Be alert to the possibility of medication overuse headache / Esteja alerta para a possibilidade de dor de cabeça por uso excessivo de medicamentos

Affecting 1-2% of the world's population and representing up to 40% of patients in specialist headache services, medication overuse headache remains a challenge. Starting with the need to make professionals aware since basic care, through patient education and ending with adequate (and successful) management, there is still much to be done. This literature review seeks to draw attention not only to the importance of recognizing the condition, but mainly to bring out the latest in the best management of patients who suffer from pain more than 14 days a month and who still see analgesics as the only way to manage their pain.

Afectando 1-2% da população mundial e representando até 40% dos pacientes em serviços especializados em cefaleias, a cefaleia por uso excessivo de medicamentos continua a ser um desafio. Começando pela necessidade de conscientizar os profissionais desde a atenção básica, passando pela educação do paciente e terminando no manejo adequado (e bem sucedido), ainda há muito a ser feito. Esta revisão de literatura busca chamar a atenção não apenas para a importância do reconhecimento da condição, mas principalmente trazer à tona o que há de mais moderno no melhor manejo de pacientes que sofrem com dores por mais de 14 dias por mês e que ainda veem os analgésicos como a única forma de administrar sua dor.

The state of the art in treating patients with a dual diagnosis of chronic migraine and medication-overuse headache / O estado da arte no tratamento de pacientes com diagnóstico duplo de enxaqueca crônica e cefaléia por uso excessivo de medicamentos

Migraine is a common, highly prevalent genetic neurological disorder. Its most burdensome form is the chronic migraine, which is clinically defined by the presence of headache on ≥15 days/month for longer than three months, with eight or more typical migraine days. Medication-overuse headache (MOH) is a secondary headache disorder associated with the overuse of symptomatic headache medications on ≥10 days/month for longer than 3 months. Chronic migraine and medication-overuse headache often coexist and most chronic migraineurs have medication overuse headache. Despite that, general practitioners and health professionals do not know about MOH. This review aims at presenting insights, recent knowledge, and guidance regarding the approach and treatments for patients with a dual diagnosis of chronic migraine and medication-overuse headache.

A enxaqueca é um distúrbio neurológico genético comum e altamente prevalente. Sua forma mais grave é a enxaqueca crônica, que é clinicamente definida pela presença de cefaleia ≥15 dias/mês por mais de três meses, com oito ou mais dias típicos de enxaqueca. A cefaleia por uso excessivo de medicamentos (MOH) é uma cefaleia secundária associada ao uso excessivo de medicamentos sintomáticos para cefaleia em ≥10 dias/mês por mais de 3 meses. A enxaqueca crônica e a cefaleia por uso excessivo de medicamentos geralmente coexistem e a maioria dos pacientes com enxaqueca crônica apresenta cefaleia por uso excessivo de medicamentos. Apesar disso, os clínicos gerais e os profissionais de saúde não conhecem o MS. Esta revisão tem como objetivo apresentar insights, conhecimentos recentes e orientações sobre a abordagem e tratamentos para pacientes com diagnóstico duplo de enxaqueca crônica e cefaleia por uso excessivo de medicamentos.

Impulsivity in migraine and in medication overuse headache: A literature review / Impulsividade na enxaqueca e na cefaleia por uso excessivo de medicamentos: uma revisão da literatura

Introduction: Psychiatric symptoms and analgesic overuse may contribute to migraine chronification. Impulsivity is a common symptom in several psychiatric disorders that can potentiate substance overuse, including analgesics. Dopamine has been associated with migraine pathophysiology and impulsivity. Objective: This review aims to assess the current knowledge about the potential association between migraine and impulsivity. Methods: PubMed and LILACS were queried using relevant descriptors related to migraine and impulsivity. Results: Five articles were selected; however, none revealed a significant correlation between migraine and impulsivity. This lack of correlation was verified in different migraine subtypes (with or without aura, chronic, or episodic). Conclusion: The heterogeneity in patient grouping and diverse impulsivity assessment tools of the studies precluded definitive conclusions. The Barratt Impulsivity Scale (BIS-11) was the most frequently used tool. Given the paucity of data and the potential impact on migraine management, further studies are crucial to elucidate the potential association between migraine and impulsivity.

Introdução: Sintomas psiquiátricos e uso excessivo de analgésicos podem contribuir para a cronificação da enxaqueca. A impulsividade é um sintoma comum em vários transtornos psiquiátricos que pode potencializar o uso excessivo de substâncias, incluindo analgésicos. A dopamina tem sido associada à fisiopatologia e impulsividade da enxaqueca. Objetivo: Esta revisão tem como objetivo avaliar o conhecimento atual sobre a potencial associação entre enxaqueca e impulsividade. Métodos: PubMed e LILACS foram consultados utilizando descritores relevantes relacionados à enxaqueca e impulsividade. Resultados: Foram selecionados cinco artigos; no entanto, nenhum revelou uma correlação significativa entre enxaqueca e impulsividade. Essa falta de correlação foi verificada em diferentes subtipos de enxaqueca (com ou sem aura, crônica ou episódica). Conclusão: A heterogeneidade no agrupamento de pacientes e as diversas ferramentas de avaliação da impulsividade dos estudos impediram conclusões definitivas. A Escala de Impulsividade Barratt (BIS-11) foi o instrumento mais utilizado. Dada a escassez de dados e o potencial impacto no tratamento da enxaqueca, mais estudos são cruciais para elucidar a potencial associação entre enxaqueca e impulsividade.

