Guideline on the preventive treatment of chronic migraine, chronic tension type headache, hemicrania continua and new daily persistent headache on behalf of the Colombian Association of Neurology / Guía de la Asociación Colombiana de Neurología para el tratamiento preventivo de la migraña crónica, cefalea tipo tensión crónica, hemicránea continua y cefalea diaria persistente de novo

SUMMARY INTRODUCTION: Chronic daily headache is a high impact entity in the general population. Although chronic migraine and tension-type headache are the most frequent conditions, it is necessary to consider hemicrania continua and new daily persistent headache as part of the differential diagnoses to perform a correct therapeutic approach. OBJECTIVE: To make recommendations for the treatment of chronic daily headache of primary origin METHODOLOGY: The Colombian Association of Neurology, by consensus and Grade methodology (Grading of recommendations, assessment, development and evaluation), presents the recommendations for the preventive treatment of each of the entities of the daily chronic headache of primary origin group. RESULTS: For the treatment of chronic migraine, the Colombian Association of Neurology recommends onabotulinum toxin A, erenumab, topiramate, flunarizine, amitriptyline, and naratriptan. In chronic tension-type headache the recommended therapeutic options are amitriptyline, imipramine, venlafaxine and mirtazapine. Topiramate, melatonin, and celecoxib for the treatment of hemicrania continua. Options for new daily persistent headache include gabapentin and doxycycline. The recommendations for inpatient treatment of patients with chronic daily headache and the justifications for performing neural blockades as a therapeutic complement are also presented. CONCLUSION: The therapeutic recommendations for the treatment of chronic daily headache based on consensus methodology and Grade System are presented.

RESUMEN INTRODUCCIÓN: La cefalea crónica diaria es una entidad de alto impacto en la población general. Aunque la migraña crónica y la cefalea tipo tensión son las condiciones más frecuentes, es necesario considerar la hemicránea continua y la cefalea diaria persistente de novo como parte de los diagnósticos diferenciales para realizar un enfoque terapéutico correcto. OBJETIVO: Hacer recomendaciones para el tratamiento de la cefalea crónica diaria de origen primario METODOLOGÍA: La Asociación Colombiana de Neurología, mediante consenso y metodología GRADE (Grading of Reccomendations, Assesment, Development and Evaluation), presenta las recomendaciones para el tratamiento preventivo de cada una de las entidades del grupo de la cefalea crónica diaria de origen primario. RESULTADOS: Para el tratamiento de la migraña crónica, la Asociación Colombiana de Neurología recomienda onabotulinum toxina A, erenumab, galcanezumab, fremanezumab, topiramato, flunarizina, amitriptilina y naratriptan. En cefalea tipo tensional crónica las opciones terapéuticas recomendadas son amitriptilina, imipramina, venlafaxina y mirtazapina. Para el tratamiento de la hemicránea continua topiramato, melatonina y celecoxib. Las opciones para cefalea diaria persistente de novo incluyen gabapentin y doxiciclina. Se presentan adicionalmente las recomendaciones para el tratamiento intrahospitalario de los pacientes con cefalea crónica diaria y las justificaciones para la realización de bloqueos neurales como complemento terapéutico. CONCLUSIÓN: se presentan las recomendaciones terapéuticas para el tratamiento de la cefalea crónica diaria basado en metodología de consenso y sistema GRADE.

Personality Characteristics of Male Sufferers of Chronic Tension-Type and Cervicogenic Headache

BACKGROUND AND PURPOSE: Chronic tension-type headache (a primary headache disorder) and cervicogenic headache (a secondary headache disorder that is attributable to upper cervical spine pathology) share similar clinical manifestations, but their associated personality traits may differ. We evaluated the personality differences between sufferers of chronic tension-type headache and cervicogenic headache. METHODS: We administered the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) and the Zuckerman Sensation-Seeking Scale (SSS) to 18 patients suffering from chronic tension-type headache, 19 suffering from cervicogenic headache, and 26 healthy volunteers. Depressive trends were measured with the Plutchik-van-Praag Depression Inventory (PVP). RESULTS: Compared to healthy controls, the chronic tension-type headache group scored significantly higher on ZKPQ Neuroticism-Anxiety and on the PVP, while the cervicogenic headache group scored significantly lower on SSS Thrill and Adventure Seeking. In addition, the total SSS score was significantly lower in the cervicogenic headache group than in both the chronic tension-type headache group and the healthy controls. CONCLUSIONS: The results of this study indicate that higher scores for neuroticism-anxiety and depression were associated with chronic tension-type headache, while lower sensation-seeking scores were associated with cervicogenic headache.

Patients with sudden onset headache not meeting the criteria of the International Headache Society for new daily persistent headache. How to classify them? / Pacientes com cefaleia persistente e diária desde o início que não preenchem os critérios da International Headache Society. Como classificá-los?

