[show abstract][hide abstract] ABSTRACT: Headache disorders determine relevant personal and societal burden, and thus the use of patient-reported outcome measures (PROMs) investigating the level of disability and health-related quality of life (HRQoL) have been increasingly used in headache research. The aim of this review was to address the status of research on disability and HRQoL, by addressing results from recently published clinical trials as well as in longitudinal observational studies on headache patients. PubMed has been searched for papers in which measures of HRQoL and/or disability were used as primary or secondary outcome on adult subjects with primary headache, and published in 2010-2012. Among the 70 records retrieved, 12 papers were selected for narrative synthesis. They included data on 2,621 patients with episodic migraine with and without aura, chronic daily headache, and/or chronic migraine with and without medication overuse. The selected trials investigated the efficacy of different pharmacological prophylaxis, of some surgical approaches, of education programmes and osteopathic manipulative treatment; two studies reported longitudinal observations of patients currently under treatment. Overall, the results of our review showed that headache frequency as well as HRQoL and disability were positively impacted by treatment interventions; positive outcomes were less evident in two studies, and similar results were found in the two observational studies. Our findings confirmed that the most commonly used PROMs, including disease-specific tools to assess disability and HRQoL and SF-36, are sensitive to the beneficial effects occurring over time in functioning and quality of life domains in headache patients. They also suggest that the personal and societal costs of headache disorders are likely to be reduced when headache patients receive appropriate treatments and when continuity of care is offered. In terms of future directions, we note that the systematic use of appropriate PROMs should be encouraged both in the clinical practice and in the research field, as they offer a valid option to assess the global effect of treatments on patient-perceived sense of well-being and quality of performance.
[show abstract][hide abstract] ABSTRACT: Patients with chronic headache and medication overuse are particularly difficult to treat, with no one approach being universally accepted. Some type of withdrawal program, however, is typically implemented before beginning a pharmacological prophylaxis treatment. Different withdrawal modalities have been performed for managing these patients: at first step, in-patient withdrawal has been confirmed effective in preceding clinical experiences. In recent years, new modalities for withdrawal have been developed as day-hospital setting. Purpose of this study was to determine the clinical course of a sample of chronic migraine patients with medication overuse 3 years after day-hospital withdrawal. A group of 202 patients were treated. Patients were suffering from chronic migraine with medication overuse according with IHS criteria. All patients were submitted to a day-hospital withdrawal and then they were followed with meetings every 3 months until the first year and then every 6 months until the last follow-up 3 years after withdrawal. Eighty patients achieved the last follow-up meeting 3 years after withdrawal. Patients clinically improved, significantly, both for days of headache per month and consumption of medications per month. From these results, the day-hospital setting for withdrawal, followed by periodic clinical meetings, seems to be effective for this category of patients to improve significantly at long-term headache frequency and analgesics intake.
[show abstract][hide abstract] ABSTRACT: Psychiatric disorders in migraine patients have a higher prevalence than general population. The presence of psychiatric comorbidities may influence the complexity of the migraine pictures and be related to medication overuse. Severely impaired chronic migraineurs presenting with medication overuse are a challenge for headache clinics. Psychiatric comorbities, such as dependency-like behaviors, anxiety and mood symptoms, might account for headache-related disability and recurrent relapses into medication overuse after a successful detoxification. Within a sample of 63 chronic migraineurs with medication overuse and severe disability, we investigated to which extent clinical severity, affective states and attitudes about medication impact the overall functioning at time of detoxification. To unravel whether some of these factors could predict their long-term outcome, we followed and retest them 1 year after withdrawal. We hypothesized that the detoxification would have led to a partial improvement and not modified the attitudes toward medication and dependence. Detoxification improves most of the clinical and affective measures, but does not free from significant levels of pain intensity and headache-related disability. The partial benefit from detoxification, the severity bias and the maladaptive cognitive profile led us to believe that subgroups of chronic-relapsing migraineurs deserve a multidisciplinary approach that addresses not only the reduction of clinical severity but also specific cognitive and behavioral impairments.
