Medication-Overuse Headache: Results from a Pain Medicine Clinic Cohort

Background and Objective: Medication-overuse headache (MOH) is a common, disabling, and treatable cause of chronic daily headache. This study evaluates the characteristics of a cohort of patients with MOH seen in a pain medicine clinic. Methods: We conducted a retrospective study of consecutive patients seen by a neurologist in the pain medicine clinic at the University of California, San Diego. Demographics, headache diagnoses, and overused medications were extracted from clinical records from 83 patients ≥ 18 years of age where a diagnosis of MOH was entered into the electronic medical record September 12, 2017-March 30, 2020. Results: Opioids were the most overused medications (42/83, 50.6%) followed by caffeine-containing compounds (20/83, 24.1%), triptans (12/83, 14.5%) and non-steroidal anti-inflammatory drugs (10/83, 12.9%). Chronic migraine was the most common underlying headache syndrome (54/83, 65.1%), followed by secondary headache disorder (13/83, 15.7%) and tension-type headache (8/83, 9.6%). Men were more likely to be overusing opioids (OR 3.3, p = 0.026) while women were more likely to be overusing caffeine-containing compounds (OR 5.4, p = 0.041). Discussion and Conclusions: It is crucial for pain specialists to recognize MOH in the pain clinic setting. Opioid overuse headache is more common among men, likely in part due to migraine being underrecognized in men and therefore men not receiving migraine-specific medications. Caffeine-containing compound overuse is more common among women; these are over-the-counter (OTC) and often do not appear on patients’ medications lists. Pain specialists should specifically ask patients with headache whether they are using OTC caffeine-containing compounds.

Possibilities of colecalciferol therapy for tension type headache combined with hypovitaminosis D

Introduction. Modern studies indicate the therapeutic effect of vitamin D (VD) in chronic pain conditions, but there is no data on the use of VD in chronic tension type headache (CTTH) treatment.Objective: comparative evaluation of the effectiveness of various options for preventive treatment of CTTH: the use of colecalciferol, standard therapy of the disease and a combination of these methods.Materials and methods. 125 women with CTTH and hypovitaminosis D were treated in the study. The frequency, duration and intensity of headache (HF, HD and HI, respectively), HIT index, frequency of analgesics taking, pericranial muscle dysfunction were evaluated. The VD level was measured by the concentration of 25-hydroxyvitamin D [25(OH)D]. The patients received differentiated therapy for 16 weeks: group 1 – colecalciferol, group 2 – amitriptyline, group 3 – a combination of these medicines. Results. In group 1, HF, HD, HIT-index and the frequency of analgesics taking decreased, all p ≤ 0.001. In groups 2 and 3, the values of all CTTH-parameters decreased, all p < 0.05. HF, HIT-index and the frequency of analgesics taking in group 3 decreased more than in group 2, all p >< 0.017. In women who had VD deficiency before treatment, the decrease in HF from the initial one was 36% in group 1, 55% in group 2, and 74% in group 3. In patients who had VD deficiency before treatment, the effectiveness of therapy in group 3 was higher than in group 2: 74% vs. 55%, respectively, p >< 0.001.Conclusions. Treatment of hypovitaminosis D in women with CTTH is accompanied by a decrease in HF, the effect of headache on the quality of life of patients and the frequency of taking analgesics. In CTTH and VD deficiency normalization of 25(OH)D level contributes to higher efficiency of standard therapy.

Differentiating Between Migraine and Post-traumatic Headache Using a Machine Learning Classifier

