Socio-economic factors, lifestyle, and headache disorders - a population-based study in Sweden

Objective.— To study the association between socio‐economic factors, lifestyle habits, and self‐reported recurrent headache/migraine (RH/M) in a general population. Methods.— The study population comprised a random sample of men and women aged 18‐79 years. The data were obtained using a postal survey questionnaire during March‐May 2000. The overall response rate was 65%. The area investigated covers 58 municipalities with about one million inhabitants in central part of Sweden. The study is based on 43,770 respondents. Odds ratios for RH/M were calculated for a set of variables using multiple logistic regression models. Results.— The overall prevalence of self‐reported RH/M during the last 3 months was 10% among men and 23% among women and decreased with increasing age. Physically inactive subjects were more likely to suffer from headache disorders than physically active subjects. Smoking was only moderately associated with RH/M. There was an inverse relationship between heavy alcohol use and RH/M. Underweight and obesity were not associated with headache disorders when adjusted for socio‐economic factors. Subjects with frequent economic problems had almost twice the risk of RH/M compared with subjects with no economic problems. Poor social support was associated with headache disorders and subjects who had been belittled during the last 3 months were more than twice as likely to suffer from RH/M as subjects who had not been belittled. The effect of educational level was modest. Marital status and country of origin were not associated with headache disorders after adjustment for other socio‐economic factors. Dissatisfaction with work, worry about losing one's job, and absenteeism due to illness were strongly associated with headache disorders. Physical working conditions and working hours were not associated with RH/M. Conclusion.— Headache disorders mainly affect young and middle‐aged adults. There are, however, socio‐economic disparities in self‐reported recurrent headache and migraine. The relationship was particularly evident for economic hardship and psychosocial factors. Of lifestyle factors, physical inactivity was strongly associated with headache disorders independent of economic and psychosocial factors.     

The prevalence of migraine and probable migraine in a Brazilian favela: results of a community survey

(Headache 2011;51:971‐979) Objectives.— The objectives of the present study were to estimate the 1‐year prevalence of primary headaches and the role of select socio‐demographic aspects in a representative sample of adults living in a Brazilian shanty town. Background.— Some socio‐demographic factors, such as marital status, income, education, and job status have been described in studies with contentious results. Nevertheless, few studies have assessed the prevalence of headache and the role of socio‐demographic aspects in very low‐income communities. Methods.— A cross‐sectional, population‐based study was undertaken. Door‐to‐door interviews with 383 people were conducted. Individuals were aged greater than 18 years, randomly selected from the “Paraisopolis” shanty town in São Paulo, Brazil. The degree of the association was calculated through prevalence ratios and adjusted with backward logistic regression by gender, age, and some socio‐demographic factors, including living conditions. Results.— The estimated 1‐year prevalence of headache, migraine, chronic migraine, and tension‐type headache were 47% (CI 95%: 39.5‐52.6%), 20.4% (CI 95%: 16.6‐24.9%), 8.4% (CI 95%: 6.1‐12.0%), and 6.2% (CI 95%: 3.3‐9.8%), respectively. Migraine was more prevalent in women and among employed people. No other relationship was found. The overall prevalence of migraine and chronic migraine in this very low‐income community were high and migraine was associated with gender and job status. Conclusion.— The overall prevalence of migraine and chronic migraine in this very low‐income community were high and tension‐type headache was low. A paradox was noted in the employment status and income association, one would expect higher levels of migraine in a low‐income population, but higher numbers were found in those employed vs unemployed. These findings will need to be replicated in other population samples.     

