Botulinum toxin: could it be an effective treatment for chronic tension-type headache?

Several clinical trials suggest that botulinum toxin type-A (BTX-A) may be an effective treatment option for patients with chronic tension-type headache (CTTH); however, controversy remains as to how the botulinum toxin optimally should be used for treating headache and which patient's profile fits this treatment. The objective of this study was to evaluate the efficacy and tolerability of BTX-A for the prophylactic treatment of CCTH in Egyptian patients. This was a randomized, single-blind, placebo-controlled study of BTX-A for the treatment of patients aged 25–50 years old with CCTH. Following a 30-day screening, headache parameters and severity assessed by the standard visual analogue scale (VAS), and the 25-item Henry Ford Hospital Headache Disability Inventory (HDI) were recorded as a baseline. Then, injection was done with either BTX-A or with saline by a combination of two methods for detecting injection sites (the fixed-site approach and follow-the-pain approach). Our study showed significant improvement after 1 month of BTX-A injection regarding headache days/month, severity measured by VAS and HDI in headache severity. There was significant reduction of prophylactic medications, and there were minor complications, but these reversed spontaneously without further treatment. BTX-A was an effective and well-tolerated prophylactic treatment in Egyptian patients with CCTH.     

What's in a name? tension-type headache versus migraine

For years clinicians and researchers have debated the nosology of headache generally and of “migraine” versus “tension-type headache” in particular, an exhaustive process that arguably has done little to improve patient management and clinical outcome. New research data now indicate that the migraine versus tension-type distinction indeed may possess some clinical use, because patients with migraine or “mixed” headache syndromes may respond differently to a specific therapeutic intervention than patients with “pure” tension-type headache. This variable response to treatment intervention would seem to imply that similarly distinctive biologies are generating the respective headache syndromes, but to date we have insufficient evidence to support that conclusion.     

Phantom headache: pain-memory-emotion hypothesis for chronic daily headache?

The neurobiology of chronic pain, including chronic daily headache (CDH) is not completely understood. “Pain memory” hypothesis is one of the mechanisms for phantom limb pain. We reviewed the literature to delineate a relation of “pain memory” for the development of CDH. There is a direct relation of pain to memory. Patients with poor memory have less chance to develop “pain memory”, hence less possibility to develop chronic pain. Progressive memory impairment may lead to decline in headache prevalence. A similar relation of pain is also noted with emotional or psychiatric symptoms. Literature review suggests that there is marked overlap in the neural network of pain to that of memory and emotions. We speculate that pain, memory, and emotions are interrelated in triangular pattern, and each of these three is related to other two in bidirectional pattern, i.e., stimulation of one of these will stimulate other symptoms/networks and vice versa (triangular theory for chronic pain). Longstanding or recurrent noxious stimuli will strengthen this interrelation, and this may be responsible for chronicity of pain. Reduction of both chronic pain and psychological symptoms by cognitive behavioral therapy or psychological interventions further suggests a bidirectional interrelation between pain and emotion. Longitudinal studies are warranted on the prevalence of headache and other painful conditions in patients with progressive memory impairment to delineate the relation of pain to memory. Interrelation of headache to emotional symptoms should also be explored.     

Risk factors for migraine and tension-type headache in 11?year old children

Background

Though migraine and tension type headache are both commonly diagnosed in childhood, little is known about their determinants when diagnosed prior to puberty onset. Our aim was to determine psychosocial- and health-related risk factors of migraine and tension-type headache in 11 year old children.

Methods

871 New Zealand European children were enrolled in a longitudinal study at birth and data were collected at birth, 1, 3.5, 7, and 11 years of age. Primary headache was determined at age 11 years based on the International Headache Society. Perinatal factors assessed were small for gestational age status, sex, maternal smoking during pregnancy, maternal perceived stress, and maternal school leaving age. Childhood factors assessed were sleep duration, percent body fat, television watching, parent and self-reported total problem behaviour, being bullied, and depression.

Results

Prevalence of migraine and tension-type headache was 10.5% and 18.6%, respectively. Both migraine and TTH were significantly associated with self-reported problem behaviour in univariable logistic regression analyses. Additionally, migraine was associated with reduced sleep duration, and both sleep and behaviour problems remained significant after multivariable analyses. TTH was also significantly associated with antenatal maternal smoking, higher body fat, and being bullied. For TTH, problem behaviour measured at ages 3.5 and 11 years both remained significant after multivariable analysis. Being born small for gestational age was not associated with either headache group.

