Validation of criterion-based patient assignment and treatment effectiveness of a multidisciplinary modularized managed care program for headache

This prospective observational study evaluates the validity of an algorithm for assigning patients to a multidisciplinary modularized managed care headache treatment program. N = 545 chronic headache sufferers [migraine (53.8 %), migraine + tension type (30.1 %), tension type (8.3 %) or medication overuse headache (6.2 %), other primary headaches (1.5 %)] were assigned to one of four treatment modules differing with regard to the number and types of interventions entailed (e.g., medication, psychological intervention, physical therapy, etc.). A rather simple assignment algorithm based on headache frequency, medication use and psychiatric comorbidity was used. Patients in the different modules were compared with regard to the experienced burden of disease. 1-year follow-up outcome data are reported (N = 160). Headache frequency and analgesic consumption differed significantly among patients in the modules. Headache-related disability was highest in patients with high headache frequency with/without medication overuse or psychiatric comorbidity (modules 2/3) compared to patients with low headache frequency and medication (module 0). Physical functioning was lowest in patients with chronic headache regardless of additional problems (modules 1/2/3). Psychological functioning was lowest in patients with severe chronicity with/without additional problems (module 2/3) compared to headache suffers with no/moderate chronicity (module 0/1). Anxiety or depression was highest in patients with severe chronicity. In 1-year follow-up, headache frequency (minus 45.3 %), consumption of attack-aborting drugs (minus 71.4 %) and headache-related disability decreased (minus 35.9 %). Our results demonstrate the clinical effectiveness and the criterion validity of the treatment assignment algorithm based on headache frequency, medication use and psychiatric comorbidity.     

Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents

The main aim of the study was to examine the relationship between headache and familial recurrence of psychiatric disorders in parents and their children. Headache history and symptomatology have been collected in a clinical sample of 200 patients and their families, using a semi-structured interview (ICHD-II criteria). Psychiatric comorbidity was assessed by DSM-IV criteria. Chi squares and a loglinear analysis were computed in order to evaluate the main effects and interactions between the following factors: frequency and headache subtypes (migraine/not-migraine) in children, headache (migraine/not-migraine-absent/present) in parents, headache (absent/present) in grandparents, and psychiatric comorbidity (absent/present) have been analyzed: 94 mothers (47%) and 51 fathers (25.5%) had at least one psychiatric disorder, mainly mood and anxiety disorders. Considering the significant prevalence of Psi-co in children (P < 0.0001), we compared it with the presence of familiarity to headache: a significant interaction has been found (P < 0.05) showing that migraineurs with high familial recurrence of headache had a higher percentage (74.65%) of psychiatric disorders, than no-migraineurs (52.17%). Absence of headache familial loading seems to be related to psi-co only in no-migraine headache (87.5 vs. 45.5%). The occurrence of psychiatric disorders is high in children with headache, but a very different pattern seems to characterize migraine (familial co-transmission of migraine and Psi-Co?) if compared with non-migraine headache.     

Hemicrania continua in a headache clinic: referral source and diagnostic delay in a series of 22 patients

Hemicrania continua (HC) is a unilateral and continuous primary headache with superimposed exacerbations frequently associated with autonomic features. Diagnostic criteria of HC, according to II Edition of International Classification of Headache Disorders require complete response to indomethacin. HC is probably misdiagnosed more often than other primary headaches. We aim to analyze characteristics of a series of 22 consecutive cases of HC. We recruited patients from a headache outpatient clinic in a tertiary hospital over a 3-year period (January 2008 to January 2011). We prospectively gathered demographic and nosological characteristics and considered referral source and delay between onset of headache and diagnosis of HC. Twenty-two patients (14 females, 8 males) out of 1,150, who attended the mentioned clinic during the inclusion period (1.9 %) were diagnosed with HC. All cases responded to indomethacin. No patient received a diagnosis of HC before attending our headache office. Mean latency of diagnosis was 86.1 ± 106.5 months (range 3–360). 11 patients (50 %) were referred from primary care, with 9 (40.9 %) from other neurology clinics and 2 (9.1 %) from other specialities offices. According to our series, HC is not an infrequent diagnosis in a headache outpatient clinic. Diagnostic delay is comparable to data collected in previous studies. As HC is frequently misdiagnosed, we thing there is a need for increasing the understanding of this entity, potentially responsive to indomethacin.     