PTSD, Combat Injury, and Headache in Veterans Returning From Iraq/Afghanistan

Objective.— To examine the relationship between posttraumatic stress disorder, combat injury, and headache in Operation Iraqi Freedom and Operation Enduring Freedom veterans at the VA San Diego Healthcare System. Background.— Previous investigations suggest that a relationship between posttraumatic stress disorder and primary headache disorders exists and could be complicated by the contribution of physical injury, especially one that results in loss of consciousness. These associations have not been systematically examined in Operation Iraqi Freedom and Operation Enduring Freedom veterans. Methods.— In this observational cross‐sectional study, a battery of self‐report, standardized questionnaires was completed by 308 newly registered veterans between March and October 2006. The Davidson Trauma Scale was used to determine the degree of posttraumatic stress disorder symptoms and combat‐related physical injury was assessed by self‐report. The presence of headache was based on a symptom checklist measure and self‐reported doctor diagnoses. Logistic regression analysis was performed to predict presence of headache and determine odds ratios and 95% confidence intervals associated with demographic, military, in‐theatre, and mental health characteristics. Results.— About 40% of the veterans met the criteria for posttraumatic stress disorder; 40% self‐reported current headache, 10% reported a physician diagnosis of migraine, 12% a physician diagnosis of tension‐type headache, and 6% reported both types of headache. Results from the logistic regression model indicated that combat‐related physical injury (odds ratio: 2.25; 95% confidence interval: 1.17‐4.33) and posttraumatic stress disorder (odds ratio: 4.13; 95% confidence interval: 2.44‐6.99) were independent predictors of self‐reported headache. Additional analyses found that veterans with both tension and migraine headache had higher rates of posttraumatic stress disorder (chi‐square [d.f. = 3] = 15.89; P = .001) whereas veterans with migraine headache alone had higher rates of combat‐related physical injury (chi‐square [d.f. = 9] = 22.00; P = .009). Conclusion.— Posttraumatic stress disorder and combat‐related physical injury were related to higher rates of self‐reported headache in newly returning veterans. Our finding that posttraumatic stress disorder and injury during combat are differentially related to migraine and tension‐type headache, point to a complex relationship between physical and psychological trauma and headache. These findings have implications for a comprehensive approach to interventions for headache and the physical and psychological sequelae of trauma.     

Higher Prevalence of Psychopathological Symptoms in Adolescents With Headache. A Population‐Based Cross‐Sectional Study

(Headache 2010;50:738‐748) Background.— Headache is commonly voiced by adolescents and is known to be associated with reduced quality of life. Otherwise, there are only limited data regarding associations between different types of headache and psychopathological symptoms in adolescents. Objectives.— Aim of the present study in adolescents was to assess the impact of headache on psychopathological symptoms and whether these differ between types of headache. Methods.— Data were derived from a population‐based sample (n = 1047, ages 13‐17 years). Type of headache (ie, migraine, tension‐type headache, miscellaneous headache) was ascertained for subjects reporting headache episodes at least once per month. Psychopathological symptoms were assessed with the Strengths and Difficulties Questionnaire. The following dimensions were taken into account: emotional symptoms, conduct problems, hyperactivity/inattention, peer problems (these 4 add to the total difficulties score), and prosocial behavior. Associations were estimated with logistic regression models with adjustment for age group, sex, and family situation. Results.— Headache at least once per month was reported by 47.8% of the adolescents. Subjects with any headache were found to be at higher risk for emotional symptoms (odds ratio 1.5; 95% confidence interval 1.0‐2.2) and hyperactivity/inattention (1.4; 1.0‐1.9), resulting in a higher total difficulties score (1.6; 1.1‐2.4). While the risk for psychopathological symptoms was not significantly increased in subjects with tension‐type headache compared with subjects without headache, significant associations with emotional symptoms were found in subjects with migraine (2.9; 1.3‐6.2; total difficulties score: 3.1; 1.4‐6.8). Miscellaneous headache was associated with a broad spectrum of psychopathological symptoms: emotional symptoms (1.8; 1.0‐3.3), conduct problems (1.6; 1.0‐2.6), hyperactivity/inattention (1.9; 1.2‐3.1), total difficulties score (2.7; 1.6‐5.6). Conclusion.— Previously reported associations between headache and psychopathological symptoms in adolescents could be confirmed, but might vary with type of headache. As psychopathological symptoms may be a precursor for manifest psychiatric disorders, adolescents particularly with migraine and miscellaneous headache appear to be a vulnerable population.     

