Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main

Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." -----------------------------------------------------------------------------------------------------------------Article Date: 23 Sep 2007 - 0:00 PDT Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007.

"Those with less education are more likely to develop health problems and those with low incomes who already have health problems are more likely to see their health worsen," said lead author Pamela Herd, a University of Wisconsin-Madison sociologist. The study appears in the September issue of the Journal of Health and Social Behavior and examines how health differences in the United States often relate to people's socioeconomic status. Herd and colleagues say education influences occupation, income and wealth and with higher education comes healthier behaviors, such as good diet, increased physical activity, reduced stress and better use of preventive and therapeutic healthcare. The authors used data collected from 1986 to mid-2002 in the "Americans' Changing Lives Study," which conducted four waves of interviews of adults who were 25 years old and older. Herd and colleagues analyzed data for 8,287 participants. They looked at two groups of health problems: chronic conditions and functional limitations or disabilities. Compared with those with a college degree, the odds of having health problems were 81 percent higher for those without a high school diploma and 56 percent greater for those with a high school diploma. When comparing income, the researchers found that those with incomes of less than $10,000 had a 35 percent greater chance of developing health problems than those who made more than $30,000. In addition, those with incomes less than $10,000 had a 195-percent greater chance that their health problems would get worse. ----------------------------------------------------------------------------------------------------------------------------- Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT This report summarizes the results of that analysis, which indicated that, in 2002, approximately 22.5% of adults were current smokers. Although this prevalence is slightly lower than the 22.8% prevalence among U.S. adults in 2001 and substantially lower than the 24.1% prevalence in 1998, the rate of decline has not

been at a sufficient pace to achieve the 2010 national health objective. Cigarette smoking prevalence rates varied substantially across population subgroups (Table). The prevalence of smoking was higher among men (25.2%) than women (20.0%) and inversely related to age, from 28.5% for those aged 18--24 years to 9.3% for those aged >65 years. Among racial/ethnic groups, Asians (13.3%) and Hispanics (16.7%) had the lowest prevalence, and American Indians/Alaska Natives had the highest (40.8%). Current smoking prevalence also was higher among adults living below the poverty level* (32.9%) than among those at or above the poverty level (22.2%). During 1983--2002, the gap in smoking prevalence between those living below the poverty line and those living at or above it increased from 8.7 percentage points to 10.7 percentage points (Figure 1). By education level, smoking prevalence was highest among adults who had earned a General Educational Development diploma (42.3%) and lowest among those with graduate degrees (7.2%). Women with undergraduate (10.5%) or graduate degrees (6.4%) and men with graduate degrees (7.8%) also had smoking prevalence rates below the overall U.S. 2010 objective. During 1983--2002, the largest decreases in smoking prevalence occurred among adults with a college degree (10.0 percentage points) and those with some college education (9.3 percentage points); those with a high school diploma (6.6 percentage points) and those with less than a high school education (5.8 percentage points) showed the smallest decreases. During this period, the gap in smoking prevalence between adults who had graduated from college and those with less than a high school education increased from 14.0 percentage points in 1983 to 18.2 percentage points in 2002 (Figure 2). Similar patterns occurred in the percentage of ever smokers who had quit among different educational groups. The percentage of ever smokers who had quit was highest for those with college degrees, followed by persons with some college education. High school graduates and those with less than high school education had the lowest percentage of ever smokers who had quit. The gap between adults with a college degree and those with less than a high school education increased from 19.0 percentage points in 1983 to 25.9 percentage points in 2002. Editorial Note: The findings in this report indicate that 1) the socioeconomic status of U.S. adults is inversely related to their likelihood of smoking and 2) during 1983--2002, the gap in smoking prevalence by socioeconomic status did not narrow and might have widened. These findings underscore the need for targeted interventions that can better reach persons of lower socioeconomic status. Persons of low socioeconomic status have less access to health care than those of high socioeconomic status (3). ----------------------------------------------------------------------------------------------------------------------------- -----

Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M. Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 2028(9) Abstract: Objective.To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. Background.Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. Methods.The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC)

Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. Results.Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. Conclusions.A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted. -------------------------------------------------------------------------------------------------------------- -Cardiovascular risk factors and migraine: The GEM population-based study. Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Abstract: Background: Migraine, particularly with aura, is a risk factor for early-onset ischemic stroke. The underlying mechanisms are unknown, but may in part be due to migraineurs having an increased risk profile for cardiovascular disease. In this study, the authors compare the cardiovascular risk profile of adult migraineurs to that of nonmigraineurs. Methods: Participants (n = 5,755, 48% men, age 20 to 65 years) are from the Genetic Epidemiology of Migraine (GEM) study, a population-based study in the Netherlands. A total of 620 current migraineurs were identified: 31% with aura (MA), 64% without aura (MO), and 5% unclassified. Controls were 5,135 individuals without lifetime migraine. Measured cardiovascular risk factors included blood pressure (BP), serum total and high-density lipoprotein cholesterol (TC, HDL), smoking, oral contraceptive use, and the Framingham risk score for myocardial infarction or coronary heart disease (CHD) death. Results: Compared to controls, migraineurs were more likely to smoke (OR = 1.43 [1.1 to 1.8]), less likely to consume alcohol (OR = 0.58 [0.5 to 0.7]), and more likely to report a parental history of early myocardial infarction. Migraineurs with aura were more likely to have an unfavorable cholesterol profile (TC >= 240 mg/dL [OR = 1.43 (0.97 to 2.1)], TC:HDL ratio > 5.0 [OR = 1.64 (1.1 to 2.4)]), have elevated BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg [OR = 1.76 (1.04 to 3.0)]), and report a history of early onset CHD or stroke (OR = 3.96 [1.1 to 14.3]); female migraineurs with aura were more likely to be using oral contraceptives (OR = 2.06 [1.05 to 4.0]). The odds of having an elevated Framingham risk score for CHD were approximately doubled for the migraineurs with aura. Conclusions: Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine. ----------------------------------------------------------------------------------------------------------------------------- Impact of comorbidity on headache-related disability. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA. saunders.k@ghc.org OBJECTIVE: To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches. METHODS: A probability sample of US adults (n = 5,692) was interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers.

Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning. RESULTS: Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio [OR] 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches. CONCLUSIONS: Comorbidity is an important factor in understanding disability among persons with headache. ----------------------------------------------------------------------------------------- -----------------------Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008 Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center Headache is a pervasive symptom and the most common problem neurologists encounter in their clinical practices. It affects an estimated 60-80% of Americans at any time. The history of headache can be traced almost to the beginning of the history of humankind. The first description of headache dates back to the third millennium BCE. Headache has been written about extensively since the time of the Babylonian civilization. Migraine headache and hemicrania are discussed in the Bible. Some famous historical figures (eg, Napoleon) are known to have had terrible headaches. Prevalence Migraine affects 17% of females and 6% of males in the United States.3 Before puberty, both the prevalence and incidence of migraine are higher in boys than in girls. In individuals older than 12 years, the prevalence increases in both males and females, and the incidence declines in individuals older than 40 years, except for women in perimenopause. The overall prevalence is higher in females than in males. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years, after which it declines. The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 14-17 years. The incidence of migraine in females of reproductive age has increased over the last 20 years, probably due to more awareness of the condition. In the United States, white women have the highest incidence of migraine, whereas Asian women have the lowest incidence. Moreover, low socioeconomic status is associated with migraine. Currently, 1 of 6 American women has migraine headaches. Genetics Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. However, no genetic basis has been identified for common migraine, although it generally demonstrates a maternal inheritance pattern.

NOVEMBER/DECEMBER 2004 ISSUE OF HEADACHE (sursa 11) Costul total consta din: 1.Costul direct medical de ingrijire ba migrenei asha ca:

a)medicatia b)vizita la doctor 2.costul indirect,ce include:timpul pierdut de lucru, studii,sau activitatile din timpul liber. Acordarea medicatiei care previne migrena,daca folosirea ei ar fi dirijata ar putea reduce costul tratamentelor migrenei. Autorii anexeaza listea preturilor la 70preparate preventive,aratind ca gasirea sau apropierea de standard in reducerea producerii cefaleei cu 50% la 1/2 din pacientii tratati.

