intensity and duration. RESULTS: Almost 64% of the headache patients reported one or more major traumatic stressors. This percentage was not significantly different from that of the comparison group, and fell within the broad range reported for exposure to traumatic stressors in epidemiologic studies with nonpatient populations. One out of 6 patients in the total headache sample, and 1 out of 4 of those reporting a traumatic stressor, reported symptoms suggestive of current PTSD. The prevalence of current PTSD-like symptomatology reported by the headache patients was comparable to that of the comparison group of the present study, but higher than that reported for the general population in the available literature printed in English. Traumatic stressors most often reported were not related to direct physical trauma, but rather associated with loss or serious illness of a loved one. CONCLUSION: Exposure to traumatic events in patients with a primary diagnosis of recurrent headaches is similar to that reported for chronic masticatory muscle pain patients or nonpatient populations. However, symptoms consistent with a diagnosis of current PTSD appear to be more frequent in patients with recurrent headaches than reported in the scientific literature printed in English for nonpatient populations. Screening for PTSD symptomatology is recommended as part of the routine clinical evaluation of headache.     

Characteristics of the first 1000 headaches in an outpatient headache clinic registry

(Headache 2011;51:226‐231) Objective.— To analyze the incidence and characteristics of the first 1000 headaches in an outpatient clinic. Background.— Headache is a common cause of medical consultation, both in primary care and in specialist neurology outpatient clinics. The International Classification of Headache Disorders, 2nd Edition (ICHD‐II), enables headaches to be classified in a precise and reproducible manner. Methods.— In January 2008, an outpatient headache clinic was set up in Hospital Clínico Universitario, a tertiary hospital in Valladolid, Spain. Headaches were classified prospectively in accordance with ICHD‐II criteria. In each case we recorded age and sex, duration of headache, ancillary tests required, and previous symptomatic or prophylactic therapies. Results.— In January 2010, the registry included 1000 headaches in 682 patients. The women/men ratio was 2.46/1 and the mean age of the patients was 43.19 ± 17.1 years (range: 14‐94 years). Patients were referred from primary care (53.4%), general neurology clinics (36.6%), and other specialist clinics (9%). The headaches were grouped (ICHD‐II classification) as follows: group 1 (Migraine), 51.4%; group 2 (Tension‐type headache), 16%; group 3 (Trigeminal autonomic cephalalgias), 2.6%; group 4 (Other primary headaches) and group 13 (Cranial neuralgias), 3.4%. The diagnostic criteria of chronic migraine were satisfied in 8.5% of migraines. Regarding secondary headaches, 1.1% of all cases were included in group 5 (Headaches attributed to trauma) and 8.3% in group 8 (Headaches attributed to a substance or its withdrawal). Only 3.4% of headaches were classified in group 14 (Unspecified or not elsewhere classified), and 5.2% were included in the groups listed in the ICHD‐II research appendix. Conclusion.— This registry outlines the characteristics of patients seen in an outpatient headache clinic in a tertiary hospital; our results are similar to those previously reported for this type of outpatient clinic. Migraine was the most common diagnosis. Most headaches can be classified using ICHD‐II criteria.     

Chronic daily headache in Taipei, Taiwan: prevalence, follow-up and outcome predictors

We conducted a two-stage population-based headache survey among subjects aged > or = 15 in Taipei, Taiwan. Subjects with chronic daily headache (CDH) in the past year were identified, interviewed and followed-up. CDH was defined as a headache frequency > 15 days/month, with a duration > 4 h/day. Of the 3377 participants, 108 (3.2%) fulfilled the criteria for CDH, with a higher prevalence in women (4.3%) than men (1.9%). TM was the most common subtype (55%), followed by CTTH (44%). Thirty-four per cent of the CDH subjects overused analgesics. At the 2-year follow-up, 35% of the CDH subjects still had CDH. The significant predictors for persistent CDH at follow-up included: older age ( > or = 40 years) (RR = 2.4), CDH onset after 32 years (RR = 1.8), CDH duration > or = 6 years (RR = 2.0), medication overuse (RR = 1.8), and "daily" headache (RR = 2.1). We found that CDH is not uncommon in the community and its prevalence is similar among different populations. Older subjects and those with medication overuse may have a more protracted course of illness.     

Use of complementary and alternative medicine by patients with chronic tension-type headache: results of a headache clinic survey

OBJECTIVES: This study was undertaken to evaluate the rates, pattern, and presence of predictors of complementary and alternative medicine use in a clinical population of patients with chronic tension-type headache. BACKGROUND: The use of complementary and alternative medicine in the treatment of headaches is a growing phenomenon about which little is known. METHODS: A total of 110 chronic tension-type headache patients attending a headache clinic participated in a physician-administered structured interview designed to gather information on complementary and alternative medicine use. RESULTS: Past use of complementary and alternative therapies was reported by 40% of the patients surveyed (22.7% in the previous year). Chronic tension-type headache patients prefer complementary and alternative practitioner-administered physical treatments to self-treatments, the most frequently used being chiropractic (21.9%), acupuncture (17.8%), and massage (17.8%). Only 41.1% of the patients perceived complementary and alternative therapies to be beneficial. The most common source of recommendation of complementary and alternative medicine was a friend or relative (41.1%). Most of the chronic tension-type headache patients used complementary and alternative treatment as a specific intervention for their headache (77.3%). Almost 60% of complementary and alternative medicine users had not informed their medical doctors of their use of complementary and alternative medicine. The most common reasons given for choosing to use a complementary or alternative therapy was the "potential improvement of headache" it offered (45.4%). The patients who had used more complementary and alternative treatments were found to be those recording a higher lifetime number of visits to conventional medical doctors, those with a comorbid psychiatric disorder, those enjoying a higher (household) income, and those who had never tried a preventive pharmacological treatment. CONCLUSIONS: Our findings suggest that headache-clinic chronic tension-type headache patients, in their need of and quest for care, seek and explore both conventional and complementary and alternative therapies, even if only 41.1% of them perceived complementary treatments as effective. Physicians should be made aware of this patient-driven change in the medical climate in order to prevent misuse of health care resources and to be better equipped to meet patients' care requirements.