Comorbidity profiles of chronic migraine sufferers in a national database in Taiwan

Chronic migraine (CM; ≥15 headache days per month, ≥3 months) is associated with a higher prevalence of comorbidities than episodic migraine (<15 headache days per month). However, it is unclear whether a similar pattern exists in Asian patients. To examine this, a retrospective matched cohort study was conducted using the Taiwan National Health Insurance Research Database. CM cases were defined as patients with at least one neurological outpatient visit with a primary or secondary ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) code of 346.11, diagnosed by neurologists at medical centers during 2007–2008. The study group was compared with patients suffering from other migraine subtypes and non-migraineurs in the general population. Both comparison groups were matched with CM sufferers at a 4:1 ratio by age, gender, urbanization level of the residence, income, and hospital setting. Relative risk (RR) was calculated using conditional logistic regression. Compared with patients with other migraines (n = 2,226), CM sufferers (n = 681) had a higher risk of hyperlipidemia (RR = 1.32; P = 0.041), asthma (RR = 1.77; P = 0.007), depression (RR = 1.88; P < 0.0001), bipolar disorder (RR = 1.81; P = 0.022) and anxiety disorders (RR = 1.48; P = <0.0001). Compared with the non-migraineurs (n = 3,790), CM sufferers (n = 948) had significantly increased risks of cardiovascular disease, sinusitis, asthma, gastrointestinal ulcers, vertigo and psychiatric disorders by 1.6–3.9-fold. In conclusion, CM is associated with significant comorbidities in Asian patients. Differences in the comorbidity profiles of CM compared with other migraines have highlighted that patients with CM differ not just in terms of headache frequency but also in other important aspects.     

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.     

Alexithymia in juvenile primary headache sufferers: a pilot study

Starting in the 1990s, there has been accumulating evidence of alexithymic characteristics in adult patients with primary headache. Little research has been conducted, however, on the relationship between alexithymia and primary headache in developmental age. In their research on alexithymia in the formative years, the authors identified one of the most promising prospects for research, as discussed here. The aim of this study was to verify whether there is: (a) a link between tension-type headache and alexithymia in childhood and early adolescence; and (b) a correlation between alexithymia in children/preadolescents and their mothers. This study was based on an experimental group of 32 patients (26 females and 6 males, aged from 8 to 15 years, mean 11.2 ± 2.0) suffering from tension-type headache and 32 control subjects (26 females and 6 males, aged from 8 to 15 years, mean 11.8 ± 1.6). Tension-type headache was diagnosed by applying the International Headache Classification (ICHD-II, 2004). The alexithymic construct was measured using an Italian version of the Alexithymia Questionnaire for Children in the case of the juvenile patients and the Toronto Alexithymia Scale (TAS-20) for their mothers. Higher rates of alexithymia were observed in the children/preadolescents in the experimental group (EG) than in the control group; in the EG there was no significant correlation between the alexithymia rates in the children/preadolescents and in their mothers.     

Metabolic syndrome and insulin resistance in migraine

Metabolic syndrome is associated with migraine but there is no study comparing the characteristics of migraine with and without metabolic syndrome from Southeast Asia. This study was therefore undertaken to compare the clinical characteristics of migraine in patients with and without metabolic syndrome and insulin resistance. 135 consecutive patients with migraine diagnosed on the basis of International Headache Society criteria were subjected to clinical evaluation as per fixed protocol. Headache severity, frequency and functional disability were recorded. Metabolic syndrome was diagnosed as per National Cholesterol Education Programme: Adult Treatment Panel III and International Diabetic Federation criteria. Insulin resistance was calculated by homeostases model assessment. Their age ranged between 14 and 61 years and 108 were females. Metabolic syndrome was present in 31.9% patients and only 13 were obese. Insulin resistance was present in 11.1%. Metabolic syndrome was correlated with age, gender, number of triggers, years of headache and duration of migraine attacks. Insulin resistance correlated with duration of migraine attacks. From this study, it can be concluded that metabolic syndrome was present in 31.9% of the migraineurs which was mainly in elderly who had longer duration of headache and multiple triggers.     

