Chronic headaches and sleep disorders

BACKGROUND: Headaches and sleep problems are common complaints in the daily practice of the general practitioner. Since the relationship between headaches and sleep complaints is complex, clear models of interaction are needed for adequate diagnosis and treatment. METHODS: All subjects, successively seen in a headache clinic during a defined period, were subdivided based on the time of onset of cephalalgia. Subjects who reported onset of headache on a long-term basis, during the nocturnal or early morning (before final awakening) period, were systematically studied by a headache clinic and a sleep disorders center. This subgroup represented 17% of the total headache group. RESULTS: Although the results of the headache clinic study did not differentiate this subgroup from the other patients, the sleep disorders center's interviews and questionnaires demonstrated a significant impact of the sleep disorders on headache and daytime function. Nocturnal monitoring during sleep identified specific sleep disorders in 55% of the subjects with onset of headache during the nocturnal sleep period. Follow-up after treatment of the sleep disorder showed that all subjects with an identifiable sleep disorder reported either an improvement or absence of their headache. The subjects identified with periodic limb movement syndrome were mostly those who reported only an improvement in their sleep and still needed treatment for their headaches. The question of the interaction and association of sleep-related headache and periodic limb movement syndrome is unresolved. CONCLUSION: Headaches occurring during the night or early morning are often related to a sleep disturbance.     

Side-locked unilaterality and pain localization in long-lasting headaches: migraine, tension-type headache, and cervicogenic headache

Side-locked unilaterality and specific localization of pain are not as well-defined clinical characteristics in long-lasting headaches (duration more than 4 hours) as they are in short-lasting forms. We examined side-locked unilaterality and pain distribution at onset and at peak headache in 74 patients with different forms of long-lasting headache: migraine and tension-type headache (IHS) and cervicogenic headache (according to Sjaastad et al). Side-locked unilaterality of pain was found in all forms, but to differing extents - 20.8% in migraine, 12.5% in tension-type headache, while it was a mandatory criterion for cervicogenic headache. The pain tended to localize anteriorly, particularly at onset, in migraine; was more diffuse in tension-type headache; and always began in the occipitonuchal region in cervicogenic headache. Our results may contribute to a better clinical definition of long-lasting headaches.     

Biofeedback and relaxation training with three kinds of headache: Treatment effects and their prediction.

After a 4-wk baseline period during which daily ratings of headache activity were made and all participants took several psychological tests, 91 18–68 yr old patients with chronic headache (tension, migraine, and combined tension and migraine) were given a 10-session relaxation-training regimen. Ss who did not show substantial reductions in headache activity from the relaxation therapy were given a 12-session regimen of biofeedback (thermal biofeedback for vascular headaches and frontal EMG biofeedback for tension headaches). Relaxation therapy alone led to significant improvement for all groups, with a trend for the tension headache group to respond the most favorably. Biofeedback therapy led to further significant reduction in headache activity for all who received it, with a trend for combined migraine and tension headache patients to respond the most favorably. Multiple regression analyses revealed that approximately 32% of the variance in end-of-treatment headache diary scores could be predicted after relaxation and that 44% of the variance after biofeedback could be predicted using standard psychological tests. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A new type of headache of ocular origin: ophthalmotonic headache. Diagnosis and treatment

INTRODUCTION: In some patients it was seen that chronic headaches disappeared after laser iridectomies had been done to prevent glaucoma, in persons with normal intra-ocular pressure (IOP). OBJECTIVE: To make a study of patients with headache, some of whom were treated with topical beta-blockers (carteolol) and others by Yag-laser iridectomies. The effect on headache and IOP was analyzed. MATERIAL AND METHODS: A survey, ophthalmological examination and headache provocation test were carried out in patients with headaches, and the changes in IOP determined by pharmacologically inducing miosis and mydriasis were recorded. Three treatment groups were formed and the results analyzed statistically. RESULTS: In the 12 patients treated pharmacologically, 62% improved and in 14% the headaches disappeared. In the 16 treated using laser 94% were cured and 6% improved. When both types of treatment were used on 9 patients, 22% improved and 78% were cured. The validity of the ocular pressure curve was checked in the diagnosis of blockage of the pupil. CONCLUSIONS: Some headaches of ocular origin (ophthalmotonic), not previously described, occur due to abrupt changes in intraocular pressure, and improve significantly when the IOP is reduced by beta-blockers or Yag-laser iridectomies are done. A valid provocation tests for diagnosis of this type of headache is described. We consider that blockage of the pupil and/or of the angle of the anterior chamber are possible etiopathogenic mechanisms.     

Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.     

Ocular adnexal oncocytoma: a case series and clinicopathologic review of the literature

OBJECTIVE: Headache is a common complaint in children and brain imaging has become widely used to evaluate this clinical condition. We studied the value of neuroimaging in children with chronic headaches. PATIENTS AND METHODS: A retrospective chart review was conducted of all children referred to the pediatric outpatient clinic for evaluation of headache over a 3-year period. The charts were reviewed for headache characteristics, clinical indications for performing neuroimaging, and imaging results. Special attention was paid to evidence of space-occupying lesions. RESULTS: A total of 160 records were studied, with subjects ranging in age from 4 to 14 years. Most patients were diagnosed as having migraine headaches (60%) or chronic tension headaches (29.5%). Other diagnoses were post-traumatic (6%) and unclassified (4%). Sixty-six patients (41%) had computed tomography imaging performed. In most cases, brain imaging studies were performed because of clinical data (41%) like atypical pattern, sleep-related headache or increase of headache, because of the parents' concerns about brain lesions (38%) and because of an age less than 5 years (14%). Structural changes were found on brain imaging in 4 patients, but none indicated the presence of a treatable space-occupying lesion and all were deemed unrelated to the headache. Our findings of no relevant abnormalities in a series of 66 neuroimaging studies indicate that the maximal rate at which such abnormalities might appear in this population is 4.4%. CONCLUSIONS: These results indicate that neuroimaging studies have very limited value in the clinical evaluation of pediatric patients with chronic headache and should be reserved for those patients with clinical evidence suggestive of underlying structural lesion.     

Bacterial causes of bovine mastitis in Wondogenet, Ethiopia

This community study on headache in Malaysia was based on IHS diagnostic criteria and showed the last-year prevalence of migraine was 9.0%. Migraine with aura accounted for only 10.6% of the migrainous population. The last-year prevalence of tension headache was 26.5% (94.4% episodic, 5.6% chronic) and 28.2% for other types of headache. No case of cluster headache was found. Almost two thirds of the migraine subjects graded their headaches as severe, while almost 60% of the tension headache subjects and almost 70% of the other headache subjects graded their headaches as mild. Overall, there was higher prevalence in females for migraine and tension headache, and in males for the other types of headache. The prevalence of headache was lower among those younger than 15 and older than 65 years of age. No significant differences were found in the prevalence of headache among the different racial groups nor among the urban versus the rural population. All the headache types shared the same triggering factors suggesting that different physiological characteristics are responsible for the type of pain suffered. In the location of this community with its tropical climate, headache was attributed to sun exposure in 51.9% of the migraine subjects, 55.7% of the tension headache subjects, and 36.6% of the group with other headaches.     

Treating headaches. A conceptual framework

BACKGROUND: Similar medications are effective in migraine and muscle contraction headache therefore the term recurrent headache is used to cover the spectrum of classic migraine and muscle contraction headache. OBJECTIVE: The concept of a threshold to headache triggers is proposed. Treatment for chronic headaches is directed at raising the threshold or removing triggers. DISCUSSION: The most important factors that lower the threshold to headaches are hormones, mood and sleep disturbance. Therapeutic strategies for raising the threshold and treatment of the acute headache are discussed.     

The types of headache that affect the elderly

Older people often describe their headaches as starting with vague neck discomfort and eventually moving to the temples and forehead. These are muscle-tension headaches, by far the most common type in the elderly. Although cervical osteoarthritis often is at fault, depression can be a significant factor, patricularly when headaches are chronic. There is no sure cure for tension headache, and often, several of the many remedies-ethyl chloride spray, moist heat, massage, antidepressant drugs, analgesics, local anesthetics, etc.-must be tried before an effective one is found. But just as important to successful therapy are concern, compassion, and a willingness to listen on the part of the physician. True migraine headaches are rare in the elderly. More prevalent is the type of vascular headache associated with giant cell arteritis, which is severe and resistant to any form of analgesic except the strongest narcotics. Vascular headaches also may result from congestive heart failure (which produces venous congestion in the cranial cavity), transient ischemia, increased intracranial pressure, and a variety of metabolic disturbances.     

