A review of the treatment of primary headaches. Part II: Tension-type headache.

This paper reviews pharmacological and other approaches currently used to treat tension-type headache (TTH), and examines aspects of the classification and pathogenesis of this common complaint. Accurate diagnosis is essential before treatment is prescribed and should involve complete history taking, thorough neurological examination and evaluation of possible associated factors. The most frequently used drugs for the acute treatment of TTH are non-steroidal anti-inflammatory drugs (NSAIDs) of which only some have been shown to be efficacious in placebo-controlled trials. Amitriptyline remains the first choice treatment for prophylaxis. Other antidepressants, muscle relaxants and benzodiazepines may be used, but few have been evaluated adequately in placebo-controlled trials. Biofeedback and relaxation training, demonstrated efficacious by controlled studies, may be used when the aim is to avoid the side effects of pharmacological treatment.     

A review of the treatment of primary headaches. Part I: Migraine

Finding the best treatment for a patient's migraine is often a problem in clinical practice since the condition is very common, often debilitating and may prove refractory to therapy. Over recent years, more effective migraine treatments have been found and validated, and the traditional remedies have undergone controlled testing. This article reviews the various therapies available for both the acute treatment and prevention of migraine. Treatments often effective against migraine attacks are: aspirin, analgesics, non steroid antiinflammatory drugs (NSAIDs), ergot derivatives and sumatriptan. Five main classes of prophylactic drug are currently used: beta-blockers, calcium antagonists, serotonin modulators, NSAIDs and ergot compounds. Biofeedback, one of the most efficacious non-pharmacological preventive treatments of migraine, is also discussed.The variables influencing the choice of acute and preventive treatments, including contriandications and drug availability, are also described in order to provide a practical and up-to-date guide to migraine therapy.

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Sommario L'emicrania è un disturbo che colpisce circa il 15% della popolazione generale risultando spesso debilitante tale da risultare un problema clinico di rilievo soprattutto quando refrattario alla terapia. Questo articolo fornisce una guida razionale ed aggiornata al trattamento di questa malattia, sia per gli attacchi che per la profilassi. Per quanto riguarda gli attacchi i farmaci risultati efficaci nei diversi studi clinici controllati sono l'aspirina, gli analgesici, gli antiinfiammatori non steroidei, gli ergot derivati ed il sumatriptan. I farmaci riconosciuti efficaci nella profilassi dell'emicrania sono identificabili tra 5 principali categorie di sostanze: beta-bloccanti, calcio antagonisti, serotonino-modulatori, antiinfiammatori non steroidei e gli ergot derivati. Tra le terapie non farmacologiche, viene brevemente discussa l'utilità del biofeedback nella prevenzione di alcune forme di emicrania.Vengono inoltre discusse le numerose variabili che influenzano la scelta del farmaco sia per la profilassi che per l'attacco con le relative controindicazioni.

     

Tension-type headache: an update on mechanisms and treatment

Tension-type headache represents one of the most costly diseases in modern society because of its very high prevalence. Very little research on this disease has actually been carried out, and knowledge about key pathophysiological issues such as the nature and site of the noxious stimulus is surprisingly limited. As a result of this and the lack of scientific interest from the medical field, treatment is widely non-specific, very often ineffective and consists mainly of simple analgesics. The only new strategy is the pericranial injection of botulinum toxin. If current progress in our understanding of the mechanisms of tension-type headache continues, this may lead to greater scientific interest and the development of more specific and more effective drugs in the future.     

Tension-type headache: current research and clinical management

Tension-type headache (TTH) is the most common form of headache, and chronic tension-type headache (CTTH) is one of the most neglected and difficult types of headache to treat. The pathogenesis of TTH is multifactorial and varies between forms and individuals. Peripheral mechanisms (myofascial nociception) and central mechanisms (sensitisation and inadequate endogenous pain control) are intermingled: the former predominate in infrequent and frequent TTH, whereas the latter predominate in CTTH. Acute therapy is effective for episodes of TTH, whereas preventive treatment--which is indicated for frequent and chronic TTH--is, on average, not effective. For most patients with CTTH, the combination of drug therapies and non-drug therapies (such as relaxation and stress management techniques or physical therapies) is recommended. There is clearly an urgent need to improve the management of patients who are disabled by headache. This Review summarises the present knowledge on TTH and discusses some of its more problematic features.     