Primary Headache and Sleep Disturbances in Adolescents

Posted 10/18/2007 Deborah K. Gilman, PhD; Tonya M. Palermo, PhD; Marielle A. Kabbouche, MD; Andrew D. Hershey, MD, PhD; Scott W. Powers, PhD, ABPP Author Information
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Abstract and Introduction

Abstract Objective: The aim of the present study was to assess sleep patterns and the prevalence of sleep problems in adolescents with primary headaches using a validated sleep screening instrument, as well as to test the association between headache and pain features and adolescent sleep behaviors. Background: Sleep disturbance is a common complaint that has long been associated with primary headaches, but there exists limited evidence of the headache-sleep relationship among teens. Methods: Sixty-nine adolescents aged 13 to 17 years (M = 14.7; SD = 1.4) were evaluated for headaches at 2 pediatric neurology departments (90% migraine; 10% tension-type headache diagnoses). Participants completed the School Sleep Habits Questionnaire and a standardized questionnaire regarding headache characteristics. Results: Sleep complaints were prevalent among adolescents with headaches including insufficient total sleep (65.7%), daytime sleepiness (23.3%), difficulty falling asleep (40.6%), and night wakings (38%). Statistically significant relationships between headache characteristics (eg, frequency, pain intensity) and teen sleep behaviors also emerged. Conclusions: Our findings provide further support for an association between headache and sleep disturbances among adolescents with primary headaches. This information may provide further understanding of the nature and course of the patient's headache experience, as well as facilitate treatment planning to include recommendations for promoting good sleep hygiene. Introduction

Headaches are the most frequently reported pain among children and adolescents.[1-3] According to data recently obtained from the National Health Interview Survey (NHIS) greater than 3.7 million children and adolescents (6.7%) aged 417 years in the United States had frequent headache pain over a 12 month period of time.[4] Although headache is rare before the age of 4 years, its prevalence increases throughout childhood reaching a peak at about 13 years of age in both males and females.[5] In a population study of adolescents aged 1121, over 90% had experienced headaches, regardless of type, over 1 year.[6] Sleep disturbance is a common complaint that has long been associated with primary headaches. Headaches have been observed to occur during sleep,[7] after sleep,[7,8] and in relationship with various sleep stages.[9] An excess of sleep, a poor quality of sleep, and inadequate sleep duration are commonly associated with the precipitation of headaches.[10,11] It is not known whether sleep disturbances cause or aggravate headaches, or if sleep disturbances are caused by headaches, or if headaches and sleep disturbances are interwoven. In teens with primary headache, sleep disturbances have been a clinically suspected phenomenon. Although sleep has been examined in child populations with headache, very little empirical research has examined this relationship among adolescent populations. Of the few studies that included adolescents, results demonstrated that adolescents also report a variety of sleep concerns, including difficulties falling asleep, frequent night awakenings, early morning awakening, and excessive daytime sleepiness.[12,13] There is lack of data, however, on the nature of the headache-sleep relationship and how certain headache characteristics, such as pain intensity, duration, and frequency, relate to sleep behaviors among the adolescent population. Additionally, previous studies have assessed sleep disturbances in a variety of ways, making it difficult to compare findings across studies. Elucidating the nature of sleep patterns and sleep problems among adolescents with recurrent headache is worthwhile, as identification of specific headache characteristics related to disturbances in sleep may lead to improvements in headache treatment and ultimately in improvement of headache symptoms. Thus, the primary aim of the present study was to further assess sleep patterns and the prevalence of sleep problems in adolescents with primary headaches using a validated sleep screening instrument, as well as to test the association between headache and pain features and adolescent sleep behaviors. We hypothesized that adolescents with primary headache would experience frequent difficulties with initiating and maintaining sleep, and would have frequent sleep disruptions. Moreover, it was hypothesized that more frequent and intense headache pain would be significantly related to increased sleep problems.