Management of primary headache in emergency services of Santos and surrounding towns

OBJECTIVES: Primary headaches are often seen by Clinicians on duty at Emergency Services. We have investigated the treatment of such patients by 43 medical doctors who have been working at Emergency Services in the city of Santos and surrounding towns for many years. RESULTS: We confirmed the high prevalence of primary headaches in Emergency Services. There seem to be diagnosis difficulties concerning differentiating attacks of migraine and tension type headache. We also observed that IV dipirone was the most frequently prescribed treatment for patients with primary headaches in this study. There is no protocol in the literature which recommends IV dipirone for the treatment of migraine attacks or other primary headaches. CONCLUSION: It would be advisable to perform controlled double blind studies in order to verify the advantages of IV dipirone in the treatment of intense attacks primary headaches. We concluded that headache management recycling programs could be of interest for doctors who regularly work at Emergency Services.     

Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants

Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.     

A sixth-century Irish headache cure and its use in a south German monastery

Medieval headache treatment is largely unknown. Medieval incantations against headache enumerate bodily organs to be protected. One 8th-century Latin hymn from Lake Constance using this device is addressed to St. Aid "mechprech", who has been identified as Aed Mac Bricc, Bishop of Killare, 6th century. This Irish Saint inspired unusual legends by some rather unorthodox activities: He abducted a young girl as hostage while his inheritance was withheld, but at the same time was seen surrounded by angels. He prayed for a nun who was pregnant and made the pregnancy vanish by a miracle, and he replaced the severed heads of maids, men and horses, creating a new spring as a by-product of this operation. Already at his birth his head had hit a stone, leaving a hole in the stone which collected rainwater that cured all ailments. In our own time, such "bullaun stones" are still believed to cure headache in Ireland. According to the legends collected by Plummer and Colgan, St. Aed Mac Bricc was well known for his power to cure headaches. He relieved St. Brigid's headache when she was suffering many miles away, but his most impressive cure was in convincing a headache sufferer that the patient's headache could actually be transferred own head. The headache hymn or incantation is intended to repeat Aed's unique miracle.     

Methylergonovine maleate as a cluster headache prophylactic: a study and review

Methylergonovine maleate (Methergine), an ergot derivative with vasoconstrictive properties, has been cited as an effective treatment for vascular headaches. Few studies are available to support its use in headache management. An uncontrolled pilot study of 20 episodic cluster headache patients confirmed its effectiveness and tolerability as an adjunct cluster headache prophylactic. Decreased headache frequency was reported by 19 of 20 patients (95%), and 15 of 20 patients (75%) reported decreased intensity of headaches within 1 week of initiating therapy. A review of methylergonovine's pharmacokinetic, molecular, and tolerability profile clarifies its mechanisms and clinical role in headache management.     

Response to prophylactic treatment of benign headache in children

INTRODUCTION: Common childhood headaches seldom require prophylactic treatment which, nevertheless, is quite often unsatisfactory. OBJECTIVE: To study drug and non-drug related factors that may influence the therapeutic response. MATERIAL AND METHODS: A four-month follow-up study of all patients attended during a year at the neuropediatric, outpatient hospital-based clinic, with > or = 2 monthly migraine without aura attacks, > or = 10 tension-type headaches, or both types of headaches. Patients were randomized to be treated on an open basis, placebo controlled, with flunarizine or piracetam. Headache frequency was evaluated according to treatment and patients' basal characteristics. RESULTS: 98 patients studied (56 migraine without aura, 24 tension-type headache, 18 mixed). 33% dropped out; they were school underachievers more frequently than those that completed the protocol. Of those completing the protocol and treated with placebo as the first choice of therapy, 27% reported total remission of symptomatology; those not remitting with placebo were high achievers at school significatively more frequently. At the end of the trial, 43% of the initially randomized patients still complained of headaches, regardless of treatment, showing a seasonal relationship. CONCLUSIONS: Prophylaxis of benign childhood headaches is needed in less than half of those reporting a high headache frequency; school achievement should be taken into consideration as another clue to compliance and headache persistence. On a short-term basis only the seasonal influence and the placebo effect can be held responsible for amelioration of symptomatology.     