Conclusions

Although they share some commonality, migraine and tension-type headache are separate entities in childhood with different developmental characteristics. The association between primary headache and problem behaviour requires further investigation.     

Is there hope for chronic pain and headache?

Currently the clinical needs for pain and headache management are not met. Despite the numerous and exciting recent advances in understanding the molecular and cellular mechanisms that originate pain, we cannot yet fully explain the mechanism underlying the biology of chronic pain. Pain is a natural mechanism preserving our species survival; however, when the protective quality is lost, physiologic changes to the peripheral and central nervous systems result in the formation of chronic pain states. Once we understand how this chronic pain state is created, either through genetic, environmental, therapeutic, or other triggers we may be able to enhance our species existence, limiting maladaptive pain and suffering. The future therapeutic targets will need to address the genetics, neurophysiologic changes of the neurons and brain as well as help control immune systems including the glia. The key to successful headache and pain therapy is research aimed at prevention and minimizing the plastic changes triggering chronic pain.     

Are manual therapies effective in reducing pain from tension-type headache?: a systematic review

OBJECTIVES: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH). METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence. RESULTS: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3). CONCLUSIONS: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.     

Are infrequent episodic,frequent episodic and chronic tension-type headache inherited? A population-based study of 11 199 twin pairs

The objective was to investigate the importance of genetic and environmental factors for infrequent episodic, frequent episodic and chronic tension-type headache. Twin pairs recruited from the population-based Danish Twin Registry received a posted questionnaire. Only twin pairs where both twins replied were included. A total of 3523 monozygotic (MZ), 4150 dizygotic (DZ) same-gender and 3526 DZ opposite-gender twin pairs were included. The prevalence of frequent episodic and chronic tension-type headache was significantly more frequent in women than men, and significantly higher in those with co-occurrence of migraine. The concordance rates were significantly higher in MZ than same-gender DZ twin pairs with no or frequent episodic tension-type headache, while the difference was not significant in chronic tension-type headache. The concordance rates of infrequent episodic tension-type headache in MZ and same-gender DZ twin pairs was significantly different in women but not in men, although the difference was small in both genders. We conclude that genetic factors play a role in no and frequent episodic tension-type headache, while infrequent episodic tension-type headache is caused primarily by environmental factors. The data regarding chronic tensiontype headache were limited, so no firm conclusion could be drawn. Greppi-Sicuteri Commitee: Giorgio Zanchin, Miguel J.A. Lainez, Marcello Fanciullacci, Paolo Martelletti, Arne May, Lorenzo Pinessi     

Primary and secondary chronic cluster headache: two separate entities?

The International Headache Society (IHS) classification divides chronic cluster headache (CH) into two subtypes: chronic CH unremitting from onset (CCHU) and chronic CH evolved from episodic (CCHE). The purpose of our study was to point out any similarities and differences between the two chronic CH subtypes and to determine whether or not they can be considered as two separate clinical entities. We reviewed data about 31 CCHE patients and 38 CCHU patients referred to the Parma Headache Centre between 1975 and 1999. Clinically, CCHE patients exhibited statistically significant differences from CCHU patients, i.e. earlier CH onset and duration of attacks varying more frequently between 120 and 180 min. From the point of view of lifestyle, heavy alcohol and coffee drinkers prevailed among CCHU patients, while CCHE patients were more frequently heavy smokers. Based on clinical features, it seems reasonable to suppose that chronic CH may occur as two distinct entities.     

Is Chiari type I malformation a reason for chronic daily headache?

This article briefly reviews the spectrum of headaches associated with Chiari type I malformation and specifically analyzes current data on the possibility of this malformation as an etiology for some cases of chronic daily headache (CDH). Chiari type I malformation is definitely associated with cough headache and not with primary episodic headaches, with the rare exception of basilar migraine-like cases. With regard to CDH, there is no clear evidence supporting an association with this malformation. An MRI study would be justified only in patients showing either a Valsalva-aggravating component or cervicogenic features. Hydrocephalus and low intracranial pressure syndrome should be ruled out in patients showing tonsillar herniation in an MRI study and consulting due to daily headache.     

