Recurrent headache and migraine as a public health problem--a population-based study in Sweden

OBJECTIVE: To study the prevalence of recurrent headache and/or self-considered migraine (RH/M) and its association with self-rated health, other symptoms, and use of health care and medication in the general population. METHODS: The study comprised a random population sample of 43,770 men and women aged 18 to 79 years covering an area of 58 municipalities in Sweden. The data were obtained using a postal survey questionnaire during March to May 2000. The overall response rate was 65%. RESULTS: The overall prevalence of self-reported RH/M was 10% among men and 23% among women. RH was more common (15%) than migraine (4%). The prevalence of RH was highest in the younger age groups (18 to 34 years) and decreased with increasing age. The prevalence of migraine was highest (6%) among 35 to 49 years old. Subjects with RH/M had poorer self-rated health compared to subjects with no reported headache independent of age. Poor self-rated health was most common among subjects with both RH and M. Musculoskeletal pain and psychosomatic symptoms were more common among those with RH/M. The association between RH/M and poor self-rated health was partly explained by these symptoms. Those with RH/M utilized more health care at all levels than those with no RH/M. In addition, subjects with RH/M reported two to three times more often that they had been in need of medical care but not sought it. About two-thirds of the subjects with RH/M had used analgesic during the last 2 weeks compared with less than one-third among subjects with no RH/M. CONCLUSION: RH/M constitutes a substantial public health problem that mainly affects young and middle aged adults. It is associated with poor self-rated health, musculoskeletal and psychosomatic symptoms, increased use of health care and medication as well as unmet needs of health care.     

Psychosocial factors in children and adolescents with migraine and tension-type headache: a controlled study and review of the literature

We investigated 341 children and adolescents to evaluate the relevance of psychosocial factors in idiopathic headache. According to the criteria of the International Headache Society, 151 subjects had migraine and 94 had tension-type headache (TTH). Ninety-six subjects were headache-free controls. Psychosocial factors covered family and housing conditions, school problems, relations in the peer group, and several other items. We found that migraine patients did not differ from headache-free controls. Patients with TTH more often had divorced parents than the headache-free controls, and they had fewer peer relations than migraineurs and controls. In addition, migraine patients were significantly more often absent from school due to headache. All other psychosocial factors failed to discriminate between the three study groups. In conclusion, this controlled study in children and adolescents suggests that migraine is not related to family and housing conditions, school situation, or peer relations, whereas TTH is associated with a higher rate of divorced parents and fewer peer relations.     

Pain-relieving factors in migraine and tension-type headache

We performed the present study to compare patients with migraine and tension-type headache (TTH) in their behaviour during the attacks and the manoeuvres to relieve the pain. One hundred thirty consecutive patients with either migraine (n = 75) or TTH (n = 55) were questioned (including the use of a checklist) concerning their usual behaviour during the attacks and non-pharmacological manoeuvres performed to relieve the pain. The results of the two types of headache were compared. Patients with migraine tended to perform more manoeuvres than patients with TTH (mean: 4.3 vs. 3.6). These manoeuvres included pressing and applying cold stimuli to the painful site, trying to sleep, changing posture, sitting or reclining in bed (using more pillows than usual to lay down), isolating themselves, using symptomatic medication, inducing vomiting, changing diet and becoming immobile during the attacks. The only measure predominantly reported by patients with TTH was scalp massage. Migraineurs, compared to patients with TTH, changing eating habits, pressed the pain site; there were no significant differences between the two groups. The behaviour of patients during headache attacks varies with the diagnosis. Measures that do not always result in pain relief are performed in order to prevent its worsening or to improve associated symptoms. These behavioural differences may be because of the different pathogenesis of the attacks or of various styles of dealing with the pain. They can also aid the differential diagnosis between headaches in doubtful cases.     

Migraine, tension headache and left-handedness

The Geschwind-Behan hypothesis, that migraine is more common among left-handed patients, was tested in 320 migraine sufferers. The frequency of left-handedness was also assessed in 68 tension headache patients and compared to that in 140 healthy controls. No significant differences were observed. This study failed to support the association between migraine, tension headache and left-handedness using the IHS classification of headache.     