[show abstract][hide abstract] ABSTRACT: This paper aims to evaluate changes in disease severity, disability and mood state in patients with chronic migraine associated to medication overuse (CM-MO). MIDAS was used for assessing disease activity, WHO-DAS-2 for disability, DBI-2 for mood state. ANOVA was used to test change over time; t-test to assess follow-up differences in WHO-DAS-2 and BDI-2 between patients with MIDAS ≤20 and ≥21. Change in MIDAS, WHO-DAS-2 and BDI-2 scores were computed: Pearson's index was used to assess correlation between them; linear regression to assess change in WHO-DAS-2, using MIDAS and BDI-2 change as predictors. Mean MIDAS decreased significantly (from 101.9 to 52.0). In 26.1 % of the sample, MIDAS fell below 21 at follow-up: these patients had lower WHO-DAS-2 score. WHO-DAS-2 change was little correlated to MIDAS change and strongly correlated to changes in BDI-2 scores. 57.1 % of WHO-DAS-2 change variance is explained by change in BDI-2 and MIDAS scores. There was a clear clinical improvement 14 months after detoxification, and a modest reduction in disability which is explained by reduced disease activity and improved mood state. An appropriate treatment of CM-MO, based on detoxification and prophylaxis, is likely to reduce disease burden: recognition and treatment of mood problems may be a key factor to reduce disability.
[show abstract][hide abstract] ABSTRACT: Patients with chronic migraine developing medication-overuse headache (MOH) show dependency-like behaviors such as loss of control over analgesics despite adverse consequences on headaches, high rates of relapse after withdrawal from symptomatic medications, and compromised social functioning. Neuroimaging research suggests a common pathophysiology between substance-use disorders and MOH, which involves functional alterations in fronto-striatal networks, particularly in the orbitofrontal region of prefrontal cortex. These findings could explain the impaired decision-making observed in substance-use disorders. We hypothesize that MOH could share fronto-striatal circuit dysfunction and relative decision-making deficit with addiction. We further examine whether this deficit is a persistent cognitive trait or a reversible consequence of medication overuse. This study shows a dataset of 50 patients with MOH before the detoxification. All patients underwent a complete neurological and psychiatric examination. Psychiatric examination consisted of a clinical interview, Structured Clinical Interview for DSM-IV TR Axis II Personality Disorders, Anxiety and Depression Hamilton Scales, Severity of Dependence Scale. The neurological examination included the migraine disability assessment questionnaire. Neuropsychological assessment of fronto-striatal circuits was investigated using the Iowa gambling task (IGT). Twenty patients monitored for any relapse into medication overuse had 12 months of follow-up. Our sample, characterized by high rates of disability and dependency-like behaviors, exhibited a deficit in IGT performance, indicating an overall impairment in decision-making. All the 20 patients showed neurological and psychiatric improvement at 12-month follow-up, notwithstanding the overuse relapse, but a persistent IGT deficit was found. To our knowledge this is the first study that assesses this cognitive function in patients with MOH. Medication-overuse headache seems to share a persistent decision-making deficit with substance abuse that confirms the orbitofrontal cortex hypometabolism described in literature from a neuropsychological perspective. Looking at these shared neurocognitive features, our results suggest that MOH could belong to the addiction spectrum. Fronto-striatal dysfunction could be a premorbid psychobiological condition of vulnerability explaining the clinical onset of medication overuse and recurrent relapses. We propose that IGT could be used to identify chronic migraine patients with higher risk for medication overuse and relapse.