Cefalea por abuso de medicamentos y sus marcadores clínicos / Medication overuse headache and its specific clinical markers

Resumen Introducción: Los marcadores clínicos de la cefalea por uso excesivo de medicación (CMA) se basan en la clasificación de las cefaleas desarrollada por la Sociedad Internacional de Cefaleas (IHS). Esta clasificación incluye sólo dos criterios: la frecuencia de los días de cefalea debe ser de 15 o más días al mes durante al menos tres o más meses; - y el número de días de uso excesivo de la medicación debe ser de 10 o 15 días al mes dependiendo del tipo de medicación. Sin embargo, los pacientes suelen tener otros marcadores clínicos asociados distintos, que la mayoría de los médicos pasan por alto durante la evaluación inicial. Metodología: Este estudio es un estudio prospectivo, longitudinal y observacional de 76 pacientes ingresados en la Unidad de Cefaleas del hospital DIPRECA. Todos ellos fueron diagnosticados de HMO según los criterios establecidos por su ICHD III beta.(1) Los pacientes recibieron un tratamiento estándar que incluía desintoxicación y medicación preventiva y fueron seguidos durante 6 meses. Se registraron los síntomas de interés en cada visita de seguimiento clínico y se administraron escalas de evaluación como Zung, MIDAS, HIT-6. Resultados: Los medicamentos sobreutilizados incluyeron antiinflamatorios no esteroideos (AINE), triptanes y cornezuelos. Los síntomas clínicos más significativos asociados fueron: despertar por la mañana con dolor de cabeza, despertar al paciente al amanecer por dolor de cabeza, dificultades de atención, depresión, dolor cervical y síndrome de dolor miofascial. Todos los síntomas mejoraron significativamente al iniciar el tratamiento, al igual que la calidad de vida medida por las escalas MIDAS y HIT-6. Discusión: Al evaluar a los pacientes con HMO, hay que tener en cuenta tanto los criterios diagnósticos de la ICHD III beta como los síntomas comunes y específicos que se observan en la mayoría de los casos de HMO.

Introduction: Clinical markers of medication overuse headache (MOH) are based on headache classification developed by the International Headache Society (IHS). This classification include only two criteria: frequency of headache days must be 15 or more days per month for at least three or more months; - and the number of days of overuse medication must be either 10 or 15 days per month depending on the type of medication. However, patients often have others distinct associated clinical markers, which are overlooked by most physicians during the initial evaluation. Methodology: This study is a prospective, longitudinal and observational study of 76 patients admitted to DIPRECA´s hospital Headache Unit. They were all diagnosed with, MOH according to the criteria established by the his ICHD III beta.(1) Patients were given standard treatment including detoxification and preventive medications and followed for 6 months. Symptoms of interest were recorded in at each clinical monitoring visit and assessment scales such as Zung, MIDAS, HIT-6 were administered. Results: Overused medications included nonsteroidal anti-inflammatory drugs (NSAIDs), triptans and ergots. The most significant clinical symptoms associated were: awaking in the morning with headache, awaking the patient at dawn by headache, attention difficulties, depression, cervical pain and myofascial pain syndrome. All symptoms significantly improved when treatment began, as did quality of life as measured by MIDAS and HIT-6 scales. Discussion: In evaluating patients with MOH consider both the ICHD III beta diagnostic criteria and the common and specific symptoms seen in most cases of MOH.

Evaluation of structural changes in orbitofrontal cortex in relation to medication overuse in migraine patients: a diffusion tensor imaging study / Avaliação das mudanças estruturais no córtex orbitofrontal em relação ao uso excessivo de medicamentos em pacientes com migrânea: um estudo de imagem por tensor de difusão

Abstract Background: Migraine is a prevalent neurological disease that leads to severe headaches. Moreover, it is the commonest among the primary headaches that cause medication overuse headache (MOH). The orbitofrontal cortex (OFC) is one of the structures most associated with medication overuse. Objective: To determine microstructural changes in the OFC among migraine patients who developed MOH, through the diffusion tensor imaging (DTI) technique. Methods: Fifty-eight patients who had been diagnosed with migraine based on the Classification of Headache Disorders (ICHD-III-B) were included in the study. Patients were sub-classified into two groups, with and without MOH, based on the MOH criteria of ICHD-III-B. DTI was applied to each patient. The OFC fractional anisotropy (FA), and apparent diffusion coefficient (ADC) values of the two groups were compared. Results: The mean age of all the patients was 35.98±7.92 years (range: 18-65), and 84.5% (n=49) of them were female. The two groups, with MOH (n=25) and without (n=33), were alike in terms of age, gender, family history, migraine with or without aura and duration of illness. It was found that there was a significant difference in FA values of the left OFC between the two groups (0.32±0.01 versus 0.29±0.01; p=0.04). Conclusions: An association was found between MOH and changes to OFC microstructure. Determination of neuropathology and factors associated with medication overuse among migraine patients is crucial in terms of identifying the at-risk patient population and improving proper treatment strategies specific to these patients.