We conducted a retrospective analysis of the records of 1348 patients regularly treated at the headache clinic of Department of Neurology of Santa Casa de São Paulo, Brazil. Sixty-two patients reported history of daily and persistent headache. From the 62 patients selected, only 21 (group 1) could be diagnosed with new daily-persistent headache (NDPH) according to the International Headache Society (HIS) 2004 criteria. The 41 remaining patients (group 2) could not be diagnosed with NDPH according to IHS-2004 once they presented two or more migraine attack-related symptoms, such as: nausea, photophobia, phonophobia and vomiting, in different combinations. It was not possible to classify them in groups 1 to 4 of primary headaches either. How to classify them? We suggest that the criteria are revised. And one way we can classify them, would be the subdivision: NDPH with migraine features and without migraine features that would allow the inclusion of all individuals present who has a daily and persistent headache from the beginning.

Realizamos uma análise retrospectiva do prontuário de 1348 pacientes acompanhados no ambulatório de Cefaleia do Departamento de Neurologia da Santa Casa de São Paulo, Brasil. Sessenta e dois pacientes relataram história de cefaleia persistente e diária (NDPH) desde o início. Destes, apenas 21 (grupo 1) puderam ser diagnosticados com NDPH de acordo com os critérios da Sociedade Internacional de Cefaleia 2004. Os 41 pacientes restantes (grupo 2) não puderam ser diagnosticados como NDPH, uma vez que apresentaram dois ou mais sintomas relacionados a cefaleia do tipo enxaqueca, tais como: náuseas, fotofobia, fonofobia e vômitos, em diferentes combinações. Não foi possível, também, classificá-los entre os grupos de 1 a 4 das cefaleias primárias. Como classificá-los? Sugerimos que os critérios sejam revistos. E uma maneira de podermos classificá-los seria a subdivisão da NDPH em: com características de enxaqueca e sem características de enxaqueca. Isso permitiria a inclusão de todos os indivíduos portadores de uma cefaleia diária e persistente desde o início.

Biofeedback-Assisted Autogenic Training for Chronic Tension-Type Headache in a Korean Population / 신경정신의학

OBJECTIVES: We aimed to evaluate the efficacy of biofeedback-assisted autogenic training for chronic tension-type headache, and to determine the relationship among the changes in electromyography (EMG) activity, headache activity, and mood states according to the psychophysiological treatment. METHODS: Chronic tension-type headache patients aged from 20 to 40 years (n=35) were randomized to the treatment group receiving biofeedback-assisted autogenic training (8 sessions) or the monitoring-only control group. EMG activities, headache index, and various psychological variables were examined. RESULTS: We found greater treatment response rate (> or =50% reduction in headache index) in patients with biofeedbackassisted autogenic training than in the monitoring group (61% vs. 18%; chi-square=6.882, df=1, p=0.01). There were no significant changes in the mean values of the pretreatment EMG activities across the sessions in either group (all p's>0.1). Mood states including anxiety and depression improved over time in the both groups, with the improvements being more prominent in the treatment group. Moreover, the reduction in depression level predicted treatment outcome in terms of headache index (95% confidence interval: 0.272-0.966, p=0.039). CONCLUSION: These results show that biofeedback-assisted autogenic training is effective for the treatment of chronic tension-type headache in a Korean population. Changes in mood states may be closely associated with the clinical outcome in the treatment of chronic tension-type headache using biofeedback-assisted autogenic training.

Cefaléias primárias: abordagem diagnóstica por médicos não-neurologistas / Primary headaches: a diagnostic approach by non-neurologist doctors

OBJETIVO: Avaliar o conhecimento do diagnóstico e conduta de médicos não-neurologistas quanto às cefaléias primárias. MÉTODO: 91 médicos foram solicitados a diagnosticar e estabelecer condutas em três histórias de pacientes com características clínicas de migrânea sem aura (MSA), cefaléia do tipo tensional crônica (CTTC) e migrânea com aura (MCA), elaboradas de acordo com a Classificação Internacional das Cefaléias - 2ª Edição (CIC-II). RESULTADOS: MSA: dois profissionais (2,2 por cento) fizeram o diagnóstico correto, 54 (59,3 por cento) diagnosticaram migrânea sem especificar o subtipo. CTTC: 15 médicos (16,5 por cento) diagnosticaram cefaléia de tensão sem especificar o subtipo. MCA: 26 (28,6 por cento) fizeram o diagnóstico de migrânea e apenas um médico (1,1 por cento) fez o diagnóstico correto do subtipo. Dezesseis médicos (17,6 por cento) afirmaram conhecer a CIC-II. CONCLUSÃO: A maioria dos médicos não-neurologistas desconhece os critérios utilizados para diagnóstico e classificação das formas mais freqüentes de cefaléias primárias.