Migraine and behavior in children: influence of maternal headache frequency

We took advantage of a large population study in order to measure child behavior, as captured by the Child Behavior Checklist (CBCL) as a function of headache status in the children and their mothers. Of the target sample, consents and analyzable data were obtained from 1,856 families (85.4 %). Headache diagnoses were defined according to the second edition of the International Classification of Headache Disorders, and behavioral and emotional symptoms were assessed by the validated Brazilian version of the CBCL. We calculated the relative risk of abnormalities in the CBCL domains as a function of headache status in the children, after adjusting by a series of main effect models. Children with migraine were more likely to present abnormal scores in several of the CBCL scales, relative to children without migraine, and maternal migraine status contributed little to the model. However, when the mother had daily headaches, both children with and without migraine had similar CBCL scores. In multivariate analyses, migraine status in the children predicted CBCL scores (p < 0.01). Headache status and headache frequency in the mother did not predict CBCL scores in children with migraine but predicted in children without migraine (p < 0.01). The burden of migraine to the family is complex. Children with migraine are more likely to have behavioral and emotional symptoms than children without migraine. Children without migraine may be affected, in turn, by frequent headaches experienced by their mothers.     

Serum levels of N-acetyl-aspartate in migraine and tension-type headache

Serum levels of N-acetyl-aspartate (NAA) may be considered a useful marker of neuronal functioning. We aimed to measure serum NAA in cohorts of migraine and tension-type headache patients versus controls, performing correlations with main clinical features. A total of 147 migraine patients (including migraine without aura, with aura and chronic migraine), 65 tension-type headache (including chronic and frequent episodic tension-type headache) and 34 sex- and age-matched controls were selected. Serum was stored at −80 °C. Quantification of NAA was achieved by the standard addition approach and analysis was performed with liquid-chromatography–mass-spectrometry (LC/MS) technique. The NAA levels were significantly decreased in migraine group (0.065 ± 0.019 mol/L), compared with both tension-type headache patients (0.078 ± 0.016 mol/L) and controls (0.085 ± 0.013 mol/L). Control subjects were significantly different from migraine with and without aura and chronic migraine, who differed significantly from episodic and chronic tension-type headache. Migraine with aura patients showed lower NAA levels when compared to all the other headache subtypes, including migraine without aura and chronic migraine. In the migraine group, no significant correlation was found between NAA serum levels, and headache frequency, allodynia and interval from the last and the next attack. The low NAA in the serum may be a sign of neuronal dysfunction predisposing to migraine, probably based on reduced mitochondria function.     

Headache in a Population-Based Elderly Cohort. An Ancillary Study to the Italian Longitudinal Study of Aging (ILSA)

The aims of this ancillary study to the Italian Longitudinal Study of Aging were: (1) to provide reliable prevalence data on headache in an elderly population, (2) to classify the subtypes of headache according to International Headache Society criteria, and (3) to identify possible risk factors and associated pathologies in the elderly.
A total of 312 subjects were examined, 148 women and 164 men, with a mean age of 73 years (SD 5.5). For 236 subjects (75.7%), 141 men (85.9%) and 95 women (64.2%), headache had never been a problem; 57 subjects (18.3%), 21 men (12.8%) and 36 women (24.3%), reported troublesome headache only in the past. Nineteen subjects (6%), 6 men (3.6%) and 13 women (8.8%), reported current headache: in this group tension-type headache was the most prevalent, accounting for 2.6%; secondary headaches ranked second, accounting for 2.2%; and only 1% had current migraine.
Our data indicate female sex and younger age as risk factors for headache, and associate migraine and secondary headaches with hypertension, tension-type headaches and secondary headaches with diabetes, and tension-type headaches with myocardial ischemia.     

