Clinical features of headache patients with fibromyalgia comorbidity

Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.     

At the crossroads between tension-type headache and fibromyalgia

Fibromyalgia syndrome and tension-type headache have multiple clinical features in common, and pathogenic mechanisms partly overlap. Significant differences need to be recognized as well. Studying the correlations of these often comorbid conditions represents a unique opportunity to gain insight into their pathophysiology and that of other chronic pain syndromes, to increase the accuracy of their diagnosis, and to improve the therapeutic armamentarium.     

Neuromodulators for the treatment of headache disorders and fibromyalgia

Migraine and fibromyalgia are prevalent and disabling disorders with few preventive medications approved by the US Food and Drug Administration (FDA). Neuromodulators (or antiepileptic drugs; AEDs) are often effective in the treatment of these conditions. Divalproex sodium and topiramate are FDA-approved AEDs for migraine. For fi bromyalgia, pregabalin has recently been approved in the United States. We review the use of AEDs in the preventive treatment of these highly prevalent disorders.     

Psychological trauma in chronic pain: Implications of PTSD for fibromyalgia and headache disorders

The association of traumatic exposures with posttraumatic stress disorder (PTSD) and other mental health conditions is well known. Patients with chronic pain, particularly headache disorders and fibromyalgia (FM), associated with psychological traumas need a special management strategy. Diagnosis of headache disorders and FM in traumatized patients and collecting the clinical history of a traumatic event or diagnosing PTSD in chronic pain patients is of great importance. Psychotherapy and pharmacotherapeutic options should be started on patients with comorbid PTSD and headache disorders and/or FM.     

The science of fibromyalgia

Fibromyalgia (FM) is a common chronic widespread pain disorder. Our understanding of FM has increased substantially in recent years with extensive research suggesting a neurogenic origin for the most prominent symptom of FM, chronic widespread pain. Neurochemical imbalances in the central nervous system are associated with central amplification of pain perception characterized by allodynia (a heightened sensitivity to stimuli that are not normally painful) and hyperalgesia (an increased response to painful stimuli). Despite this increased awareness and understanding, FM remains undiagnosed in an estimated 75% of people with the disorder. Clinicians could more effectively diagnose and manage FM if they better understood its underlying mechanisms. Fibromyalgia is a disorder of pain processing. Evidence suggests that both the ascending and descending pain pathways operate abnormally, resulting in central amplification of pain signals, analogous to the "volume control setting" being turned up too high. Patients with FM also exhibit changes in the levels of neurotransmitters that cause augmented central nervous system pain processing; levels of several neurotransmitters that facilitate pain transmission are elevated in the cerebrospinal fluid and brain, and levels of several neurotransmitters known to inhibit pain transmission are decreased. Pharmacological agents that act centrally in ascending and/or descending pain processing pathways, such as medications with approved indications for FM, are effective in many patients with FM as well as other conditions involving central pain amplification. Research is ongoing to determine the role of analogous central nervous system factors in the other cardinal symptoms of FM, such as fatigue, nonrestorative sleep, and cognitive dysfunction.     

The tension headache component of chronic daily headache

Chronic daily headache (CDH) is an overarching term that includes multiple types of frequent primary headaches that are not trigeminal-autonomic cephalgias. The components of typical CDH can be divided into a more severe or “big” headache and a less severe or “little” headache. The big headaches tend to have features of migraine while the little headaches have features of tension-type headache (TTH). Whether this represents a spectrum or continuum or whether it is the superimposition of two unique headache entities is open to debate. For subjects with big and little headache, the concept that the TTH component is part of a spectrum seems likely. Subjects with only TTH and no migrainous component seem to represent a different entity, pure chronic TTH. These patients have a daily moderate headache that is poorly responsive to current therapies and appears to be a different TTH than the migraine tension type of CDH. The TTH component of CDH may represent multiple subdivisions of TTH.     

Medication-overuse headache in patients with cluster headache

Cluster headache (CH) is associated with the most severe pain of the primary headache disorders. Barriers to optimal care include misdiagnosis, diagnostic delay, undertreatment, and mismanagement. Medication-over-use headache (MOH) may further complicate CH and may present as increased CH frequency or development of a background headache, which may be featureless or have some migrainous quality. A personal or familial history of migraine appears to be strongly associated with the development of MOH in CH, at least with the phenotype of background headache. Patients with CH, especially those with a personal and/or family history of migraine, must be carefully monitored for MOH, and medication withdrawal should be considered if a CH patient presents with features of MOH.     

The psychological profiles of patients with whiplash-associated headache

Headache often compounds chronic neck pain following whiplash injury. To better understand post-traumatic headache, the SCL-90-R symptom checklist was used to determine the psychological profiles of patients with whiplash-associated headache and of patients with whiplash-associated neck pain without headache. The psychological profiles of these patients were compared with previously published SCL-9O-R profiles of patients with post-traumatic and nontraumatic headache, and of the normal population. Patients with whiplash-associated headache were not significantly different from those with other forms of post-traumatic headache or with whiplash-associated neck pain without headache. However, when patients with whiplash-associated headache and patients with nontraumatic headache were compared to normal data, significant differences emerged. Patients with nontraumatic headache exhibited higher scores on all subscales, whereas patients with whiplash-associated headache differed from the normal sample only on somatization, obsessive-compulsive, depression and hostility subscales, and the global severity index. These differences imply that patients with whiplash-associated headache suffer psychological distress secondary to chronic pain and not from tension headache and generalized psychological distress.     

The comorbidity of headache with other pain syndromes

In this article, we consider the possible reasons and supporting evidence for the comorbidity of chronic pain conditions. To simplify the discussion, we primarily focus on the epidemiology of headache with other pain conditions, dividing studies into those based on children or adolescents and those based on adults. We consider exogenous and endogenous factors, and methodological challenges, in understanding whether and how 2 pain conditions may be related.     

The evaluation of children and adolescents with headache

Headache can be caused by primary entities (as in migraine or tension-type headache) or the pain may result from secondary causes, such as brain tumors, idiopathic intracranial hypertension, chronic meningitis, hydrocephalus, drug intoxications, paranasal sinus disease, or acute febrile illnesses (eg, influenza). To determine the nature of a child’s headache, the evaluation begins with a thorough medical history, followed by methodic physical examination with measurement of vital signs and complete neurologic examination. The diagnosis of primary headache disorders such as migraine and tension-type rests principally on clinical criteria as set forth by the International Headache Society (). Clues to the presence and identification of secondary causes of headache are uncovered through this systematic process of history and physical examination. The performance of ancillary diagnostic testing rests upon information or concerns revealed during the history and physical examination.