One-year prevalence of migraine in Sweden: a population-based study in adults

A randomly selected sample of 1668 individuals (782 women and 886 men) aged 18-74 years was interviewed by telephone using a standardized questionnaire including the International Headache Society (IHS) criteria for migraine. The survey was performed by SIFO, the national public opinion poll agency. The results obtained demonstrate that 21% of the Swedish population had suffered from severe headaches during the past year. A majority of these headache sufferers (61%) fulfilled the IHS-criteria for migraine. The 1-year prevalence of migraine in Sweden was found to be 13.2 +/- 1.9% (16.7% among women and 9.5% among men). The prevalence of migraine in this Swedish population did not differ between the northern, middle and southern part of Sweden, or between urban and rural areas or different income groups. Only about half (49%) of the migraineurs had been diagnosed by a physician. Among the individuals who fulfilled the IHS criteria for migraine the mean attack-frequency was 1.3 per month and the mean attack-duration was 19 h. If the duration of the attack was disregarded as a strict criterion for migraine (attacks < 4 h and > 72 h were included), the prevalence increased to 17.0 +/- 1.9% without affecting the sex distribution. With this amendment, 92% of those who considered their headaches to be migraine or migraine-like in fact fulfilled the alternative criteria for migraine. However, only 76% of those who believed that they had migraine or migraine-like headaches fulfilled the strict IHS criteria for migraine. An extension of the time window from 4 to 72 h may be reasonable both from a pragmatic and from a rational clinical point of view.     

Predisposing and provoking factors in childhood headache

Objective.–To study the differences in predisposing and provoking factors between childhood migraine and nonmigrainous headache.
Background.–Information on the predisposing and provoking factors of headache could help to find ways to prevent it. Differences in predisposing and provoking factors between migraine and nonmigrainous headache are largely unknown.
Methods.–An unselected, population-based, prospective, follow-up study on the occurrence of headache in schoolchildren was carried out in 1290 children aged from 8 to 9 years. The children who had reported headache during the 6 months prior to the study ( n = 725) were sent a more detailed questionnaire about factors that might give rise to headache. Six hundred twenty-two (86%) children returned questionnaires that were completed to an acceptable degree.
Results.–The occurrence of familial paroxysmal headache and unhappiness in the family independently predicted the occurrence of migraine in children, but this was not the case for nonmigrainous headache.
Conclusions.–In particular, the family occurrence of paroxysmal headache increases the risk of migraine in a child. The risk is still greater if their living conditions are experienced as unsatisfactory by the family.     

Drug abuse in chronic headache: a clinico-epidemiologic study

Among the patients referred to the Headache Centre in Parma between 1979 and 1984, 95 (5%) were found to be drug abusers, having taken analgesics every day for at least a year. They had had chronic headache for at least 12 months: migraine with interparoxysmal headache in 83.1% and chronic tension headache in 16.9%. Almost all patients were combination-analgesics abusers, and only about a quarter of them were taking ergotamine. The largest single factor favouring the transformation of episodic headache into a chronic one was the drug abuse. The patients studied during 1984 were subjected to detoxification with 6 months' follow-up study. Our investigation suggests that all instant-relief drugs can sustain and possibly initiate a chronic headache.     

Psychological, sleep, lifestyle, and comorbid associations with headache

OBJECTIVE: To investigate the associations of headache occurrence, severity, and frequency with psychological, sleep, and lifestyle characteristics, and comorbid conditions. BACKGROUND: Whilst associations for individual headache types, particularly migraine, have been investigated, possible associations between headache of all types and general health characteristics have not been explored. METHODS: Cross-sectional postal survey in an adult general population sample registered at five general practices in North Staffordshire, UK. RESULTS: Headache occurrence was associated with anxiety (odds ratio 4.09, 95% confidence interval 3.0, 5.6) and sleep problems (moderate sleep problems OR 3.60, 95% CI 2.5, 5.0), and the strength of the associations increased with higher levels of anxiety and sleep problem. Whilst depression showed an association with headache, this was not seen in respondents with depression in the absence of anxiety. Headache occurrence was also associated with comorbid pain anywhere in the body (OR 2.12, 95% CI 1.7, 2.6), with the strongest associations being for the neck and upper body areas compared with other areas. There was no overall link with alcohol or caffeine consumption. Increasing severity and frequency of headache resulted in stronger associations, and there were strong associations between the occurrence, severity, and frequency of headache, and both sleep problems and psychological distress. CONCLUSION: Poor sleep and anxiety appear to make a substantial contribution to the impact of headache on sufferers' lives in the general population.     