RESUMO Introdução: A migrânea é uma doença neurológica prevalente que causa fortes dores de cabeça. Além disso, é a mais comum entre as cefaleias primárias que causam cefaleia por uso excessivo de medicamentos (CUEM). O córtex orbitofrontal (OF) é uma das estruturas mais associadas ao uso excessivo de medicamentos. Objetivo: Determinar alterações microestruturais no córtex OF em pacientes com migrânea que desenvolveram CUEM, por meio da técnica de imagem por tensor de difusão (ITD). Métodos: Cinquenta e oito pacientes com diagnóstico de migrânea, com base na Classificação das Cefaleias (ICHD-III-B), foram incluídos no estudo. Os pacientes foram subclassificados em dois grupos, com e sem CUEM, com base nos critérios de CUEM da ICHD-III-B. A ITD foi aplicada a cada paciente. Os valores de anisotropia fracionada OFC (AF) e coeficiente de difusão aparente (CDA) dos dois grupos foram comparados. Resultados: A média de idade de todos os pacientes foi de 35,98±7,92 anos (variação: 18‒65), sendo 84,5% (n=49) do sexo feminino. Os dois grupos, com CUEM (n=25) e sem (n=33), são semelhantes em termos de idade, sexo, história familiar, migrânea com ou sem aura e duração da doença. Verificou-se que houve diferença significativa nos valores de AF do córtex OF esquerdo entre os dois grupos (0,32±0,01 versus 0,29±0,01; p=0,04). Conclusões: Foi encontrada associação entre o CUEM e as alterações na microestrutura do córtex OF. A determinação da neuropatologia e dos fatores associados ao uso excessivo de medicamentos entre pacientes com migrânea é crucial para identificar a população de pacientes em risco e melhorar as estratégias de tratamento adequadas específicas para esses pacientes.

Impulsivity prevalence in migraine patients without and with medication overuse / Prevalência de impulsividade em pacientes com enxaqueca sem e com abuso de medicação

ABSTRACT Background: Migraine is one of the most common disorders in neurological clinical practice and is part of the group of primary headaches. It often affects individuals in the age group of 25-55 years, when people are at their peak of economic productivity. Many patients ultimately overuse analgesics. Overuse is defined by the use of analgesics for at least 15 times a month - within a minimal three-month period. Impulsivity and migraine cause losses in the lives of individuals suffering from them, as they can compromise these individuals' social, emotional, and professional spheres. Regarding the professional sphere, it results in economic losses compared with the overall population. Objective: To investigate the presence of impulsive behavior in patients with migraine and with medication-overuse migraine. Methods: Cross-sectional study on 210 female and male patients; 140 were diagnosed with migraine according to criteria of the International Classification of Headache Disorders and were subdivided into two groups (70 patients each). One of these groups was composed of medication-overuse patients; the control group was composed of non-migraine patients (70 patients). All patients were evaluated with the Barratt Impulsivity Scale (BIS-11). Results: The group of migraine patients accounted for the highest impulsivity level, followed by the control group and, finally, by the medication-overuse group. However, these differences did not attain statistical significance. Conclusions: It was not possible to establish a clear connection between migraine and impulsive behavior. Association was higher among migraineurs without medication overuse.

RESUMO Introdução: A enxaqueca é uma das condições mais comuns na prática clínica neurológica, enquadrando-se no grupo das cefaleias primárias. Sua prevalência é maior na faixa etária de 25 a 55 anos, coincidindo com o pico da produtividade econômica. Muitos pacientes recorrem ao uso abusivo de analgésicos. O uso excessivo desses medicamentos é definido pela sua utilização por pelo menos 15 vezes ao mês, por um período de no mínimo três meses. A impulsividade e a enxaqueca causam prejuízos na vida dos indivíduos afetados, podendo comprometer os âmbitos social, emocional e profissional, resultando em um prejuízo monetário a esse grupo, em relação à população em geral. Objetivo: Investigar a presença de comportamento impulsivo em pacientes com enxaqueca com abuso de analgésico. Métodos: Estudo de corte transversal com 210 pacientes, homens e mulheres, sendo 140 com diagnóstico de enxaqueca segundo os critérios da Classificação Internacional das Cefaleias (IHCD-3), subdivididos em dois grupos de 70 pacientes cada, um composto por pacientes em uso excessivo de medicamentos, e um grupo controle composto por indivíduos sem enxaqueca. Todos os pacientes foram avaliados com a Escala de Impulsividade de Barratt - BIS 11. Resultados: O grupo com enxaqueca apresentou maior impulsividade, seguido do grupo controle e, por fim, o grupo com enxaqueca com abuso de medicamentos. No entanto, essas diferenças não atingiram significância estatística. Conclusão: Não foi possível encontrar relação direta entre a enxaqueca e comportamentos impulsivos. No entanto, esta relação foi maior entre os pacientes com enxaqueca sem abuso de analgésico.