ObjectiveThe objective was to develop classification models differentiating persistent PTH (PPTH) and migraine using clinical data and MRI-based measures of brain structure and functional connectivity.BackgroundPTH and migraine commonly have similar phenotypes. Furthermore, migraine is a risk factor for developing PTH, sometimes making it difficult to differentiate PTH from exacerbation of migraine symptoms.Design/MethodsThirty-four individuals with migraine without history of TBI and 48 individuals with mild TBI attributed to PPTH but without history of migraine or prior frequent tension type headache were included. Subjects completed questionnaires assessing headache characteristics, mood, sensory hypersensitivities and cognitive function and underwent MRI imaging during the same day. Clinical features and structural brain measures from T1-weighted imaging, diffusion tensor imaging and functional resting-state measures were included as potential variables. A classifier using ridge logistic regression of principal components (PC) was fit. Since PCs can hinder identification of significant variables in a model, a second regression model was fit directly to the data. In the non-PC based model, input variables were selected based on lowest t-test or chi-square p-value by modality. Average accuracy was calculated using leave-one-out cross validation. The importance of variables to the classifier were examined.ResultsThe PC-based classifier achieved an average classification accuracy of 85%. The non-PC based classifier achieved an average classification accuracy of 74.4%. Both classifiers were more accurate at classifying migraine subjects than PPTH. The PC-based model incorrectly classified 9/48 (18.8%) PPTH subjects compared to 3/34 (8.8%) migraine patients, whereas the non-PC classifier incorrectly classed 16/48 (33.3%) vs 5/34 (14.7%) of migraine subjects. Important variables in the non-PC model included static and dynamic functional connectivity values, several questions from the Beck Depression Inventory, and worsening symptoms and headaches with mental activity.ConclusionsMultivariate models including clinical characteristics, functional connectivity, and brain structural data accurately classify and differentiate PPTH vs migraine.

Sleep disorders in children and adolescents with tension-type headaches

Introduction. Tension-type headache (TTH) represents a widespread and recurrent disease in adults, children, and adolescents, adversely affecting the quality of life, learning achievements, and social functioning. In recent publications, a high incidence of comorbid disorders in patients with TTH is discussed, in particular sleep disorders. The aim of the study was to assess the nature and prevalence of sleep disorders in children and adolescents with frequent episodic TTH and chronic TTH. Materials and methods. One hundred fifty patients aged from 8 years to 16 years 11 months with TTH were examined. Of them, 91 (49 boys, 42 girls) had frequent episodic TTH, 59 (26 boys, 33 girls) had chronic TTH. There was used Sleep Disturbance Scale for Children including 26 questions for parents. Results. The present study confirms the high incidence of sleep disorders among TTH children and adolescents. TTH was diagnosed in 129 (86.0%) out of 150 patients. The most frequently diagnosed varying degrees of severity (clinically relevant and borderline, when assessing sleep disorders in children) were insomnia (disorders of initiating and maintaining sleep) - in 65.3% of patients (including 60.4% with frequent episodic TTH and 72.9% with chronic TTH), excessive somnolence - in 74.7% (67.1% and 86.4%), sleep breathing disorders - in 26.7% (23.1% and 32.2%), disorders of arousal/nightmares - in 46.0% (42.9% and 50.8%), sleep-wake transition disorders - in 65.3% (67.1% and 62.7%), sleep hyperhidrosis - in 31.3% (26.4% and 39.0%). Thus, all sleep disorders (except for sleep-wake transition disorders) were significantly more common among the patients with chronic TTH. At the same time, in the subgroup of patients with TTH and any sleep disorders, significantly more prominent indicators of the frequency, the intensity of TTH and its negative impact on the daily activity were revealed, compared to patients with TTH lacking sleep disorders. Conclusion. The results of the assessment of children and adolescents with TTH show that when planning preventive therapy for TTH and evaluating its results, not only main clinical characteristics of TTH should be taken into account, but also the manifestations and severity of comorbid disorders, including sleep disorders observed in most patients with TTH. The revealed prevalence of various sleep disorders in the subgroup of patients with chronic TTH confirms that sleep disorders and anxiety disorders refer to significant risk factors for the transition of TTH to a chronic form, and such patients need more active multimodal treatment.

Headache in Children and Adolescents: The Association between Screen Time and Headache within a Clinical Headache Population

Background More than half of children and adolescents have experienced headache within the last 3 months. Several risk factors for headache have been identified, including obesity and lack of sleep. The association between screen time and headache in children and adolescents is sparsely investigated. The aim of this study was to assess this association and evaluate if it varied according to headache diagnosis. Method This cross-sectional study was performed at the tertiary pediatric outpatient clinic for headache at Herlev University Hospital. A total of 139 participants who answered a questionnaire on lifestyle factors and their daily living were included. Diagnoses of migraine and tension-type headache (TTH) were made according to the International Classification of Headache Disorders-3. Children with both migraine and TTH were allocated to a mixed headache group. We differentiated between total, leisure, and school-related screen time. Results The mean age was 13.20 ± 3.38 years and 53.2% were girls. Note that 25.2% were diagnosed with migraine without aura, 23.0% migraine with aura, 28.1% TTH, 15.8% mixed headache, and 7.9% had an unclassified headache diagnosis at the time of inclusion. There was no statistically significant difference in screen time across the five headache groups. An association between screen time and headache frequency was found in children with migraine with aura. Conclusion In this study, we investigated the association between screen time and headache in children and adolescents. More screen time was associated with more frequent headaches in children with migraine with aura. Future prospective studies are needed to determine the causality of this association.