Headache among patients with HIV disease: prevalence, characteristics, and associations

Background.— Headache is one of the most common medical complaints reported by individuals suffering from human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), but limited and conflicting data exist regarding their prevalence, prototypical characteristics, and relationship to HIV disease variables in the current era of highly active antiretroviral therapy (HAART). Objectives.— The aims of the present cross‐sectional study were to characterize headache symptoms among patients with HIV/AIDS and to assess relations between headache and HIV/AIDS disease variables. Methods.— Two hundred HIV/AIDS patients (49% female; mean age = 43.22 ± 12.30 years; 74% African American) from an internal medicine clinic and an AIDS outreach clinic were administered a structured headache diagnostic interview to assess headache characteristics and features consistent with International Classification of Headache Disorders (ICHD)‐II diagnostic semiologies. They also completed 2 measures of headache‐related disability. Prescribed medications, most recent cluster of differentiation (CD4) cell count, date of HIV diagnosis, possible causes of secondary headache, and other relevant medical history were obtained via review of patient medical records. Results.— One hundred seven patients (53.5%) reported headache symptoms, the large majority of which were consistent with characteristics of primary headache disorders after excluding 4 cases attributable to secondary causes. Among those who met criteria for a primary headache disorder, 88 (85.44%) met criteria for migraine, most of which fulfilled ICHD‐II appendix diagnostic criteria for chronic migraine. Fifteen patients (14.56%) met criteria for episodic or chronic tension‐type headache. Severity of HIV (as indicated by CD4 cell counts), but not duration of HIV or number of prescribed antiretroviral medications, was strongly associated with headache severity, frequency, and disability and also distinguished migraine from TTH. Conclusions.— Problematic headache is highly prevalent among patients with HIV/AIDS, most of which conform to the semiology of chronic migraine, although with some atypical features such as bilateral location and pressing/tightening quality. A low frequency of identifiable secondary causes is likely attributable to reduced frequency of opportunistic infections in the current era of HAART. Disease severity is strongly predictive of headache, highlighting the importance of physician attention to headache symptoms and of patient adherence to treatment. (Headache 2012;52:455‐466)     

Associations of Diet and Lifestyle With Headache in High‐School Students: Results From a Cross‐Sectional Study

(Headache 2010;50:1104‐1114) Background.— Diet and lifestyle are seen as factors which influence headache in adults. However, population‐based studies on this issue in adolescents are rare. Objective.— Aim of the present study was to investigate associations between diet and lifestyle factors and different types of headache, ie, migraine and tension‐type headache (TTH) in adolescents. Methods.— A total of 1260 adolescents from the 10th and 11th grades of high schools filled in questionnaires on intake of meals, coffee, nonalcoholic and alcoholic drinks, smoking, and physical activity. Type of headache was classified according to the International Classification of Headache Disorders – 2nd edition. Multiple logistic regression models, adjusted for sex and grade, were calculated. Results.— High consumption of cocktails (odds ratio = 3.4; 95% confidence interval 1.9‐6.0) and coffee (2.4; 1.3‐4.7), smoking (2.7; 1.4‐5.1), and lack of physical activity (2.2; 1.3‐3.7) were significantly associated with migraine plus TTH episodes, consumption of coffee and physical inactivity particularly with migraine (3.4; 1.6‐7.0 and 4.2; 2.2‐7.9, respectively) and physical inactivity with TTH (1.7; 1.1‐2.7). Skipping of meals or insufficient fluid intake were not associated with any type of headache. Conclusions.— Adolescents with any type of headache might benefit from regular physical activity and low consumption of alcoholic drinks, while for migraine patients a low consumption of coffee should additionally be recommended. Intervention studies are warranted to assess whether psycho‐educational programs conferring knowledge of these associations will influence headache‐triggering behavior and headache in adolescents.     

Behavioral medicine for migraine and medication overuse headache

Primary headaches, including migraine and medication overuse headache (MOH), can be conceptualized as biobehavioral disorders based on the interaction of biological, psychological, and environmental factors. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of headaches in general, with an emphasis on migraine and MOH from a biopsychosocial perspective. Evidence-based behavioral medicine treatments for migraine and MOH are reviewed, including patient education, cognitive behavioral therapy, and biobehavioral training (biofeedback, relaxation training, and stress management). Information regarding psychological comorbidities and risk factors for progression of migraine and the development of MOH is also reviewed. Strategies are provided for enhancing adherence and motivation, as well as facilitating medical communication.     