The Development of Evidence-Based Guideline for Diagnosis and Management of Headache in Korea

OBJECTIVE: We aimed to develop the clinical guideline for headache by the systematic review and synthesis of existing evidence-based guidelines. The purpose of developing the guideline was to improve the appropriateness of diagnosis and treatment of headache disorder, and consequently, to improve patients’ pain control and quality of life. The guideline broadly covers the differential diagnosis and treatment of tension-type headache, migraine, cluster headache, and medication-overuse headache. METHODS: This is a methodological study based on the ADAPTE methodology, including a systematic review of the literature, quality assessment of the guidelines using the Appraisal of Clinical Guidelines for REsearch & Evaluation II (AGREE II) Instrument, as well as an external review using a Delphi technique. The inclusion criteria for systematic search were as follows: topic-relevant, up-to-date guidelines including evidence from within 5 years, evidence-based guidelines, guidelines written in English or Korean, and guidelines issued by academic institutions or government agencies. RESULTS: We selected five guidelines and conducted their quality assessment using the AGREE II Instrument. As a result, one guideline was found to be eligible for adaptation. For 13 key questions, a total of 39 recommendations were proposed with the grading system and revised using the nominal group technique. CONCLUSION: Recommendations should be applied to actual clinical sites to achieve the ultimate goal of this guideline; therefore, follow-up activities, such as monitoring of guideline usage and assessment of applicability of the recommendations, should be performed in the future. Further assessment of the effectiveness of the guideline in Korea is needed.

Medication-overuse headache. Retrospective comparison of preventive treatments / Cefaleia por uso excessivo de medicamentos. Comparação retrospectiva de tratamentos preventivos

ABSTRACT Objectives: Medication-overuse headache is commonly seen in tertiary centers. Limited evidence is available regarding treatment. We compared the use of one or two drugs, three drugs, or four pharmacological agents for the prevention of headache. Methods: This was a retrospective analysis of 149 consecutive patients. Sudden withdrawal and pharmacological prevention with one or more drugs were carried out. Adherence and the decrease of headache frequency of more than 50% were compared after four months between the one or two, three, and four drug groups. Results: There was no difference in adherence (p > 0.6). Headache frequency reduction was shown in 23 (54.8%, one or two drugs), 33 (70%, three drugs) and 11 (55%, four drugs); p = 0.13 and p = 0.98, not significant. There was a tendency towards significance between the one or two drug takers versus the three drug and four drug takers together (p = 0.09). Conclusions: The use of more drugs was not better at improving headache. However, there is the possibility that acting simultaneously on different sites may promote broader modulation and better outcome.

RESUMO Objetivos: Cefaleia por uso excessivo de medicamentos (CEM) é comum em centros terciários. Existe evidência limitada quanto a estratégias de tratamento e se combinar drogas é melhor do que abordagens com monoterapia. Objetivamos comparar o uso de até dois, três ou quatro agentes farmacológicos para a prevenção. Métodos: Estudo retrospectivo de 149 pacientes consecutivos. A suspensão súbita das drogas usadas em excesso e o início de prevenção foram realizados. A adesão e a redução superior a 50% na frequência da cefaleia foram comparadas após quatro meses entre até duas drogas, três drogas e quatro drogas. Resultados: A adesão não foi diferente (p > 0.6). A redução da frequência de cefaleia foi de 23 (54.8%, até duas drogas, 33 (70%, três drogas) e 11 (55%, quatro drogas; p = 0.13 e p = 0.98, não significativo). Houve uma tendência à significância quando comparamos até duas drogas com três e quatro drogas (p = 0.09). Conclusões: Não demonstramos superioridade de mais drogas, comparando-se a um ou dois medicamentos. Acreditamos na possibilidade de atuação em sítios de diferentes de forma simultânea e a modulação mais abrangente com melhores parâmetros evolutivos.

Volume Gain of Brainstem on Medication-Overuse Headache Using Voxel-Based Morphometry / 中华医学杂志(英文版)

<p><b>Background</b>Histopathology identified the anatomical and molecular abnormalities of brainstem nuclei in migraine patients. However, the exact whole brainstem structural changes in vivo have not yet been identified in medication-overuse headache (MOH) transformed from migraine. The aim of this study was to investigate the regional volume changes over the whole brainstem in the MOH patients using voxel-based morphometry (VBM) in vivo.</p><p><b>Methods</b>High-resolution three-dimensional structural images were obtained using a 3.0-Tesla magnetic resonance system from 36 MOH patients and 32 normal controls (NCs) who were consecutively recruited from the International Headache Center, Chinese People's Liberation Army General Hospital, from March 2013 to June 2016. VBM was used to assess the brainstem structural alteration in the MOH patients, and voxel-wise correlation was performed to evaluate the relationship with the clinical characteristics.</p><p><b>Results</b>The brainstem region with increased volume located in the left ventrolateral periaqueductal gray (MNI coordinate: -1, -33, -8), ventral tegmental area (MNI coordinate: 0, -22, -12), bilateral substantia nigra (MNI coordinate: -8, -16, -12, 9, -16, -12), and trigeminal root entry zone (MNI coordinate: -19, -29, -31; 19, -32, -29) in MOH patients compared with NCs. The headache visual analog scale score was positively related with the left rostral ventromedial medulla (RVM) (MNI coordinate: -1, -37, -56; cluster size: 20; r = 0.602) in the MOH patients.</p><p><b>Conclusions</b>The regional volume gain of brainstem could underlie the neuromechanism of impaired ascending and descending pathway in the MOH patients, and the left RVM volume alteration could imply the impaired tolerance of nociceptive pain input and could be used to assess the headache disability in the MOH patients.</p>