Undertreatment in patients with primary headaches attending headache centres

There is debate about a possible association between natalizumab treatment and higher risk of melanoma. Here we report a case of melanoma in a patient who developed melanoma after 77 infusions of natalizumab, without known risk factors. Pharmacovigilance programs of new drugs can help to monitor adverse events in patients at risk.     

Validity of graphic headache diary for children having primary headaches

We investigated whether the graphic headache diary is useful for diagnosing headache types in children, especially suffering from chronic daily headaches. Our study involved 109 children who completed the diaries for more than 3 weeks. The headache diary was a modified version of that used in the study by Sakai et al. Of 109, 84 had migraine, 15 had tension-type headache and 10 had both tension-type headache and migraine from the questionnaire and the first interview. The diary disclosed that 20 children, initially diagnosed as having migraine, had co-existing chronic tension-type headache with a variety of psychosocial problems. The graphic headache diary seems to be helpful for headache diagnosis and awareness of stress in children who suffered from strong and persistent headaches. Our study suggested that the graphic headache diary is useful not only for diagnosing headache types in children but also for finding out problems in school and/or family.     

Tension-type headache: the most common, but also the most neglected, headache disorder

PURPOSE OF REVIEW: Tension-type headache is the most common type of headache and, in its chronic form, one of the most neglected and difficult types of headache to treat. Recently published data will be reviewed. RECENT FINDINGS: The prevalence of frequent tension-type headache increased significantly from 1989 to 2001, and several risk factors have been identified. The incidence decreases markedly with age. The prognosis is fairly favorable for the episodic forms. Chronic tension-type headache, coexisting migraine, sleep problems and not being married were identified as risk factors for a poor outcome. Previous reports of sensitization of the central nervous system in patients with chronic tension-type headache were confirmed by the findings of generalized pain hypersensitivity both in skin and in muscles, and of a decrease in the volume of gray matter in brain structures. A promising new animal model of tension-type headache has been developed. In addition, the efficacy of a prophylactic drug, mirtazapine, with fewer side-effects than the tricyclic antidepressants has been demonstrated. SUMMARY: The new data on the prevalence, incidence and prognosis of tension-type headache are valuable for health care planning and in daily clinical practice. The increased knowledge with regard to abnormal central pain modulation, together with the development of an animal model, hold promise for much-needed improvements in the understanding of pathophysiological mechanisms and treatment.     

偏头痛外科治疗

偏头痛是临床最为常见的头痛症状之一,呈反复发作,可影响患者日常生活、工作和学习,甚至导致抑郁、焦虑等心理障碍的发生。目前仍以药物治疗为主,但不能从根本上改善症状,而且存在诸多药物不良反应和并发症。为彻底治愈偏头痛,国内外学者在偏头痛的外科治疗方面进行了积极地探索,并在解剖学研究和临床疗效方面取得了一定成果。偏头痛的发生与4个压迫点有关,分别为眶上区、耳颞区、枕神经区和鼻内,通过对压迫点进行松解手术,可以达到治愈或缓解疼痛之目的 。     

Underdiagnosis of primary headaches: results of a survey on patients attending headache centres

Underdiagnosis of primary headaches was evaluated in 504 patients attending six Headache Centres in Lombardy. We found high figures of missed diagnoses (no diagnosis of a specific headache form), and of misdiagnosis (non-concordance between previous diagnoses made by the GP and the final diagnoses given by the headache specialist). We note that underdiagnosis in headache patients may have negative consequences, enhancing the risk of progressive worsening of primary headache syndromes, increasing their impact on individuals and on society, and favouring medication overuse.

     

Underdiagnosis of primary headaches: results of a survey on patients attending headache centres

Underdiagnosis of primary headaches was evaluated in 504 patients attending six Headache Centres in Lombardy. We found high figures of missed diagnoses (no diagnosis of a specific headache form), and of misdiagnosis (non-concordance between previous diagnoses made by the GP and the final diagnoses given by the headache specialist). We note that underdiagnosis in headache patients may have negative consequences, enhancing the risk of progressive worsening of primary headache syndromes, increasing their impact on individuals and on society, and favouring medication overuse.     

