Tension-type headache with medication overuse: Pathophysiology and clinical implications

Tension-type headache (TTH) is the most prevalent primary headache disorder. An important factor in the long-term prognosis of TTH is the overuse of acute medications used to treat headache. There are many reasons why patients with TTH overuse acute medications, including biobehavioral influences, dependency, and a lack of patient education. Chronic daily headache occurs in 4.1% of the general population, and chronic tension-type headache and medication overuse headache (MOH) occur in approximately 2.2% and 1.5%, respectively. A proper diagnosis is essential for the treatment of these patients. Treatment should include pathological considerations concerning TTH and MOH, which include peripheral and central mechanisms. Because TTH with MOH carries the worst prognosis, more clinical studies focusing on the complex interaction and treatments of TTH and MOH are needed.     

Presentation of a new instrument: the diagnostic headache diary

A new instrument, the Diagnostic Headache Diary, based on the operational diagnostic criteria of the International Headache Society (IHS), was tested in 61 migraine patients from a headache research clinic using the clinical diagnosis (IHS criteria) for comparison. All patients kept the diary for one to eight months. The clinical and diary diagnosis of migraine with and without aura was the same in, respectively, 72 and 87% of the patients. Nausea, photophobia and phonophobia tended to be more pronounced at the clinical interview. The diary identified 20 more cases of episodic tension-type headache and 15 fewer cases of chronic tension-type headache than the clinical interview. Two blinded observers always made the same IHS diagnoses when interpreting the diagnostic headache diary. A combination of a clinical interview and the diagnostic headache diary gives a qualitatively and quantitatively more precise diagnosis than a clinical interview alone.     

The validity of questionnaire-based diagnoses: the third Nord-Trøndelag Health Study 2006–2008

The Nord-Trøndelag Health Study (HUNT 3) performed in 2006–2008 is a replication of the cross-sectional survey from 1995 to 1997 (HUNT 2). The aim of the present study was to assess the sensitivity and specificity of questionnaire-based headache diagnoses using a personal interview by a neurologist as a gold standard. For the questionnaire-based status as headache sufferer, a sensitivity of 88%, a specificity of 86%, and a kappa statistic of 0.70 were found. Chronic headache, chronic tension-type headache (TTH), and medication overuse headache (MOH) were diagnosed with a specificity of ≥99%, and a kappa statistic of ≥0.73. Lower figures were found for the diagnoses of migraine and TTH. For individuals with headache ≥1 day per month, a sensitivity of 58% (migraine) and 96% (TTH), a specificity of 91 and 69%, and a kappa statistic of 0.54 and 0.44 were found, respectively. The specificity for migraine with aura was 95%. In conclusion, the HUNT 3-questionnaire is a valid tool for identifying headache sufferers, and diagnosing patients with chronic headache, including chronic TTH and MOH. The more moderate sensitivity for migraine and TTH makes the questionnaire-based diagnoses of migraine and TTH suboptimal for determining the prevalence. However, the high specificity of the questionnaire-based diagnosis of migraine, in particular for migraine with aura, makes the questionnaire a valid tool for diagnosing patients with migraine for genetic studies.     

Medication overuse headache and chronic migraine in a specialized headache centre: field-testing proposed new appendix criteria

The classification subcommittee of the International Headache Society (IHS) has recently suggested revised criteria for medication overuse headache (MOH) and chronic migraine (CM). We field tested these revised criteria by applying them to the headache population at the Danish Headache Centre and compared the results with those using the current criteria. For CM we also tested two alternative criteria, one requiring > or = 4 migraine days/month and > or = 15 headache days/month, the second requiring > or = 15 headache days/month and > or = 50% migraine days. We included 969 patients with migraine or tension-type headache (TTH) among 1326 patients treated and dismissed in a 2-year period. Two hundred and eighty-five patients (30%) had TTH, 265 (27%) had migraine and 419 (43%) had mixed migraine and TTH. The current criteria for MOH classified 86 patients (9%) as MOH, 98 (10%) as probable MOH and 785 (81%) as not having MOH after a 2-month drug-free period. Using the appendix criteria, 284 patients (29%) were now classified as MOH, no patients as probable MOH and 685 (71%) as not having MOH. For CM only 16 patients (3%) fulfilled the current diagnostic criteria. This increased to 42 patients (7%) when we applied the appendix criteria. Using the less restrictive criteria of > or = 4 migraine days and > or = 15 headache days, 88 patients (14%) had CM, whereas the more restrictive criteria of > or = 15 headache days and > or = 50% migraine days resulted in 24 patients (4%) with CM. Our data suggest that the IHS has succeeded in choosing new criteria for CM which are neither too strict, nor too loose. For MOH, a shift to the appendix criteria will increase the number of MOH patients, but take into account the possibility of permanent changes in pain perception due to medication overuse and the possibility of a renewed effect of prophylactic drugs due to medication withdrawal. We therefore recommend the implementation of the appendix criteria for both MOH and CM into the main body of the International Classification of Headache Disorders.     