The prevalence of primary headache disorders in the adult population of Mongolia / Монголын Анагаах Ухаан

Background@#Headache disorders are most prevalent public-health problem. Worldwide, among the adults 46% suffer from primary headache, where the migraine presents 11% and tension type headache (TTH) presents 25%. Recently, one type of the primary headache, medication overuse headache tends to increase. Nowadays, there is no sufficient study about primary headache in Mongolia. So that, it is necessary to investigate prevalence, clinical type and risk factors of the primary headache.@*Purpose@#To study prevalence and risk factors of primary headache in Mongolia.@*Materials and Methods@#This cross-sectional study was carried out from June to November of 2017. Participants aged 18-65 years old were randomly selected from four provinces and three districts of Ulaanbaatar city. The diagnosis of headache was made using the International Classification of Headache Disorders-3 beta. Statistical analysis was performed on SPSS-23 program.@*Results@#A total of 2043 participants (812 men and 1231 women) were reviewed. The participant’s average age was 38.6±13.4years. 1350 (66.1%) participants reported recurrent headache within the last 1 year. Of the total study population, the prevalence rate of primary headache was 1305 (63.9%). Number of people who suffered from migraine was 494 (24.2%), significantly greater in female than male participants (p=0.0001), with most frequent attacks at age 26-45 years. The risk of migraine associated with sex, education and family history (p=0.001). 592 (29.0%) of participants had TTH, mean age of them was 37.7±5.24, significant high rate in female than men, risk of TTH depends on education and job. The medication overuse headache was diagnosed at 116 (5.7%), 29.4% in men and 70.5% in women with average of 45.6±11.4 and 43±12.7 respectively. Among the participants 38.6% used medications, 28% people had one drug, 8.5% two drugs and 2% used three or more drugs. Use of non-steroid anti-inflammatory drugs (NSAID) made up major percent in headache patients. Increased frequency of medication and multidrug affected to medication overuse headache (p=0.008).@*Conclusion@#More than half of studied population had primary headache. Migraine was in 24.2%, TTH in 29.0% of people, and associated with sex, education and family history. Use of non-steroid anti-inflammatory drugs made up major percent in headache patients.

Changes of cerebral white matter in patients with medication-overuse headache / 中国神经精神疾病杂志

Objective To investigate the microstructural abnormalities of cerebral white matter in patients with medication-overuse headache with diffusion tensor imaging.Methods Diffusion tensor magnetic resonance imaging (DT-MRI) was carried out in 80 migraine patients with medication-overuse headache (case group) and 80 age-and sex-matched healthy controls (control group).Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were measured and the correlation between clinical characteristics and the changes was examined.Results ① The FA values at the bilateral orbitofrontal cortex,cingulate cortex,splenium of the corpus callosum and the right anterior limb of the capsula interna were significantly lower than those in the controls(P＜0.05).② The ADC values at the right orbitofrontal cortex,left inferior frontal gyrus and anterior cingulate cortex were significantly higher than those in the controls (P＜0.05).③ There were negative correlations between FA values at the bilateral orbitofrontal cortex and right hind legs of the capsula interna and headache course as well as frequency.There was negative correlation between FA values at the left hind legs of capsula interna and headache frequency.④ There were positive correlations between ADC values at the left orbitofrontal cortex and headache course as well as frequency.There were positive correlations between ADC values at the right orbitofrontal cortex and prior cingulate cortex and headache frequency.There was positive correlation between ADC values at the posterior cingulate cortex and headache course.Conclutions There might be an integrity change of neurofibrotic microstructures in the bilateral orbitofrontal cortex and cingulate cortex in patients with medication-overuse headache,FA values are negatively associated with headache course and frequency whereas ADC values are positively associated with headache course and frequency.

Characteristics of Elderly-Onset (≥65 years) Headache Diagnosed Using the International Classification of Headache Disorders, Third Edition Beta Version