Prevalence and risk factors for depression and anxiety among outpatient migraineurs in mainland China

This study aimed to investigate the prevalence and risk factors for anxiety and depression symptoms in outpatient migraineurs in mainland China. In addition, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) provided sufficient validity to screen depression and anxiety. A cross-sectional study was conducted consecutively at our headache clinic. Migraine was diagnosed according to International Classification of Headache Disorders, 2nd edition (ICHD-II). Demographic characteristics and clinical features were collected by headache questionnaire. Anxiety and depression symptoms about migraineurs were assessed using HADS. Several questionnaires were simultaneously used to evaluate patients with depressive disorder including the Hamilton Depression Rating Scale-17 (HAMD), Hamilton Anxiety Rating Scale (HAMA) and HADS. Pearson correlation analysis was applied to test the validity of HADS. 176 outpatients with migraine (81.8 % female) were included. Overall, 17.6 and 38.1 % participants had depression and anxiety, respectively. Possible risk factors for depression in migraineurs included headache intensity of first onset of migraine, migraine with presymptom, migraine with family history and migraine disability. The possible risk factors for anxiety included fixed attack time of headache in one day and poor sleeping, and age represented a protective factor for anxiety. The correlation coefficient of HADS-A and HADS-D with HAMA and HAMD was 0.666 and 0.508, respectively (P < 0.01). This study demonstrates that depression and anxiety comorbidity in our mainland Chinese migraineurs are also common, and several risk factors were identified that may provide predictive value. These findings can help clinicians to identify and treat anxiety and depression in order to improve migraine management.     

Headache in acute cerebrovascular disease: a prospective clinical study in 240 patients

To evaluate the clinical features of headache in stroke, a prospective study was carried out in 240 consecutive patients with acute stroke who had intact expressive function. Headache occurred in 38%: 32% of 195 patients with ischemic stroke and 64.5% of 45 patients with hemorrhagic stroke ( p < 0.0001). Headache patients were younger (mean age 62 ± 15 vs 67 ± 11.5 years) than non-headache patients ( p < 0.01). A history of previous vascular or tension-type headache was found in 40.5% of the headache group, but in only 23.5% of the non-headache group ( p < 0.01). In ischemic stroke, headache was observed in 41% of thrombotic infarcts, in 39% of cardioembolic infarcts, in 23% of lacunar infarcts and in 26% of TIA. Headache was significantly more common in thrombotic than lacunar infarcts ( p < 0.05). In hemorrhagic stroke, headache was observed in all subarachnoid hemorrhages and in 58% of intraparenchymal hemorrhages. In ischemic stroke, the mean duration of the headache was 25 ± 28 h and in hemorrhagic stroke 64.5 ± 36.5 h ( p < 0.00001). In ischemic stroke the headache was focal in 74% and mild or moderate in intensity in 74%. In hemorrhagic stroke, it was diffuse in 52% and the pain intensity was incapacitating in 70%. Headache was more common in vertebrobasilar stroke (59%), in comparison with carotid stroke (26%) or stroke of unclear vascular topography (33%) (p < 0.00001). Fifty-six and a half percent of patients with cortical stroke had headaches, as opposed to only 26.5% of patients with subcortical stroke ( p < 0.005). Ten percent of the patients presented with sentinel headache.     

Brain-derived neurotrophic factor in primary headaches

Brain derived neurotrophic factor (BDNF) is associated with pain modulation and central sensitization. Recently, a role of BDNF in migraine and cluster headache pathophysiology has been suspected due to its known interaction with calcitonin gene-related peptide. Bi-center prospective study was done enrolling four diagnostic groups: episodic migraine with and without aura, episodic cluster headache, frequent episodic tension-type headache, and healthy individuals. In migraineurs, venous blood samples were collected twice: outside and during migraine attacks prior to pain medication. In cluster headache patients serum samples were collected in and outside cluster bout. Analysis of BDNF was performed using enzyme-linked immunosorbent assay technique. Migraine patients revealed significantly higher BDNF serum levels during migraine attacks (n = 25) compared with headache-free intervals (n = 53, P < 0.01), patients with tension-type headache (n = 6, P < 0.05), and healthy controls (n = 22, P < 0.001). There was no significant difference between patients with migraine with aura compared with those without aura, neither during migraine attacks nor during headache-free periods. Cluster headache patients showed significantly higher BDNF concentrations inside (n = 42) and outside cluster bouts (n = 24) compared with healthy controls (P < 0.01, P < 0.05). BDNF is increased during migraine attacks, and in cluster headache, further supporting the involvement of BDNF in the pathophysiology of these primary headaches.     