Description and validation of an Italian ICHD-II-based questionnaire for use in epidemiological research

Background.— In the absence of biological markers, the diagnosis of primary headache in epidemiological studies rests on clinical findings, as reported through ad‐hoc interviews. Objectives.— The aim of this study was to validate a specially designed headache questionnaire to be administered by a physician for the diagnosis of primary headaches or of probable medication overuse headache in the general population according to the 2004 International Classification of Headache Disorders, 2nd edition (ICHD‐II). Methods.— The questionnaire comprises 76 questions based on the ICHD‐II diagnostic criteria for migraine (codes 1.1, 1.2.1, 1.2.2, 1.2.3, 1.5.1, and 1.6), tension‐type headache (codes 2.1, 2.2, 2.3, and 2.4), primary stabbing headache (code 4.1), and probable medication‐overuse headache (code 8.2.7), as well as on other clinical features (eg, age at onset, relation between headache and pregnancy, etc). The answers to each question could be of the following types: (1) numbers (ie, age at onset); (2) “Yes” or “No” (eg, as in reply to “Do you have nausea during headache?”); and (3) predefined answers (eg, quality of pain). We assessed the validity and reliability of the questionnaire and its sensitivity and specificity for migraine and tension‐type headache. Results.— The study population consisted of 50 patients (37 women and 13 men) aged 18‐76 years (mean, 40.7) seen for the first time on a consecutive basis at the University of Parma Headache Centre. The questionnaire was administered independently by 2 trained physicians (E1 and E2) prior to the visit performed by a headache specialist taken as the gold standard (GS). GS, E1, and E2 were blind to the diagnosis made by each others. If appropriate, more than 1 headache type were considered. When present, we defined the 2 different headache types in the same subject as Diagnosis 1 and Diagnosis 2. Questionnaire‐based diagnosis was compared with the diagnosis established by GS. For Diagnosis 1 (n = 50), we found an agreement rate of 98% (K‐value: 0.96; 95% confidence interval [CI]: 0.88‐1.00) between E1 and GS and between E2 and GS, and of 96% (K‐value: 0.91; 95% CI: 0.80‐1.00) between E1 and E2. For Diagnosis 2 (n = 24), we found an agreement rate of 83.3% (K‐value: 0.80; 95% CI: 0.63‐0.98) between E1 and GS, of 62.5% (K‐value: 0.62; 95% CI: 0.41‐0.82) between E2 and GS, and of 70.8% (K‐value: 0.66; 95% CI: 0.45‐0.87) between E1 and E2. Sensitivity and specificity were 100% and 93.3%, respectively, for migraine without aura (code 1.1) and 100% for frequent episodic tension‐type headache (code 2.2). Conclusion.— Our findings support the use of this questionnaire as a valid and reliable tool for diagnosis of headaches in epidemiological studies.     

Electronic Momentary Assessment of Weather Changes as a Trigger of Headaches in Children

(Headache 2010;50:779‐789) Background.— Variables that are thought to precipitate migraine or tension‐type headache episodes in children hitherto have only been studied using retrospective reports. As such, there is little empirical evidence to support the actual predictive association between presumed headache triggers and actual headache occurrence in children. Objective.— The present study sought to determine if fluctuations in weather, a commonly reported headache trigger in children, predict increased likelihood of headache occurrence when evaluated using rigorous prospective methodology (“electronic momentary assessment”). Methods.— Twenty‐five children (21 girls, 4 boys) between the ages of 8‐17 years attending a new patient neurology clinic appointment and having a diagnosis of chronic migraine, chronic tension‐type, or episodic migraine headache (with or without aura) participated in the study. Children completed baseline measures on headache characteristics, presumed headache triggers, and mood and subsequently were trained in the use of electronic diaries to record information on headaches. Children then completed thrice daily diaries on handheld computers for a 2‐week time period (42 assessments per child) while data on weather variables (temperature, dew point temperature, barometric pressure, humidity, precipitation, and sunlight) in the child's geographic location were recorded each time a diary was completed. Data were analyzed using multilevel models. Results.— Of the weather variables, relative humidity and presence of precipitation were significantly predictive of new headache onset, with nearly a 3‐fold increase in probability of headache occurrence during times of precipitation or elevated humidity in the child's area, b = 0.38, t(821) = 2.10, P = .04, and b = 0.02, t(821) = 2.81, P = .01, respectively. These associations remained after accounting for fluctuations in mood, and associations were not significantly stronger in children who at baseline thought that weather was a headache trigger for them. Changes in temperature, dew point temperature, barometric pressure, and sunlight were not significantly predictive of new headache episode occurrence in this sample. Conclusions.— Results of the present study lend some support to the belief commonly held by children with recurrent headaches that weather changes may contribute to headache onset. Although electronic momentary assessment methodology was found to be feasible in this population and to have the potential to identify specific headache triggers for children, it remains to be determined how best (or even whether) to incorporate this information into treatment recommendations.     