Assessment of headache diagnosis. A comparative population study of a clinical interview with a diagnostic headache diary

The level of agreement between headache information, attained by clinical interview and headache diary, was evaluated in subjects who frequently suffered from headache and were participating in an epidemiological study of headache. One hundred and six subjects were interviewed and asked to complete a diary for a period of 4-8 weeks; 46% completed the study. For migraine the diary and clinical diagnoses demonstrated agreement in 82%, kappa value 0.57, sensitivity 90% and specificity 64%. For tension-type headache they demonstrated agreement in 87%, kappa value 0.39, sensitivity 97%, specificity 29% and a good agreement of frequency of tension-type headache was also obtained. In migraine, but not in tension-type headache, accompanying symptoms tended to be overestimated in the interview. The diary was not useful for the diagnosis of migraine with aura, but proved valuable in distinguishing between migraine and tension-type headache, and in the identification of coexisting headache disorders. Combined use of a diagnostic diary and clinical interview is recommended.     

Efficacy of multidisciplinary treatment in a tertiary referral headache centre

Despite the high prevalence of headaches, multidisciplinary headache clinics are few and their efficacy still needs validation. We set out to describe the procedures, characterize the patients and evaluate the treatment results in Danish Headache Centre. All clinical records for patients discharged in 2002 were systematically reviewed. Diagnoses were classified in accordance with ICHD-II. Outcome results were analysed with respect to headache diagnoses, frequency, intensity, absence from work and medication use. Five hundred and five patients were included and 336 were eligible for the study. Mean age was 46 years and male/female ratio 1:2.4. For patients without medication overuse headache (MOH) a reduction in headache frequency (P<0.01) and intensity (P<0.05) was seen for frequent episodic and chronic tension-type headache (TTH), migraine, cluster and other headaches. No reduction was seen in post-traumatic headache. Absence from work decreased significantly for migraine (P<0.001) and frequent episodic TTH (P<0.05). For patients with MOH a reduction in headache frequency was seen for TTH and migraine (P<0.001). A specialized headache centre is valuable in treatment of patients with complex headache disorders.     

An electronic diary on a palm device for headache monitoring: a preliminary experience

Patients suffering from headache are usually asked to use charts to allow monitoring of their disease. These diaries, providing they are regularly filled in, become crucial in the diagnosis and management of headache disorders because they provide further information on attack frequency and temporal pattern, drug intake, trigger factors, and short-/long-term responses to treatment. Electronic tools could facilitate diary monitoring and thus the management of headaches. Medication overuse headache (MOH) is a chronic and disabling condition that can be treated by withdrawing the overused drug(s) and adopting specific approaches that focus on the development of a close doctor–patient relationship in the post-withdrawal phase. Although the headache diary is, in this context, an essential tool for the constant, reliable monitoring of these patients to prevent relapses, very little is known about the applicability of electronic diaries in MOH patients. The purpose of this study was to evaluate the acceptability of and patient compliance with an electronic headache diary (palm device) as compared with a traditional diary chart in a group of headache inpatients with MOH. A palm diary device, developed in accordance with the ICHD-II criteria, was given to 85 MOH inpatients during the detoxification phase. On the first day of hospitalization, the patients were instructed in the use of the diary and were then required to fill it in daily for the following 7 days. Data on the patients’ opinions on the electronic diary and the instructions given, its screen and layout, as well as its convenience and ease of use, in comparison with the traditional paper version, were collected using a numerical rating scale. A total of 504 days with headache were recorded in both the electronic and the traditional headache diaries simultaneously. The level of patient compliance was good. The patients appreciated the electronic headache diary, deeming it easy to understand and to use (fill in); most of the patients rated the palm device handier than the traditional paper version.     