Nabilone for the treatment of medication overuse headache: results of a preliminary double-blind, active-controlled, randomized trial

Medication overuse headache (MOH) is a severe burden to sufferers and its treatment has few evidence-based indications. The aim of this study is to evaluate efficacy and safety of nabilone in reducing pain and frequency of headache, the number of analgesic intake and in increasing the quality of life on patients with long-standing intractable MOH. Thirty MOH patients were enrolled at the University of Modena’s Interdepartmental Centre for Research on Headache and Drug Abuse (Italy) in a randomized, double-blind, active-controlled, crossover study comparing nabilone 0.5 mg/day and ibuprofen 400 mg. The patients received each treatment orally for 8 weeks (before nabilone and then ibuprofen or vice versa), with 1 week wash-out between them. Randomization and allocation (ratio 1:1) were carried out by an independent pharmacy through a central computer system. Participants, care givers, and those assessing the outcomes were blinded to treatment sequence. Twenty-six subjects completed the study. Improvements from baseline were observed with both treatments. However, nabilone was more effective than ibuprofen in reducing pain intensity and daily analgesic intake (p < 0.05); moreover, nabilone was the only drug able to reduce the level of medication dependence (−41 %, p < 0.01) and to improve the quality of life (p < 0.05). Side effects were uncommon, mild and disappeared when nabilone was discontinued. This is the first randomized controlled trial demonstrating the benefits of nabilone on headache, analgesic consumption and the quality of life in patients with intractable MOH. This drug also appears to be safe and well-tolerated. Larger scale studies are needed to confirm these preliminary findings.     

Efficacy of half-solid nutrient for the elderly patients with percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy tube feeding is widely used for patients with swallowing dysfunction and a history of repeated aspiration pneumonitis. However, liquid nutrient feeding via percutaneous endoscopic gastrostomy is not effective enough to prevent aspiration pneumonitis and related inflammatory responses. We performed this prospective multi-centre study to clarify the efficacy of half-solidification of nutrients to prevent fever possibly caused by aspiration pneumonitis in elderly patients with percutaneous endoscopic gastrostomy. The study subjects were 42 elderly patients undergoing percutaneous endoscopic gastrostomy feeding (mean age 85.8 years). All subjects were fed half-solid as well as liquid nutrients for 8 weeks respectively in a cross over design. We counted the number of days with fever caused by pneumonitis and unidentified origin. Thirty-two of 42 patients were successfully observed in both nutrient periods. Fever was frequently observed in both nutrient periods, however, the percentage of observational days with fever during half-solid nutrient feeding was significantly lower than that during liquid nutrient feeding (15.3 ± 0.3 vs 19.8 ± 0.4%, p = 0.030). The percentage of observational days when patients had diarrhea was not significantly different (10.1 ± 3.8 vs 7.2 ± 3.2%, p = 0.357). In conclusion, half-solid nutrient feeding was determined to be effective for reducing fever in patients with percutaneous endoscopic gastrostomy feeding.     