Cutaneous Allodynia in Primary Headache

A questionnaire study suggests that the condition is most common in migraine, but the study methods are flawed. To assess the prevalence and severity of cutaneous allodynia in patients with primary headache disorders, these authors developed a 12-item Allodynia Symptom Checklist questionnaire. They did not test it against the gold standard for the assessment of allodynia, quantitative sensory testing. They sent the questionnaire to 24,000 individuals who had reported at least one severe headache in the past year on a previously mailed headache questionnaire. The response rate was high at 69%. Of responders, 67% reported symptoms consistent with migraine, 9% with probable migraine, 7% with severe tension-type headache, 4% with transformed migraine, 1% with other chronic daily headache, and 12% with unclassified

headaches. The prevalences of cutaneous allodynia were 63% in migraine and 68% in transformed migraine, versus 37% to 43% in the other headache groups. Across the board, women scored higher than men; in the migraine and probable-migraine groups, the scores were higher as attack frequency increased. Comment: According to the authors, their "data suggest that cutaneous allodynia maps onto migraine biology." The meaning of this statement eludes me. Cutaneous allodynia is the latest fad in migraine research, along with the central sensitization to which it is attributed. Only nonclinicians can mistake the hypersensitivity associated with migraine headaches for allodynia as is seen in neuropathic pain. I am not even convinced that cutaneous allodynia occurs in the context of migraine. Egilius L. H. Spierings, MD, PhD Dr. Spierings is Associate Clinical Professor of Neurology, Harvard Medical School, and Consultant in Neurology, Brigham and Womens Hospital, Boston. Published in Journal Watch Neurology June 24, 2008

Citation(s):
Bigal ME et al. Prevalence and characteristics of allodynia in headache Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. - Tepper SJ - Headache - 01-OCT2004; 44(9): 856-64 (MEDLINE is the source for the citation and abstract of this record ) Abstract: CONTEXT: Headache experts have suggested that to improve the recognition of migraine, patients with a stable pattern of episodic, disabling headache and a normal physical exam should be considered to have migraine in the absence of contradictory evidence. The premise upon which this approach is based-that is, that episodic, recurrent primary headache in the clinic is usually migraine-has not been evaluated in prospective clinical studies. OBJECTIVES: To (1) evaluate the diagnoses of patients consulting their physician with primary episodic headache and (2) compare clinic diagnoses and patient self-diagnoses with International Headache Society (IHS) headache diagnoses assigned on the basis of longitudinal data from patient diaries. DESIGN: Prospective, open-label study. During the screening visit, patients self-reported a headache diagnosis and then were assigned a headache diagnosis by their physician following his or her customary practice. Patients with a new physician diagnosis of migraine or nonmigraine primary headache were given diaries to record headache symptoms for up to 3 months or 6 attacks. Members of an expert panel, unaware of the clinic diagnosis, used diary data to assign a headache diagnosis to each attack and to each patient. SETTING: One hundred twenty-eight (128) practices in 15 countries including the United States. PATIENTS: A total of 1203 male and female patients between 18 and 65 years of age who consulted their physician with headache as a primary or secondary complaint. RESULTS: Overall, 94% of patients with a physician diagnosis of nonmigraine primary headache or a new clinic diagnosis of migraine had IHSdefined migraine (76%) or probable migraine (migrainous) (18%) headache on the basis of longitudinal diary data. A new clinic diagnosis of migraine was almost always correct: 98% of patients with a clinic diagnosis of migraine had IHS-defined migraine (87% of patients) or probable migraine (11% of patients) headache on the basis of longitudinal diary data. On the other hand, review of diaries of patients with a clinic diagnosis of nonmigraine revealed that

82% of these patients had IHS-defined migraine (48%) or probable migraine (34%) headache. Altogether, one in four patients (25%) with IHS-defined migraine according to longitudinal diary data did not receive a clinic diagnosis of migraine. CONCLUSIONS: These findings support the diagnostic approach of considering episodic, disabling primary headaches with an otherwise normal physical exam to be migraine in the absence of contradictory evidence. If in doubt of diagnosis or when assigning a nonmigraine diagnosis, strong consideration should be given to the use of a diary to confirm primary headache diagnosis. Citation: Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Tepper SJ - Headache - 01-OCT-2004; 44(9): 856-64 MEDLINE is the source for the citation and abstract of this record NLM Citation ID: 15447694 (PubMed ID) Full Source Title: Headache Publication Type: Clinical Trial; Comparative Study; Journal Article; Multicenter Study; Research Support, NonU.S. Gov't Language: English Author Affiliation: The New England Center for Headache, Stamford, CT, USA. Authors: Tepper SJ; Dahlf CG; Dowson A; Newman L; Mansbach H; Jones M; Pham B; Webster C; Salonen R