Panic Disorder and Migraine: Comorbidity,Mechanisms, and Clinical Implications

A growing body of literature suggests that comorbid anxiety disorders are more common and more prognostically relevant among migraine sufferers than comorbid depression. Panic disorder (PD) appears to be more strongly associated with migraine than most other anxiety disorders. PD and migraine are both chronic diseases with episodic manifestations, involving significant functional impairment and shared symptoms during attacks, interictal anxiety concerning future attacks, and an absence of identifiable secondary pathology. A meta‐analysis of high‐quality epidemiologic study data from 1990 to 2012 indicates that the odds of PD are 3.76 times greater among individuals with migraine than those without. This association remains significant even after controlling for demographic variables and comorbid depression. Other less‐rigorous community and clinical studies confirm these findings. The highest rates of PD are found among migraine with aura patients and those presenting to specialty clinics. Presence of PD is associated with greater negative impact of migraine, including more frequent attacks, increased disability, and risk for chronification and medication overuse. The mechanisms underlying this common comorbidity are poorly understood, but both pathophysiological (eg, serotonergic dysfunction, hormonal influences, dysregulation of the hypothalamic–pituitary–adrenal axis) and psychological (eg, interoceptive conditioning, fear of pain, anxiety sensitivity, avoidance behavior) factors are implicated. Means of assessing comorbid PD among treatment‐seeking migraineurs are reviewed, including verbal screening for core PD symptoms, ruling out medical conditions with panic‐like features, and administering validated self‐report measures. Finally, evidence‐based strategies for both pharmacologic and behavioral management are outlined. The first‐line migraine prophylactics are not indicated for PD, and the selective serotonin re‐uptake inhibitors used to treat PD are not efficacious for migraine; thus, separate agents are often required to address each condition. Core components of behavioral treatments for PD are reviewed, and their integration into clinical headache practice is discussed.     

Family History for Chronic Headache and Drug Overuse as a Risk Factor for Headache Chronification

Objectives.— To assess whether family history for chronic headache (CH) and drug overuse could represent a risk factor for headache chronification. Background.— Among factors investigated as risk factors for chronification of headache disorders, familial liability for CH and drug overuse has been rarely investigated. Patients and Methods.— A total of 105 consecutive patients with daily or nearly daily headache, and 102 consecutive patients with episodic headache matched by age, sex, and type of headache at onset, underwent a structured direct interview about family history for episodic headache, CH with and without medication overuse, substance abuse/dependence, and psychiatric disorders. Results.— In total, 80 out of 105 patients with CH received a diagnosis of medication overuse headache (MOH), 21 patients were classified as chronic migraine (CM), and 4 as chronic tension‐type headache (CTTH) without drug overuse. Some 38.1% of CH patients reported family history for CH vs only 13.7% of episodic headaches (P = .001). Familiality for CH with medication overuse was reported by 25.7% of cases vs 9.8% of controls (P = .0028). A familial history of substance abuse was reported by 20% of patients vs 5.9% of controls (P = .0026). In all, 28.7% of MOH patients reported family history for CH with medication overuse (P = .0014) and 21.2% for substance abuse (P = .002). Relatives of patients with MOH were more likely than control relatives to suffer from CH (OR = 4.19 [95% CI 2.05‐8.53]), drug overuse (OR = 3.7 [95% CI 1.66‐8.24]), and substance abuse (OR = 4.3 [95% CI 1.65‐11.19]). No differences regarding family history for episodic headache and for psychiatric disorders were found. No differences in family history for CH with drugs overuse and for substance abuse were found between CH patients without overuse and controls. Fifteen CH patients reported family history for alcohol abuse (P = .0003). Conclusions.— The significantly increased familial risk for CH, drug overuse, and substance abuse suggests that a genetic factor is involved in the process of headache chronification.     