[show abstract][hide abstract] ABSTRACT: This study aims to compare disability and mood state in patients with episodic (EM) and chronic migraine associated to medication overuse (CM-MO), and to assess the relationships between the two outcomes. Patients, matched for age and gender, were administered the MIDAS, the WHO-DAS-2 and BDI-2. Difference between EM and CM-MO was assessed with the Kolmogorov-Smirnov Test; difference in distribution of patients with severe disability and low mood was tested with contingency coefficient; the correlation between MIDAS, WHO-DAS-2 and BDI-2 was tested with Spearman's index. Seventy patients were enrolled: CM-MO patients reported higher BDI-2 scores and higher MIDAS and WHO-DAS-2 scores, and were more likely to have severe disability and low mood state than those with EM; BDI-2 scores were correlated with disability scores, particularly with WHO-DAS-2. The study shows that disability and mood state are negatively impacted by the presence of more frequent headaches and by the overuse of acute medications.
[show abstract][hide abstract] ABSTRACT: Aim of this literature review is to summarize the most relevant research findings on disability in subjects with chronic daily headache (CDH) and chronic migraine (CM) measured with the MIDAS and the HIT-6, and to address issues for further research in the field. Research strategy aimed to find papers published after 2001 that focused on disability in patients with CDH, CM and transformed migraine. Both, general population surveys or clinical series were included if they reported total scores, or distribution of the different disability levels, derived from the MIDAS and/or from the HIT-6. Fifteen papers were selected. Studies demonstrated that these subjects report a remarkable impact on functioning, with high disability scores, and reduced ability in work and non-work activities. Modern definitions of disability conceptualize it as the result of the interaction between a health condition and environmental factors. Research strategies should therefore recognize that disability may represent a global evaluation which should be added to more specific endpoints, using instruments that measure disability in a multi-dimensional way, such as the WHO-DAS II.
[show abstract][hide abstract] ABSTRACT: Based on recent data about the association between restless legs syndrome (RLS) and migraine, we performed an observational study on the occurrence of RLS in patients affected by "pure" migraine with aura (pMA). We recruited 63 patients (33 females and 30 males) affected by MA without other types of primary headache among all patients referred in five Italian headache centers in a 1-year period. The prevalence of RLS in pMA patients (9.5%) is similar to that observed in Italian headache-free subjects (8.3%). No significant differences were found between pMA patients with and without RLS about clinical features of MA attacks and systemic and psychiatric diseases were investigated. Moreover, no association appeared between RLS and familial cases of MA. Differently from migraine without aura, our data do not confirm the existence of an association between RLS and MA, not even when a genetic factor is involved.
[show abstract][hide abstract] ABSTRACT: Headache is a common symptom in children and adolescence. In this retrospective analysis, we interviewed a population of young patients who were arrived to our observation 10 years before, in order to: (1) determine if the first diagnosis was still adequate and (2) which percentage of these young patients developed chronic forms (more than 15 days/month) from episodic forms. One hundred and seventy-seven patients suffering from different forms of headache were contacted and interviewed. The original diagnosis was confirmed in all the population of patients and the percentage of chronic forms developed from episodic forms was not significant. From this retrospective study, it does not seem the evolution of episodic forms in young age is necessarily a chronic form in adult as this depends from other behavioural or biological or environmental factors.
[show abstract][hide abstract] ABSTRACT: Chronic migraine accompanied by medication overuse is particularly difficult to treat. The number of treatment investigations is limited, few have included follow-up beyond 6 months and almost none has examined whether treatment leads to concurrent improvements in disability and functional impairment. This open-label study addresses these limitations. We have been prospectively following an initial cohort of 84 chronic migraine patients with medication overuse, who at the time of this evaluation had been reduced to 58, for an extended period to assess longer-term maintenance of effects, using measurement procedures identical to those in the original investigation. Thus, the specific aim was to determine the clinical status, with respect to pain indices and disability level, of chronic migraine patients with medication overuse who were treated and followed prospectively for 5 years. All patients completed a brief inpatient treatment programme, in which they were withdrawn from their offending medications and subsequently placed on more appropriate preventive antimigraine medications. Both end-point, wherein missing data points were estimated, and continuer analyses, wherein data analysis was limited to the 58 individuals with complete datasets, revealed significant improvement on all measures studied-headache days per month, analgesic consumption and Migraine Disability Assessment (MIDAS) total score. The percentage reduction from baseline to 5 years for the MIDAS total score was 76.0%, while the percentage of individuals revealing improvements of clinically significant magnitude (≥ 50%) on the MIDAS was 91.9%. MIDAS total scores were lower at 5 years than at some of the intervening follow-up intervals. Comparisons of those who completed the 5-year follow-up (n = 58) with those who did not revealed no differences at baseline. This finding, coupled with the nearly identical results for the end-point and continuers analyses, suggests that attrition did not have a bearing on outcome. None of the patients completing the 5-year follow-up had relapsed since the prior 3-year follow-up assessment. High levels of maintenance were revealed at 5 years, with disability scores showing some continued improvement over time. The implications of these findings and the limitations of the study are discussed.