A transcranial doppler study in interictal migraine and tension-type headache

PURPOSE: To use transcranial Doppler (TCD) sonography to determine if patients with migraine without aura have interictal hemodynamic abnormalities compared with patients who have episodic tension-type headache (TH). METHODS: Thirty-six migraine patients without aura and 51 TH patients (age range, 16-50 years) who were diagnosed according to the criteria of the International Headache Society 1988 participated in the study. Forty-four healthy volunteers, matched for age and sex, formed the control group. Time-averaged mean velocity (TAMV), pulsatility index (PI), and breath-holding index (BHI) were measured via TCD sonography in the middle cerebral artery. RESULTS: TAMV was higher in migraine without aura than in episodic TH (p = 0.034). There were no differences between groups regarding PI or BHI. CONCLUSION: Our findings support the arteriolar vasodilatation theory in migraine without aura.     

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.     

Examination of anxiety, hostility and psychiatric disorders in patients with migraine and tension-type headache

The role of psychological factors related to headache has long been a focus of investigation. The aim of this study was to evaluate anxiety, depression, hostility and psychological symptoms in patients with migraine and tension-type headache (TTH) and to compare the results with healthy controls. Seventy-five subjects with migraine and 55 subjects with TTH (according to the criteria of the International Headache Society classification) and a control group including 73 healthy subjects were studied. The Buss-Durkee Hostility Inventory, Brief Symptom Inventory, State-trait Anxiety Inventory, Trait form were administered to the subjects. Compared with healthy controls, the patients with headache had significantly higher scores on measures of anxiety, depression and hostility and lower scores on psychological symptoms. The present results indicate the need to distinguish the unique dimensions of anxiety, depression and hostility that should be assessed in the population with headaches.     

The misdiagnosis of cluster headache: a nonclinic, population-based, Internet survey

OBJECTIVE: We conducted the first nonclinic, Internet-based survey of cluster headache to investigate this population with regard to diagnostic problems encountered, effective and ineffective medications, problems obtaining medications through third-party payers, and symptoms as they relate to International Headache Society criteria. BACKGROUND: Previous cluster headache surveys have been at specialty centers. These patients might be different from cluster headache sufferers in the general population. An Internet-based population of cluster headache sufferers who connected to a Web site responded to the questionnaire, and e-mailed it back to our site to be analyzed. We analyzed a total of 789 respondents, 76% men and 28% women. RESULTS: Eighty-seven percent of respondents qualified as having cluster headache according to International Headache Society criteria. However, diagnosis was delayed an average of 6.6 years from the onset of symptoms. The average number of physicians seen before the correct diagnosis was made was 4.3, and the average number of incorrect diagnoses was 3.9. Seventy-one percent of respondents had undergone unnecessary magnetic resonance or computed tomography scans, and 4% had unnecessary sinus or deviated septum surgery. We found that many inappropriate medications such as propranolol, amitriptyline, and antibiotics were prescribed and that successful medications for clusters such as sumatriptan and oxygen were often denied due to a failure to understand the nature of this disorder. Seventy-seven percent of respondents were smokers. Seventy-four percent stopped smoking in an attempt to improve their condition; however, only 3% experienced relief. CONCLUSIONS: The most alarming finding was the delay in diagnosing cluster headache in this population--an average of 6.6 years. The selection of medications demonstrated to be successful in the treatment of clusters proved effective for the majority of this population. Many respondents reported being denied some of these effective medications by their physicians or third-party payers. Using International Headache Society criteria for cluster headache, 87% of the respondents should have been correctly diagnosed by the first physician seen.     