Multidisciplinary integrated headache care: a prospective 12-month follow-up observational study

This prospective study investigated the effectiveness of a three-tier modularized out- and inpatient multidisciplinary integrated headache care program. N = 204 patients with frequent headaches (63 migraine, 11 tension-type headache, 59 migraine + tension-type headache, 68 medication-overuse headache and 3 with other primary headaches) were enrolled. Outcome measures at baseline, 6- and 12-month follow-ups included headache frequency, Migraine Disability Assessment (MIDAS), Hospital Anxiety and Depression Scale (HADS), standardized headache diary and a medication survey. Mean reduction in headache frequency was 5.5 ± 8.5 days/month, p < 0.001 at 6 months’ follow-up and 6.9 ± 8.3 days/month, p < 0.001 after 1 year. MIDAS decreased from 53.0 ± 60.8 to 37.0 ± 52.4 points, p < 0.001 after 6 months and 34.4 ± 53.2 points, p < 0.001 at 1 year. 44.0 % patients demonstrated at baseline an increased HAD-score for anxiety and 16.7 % of patients revealed a HAD-score indicating a depression. At the end of treatment statistically significant changes could be observed for anxiety (p < 0.001) and depression (p < 0.006). The intake frequency of attack-aborting medication decreased from 10.3 ± 7.3 days/month at admission to 4.7 ± 4.1 days/month, p < 0.001 after 6 months and reached 3.8 ± 3.5 days/month, p < 0.001 after 1 year. At baseline 37.9 % of patients had experience with non-pharmacological treatments and 87.0 % at 12-month follow-up. In conclusion, an integrated headache care program was successfully established. Positive health-related outcomes could be obtained with a multidisciplinary out- and inpatient headache treatment program.     

Osmophobia in primary headache patients: associated symptoms and response to preventive treatments

BackgroundOsmophobia, is common among primary headaches, with prevalence of migraine.The study aimed to evaluate prevalence and clinical characteristics of patients with osmophobia in a cohort of primary headache patients selected at a tertiary headache center. The second aim was to verify the possible predicting role of osmophobia in preventive treatment response in a sub cohort of migraine patients.MethodsThis was an observational retrospective cohort study based on data collected in a tertiary headache center.We selected patients aged 18–65 years, diagnosed as migraine without aura (MO), migraine with aura (MA) or Chronic Migraine (CM), Tension-Type Headache (TTH); and Cluster Headache (CH). We also selected a sub-cohort of migraine patients who were prescribed preventive treatment, according to Italian Guidelines, visited after 3 months follow up.Patients were considered osmophobic, if reported this symptom in at least the 20% of headache episodes. Other considered variables were: headache frequeny, the migraine disability assessment (MIDAS), Allodynia Symptom Checklist, Self-rating Depression scale, Self-rating Anxiety scale, Pain intensity evaluated by Numerical Rating Scale-NRS- form 0 to 10.ResultsThe 37,9% of patients reported osmophobia (444 patients with osmophobia, 726 without osmophobia).Osmophobia prevailed in patients with the different migraine subtypes, and was absent in patients with episodic tension type headache and cluster headache (chi square 68.7 DF 7 p < 0.0001). Headache patients with osmophobia, presented with longer hedache duration (F 4.91 p 0.027; more severe anxiety (F 7.56 0.007), depression (F 5.3 p 0.019), allodynia (F 6 p 0.014), headache intensity (F 8.67 p 0.003). Tension type headache patients with osmophobia (n° 21), presented with more frequent headache and anxiety. A total of 711 migraine patients was visited after 3 months treatment. The change of main migraine features was similar between patients with and without osmophobia.ConclusionsWhile the present study confirmed prevalence of osmophobia in migraine patients, it also indicated its presence among chronic tension type headache cases, marking those with chronic headache and anxiety.Osmophobia was associated to symptoms of central sensitization, as allodynia. It was not relevant to predict migraine evolution after first line preventive approach.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-021-01327-2.     