BACKGROUND AND PURPOSE: New-onset headache in elderly patients is generally suggestive of a high probability of secondary headache, and the subtypes of primary headache diagnoses are still unclear in the elderly. This study investigated the characteristics of headache with an older age at onset (≥65 years) and compared the characteristics between younger and older age groups. METHODS: We prospectively collected demographic and clinical data of 1,627 patients who first visited 11 tertiary hospitals in Korea due to headache between August 2014 and February 2015. Headache subtype was categorized according to the International Classification of Headache Disorders, Third Edition Beta Version. RESULTS: In total, 152 patients (9.3%, 106 women and 46 men) experienced headache that began from 65 years of age [elderly-onset group (EOG)], while the remaining 1,475 patients who first experienced headache before the age of 65 years were classified as the younger-age-at-onset group (YOG). Among the primary headache types, tension-type headache (55.6% vs. 28.8%) and other primary headache disorders (OPH, 31.0% vs. 17.3%) were more common in the EOG than in the YOG, while migraine was less frequent (13.5% vs. 52.2%) (p=0.001) in the EOG. Among OPH, primary stabbing headache (87.2%) was more frequent in the EOG than in the YOG (p=0.032). The pain was significantly less severe (p=0.026) and the frequency of medication overuse headache was higher in EOG than in YOG (23.5% vs. 7.6%, p=0.040). CONCLUSIONS: Tension-type headache and OPH headaches, primarily stabbing headache, were more common in EOG patients than in YOG patients. The pain intensity, distribution of headache diagnoses, and frequency of medication overuse differed according to the age at headache onset.

Chronic Daily Headache and Medication Overuse Headache in First-Visit Headache Patients in Korea: A Multicenter Clinic-Based Study

BACKGROUND AND PURPOSE: Chronic daily headache (CDH) is defined as a headache disorder in which headaches occur on a daily or near-daily basis (at least 15 days/month) for more than 3 months. Chronic migraine (CM) and medication overuse headache (MOH) are very disabling headaches that remain underdiagnosed. The aim of this study was to establish the frequency of CDH and its various subtypes, and examine the associations with MOH among first-visit headache patients presenting at neurology outpatient clinics in Korea. METHODS: Eleven neurologists enrolled first-visit patients with complaints of headaches into outpatient clinics for further assessment. Headache disorders were classified according to the International Classification of Headache Disorder (third edition beta version) by each investigator. RESULTS: Primary CDH was present in 248 (15.2%) of the 1,627 included patients, comprising CM (143, 8.8%), chronic tension-type headache (CTTH) (98, 6%), and definite new daily persistent headache (NDPH) (7, 0.4%). MOH was associated with headache in 81 patients (5%). The association with MOH was stronger among CM patients (34.5%) than patients with CTTH (13.3%) or NDPH (14.3%) (p=0.001). The frequency of CDH did not differ between secondary and tertiary referral hospitals. CONCLUSIONS: The frequencies of CDH and MOH diagnoses were 15.2% and 5%, respectively in first-visit headache patients presented at secondary or tertiary referral hospitals in Korea. CM was the most common subtype of CDH and was most frequently associated with MOH.

Study of the use of analgesics by patients with headache at a specialized outpatient clinic (ACEF) / Estudo do uso de analgésicos em pacientes com cefaleia em um ambulatório especializado (ACEF)

Objective : To evaluate the use of analgesics in headache diagnosed in Outpatients Headache Clinic (ACEF), as well as his involvement in the activities of the patients. Method : 145 patients with headache seen at ACEF during the period August/July 2009/2010 underwent a questionnaire and interview with neurologist responsible for the final diagnosis according to ICHD-II. Results : Relationship Women:Men 7:1. 1) Prevalence: Migraine without aura (52.4%), migraine with aura (12.4%), chronic migraine (15.2%) and medication overuse headache (MOH) (20%). 2) Analgesic drugs used: Compounds with Dipyrone (37%), Dipyrone (23%), Paracetamol (16%) compound with Paracetamol (6%), triptans (6%) and non steroidal anti-inflammatory drugs (12%). There was a significant decrease in the duration of pain and less interference in the activities of the headache patients after the use of analgesics. Conclusion : Prevalence of MOH has been increasing in population level and specialized services. New studies emphasizing the MOH are needed to assist in the improvement of their diagnostic and therapeutic approach. .

Objetivo : Avaliar a utilização de analgésicos nas cefaleias diagnosticadas no Ambulatório de Cefaleias (ACEF), bem como a sua intervenção nas atividades dos pacientes. Método : 145 pacientes com cefaleia atendidos no ACEF durante o período entre Agosto/2009 a Julho/2010 foram submetidos a um questionário e à entrevista com médico neurologista responsável pelo diagnóstico final, segundo a ICHD-II. Resultados : Relação Mulheres:Homens de 7:1. 1) Prevalência: Migrânea sem aura (52,4%), migrânea com aura (12,4%), migrânea crônica (15,2%) e CEM (20%). 2) Analgésicos utilizados: Compostos com Dipirona (37%), Dipirona (23%), Paracetamol (16%), compostos com Paracetamol (6%), triptanos (6%) e drogas antiinflamatórias esteroidais (12%). Houve uma diminuição significativa da duração da dor e menor interferência da cefaleia nas atividades dos pacientes após o uso dos analgésicos. Conclusão : Prevalência da cefaleia por uso excessivo de medicamento (CEM) vem aumentando em nível populacional e em serviços especializados. Novos estudos enfatizando a CEM são necessários para auxiliar na melhora da sua abordagem diagnóstica e terapêutica. .