Headache
This is one of the commonest reasons for attending a general practice surgery or a neurology clinic. This record is based on the British Association for the Study of Headache (2007) Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache.1 Epidemiology Some 15% of the UK adult population have migraine, and 80% have episodic tension-type headache from time to time.2 The lifetime prevalence of headache is 96%; higher in women than in men. Classification

Headaches can be primary or secondary.

Primary headache
The two most common are:

Tension-type headaches (TTH): o These are the most common type of headache, with lifetime prevalence ranging between 30% and 78%.3,4 Migraine o This can occur with or without aura. o A typical aura lasts between five to 60 minutes, usually before the headache starts. o It may consist of transient visual, sensory, and speech disturbances. o Visual symptoms are the most common manifestation of an aura and consist of flickering lights, spots or zig-zag lines, fortification spectra or blind spots.

Cluster headaches occur less commonly, with a prevalence of 69/100,000:3,4

These are unilateral, severe headaches that occur in clusters over six to 12 weeks. They are more common in: o Men o People who smoke o Adults older than 20 years They tend to occur daily and wake the patient. The pain of cluster headaches is severe. They are associated with ipsilateral watering of the eye, conjunctival redness, rhinorrhoea, nasal blockage, and ptosis.

Document references 1. British Association for the Study of Headache (2007) Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; Full Guidance as PDF 2. Fuller G, Kaye C; Headaches. BMJ. 2007 Feb 3;334(7587):254-6. 3. Silberstein, S.D., Lipton, R.B. and Goadsby, P.J. (2002) Headache in clinical practice. 2nd edn. London: Martin Dunitz. 4. Rasmussen BK, Jensen R, Schroll M, et al; Epidemiology of headache in a general population--a prevalence study.; J Clin Epidemiol. 1991;44(11):1147-57. [abstract] 5. Headache, Clinical Knowledge Summaries (2005) 6. Zed PJ, Loewen PS, Robinson G; Medication-induced headache: overview and systematic review of therapeutic approaches. Ann Pharmacother. 1999 Jan;33(1):61-72. [abstract]

Internet and further reading

Sargeant LK, Blanda M; Headache, tension. eMedicine, May 2006. Silberstein SD, Olesen J, Bousser MG, et al; The International Classification of Headache Disorders, 2nd Edition (ICHD-II)--revision of criteria for 8.2 Medication-overuse headache. Cephalalgia. 2005 Jun;25(6):460-5. Mendizabal JE; Cluster headache. eMedicine, October 2006.

Limmroth V, Katsarava Z, Fritsche G, Przywara S, Diener HC. Features of medication overuse headache following overuse of different acute headache drugs. Neurology 2002;59:1011-4.