Causes and Treatment of Tension Headache: A Review

Tension-type headache (TTH) is the most prevalent primary headache problem, affecting 46 percent to 78 percent of people at some point in their lives. However, the majority have episodic infrequent TTH (1 day per month or fewer) with no specific need for medical treatment. The diagnosis is made based on the patient's medical history and physical examination. The exact etiology of tension-type headache is unknown. The most likely cause of rare tension-type headaches is activation of hyperexcitable peripheral afferent neurons from head and neck muscles. Nondrug management is commonly utilized and should be considered for all patients with TTH. The scientific evidence for the efficacy of most treatment approaches, on the other hand, is limited. Pharmacological treatment depends on whether the headache is acute or chronic. In this review we will cover the disease epidemiology, etiology, diagnosis, and management. The aim is to study the Causes and Treatment of Tension Headache method a population-based study in Denmark, About 24% to 37% of the population experienced TTH several times a month, 10% had it weekly, and 2% to 3% of the population had chronic TTH, In contrast to migraine, women are only slightly more affected than males (the female-to-male ratio of TTH is 5:4), and onset is delayed (25 to 30 years). Between the ages of 30 and 39.

Psychophysical testing in chronic migraine and chronic tension type headache: An observational study

Background Clinical presentation is the key to the diagnosis of patients with migraine and tension-type headache, but features may overlap when both become chronic. Psychophysical parameters may distinguish both conditions. We aimed to compare psychophysical aspects of patients with chronic migraine, chronic tension-type headache and headache-free controls, and to determine whether these can predict headache frequency. Methods An examiner blinded to the diagnosis assessed 100 participants (chronic migraine (n = 38), chronic tension-type headache (n = 31) and controls (n = 31)). Assessed variables included painful area, pressure pain thresholds, temporal summation, cervical range of motion, neck posture, headache and neck impact, quality of life, and kinesiophobia. Comparison between groups was performed with one-way ANOVA and multiple linear regression was used to assess the headache frequency predictors. Results We found differences of both headache groups compared to controls ( p < 0.01), but not between headache groups. Neck disability was a significant predictor of headache frequency for chronic tension-type headache (adjusted R2 = 0.14; β = 0.43; p = 0.03) and chronic migraine (adjusted R2 = 0.18; β = 0.51; p < 0.01). Conclusions Chronic tension-type headache and chronic migraine showed similar psychophysical results, but were significantly worse when compared to controls. The psychophysical examination did not discriminate between headache types. The variable best explaining headache frequency for both headache types was neck disability.

Immunological findings in patients with migraine and other primary headaches: a narrative review

Experimental findings suggest an involvement of neuroinflammatory mechanisms in the pathophysiology of migraine. Specifically, preclinical models of migraine have emphasized the role of neuroinflammation following the activation of the trigeminal pathway at several peripheral and central sites including dural vessels, the trigeminal ganglion and the trigeminal nucleus caudalis. The evidence of an induction of inflammatory events in migraine pathophysiological mechanisms has prompted researchers to investigate the Human leukocyte antigen (HLA) phenotypes as well as cytokine genetic polymorphisms in order to verify their potential relationship with migraine risk and severity. Furthermore, the role of neuroinflammation in migraine seems to be supported by evidence of an increase in pro-inflammatory cytokines, both ictally and interictally, together with the prevalence of Th1 lymphocytes and a reduction in regulatory lymphocyte subsets in peripheral blood of migraineurs. Cytokine profiles of cluster headache patients and those of tension-type headache patients further suggest an immunological dysregulation in the pathophysiology of these primary headaches, although evidence is weaker than for migraine. The present review summarizes available findings to date from genetic and biomarker studies that have explored the role of inflammation in primary headaches.