Hypnotic relaxation vs amitriptyline for tension-type headache: let the patient choose

(Headache 2012;52:785‐791) Background.— Although both pharmacological and behavioral interventions may relieve tension‐type headache, data are lacking regarding treatment preference, long‐term patient compliance, and feasibility of behavioral intervention in a standard neurological outpatient clinic setting. Objective.— To describe patient choice, long‐term compliance, and clinical outcome in a neurological clinic setting where patients are given the choice of the approach they wish to pursue. Design.— Patients presenting to the headache clinic with a diagnosis of tension‐type headache that justified prophylactic therapy (frequent episodic tension‐type headache or chronic tension‐type headache) were given the choice of amitriptyline (AMT) treatment or hypnotic relaxation (HR), and were treated accordingly. Patients were given the option to cross‐over to the other treatment group at each visit. HR was performed during standard length neurology clinic appointments by a neurologist trained to perform hypnosis (Y.E.). Follow‐up interviews were performed between 6 and 12 months following treatment initiation to evaluate patient compliance, changes in headache frequency or severity, and quality‐of‐life parameters. Results.— Ninety‐eight patients were enrolled, 92 agreed to receive prophylactic therapy of some kind. Fifty‐three (57.6%) patients chose HR of which 36 (67.9%) actually initiated this treatment, while 39 (42.4%) chose pharmacological therapy with AMT of which 25 (64.1%) patients actually initiated therapy. Patients with greater analgesic use were more likely to opt for AMT (P = .0002). Eleven of the patients initially choosing AMT and 2 of the patients initially choosing HR crossed over to the other group. Seventy‐four percent of the patients in the HR group and 58% of patients in the AMT group had a 50% reduction in the frequency of headaches (P = .16). Long‐term adherence to treatment with HR exceeded that of AMT. At the end of the study period, 26 of 47 patients who tried HR compared with 10 of 27 who tried AMT continued receiving their initial treatment. Conclusions.— HR treatment was a more popular choice among patients. Patients choosing HR reported greater symptom relief than those choosing AMT and were found to have greater treatment compliance. Patients receiving HR were less likely to change treatments. HR practiced by a neurologist is feasible in a standard neurological outpatient clinic setting; HR training should be considered for neurologists involved in headache treatment.     

Central pain modulation and scalp tenderness in frequent episodic tension-type headache

Objective.— To determine whether the inhibitory effect of acute limb pain on pain to mechanical stimulation of the forehead is compromised in individuals with frequent episodes of tension‐type headache. Background.— Central pain modulation processes are disrupted in patients with chronic tension‐type headache. This deficit in pain modulation might be a predisposing characteristic that increases vulnerability to tension‐type headache and to symptoms such as scalp tenderness, or could be a feature that develops secondarily during attacks and that persists for a few days afterward. To distinguish between these 2 possibilities in the present study, inhibitory pain control was investigated in participants with episodic rather than chronic tension‐type headache. Methods.— Pressure‐pain thresholds and sensitivity to sharpness in the forehead were measured in 34 individuals with 1‐10 episodes of tension‐type headache per month and in 32 controls before and after immersion of their hand in painfully cold water. Results.— Before the cold pressor test, pressure‐pain thresholds and sensitivity to the sharp stimulus were similar in both groups. Mild headache developed and pressure‐pain thresholds in the forehead decreased from 631 ± 178 g to 579 ± 196 g (mean ± SD) after the cold water immersion in the episodic tension‐type headache group (P < .05). However, sharpness ratings did not change (mean rating 3.2 ± 1.4 on a 0‐10 scale). In contrast, headache did not develop, pressure‐pain thresholds did not change, and sharpness ratings decreased from 3.0 ± 1.3 to 2.3 ± 1.1 after the immersion in controls (P < .01). Conclusions.— These findings suggest that endogenous pain modulation processes are compromised in individuals with frequent episodic tension‐type headache. This deficit could increase vulnerability to scalp tenderness and recurrent episodes of headache.     