Genetics of primary headaches.

Migraine has become an important topic in the field of complex genetic disorders. The identification of a gene on chromosome 19p encoding for an alpha 1A calcium channel subunit causing familial hemiplegic migraine has led to the classification of migraine as a channelopathy. More recently, efforts have been made to clarify the genetics of other primary headaches.     

A review of schizoaffective disorder: II. Somatic treatment.

Studies on the response of schizoaffective patients to somatic treatments are reviewed. Research suggests that in many cases the response of schizoaffective disorder to pharmacological intervention is similar to that of primary affective disorder. However, it is necessary to take into account the heterogeneity of the category when treating patients. The drugs used most frequently are lithium, neuroleptics (antipsychotics), antidepressants and anticonvulsants. Often a combination of drugs is found to be more effective than a single drug. Electroconvulsive therapy has been found to be very effective in the treatment of schizoaffective depression.     

Acupuncture in primary headache treatment

Acupuncture has a long tradition of use for the treatment of many pain conditions, including headache. Its effectiveness has been studied mainly for primary headaches, particularly for migraine and tension-type headache (TTH). Traditional Chinese Medicine (TCM) has two diagnostic frameworks for headaches: meridian diagnoses, based on the location of the pain and on the meridians (or channels) that pass through it; syndrome diagnoses, dependent on external or internal factors and on the characteristics of the pain. The four meridians involved in headache are Shaoyang (TE-GB channels, on the temporal sides of the head); Taiyang (SI-BL channels, occiput); Yangming (LI-ST channels, forehead) and Jueyin (PC-LR channels, vertex). The syndromes may be due to excess or deficit. Very generally, the excess syndromes correspond in the majority of cases to migraine and the deficit syndromes to TTH. Acupuncture is a complex intervention, which is also characterized by a close interaction between patient and therapist. The complicated system of TCM classification of headaches has frequently generated great diversity among the various therapeutic approaches used in the different studies on acupuncture in headache treatment. Despite these differences, the recent Cochrane systematic reviews on acupuncture in migraine and in TTH suggest that acupuncture is an effective and valuable option for patients suffering from migraine or frequent TTH. Moreover, acupuncture seems to be a cost-effective treatment.     

A pathophysiological view of primary headaches

The cerebral circulation is innervated by sympathetic, parasympathetic and sensory nerves which store a considerable number of neurotransmitters. The role of these has been evaluated in primary headaches. A clear association between head pain and the release of calcitonin gene-related peptide (CGRP) was demonstrated. In cluster headache and in a case of chronic paroxysmal headache there was in addition release of vasoactive intestinal peptide (VIP) which was associated with facial symptoms (nasal congestion, rhinorrhea). In parallel with sumatriptan treatment head pain subsided and neuropeptide release normalised. These data show the involvement of sensory and parasympathetic mechanisms in the pathophysiology of primary headaches.     

Pathogenesis and surgical treatment of neurovascular primary headaches

The “neurovascular primary headaches” are syndromes also pertinent to otorhinolaringology when CT demonstrates a reduced volume of the “ethmoidosphenoidal subcribriform chamber” according to the endo-exocranial hemoangiokinetics of this area. It is emphasized that in drug-resistant headaches recovery or consistent definitive improvement can be achieved only after surgical correction of certain anatomical parameters (P. Bonaccorsi, V. J. Novak, S. Hoover). Bonaccorsi and Novak independently identified the actual pathophysiologic mechanism and trigger zone (“dysmorphism”) for various types of neurovascular primary headaches. Patients (n=446) with various types of headaches (migraine, cluster headache and so-called idiopathic or primary headaches) were operated upon between 1973 and 1994. Septal correction, resection of the middle and superior concha, ethmoidectomy, and sphenoidectomy on the corresponding headache side or occasionally on both sides were carried out. Most patients (356, 80%) were asymptomatic postoperatively, 45 (10%) had a sensation of pressure in the head on rare occasions but no further migraine, and 45 (10%) continued to experience headache that occurred only rarely and was mild and of short duration. The overall success rate was 90%. For cluster headache in 20 patients, we observed the following postoperative results: 19 cured (98%), 1 improved (2%).