Clinical outcome of a headache-specific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study

This study investigated the outcome of a 5-day headache-specific multidisciplinary treatment program (MTP) and the adherence to treatment recommendations in 295 prospectively recruited consecutive headache patients [210 migraine, 17 tension-type headache (TTH), 68 combination headache, including 56 medication-overuse headache (MOH)]. Headache frequency decreased from 13.4 (±8.8) to 8.8 (±8.0) days per month after 12–18 months. Forty-three percent of the participants fulfilled the primary outcome (reduction of headache frequency of ≥50%), which was less likely in patients with combination of migraine and TTH compared to migraine (OR = 3.136, p = 0.002) or TTH (OR = 1.029, n.s.). Increasing number of headache days per month (OR = 1.092, p ≤ 0.0001) and adherence to lifestyle modifications (OR = 1.269, p = 0.004) predicted primary outcome. 51 of 56 MOH patients were treated successfully. Thirty-five percent of the patients were adherent to pharmacological prophylaxis, 61% to relaxation therapy, and 72% to aerobic endurance sports. MTP is effective in headache treatment. Adherence to therapy was associated with better outcome.     

Population-based validation of a German-language self-administered headache questionnaire

We validated a German-language self-administered headache questionnaire for migraine (M), tension-type headache (TTH) and trigeminal autonomic cephalalgia (TAC) in a general population sample of people with headache. Randomly selected subjects ( n  = 240) diagnosed by the questionnaire as M ( n  = 60), TTH ( n  = 60), a combination of M and TTH (M+TTH, n  = 60) and TAC ( n  = 60) were invited for examination by headache specialists. One hundred and ninety-three subjects (80%) were studied. Sensitivity and specificity for M were 0.85 and 0.85, for TTH 0.6 and 0.88, for M+TTH 0.82 and 0.87, respectively. Cohen's κ was 0.6 (95% confidence interval 0.50, 0.71). Of 45 patients with TAC according to the questionnaire, physicians diagnosed cluster headache in two patients only. We conclude: (i) the questionnaire can be used to diagnose M, TTH and M+TTH, but not TAC; (ii) screening questionnaires for epidemiological research should be validated in a general population sample but not in a tertiary headache clinic.     

A basic diagnostic headache diary (BDHD) is well accepted and useful in the diagnosis of headache. a multicentre European and Latin American study

Aims: We tested the usability and usefulness of the basic diagnostic headache diary (BDHD) for the diagnosis of migraine, tension-type headache and medication-overuse headache in European and Latin American countries. Methods: Patients were subdivided into two groups according to a 1:1 randomization list. Those in group 1 were sent the BDHD before their first visit to the headache centre and asked to complete it for at least 1 month. Those in group 2 made their first visit to the headache centre without receiving the BDHD. Results: A total of 626 patients from nine countries and 16 centres completed the study. The BDHD entries were complete in 97.5% of cases. BDHD information and clinical interview were, when taken together, considered complete for diagnosis in 97.7% of cases in group 1 whereas the information obtained by clinical interview alone in group 2 was considered complete in only 86.8% of cases (p?相似文献   

Validation of a guideline-based decision support system for the diagnosis of primary headache disorders based on ICHD-3 beta

Background

China may have the largest population of headache sufferers and therefore the most serious burden of disease worldwide. However, the rate of diagnosis for headache disorders is extremely low, possibly due to the relative complexity of headache subtypes and diagnostic criteria. The use of computerized clinical decision support systems (CDSS) seems to be a better choice to solve this problem.

Methods

We developed a headache CDSS based on ICHD-3 beta and validated it in a prospective study that included 543 headache patients from the International Headache Center at the Chinese PLA General hospital, Beijing, China.

Results

We found that the CDSS correctly recognized 159/160 (99.4%) of migraine without aura, 36/36 (100%) of migraine with aura, 20/21 (95.2%) of chronic migraine, and 37/59 (62.7%) of probable migraine. This system also correctly identified 157/180 (87.2%) of patients with tension-type headache (TTH), of which infrequent episodic TTH was diagnosed in 12/13 (92.3%), frequent episodic TTH was diagnosed in 99/101 (98.0%), chronic TTH in 18/20 (90.0%), and probable TTH in 28/46 (60.9%). The correct diagnostic rates of cluster headache and new daily persistent headache (NDPH) were 90.0% and 100%, respectively. In addition, the system recognized 32/32 (100%) of patients with medication overuse headache.