Comparison of pre-headache phases and trigger factors of migraine and episodic tension-type headache: do they share similar clinical pathophysiology?

Trigger factors, signs and symptoms of the preheadache phases of episodic tension-type headache (ETTH), typical aura with non-migraine headache (TANMH), migraine with (MA) and without aura (MwA) may show similar features. Our objective was to investigate the preheadache phases and trigger factors of these headache types. Questionnaires including trigger factors, signs and symptoms of preheadache phases were answered by all headache patients. A total of 96 patients, 31 ETTH, nine TANMH, 23 MA and 33 MwA patients were included in this study. Analysis of seven groups consisting of 18 individual trigger factors showed that only two groups and five individual trigger factors were significantly different between groups. Hunger and odour were significantly more common in MA, MwA and TANMH patients. Foods were a significant precipitant factor for headache in MA patients. Head and neck movements were important trigger factors in ETTH. In prodrome phase only one out of three groups differed significantly between headache types. Migraine and TANMH patients reported significantly more general signs and symptoms. Analysis of aura signs and symptoms showed that only two out of six groups were significantly more frequent in MA and TANMH patients. Visual aura symptoms were more frequent in MA and TANMH groups, where sensorial auras were reported to be the most frequent in the MA group. Our results showed that different type of headaches share common prodrome and aura signs and symptoms as well as the same trigger factors. We suggest that similar trigger factors may trigger similar mechanisms and may cause common preheadache signs and symptoms in all headache types.     

The patients’ perceptions of migraine and chronic daily headache: a qualitative study

This study aimed to gain insight into the management of migraine and chronic daily headache (CDH) from the patients perspective. This article outlines the patients perceptions of migraine and chronic daily headache. Thirteen semi–structured interviews were carried out with patients suffering from IHS migraine. Five patients, due to their headache frequency of more than 15 headache days per month, were classed as CDH patients. The data were transcribed verbatim and analysed in accordance with the grounded theory methodology. The main themes were: headaches, impact and headaches related to health issues. The theme headaches was sub-divided into their pain and symptoms, differentiating between their headaches and perceptions of headaches as barriers and facilitators to management. The patients perceptions of migraine and CDH were sometimes conflicting and influenced the patients management behaviours. The qualitative methodology may help to inform doctors, other healthcare professionals and headache researchers about the patients perspective and possibly develop future headache research, care and education.     

Botulinum toxin type A and EMG: a key to the understanding of chronic tension-type headaches?

BACKGROUND: The pathogenesis of chronic tension-type headache remains unclear, and the role of muscle tension is especially controversial. Botulinum toxin type A, a potent inhibitor of muscle tone, has been used to treat chronic tension-type headache. OBJECTIVE: To determine whether clinical response to treatment of chronic tension-type headache with Botox A parallels changes in resting muscle activity recorded through serial electromyography (EMG). METHODS: We randomly assigned eight patients with chronic tension-type headache to pericranial injection of 500 MU Botox A versus placebo (isotonic saline). RESULTS: At 6 and 12 weeks following treatment, there were no significant differences in clinical outcome between the placebo and the Botox A groups. This occurred despite EMG evidence of a reduction in resting muscle activity in the Botox A-treated patients. CONCLUSION: These results support the hypothesis that peripheral mechanisms such as increased muscle tone play, at most, a minor role in the pathophysiology of chronic tension-type headache.     

Post-infectious headache: a reactive headache?

Post-infectious disease syndrome includes both neurological and non-neurological disorders. However, headache as an isolated or a presenting complaint of post-infectious illness has not been well acknowledged in the literature. In this retrospective observation, patients having daily headache of more than 1 week and <4 weeks duration were included. We divided this group into patients having headache with preceding history of febrile illness in the recent past and patients without such history of febrile illness. We compared clinical features and therapeutic responses of various drugs between the groups. There were no significant differences in demographic features in these groups. However, associated neck pain, nausea, photophobia and meningeal signs were more prevalent in patients having history of preceding infection. A relatively lower proportion of subjects showed complete response to drugs at 3 months in post-infectious group. Good responses were noted to steroids in post-infectious group. In conclusion, a subset of patients with daily headache may be because of post-infectious pathology and treatment in the early stage may prevent it from becoming chronic. Large prospective studies are required to confirm these observations.     