Sociodemographic differences in medication use, health-care contacts and sickness absence among individuals with medication-overuse headache

The objective of this study was to analyse sociodemographic differences in medication use, health-care contacts and sickness absence among individuals with medication-overuse headache (MOH). A cross-sectional, population survey was conducted, in which 44,300 Swedes (≥15 years old) were interviewed over telephone. In total, 799 individuals had MOH. Of these, 47 % (n = 370) only used over-the-counter medications. During the last year, 46 % (n = 343) had made a headache-related visit to their physician and 14 % (n = 102) had visited a neurologist. Among individuals aged <30 years, the number of days/month with headache was greater than the number of days with medication use, whereas the opposite was true for those ≥30 years. Both the proportion using prophylactic medication and the proportion having consulted a neurologist were smaller among those who only had elementary school education than among those with higher education (p = 0.021 and p = 0.046). Those with a lower level of education also had a higher number of days/month with headache and with medication use than those with a higher educational level (p = 0.011 and p = 0.018). The MOH-sufferers have limited contacts with health-care and preventive measures thus need to include other actors as well. Particular efforts should be directed towards those with low educational levels, and more research on medication use in relation to age is required.     

Recurrent and chronic headaches in children below 6 years of age

The objective was to determine the frequency of headache subtypes, according to International Headache Society (IHS) criteria, in a population of children below 6 years visiting a Center for Diagnosis and Treatment of Headache in Youth. Medical records of the children below 6 years at their first visit, admitted for headache between 1997 and 2003, were studied. Headache was classified according to the IHS criteria 2004. Children with less than three headache attacks or less than 15 days of daily headache were excluded. We found 1598 medical records of children who visited our Headache Center in the study period. One hundred and five (6.5%) were children younger than 6 years. The mean age at the first medical control was 4.8±1.3 years (range 17–71 months). There were 59 males (56.1%) and 46 females (43.9%). The mean age at onset of headaches was 4.3 years (range 14–69 months). According to the IHS criteria we found 37 cases (35.2%) with migraine, 19 cases (18%) with episodic tension headache, 5 cases (4.8%) with chronic daily headache, 13 cases (12.4%) with primary stabbing headache, 18 cases (17.1%) with post–traumatic headache, 7 cases (6.6%) with other non–dangerous secondary headaches (otorhinolaryngological diseases, post–infectious headaches), 3 cases (2.85%) with dangerous headaches (Arnold–Chiari type 1 malformation, brain tumour) and 9 cases (8.6%) with unclassifiable headaches. Six children (5.7%) reported more than one headache subtype. The prevalence of dangerous headaches was higher than those in school age (χ²=4.70, p<0.05). Our study shows some differences in headaches in this population vs. school children. In fact at this age migraine is the most common headache, but we also found an increase of secondary causes among the chronic/recurrent and daily headaches, especially posttraumatic disorders and potentially dangerous headaches. Finally our study shows the highest prevalence of the idiopathic stabbing headache in pre–school children in comparison with other ages.     

The burden of headache disorders in India: methodology and questionnaire validation for a community-based survey in Karnataka State

Primary headache disorders are a major public-health problem globally and, possibly more so, in low- and middle-income countries. No methodologically sound studies of prevalence and burden of headache in the adult Indian population have been published previously. The present study was a door-to-door cold-calling survey in urban and rural areas in and around Bangalore, Karnataka State. From 2,714 households contacted, 2,514 biologically unrelated individuals were eligible for the survey and 2,329 (92.9 %) participated (1,103 [48 %] rural; 1,226 [52 %] urban; 1,141 [49 %] male; 1,188 [51 %] female; mean age 38.0 years). The focus was on primary headache (migraine and tension-type headache [TTH]) and medication-overuse headache. A structured questionnaire administered by trained lay interviewers was the instrument both for diagnosis (algorithmically determined from responses) and burden estimation. The screening question enquired into headache in the last year. The validation study compared questionnaire-based diagnoses with those obtained soon after through personal interview by a neurologist in a random sub-sample of participants (n = 381; 16 %). It showed high values (>80 %) for sensitivity, specificity and predictive values for any headache, and for specificity and negative predictive value for migraine and TTH. Kappa values for diagnostic agreement were good for any headache (0.69 [95 % CI 0.61–0.76]), moderate (0.46 [0.35–0.56]) for migraine and fair (0.39 [0.29–0.49]) for TTH.The survey methodology, including identification of and access to participants, proved feasible. The questionnaire proved effective in the survey population. The study will give reliable estimates of the prevalence and burden of headache, and of migraine and TTH specifically, in urban and rural Karnataka.