Conclusions

With high diagnostic accuracy for most of the primary and some types of secondary headaches, this system can be expected to help general practitioners at primary hospitals improve diagnostic accuracy and thereby reduce the burden of headache in China.     

Field testing the alternative criteria for tension-type headache proposed in the third beta edition of the international classification of headache disorders: results from the Korean headache-sleep study

Background

According to the third beta edition of the International Classification of Headache Disorder (ICHD-3 beta), the diagnostic criteria for tension-type headache (TTH) might lead to the inclusion of individuals with headaches showing migrainous features. To better define TTH, the alternative diagnostic criteria were proposed in the appendix of ICHD-3 beta. This study attempted to test the alternative criteria for diagnosis of TTH proposed in ICHD-3 beta in a population-based sample from Korea.

Methods

We selected participants from the Korean population aged 19–69 years using stratified random sampling and evaluated them by interview using a questionnaire designed to identify headache type, headache characteristics, and psychiatric comorbidities.

Results

Of the 2,762 participants, 586 (21.3%) were diagnosed as having TTH using the standard criteria. Among these, 238 (40.6%) were also classified as having TTH using the alternative criteria. All 238 TTH subjects first diagnosed as having TTH by the alternative criteria were also classified as having TTH by the standard criteria. If the standard criteria were not applied, the remaining 348 patients were subclassified as having probable migraine (115, 19.6%) and unclassified headache (233, 39.7%). Compared with subjects diagnosed with TTH using the standard criteria, those diagnosed using the alternative criteria were less likely to demonstrate unilateral, pulsating headache, which is aggravated by movement, photophobia, phonophobia, and osmophobia.

Conclusion

Using the alternative criteria, less than half of the subjects with TTH according to the standard criteria were classified as having TTH. All the subjects with TTH by the alternative criteria were classified as having TTH by the standard criteria. This study also demonstrated that subjects diagnosed with TTH using the standard criteria could include people with headaches showing migrainous features.     

Coping styles of headache sufferers

Psychological factors are important in the chronification and aggravation of headaches. We studied 90 patients suffering from migraine, chronic daily headache (CDH) evolved from migraine, and episodic or chronic tension-type headache (TTH). Emotional, cognitive, and behavioral pain coping were assessed using the Kiel Pain Inventory (KPI), Beck's Depression Inventory, the State-Trait-Anxiety Inventory, and Quality of Life Questionnaire. In addition, the clinical course of headache was analyzed using a validated headache diary. The results were as follows. Firstly, the KPI is reliable internally for the assessment of pain-coping strategy employment among headache patients. Secondly, migraine sufferers were characterized by pronounced psychological abnormalities during the headache phase, demonstrating a less adaptive coping behavior. This was in contrast to the TTH patients, who showed more general distress manifesting in elevated anxiety and lower quality of life. The only factor which appeared to be essential for differentiating between migraine and TTH was the intensity of headache. Thirdly, chronic TTH and CDH evolved from migraine demonstrated more pronounced psychological disabilities and more severe clinical courses of headaches than episodic TTH or nontransformed migraine. The predictor variable for transformation of migraine was impairment of well-being/quality of life, and for transformation of TTH, the frequency of headaches and depression. Finally, analgesic misuse seems to be less important for chronification and transformation of headaches than the degree of psychological disability. This study draws attention to the role of psychological factors in the chronification of TTH and transformation of migraine and provides some recommendations for the behavioral treatment of chronic headaches.     

Medication Overuse Headache in School‐Aged Children: More Common Than Expected?

Objective.— To investigate the prevalence of medication overuse headache (MOH) in a group of children and adolescents seen for headache in a third‐level center in Italy. Background.— Epidemiological studies indicate a prevalence of MOH in children and adolescents between 0.3 and 0.5%; no data are available for the Italian population. Methods.— We studied a group of first‐seen children and adolescents (118 patients, 43.2% male and 56.8% female, mean age: 11.9 years). A detailed history was taken, using criteria defined by Olesen et al to assess the presence of MOH. Statistical correlations between demographic and diagnostic variables were assessed. Results.— Eleven (9.3%) of our patients presented MOH; in the group with chronic daily headache, the prevalence raised to 20.8%. At follow up, after introduction of a more rationale treatment, most patients improved, but 2 of them reported a worsening of their headache. Conclusions.— We believe that a strong warning regarding medication overuse in headache therapy is essential for pediatricians and neuropsychiatrists.     

Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study

We performed a long-term follow-up examination in children and adolescents with migraine and tension-type headache (TTH) in order to investigate the evolution of clinical features and headache diagnoses, to compare International Classification of Headache Disorders (ICHD)-I and ICHD-II criteria and to identify prognostic factors. We re-examined 227 patients (52.4% female, age 17.6 +/- 3.1 years) 6.6 +/- 1.6 years after their first presentation to a headache centre using identical semistructured questionnaires. Of 140 patients initially diagnosed with migraine, 25.7% were headache free, 48.6% still had migraine and 25.7% had TTH at follow-up. Of 87 patients with TTH, 37.9% were headache free, 41.4% still had TTH and 20.7% had migraine. The number of subjects with definite migraine was higher in ICHD-II than in ICHD-I at baseline and at follow-up. The likelihood of a decrease in headache frequency decreased with a changing headache location at baseline (P < 0.0001), with the time between baseline and follow-up (P = 0.0019), and with an initial diagnosis of migraine (P = 0.014). Female gender and a longer time between headache onset and first examination tended to have an unfavourable impact. In conclusion, 30% of the children and adolescents presenting to a headache centre because of migraine or TTH become headache-free in the long-term. Another 20-25% shift from migraine to TTH or vice versa. ICHD-II criteria are superior to those of ICHD-I in identifying definite migraine in children and adolescents presenting to a headache centre. The prognosis is adversely affected by an initial diagnosis of migraine and by changing headache location, and it tends to be affected by an increasing time between headache onset and first presentation.     

Medication overuse headache and applicability of the ICHD-II diagnostic criteria: 1-year follow-up study (CARE I protocol)

Medication overuse headache (MOH) is a growing problem worldwide and a challenge for clinicians and investigators. This study aims to contribute to the ongoing debate surrounding the classification of MOH. Applying the revised diagnostic criteria for MOH contained in the updated International Classification of Headache Disorders (ICHD-II), we enrolled 140 probable MOH (p-MOH) patients. They were submitted to an in-patient detoxification protocol and re-examined 2, 6 and 12 months later to confirm, or otherwise, the diagnosis of MOH and to observe the evolution of their headache. MOH diagnosis was confirmed 2 months after detoxification in 71% of patients, who reverted to an episodic headache pattern and stopped their drug overuse The overall clinical situation at 2 months closely reflected the 1-year trend. The 2-month period after drug withdrawal should be retained as a diagnostic criterion in the ICHD-II because it is useful not only as a diagnostic parameter, but also as predictor of a good outcome of 1-year drug withdrawal. In addition, the present findings point to the need for a more objective criterion to quantify headache frequency after drug withdrawal.     

Controversy over the Classification of Medication-Overuse Headache

Medication-overuse headache (MOH) is a relatively common and impactful disorder, affecting 1% to 2% of the population, characterized by daily or near-daily headache aggravated by chronic acute medication intake. Primary headache patients do not necessarily develop MOH after acute medication overuse, although a pre-existing primary headache is inevitably present. Likewise, headache patients may deteriorate in terms of frequency without medication overuse, or suffer from chronic headache in the presence of drug abuse without any causal relationship. To classify and define diagnostic criteria for MOH in the absence of objective biomarkers is a difficult task that is presently based on clinical grounds and is limited in part by the relative lack of research in this field. The present criteria are less restrictive but also less precise than the previous versions because they allow the diagnosis without the previously required MOH confirmation after medication withdrawal. MOH should remain as a distinct secondary disorder based on the available clinical and pathophysiological evidence.     

Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons. The Akershus study of chronic headache

We studied secondary chronic headaches (≥ 15 days/month for at least 3 months) in a random sample of 30 000 persons aged 30–44 years. They received a mailed questionnaire. Those with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. The criteria of the International Classification of Headache Disorders (ICHD-II) were applied. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Of the 633 participants, 298 had a secondary chronic headache. The 1-year prevalence of secondary chronic headache was 2.14%, i.e. chronic posttraumatic headache 0.21%, chronic headache attributed to whiplash injury 0.17%, post-craniotomy headache 0.02%, medication-overuse headache (MOH) 1.72%, cervicogenic headache 0.17%, headache attributed to chronic rhinosinusitis 0.33% and miscellaneous headaches 0.04%. The majority of those with ICHD-II-defined secondary chronic headache had MOH, while about one-third had other secondary headaches often in combination with MOH.