Headache in systemic lupus erythematosus vs multiple sclerosis: a prospective comparative study

Objective.— To clarify whether headache, and particularly migraine, belongs to the spectrum of neurologic manifestations of systemic lupus erythematosus (SLE), the archetypal autoimmune disease. Methods.— Consecutive SLE patients were matched 1:1 for age, gender, and level of education with healthy control subjects. A representative subgroup of SLE patients were also matched with patients suffering from multiple sclerosis (MS), a nervous system‐specific autoimmune disease. All study participants were assessed for headache present in the previous year. Anxiety, depression, and quality of life were also estimated at baseline. During the following year, all participants were assessed every 3 months using specific headache diaries. Results.— Seventy‐two SLE/control pairs and 48 MS patients completed 12 months of follow‐up. Prevalence of migraine, with or without aura, was similar between SLE patients (21%), MS patients (23%), and controls (22%), as was the prevalence of frequent tension‐type headache. Duration and severity of migraine attacks were milder in SLE patients than controls. Only chronic tension‐type headache was significantly more prevalent in SLE patients (12.5%) compared to controls (1.4%). MS patients also presented increased frequency of chronic tension‐type headache (8.3%). No associations of any headache type with particular clinical manifestations, autoantibody, or disease activity, either in SLE or MS patient groups, were found. Irrespective of the presence of headache, anxiety symptoms and impaired quality of life were more frequent among SLE than MS patients or controls. Conclusion.— Migraine should be no longer considered a neurologic manifestation of systemic or organ‐specific autoimmunity. Increased migraine prevalence in these patients found in previous studies could be due to methodological weaknesses.     

The relationship of personality variables and patient recruitment to pain coping strategies and psychological distress in tension headache patients.

The relationship of personality variables and patient recruitment to pain coping strategies and psychological distress was assessed in a Dutch sample of 111 chronic tension headache patients. Using the Coping Strategy Questionnaire (CSQ), high scores on the factor of helplessness proved to be associated with psychological distress. In particular, patients who manifested neuroticism and hostility as personality traits and who were referred for treatment by physicians achieved higher scores on the factor of helplessness. Patients who reported a lower level of pain intensity manifested a higher perceived control of pain. Patients who reported shorter daily pain periods indicated a lower level of active coping with pain. It is concluded that future research must be more attentive to the complex interactions between personality variables, environmental factors, and the coping demands posed by the nature of the pain problem.     

Chronic Headache: The Role of the Psychologist

The role of the psychologist in chronic headache needs to be tailored to the patient’s presentation. For some patients, psychological issues need to be directly addressed (eg, psychiatric comorbidity, difficulties coping with headache, significant problems with sleep and/or stress, medication overuse, and history of abuse). Other situations (eg, patients’ beliefs about their readiness to change ability to actively manage headaches, medication adherence, and managing triggers) involve behavioral/psychological principles even when there is no direct contact with a psychologist. This article reviews the literature on the importance of psychological issues in headache management and provides suggestions for how to address behavioral and cognitive factors and their potential for improved headache care.     

Chronic Headache and Comorbibities: A Two‐Phase,Population‐Based,Cross‐Sectional Study

Background.— Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.— To estimate the 1‐year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.— This was a cross‐sectional, population‐based, 2‐phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD‐2). Medication overuse headache was diagnosed, as per the ICHD‐2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM‐IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.— A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension‐type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.— The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;50:1306‐1312)     

Migraine and tension headache in children under 6 years of age.