Randomized double-blind controlled study of prednisone in treatment of withdrawal headache in patients with medication overuse headache / 中国生化药物杂志

Objective To investigate treatment effect of prednisone to withdrawal headache in patients with medication overuse headache (MOH). Methods From June 2009 to June 2013, 96 patients with MOH were chosen as study objective for the randomized double-blind and placebo controlled study.All patients were divided into 2 groups: 48 in study group ( treated with prednisone, 100 mg/d ) and 48 in control group (treated with placebo, 100 mg/d).The clinical features of two groups were compared.After treatment, the primary endpoints, secondary endpoints , further results and the use of analgesics were compared.Results Before treatment, the age, sex gender,primary diagnosis, duration and frequency of headache, medicine had no statistical difference between two group.After treatment, the duration of headache and the rate of drug rescue had no statistical difference between two groups.The rate of withdraw symptoms had no statistical difference between two groups.The use of analgesics was less in study group than that in control group, the difference had statistical significance (P<0.05).Conclusion During withdrawal in MOH, prednisone reduces rescue medication without decreasing the severity and duration of withdrawal headache.

Association between the G252A Tumor Necrosis Factor-beta Gene Polymorphism and Medication-Overuse Headache

BACKGROUND AND PURPOSE: Migraine patients are particularly prone to the complication of medication-overuse headache (MOH). Although it has been shown that A allele carriers for the tumor necrosis factor (TNF)-beta gene G252A polymorphism are at high risk of the development of migraine without aura, the relationship between the TNF-beta gene G252A polymorphism and MOH is unknown. We investigated whether the TNF-beta gene G252A polymorphism is involved in the aggravation of migraine by overuse of medications. METHODS: Forty-seven migraine patients (6 males and 41 females; age 36.4+/-10.3 years, mean+/-SD) and 22 MOH patients (1 male and 21 females; age 39.6+/-9.9 years) who had migraine were included in this study. The genotype for the TNF-beta gene G252A polymorphism was determined by polymerase-chain-reaction restriction-fragment-length polymorphism analysis. RESULTS: The distribution of TNF-beta gene G252A genotype frequency differed significantly between migraine and MOH patients (p=0.013). The G/G genotype was carried by 23% of the migraine patients but it was absent in MOH patients. CONCLUSIONS: G/G genotype carriers appear to be less susceptible to the aggravation of migraine by overuse of medications. The G252A TNF-beta gene polymorphism may be one of the factors contributing to the complications of MOH in patients with migraine.

Differences in Clinical Features and Disability according to the Frequency of Medication Use in Patients with Chronic Migraine

BACKGROUND AND PURPOSE: Chronic migraine (CM) has a significant impact on daily activities, and analgesic overuse is a major contributing factor to migraine transformation. Limited information is available on the functional consequences of CM stemming from analgesic overuse. This study evaluated the impact of the frequency of analgesic medication use on headache-related disability and clinical features in patients with CM. METHODS: Patients with CM were enrolled consecutively and classified into two groups according to their frequency of medication use: or =15 days/month (CM-MH, n=68). All patients completed a structured questionnaire concerning the clinical features of their migraine, a validated version of the Migraine Disability Assessment questionnaire (MIDAS), and the Headache Impact Test-6 (HIT-6). RESULTS: The pain intensity, as measured by a visual analog scale, was greater in the CM-MH group than in the CM-ML group (8.5+/-0.2 vs. 7.7+/-0.3, mean+/-SD; p<0.05). In the disability domain, the MIDAS scores were significantly higher for CM-MH patients than for CM-ML patients (47.6+/-4.8 vs. 26.8+/-4.5, p<0.01). The impact from migraine, as measured by the HIT-6, was greater for CM-MH patients than for CM-ML patients (65.6+/-1.0 vs. 62.1+/-1.0, p<0.05). CONCLUSIONS: Our results indicate that the headache pain intensity and disability are greater in patients with CM who use medication frequently.

The paradoxical effects of analgesics and the development of chronic migraine / Migrânea crônica e os efeitos paradoxais dos analgésicos

In a subgroup of individuals episodic migraine evolves into a stage where individuals have headaches on more days than not. Among the risk factors for chronification, excessive use of analgesic medications figure prominently and reviewing this topic is the scope of this article. The issue of causality is discussed and evidence suggesting that specific medications, at critical doses, are risk factors for chronic migraine (CM) is reviewed. The concept of critical dose of exposure for different classes is presented and biological plausibility and putative mechanisms are reviewed.

Fração não desprezível de pacientes com migrânea episodica evolve para um estágio em que cefaléias acontecem na maior parte dos dias. Dentre os fatores de risco para esse processo de cronificação, o uso excessivo de analgésicos tem importância particular e é o tema desse artigo. A causalidade da associação é discutida, assim como a especificidade da associação. Evidência sugerindo que doses críticas de exposição podem ser inferidas também é revisada, assim como a plausibilidade da associação e mecanismos da mesma.