[show abstract][hide abstract] ABSTRACT: Withdrawal is the first step for treating patients with chronic migraine and medication overuse. Recent studies confirmed common elements in personality between these patients and subjects addicted; some neuroimaging researches showed that abnormalities revealed are related to a specific cerebral pattern and that they can return to the normal state after withdrawal. Aim of the study was to submit a group of patients suffering from chronic migraine and medication overuse (the diagnosis was made according to Silberstein-Lipton criteria) to a withdrawal, to evaluate by f-MRI the presence of specific cerebral patterns before treatment and their possible changes after withdrawal. f-MRI seems to be a useful technique to obtain information on particular neuronal changes of the pain network involved in this type of patients. The activated areas are congruent with some data of the literature and the data emerged are discussed according to preceding reports.
[show abstract][hide abstract] ABSTRACT: Medication overuse headache (MOH) is now recognized as a biobehavioral disorder, a condition wherein emotion and pain are intermingled. This review discusses the steps to consider when treating this condition. The first step involves educating patients about MOH and the pathways to chronicity. The second step concerns working with patients to identify risk factors and behaviors that are present and contributing to the condition. The final step involves behavioral intervention. Examples for accomplishing each step are provided.
[show abstract][hide abstract] ABSTRACT: Many lines of research have suggested a relationship between migraine with aura (MA) and patent foramen ovale. Right-to-left shunt (RLS) of blood might explain both the occurrence of MA attacks, as well as the increased risk of ischaemic stroke in these patients. We evaluated the prevalence and the characteristics of RLS in a series of 120 MA patients, who were studied with contrast-enhanced Transcranial Doppler examination. We found RLS in 61 of them. A latent RLS was found in 28%, a permanent RLS in 72%, a shower-curtain pattern was detected in 52% of the studied patients.
[show abstract][hide abstract] ABSTRACT: The objective was to confirm the long-term utility of magnesium salts treatment on a group of young patients suffering from episodic tension-type headache (ETTH). The study was carried out at the Outpatient Headache Center at the National Neurological Institute "C. Besta," Milan, Italy, with 45 children/adolescents with ETTH reporting consecutively for treatment. Magnesium pidolate (2.25 g) was given twice per day for three months. Medication was not administered during the year of follow-up. No other treatment was provided at any time. Patients showed significant symptom reduction. Headache days decreased by 69.9%, whereas analgesics consumption was reduced by 65.4%. Overall disability levels improved by the greatest percent - 75.7%. MIDAS subscores improved as well (question A=58.0%; question B=22.5%). Although uncontrolled, these findings are encouraging and suggest that further, better controlled research investigations are warranted.
[show abstract][hide abstract] ABSTRACT: Chronic headaches have increasingly become a focus within the field of head pain. Most patients with frequent headache eventually overuse their medications, and when it happens, the diagnosis of medication-overuse headache is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications. Properly treating medication overuse and preventing relapse require recognition of the different factors that contribute to its development and perpetuation, including some behaviours and psychological elements that are important in sustaining the overuse of medication. The different therapeutical approaches, pharmacological and nonpharmacological, initial outcomes and long-term durability of treatment are discussed.