Cluster headache: clinical presentation, lifestyle features, and medical treatment

BACKGROUND: Cluster headache (CH) is a rare but severe headache form with a distinct clinical presentation. Misdiagnoses and mismanagement among these patients are high. OBJECTIVE: To characterize clinical features and medical treatment in patients with CH. METHODS: We established a cohort of 246 clinic-based and non-clinic-based CH patients. The diagnosis of CH was verified according to International Headache Society (IHS) criteria. We used standardized questionnaires to assess associated factors as well as success or failure of treatments. RESULTS: The majority (75.6%) was not treated before at our clinic-77.6% were males; 74.8% had episodic CH, 16.7% had chronic CH, in the remaining patients, the periodicity was undetermined because they were newly diagnosed. Cranial autonomic features were present in 98.8%, nausea and vomiting in 27.8%, and photophobia or phonophobia in 61.2% of CH patients. Most (67.9%) reported restlessness during attacks and 23% a typical migrainous aura preceding the attacks. The rate of current smoking was high (65.9%). Half of the patients reported that alcohol (red wine in 70%) triggered CH attacks. Eighty-seven percent reported the use of drugs of first choice (triptans 77.6%, oxygen 71.1%) with sumatriptan subcutaneous injection being the most effective drug for acute therapy (81.2%). The most frequently used preventive medications were verapamil (70.3%) and glucocorticoids (57.7%) with equally high effectiveness. CONCLUSIONS: Apart from the IHS criteria additional features like nausea/vomiting and migrainous aura may guide the diagnosis of CH. A large number of CH patients do not receive adequate treatments.     

Head-HUNT: validity and reliability of a headache questionnaire in a large population-based study in Norway

We have assessed the validity and reliability of a self-administered headache questionnaire used in the 'Nord-Tr?ndelag Health Survey 1995-97 (HUNT)' in Norway, by blindly comparing questionnaire-based headache diagnoses with those made in a clinical interview of a sample of the participants. Restrictive questionnaire-based diagnostic criteria for migraine, assessed according to modified criteria of the International Headache Society, performed excellently in selecting 'definite' migraine patients (100% positive predictive value). The best agreement concerning migraine diagnoses was achieved by using a liberal set of criteria (kappa 0.59). Similar agreement was found evaluating patient status as headache sufferers, and as sufferers from frequent headaches (>6 days per month) (kappa 0.57 and 0.50, respectively). The kappa values of non-migrainous headache and chronic headache (> 14 days per month) were 0.43 and 0.44, respectively. The results suggest that our self-administered questionnaire may be suitable in identifying a population with 'definite' migraine, and the questionnaire is an acceptable instrument in determining the prevalence in Nord-Tr?ndelag of headache sufferers, migraine, non-migrainous headache, and frequent or chronic headache sufferers.     

Chronic headache and potentially modifiable risk factors: screening and behavioral management of sleep disorders

Sleep-related variables have been identified among risk factors for frequent and severe headache conditions. It has been postulated that migraine, chronic daily headache, and perhaps other forms of chronic headache are progressive disorders. Thus, sleep and other modifiable risk factors may be clinical targets for prevention of headache progression or chronification. The present paper is part of the special series of papers entitled "Chronification of Headache" describing the empirical evidence, future research directions, proposed mechanisms, and risk factors implicated in headache chronification as well as several papers addressing individual risk factors (ie, sleep disorders, medication overuse, psychiatric disorders, stress, obesity). Understanding the link between risk factors and headache may yield novel preventative and therapeutic approaches in the management of headache. The present paper in the special series reviews epidemiological research as a means of quantifying the relationship between chronic headache and sleep disorders (sleep-disordered breathing, insomnia, circadian rhythm disorders, parasomnias) discusses screening for early detection and treatment of more severe and prevalent sleep disorders, and discusses fundamental sleep regulation strategies aimed at headache prevention for at-risk individuals.     

Prevalence of sleep disorders in childhood and adolescence with headache: a case-control study

Although a relationship between headache and sleep disturbances has been reported in adults, only few data have been available in children. Accordingly, we performed a survey to determine the prevalence of sleep disturbances in children with migraine and tension-type headache. A questionnaire of history and clinical data and of sleep disturbances was given to parents of 283 headache subjects (164 with migraine and 119 with tension-type headache). Results were compared to a normative group comparable for age and sex of 893 normal healthy subjects. Migraine subjects showed a higher prevalence of sleep disturbances during infancy as well as 3-month colic. In both headache groups, more parents had sleep disturbances and there was a higher occurrence of co-sleeping and napping. A high frequency of sleep disturbances involving sleep quality, night awakening, nocturnal symptoms and daytime sleepiness was reported in headache children. No statistical differences were found in the prevalence of sleep disturbances between migraine and tension-type headache. However, the migraine group tended to have "disturbed sleep" more often with increased prevalence of nocturnal symptoms such as sleep breathing disorders and parasomnias. Our results give further support to an association between sleep and migraine that may have a common intrinsic origin.     