OBJECTIVE: To investigate the clinical features of idiopathic headache with early onset, whose presence is probably underestimated by parents and physicians and the influence of environmental and psychological factors on headache in children. METHODS: We report on a prospective longitudinal evaluation of 35 consecutive children referred to the Neuropsychiatry Departments of the Universities of Varese and Pavia (mean age at the first observation: 4 years and 7 months, range: 12 months-6 years; mean age at onset: 4 years and 2 months, range: 10 months-6 years) presenting with headache symptomatology. Mean duration of clinical follow-up: 9.5 months. The diagnosis based on the IHS criteria was then compared to the intuitive clinical diagnosis made in accordance with alternative case definitions. We examined our patients for the presence of early developmental disorders and interictal somatic disorders. We also studied the role of psychosocial factors at the onset and in the course of headache. RESULTS: Diagnosis: migraine without aura in two cases, episodic tension headache in four cases, migrainous disorders not fulfilling above criteria in eight cases, headache of the tension-type not fulfilling above criteria in 12 cases and headache not classifiable in nine cases. Clinical features of headache are described in the text. Early developmental disorders (0-2 years), such as eating difficulties and sleep disorders, were detected in 18/35 children. Among patients older than 2 years, we also detected interictal somatic disorders (20 cases) such as sleep disorders, eating difficulties, enuresis and idiopathic vomiting. In 14/35 subjects, we identified psychosocial components playing a significant role at the onset of, and during, the headache. CONCLUSIONS: A better clinical definition of the disorder would make it easier to identify very young affected children and consequently to plan more specific therapeutic interventions, taking into account environmental and psychological factors. A diagnosis of idiopathic headache becomes particularly significant: according to our cases, despite their being limited in number, migraine and tension headache can be considered also as indices of individual or family related problems requiring appropriate psychiatric or psychological intervention. This stresses the need for a multidisciplinary team of specialists that would include a psychologist/ psychiatrist or headache specialist with specific training in psychiatry.     

A randomized trial of a web-based intervention to improve migraine self-management and coping

Objective.— To test the clinical efficacy of a web‐based intervention designed to increase patient self‐efficacy to perform headache self‐management activities and symptom management strategies, and reduce migraine‐related psychological distress. Background.— In spite of their demonstrated efficacy, behavioral interventions are used infrequently as an adjunct in medical treatment of migraine. Little clinical attention is paid to the behavioral factors that can help manage migraine more effectively and improve the quality of care and quality of life. Access to evidenced‐based, tailored, behavioral treatment is limited for many people with migraine. Design.— The study is a parallel group design with 2 conditions: (1) an experimental group exposed to the web intervention; and (2) a no‐treatment control group that was not exposed to the intervention. Assessments for both groups were conducted at baseline (T1), 1‐month (T2), 3‐months (T3), and 6‐months (T4). Results.— Compared with controls, participants in the experimental group reported significantly: increased headache self‐efficacy, increased use of relaxation, increased use of social support, decreased pain catastrophizing, decreased depression, and decreased stress. The hypothesis that the intervention would reduce pain could not be tested. Conclusions.— Demonstrated increases in self‐efficacy to perform headache self‐management, increased use of positive symptom management strategies, and reported decreased migraine‐related depression and stress suggest that the intervention may be a useful behavioral adjunct to a comprehensive medical approach to managing migraine.     

Do Certain Headache Syndromes Occur in "Pain-Prone" Patients?

SYNOPSIS
To clarify the actual components of headache syndromes and their possible association with other types of pain and psychological traits, 177 patients subject to severe intermittent headaches were studied. Data used were derived from (a) a de tailed headache questionnaire, (b) a second questionnaire concerning the occurrence of other pain and of feelings of good or ill health, (c) the Cornell Medical Index. A stepwise regression analysis was run for each headache characteristic using data from the pain questionnaire and the Cornell Medical Index as independent variables. Interesting associations of variables were (1) increased frequency of headache with male sex and increased duration of headache with female, (2) inability to carry on work load during headache, headache preceded by spots before the eyes, weakness of arm or leg preceding headache were all positively associated with history of fainting. Neither vomiting with headache, nor unilaterality of pain was associated with any other pain variables. Also of note was the fact that there was no evidence by testing of increased psychological disturbance in patients with back pain. The results suggest that the "tension headache-neurosis" concept is dubious, that autonomic instability as evidenced by fainting is indeed important in some headache syndromes, and that new headache syndromes need to be defined.