[show abstract][hide abstract] ABSTRACT: Recurrent headaches are common in children and adolescents. Most current investigations have employed limited modalities (either medication or behavioural) and few have included comparisons of different treatments. In this study relaxation training, administered in a limited contact format, and amitriptyline were compared for juvenile episodic tension-type headache. The clinical improvement was significant for both groups at 1- and 2-year follow-up; in particular for behavioural treatment, the patients came regularly for the sessions, practised routinely, and appeared to be compliant and accepting of treatment, although we did not assess this formally. In this group of patients the percentage of drop-outs was lower than in the pharmacological tratment. Although clinical results were similar in both groups, relaxation therapy seems to be more accepted than medication. The limited contact modality seems to be as useful as other behavioural approaches that require a greater investment of time (by patients and therapists), without unpleasant side effects. Because the sample sizes are small, these conclusions are tentative.
[show abstract][hide abstract] ABSTRACT: Improved health-related quality of life (HRQOL) and reduced activity limitations are prime objectives of migraine therapy, but no data on the effect of preventive treatments on these outcomes are available. We monitored changes in HRQOL using the Short Form 36 (SF-36) and headache-related activity limitations using the Migraine Disability Assessment Score (MIDAS) in 141 consecutive migraine without aura patients on prophylaxis. A total of 102 patients completed the 3-month study. Mean (SD) number of headache days/month dropped from 8.0 (3.7) to 5.0 (2.3) (P < 0.001). Mean monthly consumption of acute drugs reduced from 7.4 (3.5) to 4.4 (3.1) (P < 0.001). MIDAS total score reduced (improved) significantly. All SF-36 scale scores increased (improved), most significantly. This first study to assess prospectively the impact of prophylaxis on HRQOL and daily activities in a large series indicates that migraine prophylaxis has the potential to reduce the global burden of migraine on individuals and society.
[show abstract][hide abstract] ABSTRACT: Topiramate is approved for the preventive treatment of migraine in several countries based on the results of three large randomised, double-blind studies that showed that this compound was significantly more effective than placebo in migraine prophylaxis. We review the results of two studies: one which pooled data from the three controlled double-blind trials using 100 mg/day of topiramate, and an open-label extension of two of these trials in which patients received different topiramate doses for an eight-month maintenance period. The overall results confirm that topiramate is effective in reducing migraine frequency, and has a satisfactory tolerability profile.
[show abstract][hide abstract] ABSTRACT: Various treatment strategies have been proposed to help clinicians provide the most effective acute treatment for migraine patients. Stratified care is based on the concept that the most appropriate initial treatment can be prescribed after evaluation of each patient's headache characteristics. The results of a large multicentre trial showed that when patients were stratified according to disability grade, clinical outcomes were significantly better than with step-care approaches. Prospective studies have shown that treating migraines with triptans when pain is mild (early intervention) considerably increases success rates for endpoints (pain-free at 2 h, sustained pain-free state) for which triptans had relatively poor efficacy in pivotal trials, and which contribute most to patient satisfaction. Stratified care and early treatment are also cost-effective. However these strategies are not suitable for all patients. Stratified care may be rendered difficult by medication contraindications and changes in attack characteristics over time. Early triptan intervention carries a risk of medication overuse and might not be indicated in patients with lack of pain progression. Successful implementation of both strategies requires that physicians are well informed, and that they elicit an exhaustive headache history from each patient.
[show abstract][hide abstract] ABSTRACT: Cytomegalovirus (CMV)-associated transverse myelitis is rare in immunocompetent patients. We report a 73-year-old man with no evidence of immune compromise, who developed acute transverse myelitis. Cerebrospinal fluid pleocytosis indicated central nervous system inflammation, and spinal MRI showed weak signal hypointensity in T1, hyperintensity in T2 and DP between C7 and T2, but no contrast enhancement. High CSF anti- CMV IgG index with normal CSF IgG index indicated intact blood-brain barrier, and supported the diagnosis of CMV-induced myelitis in an immunocompetent patient.