Sensitive Skin A Symptom Of Migraine

Main Category: Headache / Migraine Also Included In: Dermatology Article Date: 23 Apr 2008 - 5:00 PST "Migraine hurts skin" is the headline in the Daily Mirror. The newspaper describes the symptom of sensitive skin, called allodynia, where sufferers of migraine find combing their hair, wearing jewellery or getting dressed "excruciatingly painful". The newspaper reports that 10% of people in the UK suffer migraine. The Daily Telegraph covers the same story and suggests "two thirds of migraine sufferers reported symptoms of the condition allodynia". The story is based on a questionnaire sent to 24,000 people living with different types of headaches. There is a chance the results are made less accurate by the number of people (over 30%) who did not respond to the questionnaire - only about 16,500 were returned fully completed. If these people had less severe symptoms and less skin sensitivity, the prevalence could have been reduced from two thirds to less than half. However, this still means that the symptom of sensitive skin is common among people who have migraines. The researchers are unable to say whether the presence of skin sensitivity is a risk factor for migraine progression. However, this could be a useful aspect for further study. Where did the story come from? Dr Marcelo Bigal from the Department of Neurology at the Albert Einstein College of Medicine in the Bronx and colleagues from elsewhere in the United States carried out this research. The study was sponsored by the National Headache Foundation and the lead researcher is now employed by Merck Research Laboratories. It was published in Neurology, a peer-reviewed medical journal. What kind of scientific study was this? This was a cross-sectional study in which the researchers used people who had been part of a previous large study and recorded as living with headaches. Using this group, they sent a random sample of 24,000 people a questionnaire which had 82 questions asking about headache diagnosis, other illnesses, and the impact that headache had on the patient's life. They also asked background demographic questions, such as age, sex, race and income (which was classified in bands). This questionnaire had been validated in migraine sufferers. Twelve of the questions specifically related to the frequency and severity of the symptom 'cutaneous allodynia'. This symptom is described as a painful response to non-painful skin stimulation and is known to occur in migraine sufferers. The authors suggest that the presence of allodynia is suggestive of "central sensitisation", a process where nerves in the central nervous system become involved in dealing with localised pain responses, meaning more pain sensations are transmitted. The answers to the allodynia questions were scored as 0 (ie, never or rarely or does not apply to

me), 1 (less than half the time) and 2 (half the time or more). This produced scores that ranged from 0 to 24 for the allodynia section. The researchers then summarised all the data descriptively and analysed the responses, looking for links between any of the responses and headache type, frequency, severity and other personal characteristics such as weight, that could determine the prevalence of allodynia scores of three or more. What were the results of the study? Of the 24,000 people sent the questionnaire, about 16,500 (69%) returned them completed. All of them had had at least one severe headache in the previous year and most (about 11,000) had a diagnosis of migraine. The researchers diagnosed other causes of headache from the questionnaires including probable migraine, chronic daily headache, severe episodic tension type headache and transformed migraine. The prevalence of allodynia was higher (68.3%) in those with transformed migraine (a form of migraine with very frequent attacks), than in the more common episodic form of migraine (63.2%). In both these types of migraine the prevalence of allodynia was higher than with the other causes of headache (around 36 - 42%). When the researchers analysed the links between all the other personal characteristics, they found that the prevalence of allodynia in the migraine and transformed migraine groups was higher in women than in men and that it increased with disability score. Among the people with migraine, the symptom was also more common with more frequent headaches and higher body mass index. In all headache groups, the allodynia scores were higher in individuals with major depression. What interpretations did the researchers draw from these results? The researchers conclude that allodynia is more common and more severe in two types of migraine, transformed migraine and episodic migraine, than in other primary headaches. For those with migraine the chance of having allodynia is increased by being female, having frequent headaches, increased body mass index, disability and depression. What does the NHS Knowledge Service make of this study? This data, the researchers say, should be interpreted with caution: - The use of a questionnaire that has been validated only in people with migraine for general use and in a population who have a wide variety of other headache types may have led to inaccuracies. For example, the questions about migraine symptoms may not have been understood by those people who did not have migraine. - The classification of severity for the allodynia symptom was not the universally accepted 'gold standard' and although, the authors say, neither the gold standard nor their adopted scale are ideal, it will be difficult to convert the prevalence rates determined by their questionnaire into rates found in real life using conventional diagnosis. - The cross-sectional study design means that it is not possible to determine if the symptom of allodynia predicts people who are more likely to develop more severe migraine over time, as the study was conducted at one point of time only. A concern not mentioned by the researchers is the large number of uncompleted questionnaires (over 30%). This is not unusual in this type of study but in this case, it may mean that the prevalence of allodynia has been overestimated, as the non-responders may have had less severe

or fewer symptoms of allodynia. Despite these reservations, the study does provide evidence that this type of skin sensitivity is a common symptom occurring in migraine. Other studies following the development of the symptom over time and analysing the data in such a way as to allow patients and their doctors to predict either progression or responses to treatment, will no doubt be on the 'to-do list' for these researchers. Links to the headlines Migraine hurts skin. Daily Mirror, April 22 2008 Migraine sufferers have more sensitive skin. The Daily Telegraph, April 22 2008 Links to the science Prevalence and characteristics of allodynia in headache sufferers: A population study. Bigal ME, Ashina S, Burstein R, et al. Neurology 2008; 70:1525-1533

Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows
Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT

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Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. Led by Dr. Marcelo Bigal, assistant professor of neurology, the Einstein researchers mailed a headache questionnaire to 120,000 households encompassing 257,399 residents -- a sample representative of the U.S. population with respect to gender, age and geographic region. More than 32,000 teens were identified in this sample, and more than half of them (58.4 percent) answered the questionnaire. It is well known that heredity strongly influences whether someone will develop migraine

headaches. So when this study looked at teens whose parents suffered from migraines, the prevalence of teens suffering one or more migraines in the previous year was nearly the same in lower vs. higher income groups -- 8.6 percent vs. 8.4 percent, respectively. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." ---------------------------Article adapted by Medical News Today from original press release. ---------------------------In addition to Dr. Bigal and colleagues at Albert Einstein College of Medicine and its University Hospital Montefiore Medical Center, researchers from the following institutions took part in the study: The New England Center for Headache, Stamford, CT; The Palm Beach Headache Center, Palm Beach, FL; Vedanta Research, Chapel Hill, N.C.; The Diamond Headache Center, Chicago, IL; and The Center for Health Research and Rural Advocacy, Danville, PA. Source: Karen Gardner Albert Einstein College of Medicine
ARTICOLE TRADUSE

S XXXII Headache: The Journal of Head and Face Pain Vol 42 P. 963-November 2002. Issue 10 Prevalence and Clinical Characteristics of Headache in a Rural community in Oman. Dirk Deleu,MD et al. Obiective: mbuntirea studiului prospectiv epidemiologic al cefaleelor n comunitatea rural Oman, evaluarea prevalenei, profilului simptomelor i utilizarea patternului de ngrijire medical. Metode: Utilizarea studiului de estimare a prevalenei, care a fost bazat pe chestionarul structurat de evaluare a cefaleei, care efectuiaz diagnosticarea n acord cu criteriile IHS(Societii Internaionale a Cefaleelor). Rezultate:Prevalena nefinisat(preventiv)pe via i pe durata de 1 an al cefaleei a fost de 83,6% i de 78,8% respectiv,cu preponderen la femei. Prevalena de 1 an al migrenei i CTT a fost de 10,1% i 11,2% respectiv.

Nu este o diferen semnificativ dup gen(sex) n prevalena migrenei (4,55 la femei i 5,6% la brbai), dar la CTT a fost de 2,6% ori mai frecv. la femei(3,1% la brbai i 8,1% la femei). Prevalena de 1 an al cefaleelor frecvente a fost de 5,4%, 48% din respondeni au cerut asisten medical, privind cefaleea i 79% au utilizat medicaia, iar 40% din ei-automedicaia. Concluzii: Acest studiu prospectiv a demonstrat, c prevalena cefaleei este la fel de nalt n aceast comunitate. Migrena i CTT au o prevalen similar, dar distribuia dup sex e diferit de cea din Vest. Prevalena CTT ests substanial mai joas dect cea observat n alte pri ale lumii. Cefaleele frecvente au fost la fel de des ntlnite ca i n alte studii asemntoare n lume. Utilizarea analgezicelor, ct i abuzul de asemenea coexist cu cefaleea, deoarece automedicaia mai este destul de rspndit.

S XXX Curr. Pain Headache Rep. 2003 Dec;7(6):455-9. Diagnosis, epidemiology and impact of tension-type headache. Jensen R. Dei CTT este cea mai prevalent cefalee i afecteaz 78% din populaia dgeneral, impactul substanial individual i social asociat cu aceast cefalee primar este trecut cu vederea(neglijat). n contrast cu migrena , concentrarea asupra CTT este limitat. Muli pacieni cu forme de Ctt cronic, care afecteaz 3% din populaie sunt lsai (abandonai) fr orice trataent specific. CTT cronic difer de forma episodic prin frecven, lipsa efectului la majoritatea strategiilor de tratament, mai mult abuz medicamentos i o mai mare scdere(pierdere) a calitii vieii. Zilnic sau aproape(practic) zilnic deasemenea constituie o problem de diagnostic i tratament i separarea( deosebirea) CTT cronic de migren(cefaleea migrenoas) i de cefaleea indus de medicaie este o provocare, deoarece strategiile manageriale sunt complet diferite. Un beneficiu considerabil pentru societate este obinerea unor strategii specifice, ce vor conduce la reducerea n cantitate al absenteismului pe motiv de boal i a mbuntirii abilitilor de munc. Impactul supra pacienilor afectai i asupra calitii vieii familiilor lor de asemenea pot fi mbuntite prin accepterea general a patologiei(recunoaterea ei) i prin dezvoltarea unei strategii specifice de tratament.