Intravenous chlorpromazine and promethazine for treating chronic daily headache in cases of unsuccessful analgesic withdrawal / Clorpromazina e prometazina endovenosas para tratamento de cefaleia diária crônica em casos de retirada ineficaz de analgésicos

BACKGROUND AND OBJECTIVES: Chronic daily headache (CDH) may be a particularly challenging condition when the withdrawal of excessive analgesic medication is unsuccessful. Current guidelines suggest hospitalization for these patients, and a variety of pharmacological and non-pharmacological treatments have been reported. This study aimed at presenting our results on hospitalization of cases of CDH associated to medication overuse. The results on the use of intravenous chlorpromazine and promethazine for these patients have not been previously reported.METHOD: Retrospective assessment of medical records from eight patients treated at the Hospital das Clinicas de Ribeirão Preto. In all cases, analgesic withdrawal during hospitalization was associated to intravenous saline containing 25 mg of chlorpromazine and 25 mg of promethazine.RESULTS: All patients obtained at least 70% improvement of their headache. Five to 30 days were necessary to treat these patients in the hospital.CONCLUSION: Hospitalization and intravenous chlorpromazine and promethazine may be a viable alternative to treat CDH when analgesic withdrawal is unsuccessful.

JUSTIFICATIVA E OBJETIVOS: Cefaleia diária crônica (CDC) pode ser uma condição especialmente difícil quando a retirada de excesso de analgésicos é ineficaz. Diretrizes atuais sugerem internação para esses pacientes e uma série de tratamentos farmacológicos e não-farmacológicos tem sido cogitada. O objetivo deste estudo foi apresentar nossos resultados com a internação de casos de CDC associada ao uso excessivo de medicamentos. Resultados sobre o uso de clorpromazina e prometazina endovenosas para esses pacientes não haviam sido apresentados antes.MÉTODO: Avaliação retrospectiva de prontuários médicos de oito pacientes tratados no Hospital das Clínicas de Ribeirão Preto. Em todos os casos, a retirada de analgésicos durante a internação foi associada à solução fisiológica endovenosa contendo 25 mg de clorpromazina e 25 mg de prometazina.RESULTADOS: Todos os pacientes obtiveram ao menos 70% de melhora da cefaleia. Foram necessários de 5 a 30 dias para tratar esses pacientes no hospital.CONCLUSÃO: Internação e clorpromazina e prometazina endovenosas podem ser uma alternativa viável para tratar CDC quando a retirada de analgésicos é ineficaz.

Cefalea por uso excesivo de medicamentos y adicción a sustancias / Medications overuse headache and substance abuse disorders

Tanto en los trastornos de dependencia a sustancias (TDS), como en la migraña y cefalea por uso excesivo de medicaciones (CUEM), se implican mecanismos dopaminérgicos y opioides, así como alteraciones en el metabolismo de la corteza orbitofrontal. Si la CUEM y los TDS comparten una fisiopatología común, es de esperar que exista una asociación clínica entre estas entidades nosológicas. Objetivo. Determinar la asociación entre la CUEM y los TDS en una muestra de pacientes que consultaron a neurología general por cefalea diaria crónica. Materiales y métodos. Se realizó un estudio de corte observacional analítico transversal. Se tomó una muestra no probabilística, por conveniencia, que incluyó a todos los pacientes mayores de 18 años consecutivos que consultaron por cefalea diaria crónica (CDC) a un consultorio de neurología general entre octubre de 2007 y enero de 2009, a quienes luego de haber dado respuesta a un cuestionario se les hizo una entrevista clínica que indagó datos demográficos, consumo de analgésicos en los últimos tres meses, consumo de cafeína en forma de bebida caliente, dependencia a la nicotina y al alcohol, y antecedente familiar de consumo de alcohol. Los diagnósticos de CUEMy CDC se efectuaron atendiendo criterios de la IHS, y el de TDS según el DSM-IV.

In substance related disorders (SRD) like in migraine and Medication Overuse Headache (MOH) are implied dopaminergic and opioids mechanisms, as well as alterations in the metabolism of the orbitofrontal cortex. If the MOH and the SRD share a common physiopathology, it is of hoping exists a clinical association among these entities. Objective. To determine the association between the MOH and the SRD in a sample of patients that consulted with general neurologist for Chronic Daily Headache (CDH). Materials y methods. It was carried out an analytic observational cross sectional study. Was took a for convenience non probabilistic sample, that included all the serial patients 18 years old that consulted for CDH, to a consulting room of general neurology between October of 2007 and January of 2009. The patients responded a self-administrated questionnaire and a clinical interview was carried out that investigated demographic data, analgesic use in the last 3 months, consumption of caffeine in form of hot drink, nicotine dependence, alcohol dependence and family antecedent of consumption of alcohol.The diagnoses of MOH and CDH were carried out according to IHS criteria and that of SRD according to the DSM-IV. Results. A total of 129 patients presented MOH and other 103 patients were diagnosed with CDH without medication overuse. The groups were similar in age, gender, education level, socioeconomic status and the body mass index. There were not differences in the prevalence of: consumption of caffeine (49,6% vs. 47,5%; OR=1,1; IC95% 0,67-1,9); nicotine dependence (3,1% vs. 1,0%; OR=3,3 IC95% 0,36-29,4); alcohol dependence (0% vs. 1,9%; OR=0,98; IC95% 0,95-1,0); and family antecedent of consumption of alcohol (45,7% Vs. 43,7%; OR=1,1; IC95% 0,65-1,8) among patient with MOH and CDH without medication overuse. Conclusions: There is not association among consumption of caffeine, nicotine dependence, alcohol dependence and family history of consumption...