Chronic daily headache with medication overuse: predictors of outcome 1 year after withdrawal therapy.

BACKGROUND AND PURPOSE: We examined prospectively the results of withdrawal therapy in 80 patients with probable medication overuse headache. The aim was to identify baseline patient characteristics that might predict outcome after 1 year (end of study). METHODS: We classified patients according to results of withdrawal therapy measured as the improvement of headache days (HD) from baseline to end of study. RESULTS: Thirty-six per cent (29/80) had at least 50% improvement. Sixty-four per cent (51/80) had <50% improvement, and among these, 30% (24/80) had <10% improvement. The following baseline characteristics were associated with poor outcome of withdrawal therapy: use of codeine-containing drugs, low self-reported sleep quality, and high self-reported bodily pain as measured by the quality of life tool SF-36. CONCLUSION: Before suggesting withdrawal therapy, one should probably pay more close attention to sleep problems.

Chronic daily headache with medication overuse: a randomized follow-up by neurologist or PCP.

Several studies have shown the benefit of withdrawal therapy when medication overuse headache (MOH) is suspected. Our aim was to compare the effect of withdrawal therapy in patients followed by a neurologist (group A, n = 42) and a primary care physician (PCP) (group B, n = 38). Patients were randomized to A or B, and follow-up was at 3, 6 and 12 months. Calculated mean headache (MH at 6 months + MH at 12 months)/2 (primary end-point) was similar; A 1.04 (0.87, 1.21) and B 1.02 (0.82, 1.21) (P = 0.87). The number of patients with 50% improvement of headache days was also similar; 14/42 in group A vs. 12/34 in B (P = 0.86) at 3 months, 15/42 vs. 11/33 (P = 0.83) at 6 months and 15/42 vs. 14/38 (P = 0.92) at 12 months. Days without headache during the last 9 months of follow-up were 123 (96, 150) in group A and 137 (112, 161) in B (P = 0.62). After 3 months one-third were classified as MOH. Patients with MOH improved similarly in group A and B, and so did patients without MOH. Within 1 year 7/42 in A and 9/38 in B had recurrent medication overuse (P = 0.43). In summary, there were no significant differences in follow-up results between the two groups.

Management of medication overuse headache: 1-year randomized multicentre open-label trial.

It is a general belief that patients with medication overuse headache (MOH) need withdrawal of acute headache medication before they respond to prophylactic medication. In this 1-year open-labelled, multicentre study intention-to-treat analyses were performed on 56 patients with MOH. These were randomly assigned to receive prophylactic treatment from the start without detoxification, undergo a standard out-patient detoxification programme without prophylactic treatment from the start, or no specific treatment (5-month follow-up). The primary outcome measure, change in headache days per month, did not differ significantly between groups. However, the prophylaxis group had the greatest decrease in headache days compared with baseline, and also a significantly more pronounced reduction in total headache index (headache days/month x headache intensity x headache hours) at months 3 (P = 0.003) and 12 (P = 0.017) compared with the withdrawal group. At month 12, 53% of patients in the prophylaxis group had > or = 50% reduction in monthly headache days compared with 25% in the withdrawal group (P = 0.081). Early introduction of preventive treatment without a previous detoxification programme reduced total headache suffering more effectively compared with abrupt withdrawal. (ClinicalTrials.gov number, NCT00159588).

Lack of seasonal variation in menstrually-related migraine.

The aim of the study was to study seasonal variation in migraine headache in a group of women with menstrually-related migraine (MRM) compared with non-menstrual migraine. Via newspaper advertisement, women with migraine living in North Norway were invited. The patients were included by questionnaire and telephone interview. We prospectively recorded migraine attacks from a 12-month headache diary performed by a group of 62 women with a mean age of 36.0 years (range 16-46 years), who fulfilled the criteria of migraine without aura. Of these, 29 had MRM and 33 non-menstrual migraine. Mean ratio between number of attacks in the light arctic season (May-June-July) divided with total number of migraine attacks during 12 months was 0.24 (9.4/38.4) in the group of MRM compared with 0.25 (5.6/22.1) in others (confidence interval -4.2, 6.3, P = 0.84). Nor were there more migraine attacks in the dark season in an arctic area (November-December-January) in any group. We found a higher migraine attack rate in those with MRM, but no indication of more or less frequency of attacks during the bright arctic season. These findings support the assumption that MRM and seasonal variation of migraine are due to different mechanisms.

Circannual periodicity of migraine?