OBJECTIVE: To evaluate the knowledge of diagnostic and posture of non-neurologist doctors concerning primary headaches. METHOD: 91 doctors were asked to diagnose and establish procedures on three patient histories presenting clinic characteristics of migraine without aura (MA), chronic tension-type headache (CTTH) and migraine with aura (MO), according to the International Classification of Headaches - 2nd Edition (CIC-II). RESULTS: MSA: Two professionals (2.2 percent) were accurate in their diagnostic, 54 (59.3 percent) said it was migraine but did not specify the subtype. CTTC: 15 doctors (16.5 percent) diagnosed tension-type headache but did not specify the subtype. MCA: 26 (28.6 percent) said it was migraine, and only one doctor (1.1 percent) was right about the subtype. Sixteen doctors (17.6 percent) said to be aware of CIC-II. CONCLUSION: Most of non-neurologist doctors do not know the diagnostic criteria used to diagnose and to classify the most frequent forms of primary headaches.

Serotonin Transporter Gene Polymorphisms and Harm Avoidance Personality in Chronic Tension Type Headache and Migraine

BACKGROUND: Serotonin transporter protein (5-HTT) is a key modulating protein in synaptic serotonergic neurotransmission. Among serotonin gene-linked polymorphism, the promoter, located in the regulatory region of the 5-HTT gene linked polymorphic region (5-HTTLPR), has two alleles with different transcriptional efficiencies. The harm avoidance (HA) personality dimension, estimated by a self-administered tri-dimensional personality questionnaire (TPQ), has been postulated to be heritable and associated with serotonergic neurotransmitter activity. We therefore investigated 5-HTTLPR and HA in patients with chronic tension type headache and migraine. METHODS: We amplified the 5-HTTLPR by means of polymerase chain reaction and performed genotype polymorphism analyses and investigated the serotonin related personality trait by evaluating the HA dimension in tridimensional personality questionnaire (TPQ) in 107 patients with chronic tension type headache (CTH) and in 115 patients with migraine without aura (MWOA) and in 100 healthy controls. RESULTS: We found an excess frequency of the short allele and a different genotype distribution in patients with CTH. S/S genotype frequency was significantly higher in patients with CTH (76%) than in those with MWOA (61%) and controls (59%; P=0.18). TPQ questionnaires showed significantly higher HA scores in both CTH (21.4 +/- 6.3) and MWOA (21.3 +/- 7.2) compared with controls (16.31 +/- 6.1). CONCLUSIONS: This suggests a serotonergic activity might be involved in development of CTH and MWOA and 5-HTTLPR might be one of the genetically contributing factors, especially in patients with CTH through presence of the S allele.

Genetically Determined Serotonergic Activity Contributes to Development of Analgesics Overuse in Chronic Tension Type Headache

BACKGROUND: Approximately one half of the patients with chronic daily headaches report a regular use of analgesics, making it an important issue for public health matters. However, factors contributing to the dependency and overuse of analgesics for chronic tension type headaches have been little understood. We investigated the role of chronic analgesics exposure in the natural course and clinical phenotype of headaches in patients with chronic tension type headaches. We also evaluated genetically determined innate factor that could exert a profound influence on a development of analgesics overuse using a serotonin transporter protein polymorphism and serotonergically related harm avoidance (HA) personality dimension. METHODS: We analyzed the headache characteristics using a standardized questionnaire from 38 patients with chronic tension type headache with analgesics overuse (CTTH-AO), from 40 patients with chronic tension type headache without analgesics overuse (CTTH-NO) and from 100 healthy controls. We performed the serotonin transporter protein gene linked to the polymorphic region (5-HTTLPR) genotype, polymorphism analyses and investigated the serotonin related personality trait by evaluating the HA dimension in tri-dimensional personality questionnaires (TPQ). RESULTS: We found a significantly higher pain intensity and disability score in patients with CTTH-AO. Most of the patients with CTTH-AO used analgesics compound containing caffeine for pain relief. S/S genotype frequency was significantly higher in patients with CTTH-AO than in those with CTTH-NO and controls. TPQ questionnaires showed significantly higher HA scores in both CTTH-AO and CTTH-NO than in controls. CONCLUSIONS: This suggests a serotonergic activity might be involved in development of analgesics overuse in chronic tension type headaches, and 5-HTTLPR might be one of the genetically contributing factors.

Diagnosis and clinical management of tension-type headache / 中国实用内科杂志

Episodic tension-type headache is the most common headache in the general population and is usually self managed.Chronic tension-type headache may be highly disabling and often prompts medical consultation.Diagnosis is clinical,based on widely accepted and validated criteria and algorithm.Peripheral factors are implicated in episodic tension-type headache,whereas central factors probably underlie chronic tension-type headache.Simple analgesics,such as aspirin,are used for acute treatment.Amitriptyline and biofeedback assisted relaxation training have the best evidence of effectiveness for headache prevention.