Hypnic headache: another indomethacin-responsive headache syndrome?

Hypnic headache syndrome is a benign, recurrent, late-onset headache disorder that occurs exclusively during sleep. Lithium has been reported to be an effective treatment, but the side effects of this medication are sometimes prohibitive, particularly in the elderly. Other drugs have been reported to be effective in this disorder, including caffeine, flunarizine, and verapamil. Recently, indomethacin has been reported to effectively suppress hypnic headaches. We report the response of seven patients with hypnic headache who were treated with indomethacin. Hypnic headache syndrome appears to represent yet another headache disorder in which there is sometimes an impressive response to indomethacin.     

Does chronic daily headache arise de novo in association with regular use of analgesics?

BACKGROUND: The prevalence of chronic daily headache in association with regular use of analgesics is about 2%. Whether regular use of analgesics has a causal or consequential relationship to daily headache has not been established. A causal relationship has been suggested consequent to the observation of improvement or resolution of headache following analgesic withdrawal in patients attending headache clinics, but this observation has not been validated by controlled trials. PURPOSE: The aim of our investigation was to determine whether regular use of analgesics is associated with the development of chronic daily headache de novo and to characterize the clinical phenotype of those headaches by carefully studying chronic daily headache in patients with regular use of analgesics for a nonheadache indication. METHODS: Patients attending a rheumatology-monitoring clinic of second-line agents were interviewed by a training neurologist with regard to their analgesic and headache history. Headache classification was according to the criteria of the International Headache Society. Daily headache characteristics were surveyed via a standardized questionnaire, and headache features were further explored by a trained medical interviewer. RESULTS: Of 110 patients presenting to a rheumatology-monitoring clinic, 73% had a diagnosis of rheumatoid arthritis, 23% had seronegative arthritis, and 4% comprised a miscellaneous group. One hundred three were using one or more analgesics regularly for their arthritis. Of this group, 8 (7.6%) reported a history of chronic daily headache, each of whom reported a history of migraine. The onset of migraine occurred before the onset of chronic daily headache in 7 patients and at about the same time as the chronic daily headache in 1 patient. In those with onset of migraine prior to chronic daily headache, the mean interval before the onset of headache was 30 years (range, 10 to 50 years). Regular use of analgesics preceded the onset of daily headache in 5 patients by a mean of 5.4 years (range, 2 to 10 years). In 1 patient, analgesic use and the development of daily headache occurred at about the same time. In 1 patient, the onset of daily headache preceded regular use of analgesics by almost 30 years. Five of those with regular use of analgesics had been taking an opiate-based preparation in combination with a nonsteroidal anti-inflammatory agent in 4. Two had been on a combination of acetaminophen (paracetamol) and a nonsteroidal anti-inflammatory drug. The minimum number of tablets per week was 7, and the mean was 48 (range, 7 to 87). Of those patients who did not have daily headache, 41% had a history of migraine and 27% reported a history of tension-type headache. CONCLUSION: These findings suggest that individuals with primary headache, specifically migraine, are predisposed to developing chronic daily headache in association with regular use of analgesics.     

Are there predictive factors for long-term outcome after withdrawal in drug-induced chronic daily headache?

OBJECTIVES: To investigate prognostic factors for long-term outcome of patients after inpatient withdrawal because of drug-induced chronic daily headache. PROCEDURES: Fifty-five patients (36 females) were re-examined by means of a standardized interview after inpatient withdrawal. The mean observation period was 9.28 +/- 2.85 years (mean +/- SD; median 8.58; range 5.00-13.50). RESULTS: Five years after withdrawal, one-third of the patients (34.6%) had an overall favourable outcome, one-third (32.7%) had no recurrent drug overuse and reported a clear-cut improvement of headache, and one-third (32.7%) developed recurrent drug overuse. Most relapses occurred within 2 years, and a small percentage within 5 years. No predictors for long-term outcome after inpatient withdrawal were found. CONCLUSIONS: All patients with drug-induced chronic daily headache should be considered as good candidates for inpatient withdrawal, and no patient should be excluded from that therapy.