Seasonal rhythm of migraine attacks may support a role of the suprachiasmatic nucleus of the hypothalamus in the pathophysiology of migraine. The objective of this study was to provide evidence for seasonal variation in migraine. Eighty-nine female migraineurs volunteered to record every migraine attack in detail for 12 consecutive months. Attacks associated with sleep complaints were defined as insomnia-related. By using Edwards' model for recognition and estimation of cyclic trends, time-series analysis was made. Fifty-eight patients, of which 26 had migraine without aura (MO) and 32 had migraine with aura (MA), completed the study. A total of 1840 attacks were recorded. The mean age +/- SD was 36.9 +/- 6.0. Patients with a lifetime history of MA showed marked seasonal fluctuation with more attacks in the light season compared to the dark. Time of peak was May 21. Peak/low ratio was 1.30 (95% CI: 1.08-1.55). When insomnia-related attacks (n = 312) were removed the seasonal variation became insignificant. There is a seasonal trend with more migraine attacks in the light season compared to the dark season in females with MA, but not MO, living in an arctic area. This is caused by the seasonal variation of insomnia-related attacks in patients with MA.

Weekend migraine.

It is a general belief that migraine attacks are prone to occur on days off. Only a few studies, however, have addressed this issue. The objective of this study was to investigate the periodicity of migraine with respect to weekly (circaseptan) variations. Eighty-nine females of fertile age who had participated in a previous questionnaire-based study volunteered to record in detail every migraine attack for 12 consecutive months. Eighty-four patients completed recordings for a mean of 311 days (s.d. = 95.9, range 30-365). A total of 2314 attacks were recorded. Migraine occurrence was almost equally distributed during the week, except on Sundays, when there were significantly fewer attacks (t = -4.42, d.f. = 83, P < 0.001). A Mantel-Haenszel estimate of the relative risk of having an attack on a holiday vs. another day, not Sundays included, was 0.64 (95% CI 0.49-0.85). Our study suggests that days off protect against migraine.

Is uncertain diagnosis a more frequent reason for referring migraine patients to neurologist than other headache syndromes?

The objective was to assess whether the physician's uncertainty of diagnosis was a more frequent motivation for referring migraine patients than other headache patients to a neurologist. In this population based survey we included 846 consecutive patients referred to and examined at a specialist centre for headache during a period of 2 years. As primary outcome we compared cross-sectionally frequency of referring patients with migraine and other headaches to neurologist. According to the patients, uncertainty of diagnosis was the main reason for referral to a neurological specialist consultation, i.e. in 51% of cases. Thirty-nine per cent of patients classified as having migraine were referred because of an uncertain diagnosis, compared with 62% in patient with other headaches (95 CI 0.13-0.33), (P < 0.0001). Headache subtypes other than migraine and younger age were associated to more uncertainty of diagnosis. We conclude that diagnostic uncertainty was an important factor amongst half the headache patients seen by neurologists and uncertain diagnoses as reason for referral was more important amongst patients with non-migrainous headache.

Seasonal variation in migraine.

Our group has previously shown that migraineurs, as opposed to individuals with other headaches, are more likely to have headache during the bright arctic summer than during the polar night season. We set out to investigate the impact of seasonal light exposure in migraine with and without aura. We performed a questionnaire-based study of 169 female volunteer migraineurs in an arctic area where light conditions during summer and winter seasons are extreme. We included 98 patients with migraine with aura (MA) and 71 with migraine without aura (MoA). One hundred and seven patients (63%) reported seasonal variation in migraine attack frequency. Close to half (47%) of patients with aura, but only 17% of patients without aura, reported more frequent attacks during the light season (P < 0.001). Patients with MA reported interictal light hypersensitivity and light exposure as an attack precipitating factor significantly more often than individuals with MoA. They also reported significantly more frequent use of sunglasses to prevent attacks. We found no significant differences between MA and MoA as regards sleep disturbances, use of oral contraceptives, impact of headache or circadian variations. Seasonal periodicity of migraine in an arctic population with more frequent attacks during the light season is a convincing phenomenon in MA but not in MoA. The amount of light exposure seems to be pivotal to this variation.

Is obstructive sleep apnea syndrome associated with headache?

OBJECTIVE: Obstructive sleep apnea syndrome (OSA) is a common disorder in the general population. Although the mechanisms remain obscure, an association with headache has been reported. We aimed to assess the frequency of OSA in a population of headache patients based on a stratified sampling technique using questionnaire and polysomnography (PSG). METHODS: The survey was provided to new outpatients examined by a neurologist for headache over a 2-year period of time. The patients completed a headache diary during 30 days and those at risk of OSA went through a PSG examination. RESULTS: Of 903 headache patients, 75 reported heavy snoring and episodes of interrupted nocturnal breathing (8%). Among 43 patients examined with PSG, 14 (1.5% of the total study population) had an apnea/hypopnea index of 5 or higher. Eleven of the patients reported morning headache. CONCLUSION: The frequency of OSA in a patients referred to specialist for headache problems is not higher than what is reported for the general population. The relatively low rate of OSA in this selected group of patients with headache referred to neurology for second opinion does not support the notion that OSA brings about headache.