Migraine and tension-type headache in Croatia: a population-based survey of precipitating factors

The careful monitoring of the trigger factors of headache could be an important step in treatment, because their avoidance may lessen the frequency and severity of attacks. Furthermore, they may provide a clue to the aetiology of headache. The aim of the present study was to estimate the prevalence of tension-type headache (TTH) and to establish the frequency of precipitating factors in subjects with migraine and TTH in the adult population of Bakar, County of the Coast and Gorski Kotar, Croatia. Another important purpose of the study was to examine the relationship of the precipitating factors with migraine and TTH, and with migraine subtypes: migraine with aura (MA) and migraine without aura (MO). We performed a population-based survey using a 'face-to-face door-to-door' interview method. The surveyed population consisted of 5173 residents aged between 15 and 65 years. The 3794 participants (73.3%) were screened for headache history according to the International Headache Society (IHS) criteria. Headache screen-positive responders, 2475 (65.2%), were interviewed by trained medical students with a structured detailed interview focused on the precipitating factors. The following precipitating factors in lifetime migraineurs and tension-type headachers have been assessed: stress, sleep disturbances, eating habits, menstrual cycle, oral contraceptives, food items, afferent stimulation, changes in weather conditions and temperature, frequent travelling and physical activity. A total of 720 lifetime migraineurs and 1319 tension-type headachers have been identified. The most common precipitants for both migraine and TTH were stress and frequent travelling. Stress (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.17, 1.69) was associated with migraine, whereas physical activity (OR 0.72, 95% CI 0.59, 0.87) was related to TTH. Considering MA and MO, frequent travelling (OR 2.2, 95% CI 1.59, 2.99), food items (OR 2.2, 95% CI 1.35, 3.51) and changes in weather conditions and temperature (OR 1.75, 95% CI 1.27, 2.41) exhibited a significant positive association with MA. The present study demonstrated that precipitant-dependent attacks are frequent among both migraineurs and tension-type headachers. Lifetime migraineurs experienced headache attacks preceded by triggering factors more frequently than tension-type headachers. MA was more frequently associated with precipitating factors than MO. We suggest that some triggering factors may contribute to the higher occurrence of precipitant-dependent headache attacks in susceptible individuals.     

Risk factors for headache recurrence after sumatriptan: a study in 366 migraine patients

Headache recurrence (HR) is the major limitation of sumatriptan in the acute treatment of migraine attacks. The risk of HR is mainly patient dependent. We analyzed, in 366 migraine patients, clinical differences between patients who always have HR and patients who never have HR. We found remarkably few differences. HR more frequently occurred in patients with more severe attacks and longer untreated attack duration; in patients who experienced a sensation of a subclinically ongoing attack, despite headache relief after sumatriptan; and in females, mainly with menstruation-related migraine, most probably due to the more severe and longer lasting attacks these patients suffer, rather than due to hormonal factors. The incidence of HR was, among other factors, not related to the (other) clinical effects of sumatriptan, the timing of administration within the attack, the duration of use of sumatriptan, pharmacokinetic factors, or whether patients were experiencing HR after use of ergot alkaloids.     

A note on cluster headache in a population-based twin register

Evidence of a familial risk factor in cluster headache is accumulating and studies of twin concordance may resolve family resemblance into genetic and environmental influences. The past literature on cluster headache in twins comprises a few case reports of concordant monozygotic pairs. Swedish twin pairs with a diagnosis of cluster headache were selected through a cross-match of national registers of twin births and hospitalizations. Seventeen discordant twin pairs were found, in which it was possible to verify cluster headache status in 11 complete pairs (two monozygotic, four dizygotic, and five unlike-sexed pairs). In both members of a female monozygotic pair, migraine without aura developed after birth of the first child and remitted by menopause, whereas post-menopausal development of chronic cluster headache occurred in only one of them. The importance of individual specific factors for cluster headache was demonstrated. However, to explain familial aggregation a larger sample of affected twin pairs is necessary.