Factors contributing to so-called idiopathic headaches]

The interest in factors that may trigger in some cases idiopathic headache has increased in recent years. This problem has not been discussed in Polish literature up to now. An analysis of precipitating factors in a group of 116 patients: 70 with migraine, 30 with tension type of headache and 16 with cluster headache was conducted. In these groups: 60 patients (87%) with migraine, 24 patients (80%) with tension type headache and 15 patients (94%) with cluster headache confirmed activity of precipitating factors was shown. Stress was the most frequently cited precipitant in all types of idiopathic headaches (migraine-58%; tension type headache-53%; cluster headache-50%). Weather changes were in the second place. Excessive environmental factors, oversleep, some foods were also prominent factors.     

The management of acute headache in adults in an acute admissions unit

There have been no previously published studies about acute admissions with headaches to a medical admissions ward. In our retrospective case-note study of all patients admitted with headaches to the acute medical admission ward of Ninewells Hospital, Dundee over a six-month period, there were 114 admissions with headache (2.4% of all admissions). CT scans were done in 68 (59.6%) and were abnormal in 21 patients. Twenty four patients (21.1%) had serious underlying causes for headaches. Predictors for CT abnormalities are discussed. Eighteen patients had lumbar punctures and six had abnormal results. Most patients were discharged after one day, nine were transferred to the neurosurgical unit and there were two deaths. Deficiencies in record keeping were identified as was a lack of precision in diagnosis. Changes in practice are needed to improve patient care and perhaps national guidelines are required.     

A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache.

One-hundred-sixteen patients suffering from vascular headache (migraine or combined migraine and tension) were, after 4 weeks of pretreatment baseline headache monitoring, randomly assigned to one of four conditions: (a) thermal biofeedback with adjunctive relaxation training (TBF); (b) TBF plus cognitive therapy; (c) pseudomeditation as an ostensible attention-placebo control; or (d) headache monitoring. The first three groups received 16 individual sessions over 8 weeks, while the fourth group continued to monitor headaches. All groups then monitored headaches for a 4-week posttreatment baseline. Analysis revealed that all treated groups improved significantly more than the headache monitoring group with no significant differences among the three treated groups. On a measure of clinically significant improvement, the two TBF groups had slightly higher (51%) degree of improvement than the meditation group (37.5%). It is argued that the attention-placebo control became an active relaxation condition. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transformed migraine, analgesic rebound, and other chronic daily headaches

Although the International Headache Society's classification of headache has greatly enhanced the diagnosis of migraine and cluster headache, its application in chronic headache has been less than satisfactory. Based on a review of the literature and the author's experience, this article demonstrates the need for an expanded and modified classification and broader understanding of chronic headaches. The author proposes new categories, including transformed migraine. Analgesic rebound is described as a major cause of chronic headaches. The comorbidity of chronic headache disorders is also discussed. The article concludes with a suggestion for management of chronic headaches.     

Hyperprolactinemia and headaches

We investigated the frequency of headaches in women with menstrual abnormalities and hyperprolactinemia. Twenty-seven of 46 (58%) women with hyperprolactinemia indicated that headache episodes occur once or more per week; patients with sellar abnormalities (macroadenoma) or previous cranial or pituitary operation were excluded from this group of hyperprolactinemic patients. The headache episodes occurred significantly more frequently than in the control group (N = 56), where 27% indicated one or more headaches per week (p less than 0.01). In the vast majority of the women with hyperprolactinemia, headaches had preceded the finding of elevated prolactin levels for years and had not developed after the patients had become concerned about the pituitary gland. The clinical impression was that the headaches of these patients typically lack features of prodromal signs and unilaterality and resemble, in general, tension headaches; they may last for hours and often require medication. We could not demonstrate a relationship between prolactin levels and frequency or severity of these headache episodes. The etiology of these headaches is unclear. The therapeutic effect of bromocriptine deserves further investigation. In conclusion, we present data to suggest that headaches are commonly an associated finding in hyperprolactinemic women who have no evidence of significant pituitary enlargement.     

Headache and neck pain in spontaneous internal carotid and vertebral artery dissections

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.