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Sommario Le “cefalle neurovascolari primarie” sono sindromi di pertinenza anche ORL quando con esame TC viene evidenziata una ridotta volumetria della “camera etmoidosfenoidale sottocribrosa”, ai fini emoangiocinetici della circolazione endo-esocranica di questo distretto. Viene posto in risalto che i casi farmacoresistenti possono ottenere guarigioni o sostanziali, costanti miglioramenti solo dopo la correzione chirurgica di alcuni parametri anatomici. (P. Bonaccorsi, V.J. Novak, S. Hoover). Bonaccorsi e Novak indipendentemente hanno identificato l'attuale meccanismo fisiopatologico e la zona trigger (dismorfismi) per vari tipi di cefalee neurovascolari primarie. Dal 1973 al 1994 sono stati operati n. 446 pazienti sofferenti di varie forme di cefalee (emicranie, cefalee a grappolo ed altre cefalee codificate come idiopatiche o primarie). Sono state praticate correzioni del setto, resezioni del turbinato medio e superiore, etmoidectomie e sfenoidectomia sul lato corrispondente alla cefalea o occasionalmente in entrambi i lati. La maggioranza dei pazienti risulta asintomatica dopo l'intervento (356=80%), 45 pazienti (10%) hanno una sensazione di pressione al capo rare volte ma non hanno più accusato emicrania e 45 (10%) continuano ad avere cefalea solo raramente e di minore e breve durata. La positività globale è del 90%. Nei 20 pazienti sofferenti di cefalea a grappolo, osserviamo i seguenti risultati post operatori: 19 guariti (98%), 1 migliorato (2%).

     

Dihydroergotamine: a review of its use in the treatment of migraine and other headaches.

Dihydroergotamine has been one of the main drugs used in the treatment of migraine for greater than 40 years. The recent introduction of the more selective 5-HT antagonist sumatriptan will challenge the place of dihydroergotamine in migraine therapy and indicates the need to review the evidence for the use of dihydroergotamine. Although there is little evidence from double-blind clinical trials, dihydroergotamine does appear to be effective in the treatment of acute attacks and in the prevention of migraine. Its place in treatment is in cases where simple analgesics alone or in combination with other agents fail to provide relief. Further studies are necessary to compare dihydroergotamine with sumatriptan for acute migraine and with beta-blockers in prophylaxis to determine its future role in migraine therapy.     

Clinical differentiation of primary degenerative and multi-infarct dementia: a critical review of the evidence. Part II: Pathological studies

A critical examination of representative pathological studies published over the past four decades reveals that this literature fails to provide sufficient support for the antemortem differentiation of primary degenerative dementia (PDD) from multi-infarct dementia (MID) on the basis of clinical criteria. Similar conclusions with respect to clinical studies and articles are presented in Part I of this overview. Among the difficulties commonly encountered in the literature are sampling bias, retrospective design, nonblind assessments, inadequate sample size, failure to consider overlap (i.e., mixed cases), absence of pathological verification in the clinical studies and post hoc reasoning. The necessity to assure that one is dealing with a case of PDD as opposed to some other dementing process is self-evident. However, these reviews show that this capability has not been adequately established with respect to the differential diagnosis of PDD and MID; the evidence to date indicates that the clinical diagnosis of MID, in particular, should be made with caution until more conclusive methods become available.     

Somatosensory evoked potentials: Part II. A review of the clinical applications in pediatric neurology

Fundamental to the clinical application of somatosensory evoked potentials is an understanding of the neural generators, the changes in disease states, and the effects of growth and maturation; aspects relevant to pediatric somatosensory evoked potentials were discussed previously (Part I). The importance of establishing normative data across age- and size-matched controls in the pediatric population, however, cannot be overstated. The following review of the clinical applications of somatosensory evoked potentials in pediatric neurology is based on a review of the literature and on the experience gained from over 900 studies performed in our laboratory during the last 4 years.     

Rare primary headaches: clinical insights

Neurological Sciences - So-called “rare” headaches, whose prevalence rate is lower than 1% or is not known at all and have been reported in only a few dozen cases to date, constitute a...