Drug-associated headache is unrecognized in patients treated at a neurological centre.

OBJECTIVE: We studied the frequency of unrecognized headache associated with overuse of analgesic drugs in a population of headache patients treated at a neurological centre. METHODS: Patients in North Norway referred to a neurologist for headache during a 2-year period completed a questionnaire. From a total of 945, 262 patients (28%) reported headache 3 days or more per week and used analgesic drugs on a daily bases. RESULTS: A specific diagnoses given by the neurologist was reported in 134 of the patients (51%). Only two patients reported that they suffered from a possible drug-associated headache. CONCLUSION: This study shows that drug overuse may be the cause of chronic headache in more than 1/4 patients referred to neurologists. Drug-associated headache is a difficult diagnosis which deserves more attention because it is a common and treatable condition.

Are headache patients who initiate their referral to a neurologist satisfied with the consultation? A population study of 927 patients--the North Norway Headache Study (NNHS).

BACKGROUND: Headache is a common problem in primary care. Although most patients are treated by GPs, many are referred to specialist consultation. Knowledge of how the referrals can be improved is therefore an important issue. OBJECTIVES: The aim of this study was to determine the relationship between self-initiating referral to a neurologist and the patient's satisfaction with the specialist consultation. METHODS: All patients who had been examined by a neurologist for headache within a 2-year period from three neurological centres in North Norway completed a questionnaire. RESULTS: A total of 1052 patients from a population of 1403 headache patients (75%) returned the questionnaire while 927 patients answered questions about initiating the referral to the specialist. Two hundred and twenty patients (24%) initiated the referral to the neurologist themselves; 52% of those who self-initiated the referral were dissatisfied with the specialist consultation compared with 42% of those referred by the doctor, P = 0.002. Chronic headache, tension-type headache (TTH) and daily use of analgesic drugs were associated with dissatisfaction. CONCLUSIONS: Patients with headache who initiated the referral to a neurologist themselves were less satisfied with the specialist consultation. Selecting referrals containing proper medical information may improve satisfaction in severe headache patients treated in a neurological practice.

[Cluster headache--clinical aspects, pathophysiology and treatment]. / Clusterhodepine--klinikk, patofysiologi og behandling.

EPIDEMIOLOGY: Cluster headache afflicts somewhat less than one in thousand in the general population. The majority of sufferers are men. CLINICAL FEATURES: The syndrome is characterized by frequent attacks of intense pain localized in and around the eye on one side, characteristically accompanied by conjunctival injection and lacrimation in this eye, along with nasal stuffiness on the same side and sometimes a Horner's syndrome. All symptoms and signs are strictly unilateral and occur during attacks lasting between 15 minutes and three hours. The attacks occur from once to eight times daily during a period lasting from some weeks to months. After a remission of varying duration, the same pattern recurs. PATHOPHYSIOLOGY: Recent findings suggest a pivotal role of the hypothalamus in relation to the pathophysiology. TREATMENT: Sumatriptan injection or oxygen inhalation aborts pain attacks in most patients. The most frequently used prophylactic agents are verapamil, lithium and steroids.

Innervation of sweat glands in the forehead. A study in patients with Horner's syndrome.

The amount of sweating in lateral and medial sites in the forehead was investigated with quantitative evaporimetry in 18 patients with Horner's syndrome: eight cases with a central (1st), five with a preganglionic (2nd), and five with a postganglionic (3rd) neurone lesion. The amount of sweating was measured after body heating, and, at another occasion, after intracutaneous injection of the cholinergic drug pilocarpine. The two sites were at the root of the nose (medial position) and at the lateral angle of the eye (lateral position). Generally, there was a reduced level of sweating on the symptomatic versus the non-symptomatic side in both positions during body heating, except in the lateral part of the forehead in the 3rd neurone lesions, where sweating was greater on the symptomatic than on the non-symptomatic side. There was a nearly symmetrical sweating response after pilocarpine injection at all sites. There was one exception to this rule; the lateral position in the preganglionic neurone lesion group where pilocarpine induced more sweating on the non-symptomatic side. Thus, the results suggest a relative supersensitivity to pilocarpine in the medial position for all patients and in the lateral position for the central neurone lesion group. The findings suggest that the innervation of sweat glands in the medial and lateral parts of the forehead is different, the medial part being supplied by nerve fibres from the sympathetic plexus of the internal carotid artery, while the sweat glands in the lateral part is furnished from the plexus surrounding the external carotid artery.