S XXXI CNS DRUGS: 2005; 19(6): 483-97 Medication overuse headache in patients with primary headache disorders: epidemiology, management and pathogenesis. Dowson AJ, Dodick DW, Limmroth V. Cefaleea indus de abuzul medicamentos(CIAM) sau MOH- medication overuse headache este o problem medical frecvent ntlnit, dac e asociat cu o stare de boal de lung durat i cu o disabilitate considerabil(scdere considerabil a capacitii de munc). CIAM afecteaz pacienii cu cefalei primare(migrena, CTT i combinaia migrenei i a CTT), ceea, ce schimb patternul cefaleelor zilnice sau aproape zilnice pe o perioad de ani sau zeci de ani, nsoind abuzul medicaiilor simptomatice a cefaleelor.

Abuzul medicamentos Medicamentele utilizate n exces includ analgezicele, alcaloizii ergotaminici, triptanele(serotonin 5HT(1/1D) receptorii agonitilor ) i medicamentele, ce conin barbiturice, codein, cafein, tranchilizantele i analgezicele mixte. Pacienii afectai au de obicei un istoric de lung durat de cefalei primare, medicaia abuzivi cefaleea indus de abuzul medicamentos pn la adresarea la medicul-generalist pentru ngrijiri medicale(dup ajutor). Pacienii cu CIAM(Cefaleea indus de abuzul medicamentos) sunt ndreptai n centre specializate, unde sunt retrase medicamentele, ce au fost utilizate n abuz i li se aplic un tratament de retractare al simptomelor(n tratamentul n staionar i ambulator), profilaxia cefaleelor i limitarea utilizrii medicaiei simptomatice acute. Majoritatea pacienilor rspund la acest tratament, dei prognoza nu este mereu una bun, 50% pot cdea, se pot ntoarce) n starea sau perioada iniial n urmtorii 5 ani. Cea mai bun strategie practicat n prezent este prevenirea abuzului medicamentos n primul rnd prin educaia pacienilor i formal abordarea managerial dirijat(?) n medicina primar(prespitaliceasc), ce const n tratarea cefaleelor primare pn la transformarea lor CIAM. Calitatea evidenei clinice al CIAM este suboptimal i pe departe cercetrile biologice(?) i clinice (solicitate) necesit urgent un ajutor de facilitare a managementului acestor pacieni, mai eficient n viitor.

J Headache Pain 2003 Epidemiology of migraine Gian Camillo Manzoni, Paola Torelli Prevalena de 1 an al migrenei n populaia general a rilor vestice variaz de la 4% la 9% la brbai i de la 11% la 25% la femei. Brbai(%) Femei (%) Mattson et al.[8]2000 sweden(40-74 ani) 18,0 Dahlof et al. [9]2001 Sweden(18-74) 9,5 16,7 Lipton et al. *10+2001 SUA(12) 6,5 18,2 Henry et al. *12+2002 France(15) 4,0 11,2 Lipton et al. [11]2002 SUA(18-65) 6,0 17,2 Non-Western countries(rile, ce nu sunt situate n vest) Bank, Marton [17]2000 Hungary(15-80) 4,3 10,7 Zivadinov et al *18+2001 Croaia(15-65) 12,3 18,0 Kececi,Dener*18 +2002 Turkey(7) 7,9 17,0 S XXXII Eur J Epidemiol. 2005; 20(3): 243-9. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survei. Lyngberg AC, Rasmussen BK, Jorgensen T, Jensen R. Rata de participare a fost de 75%. Prevalena migrenei nu s-a schimbat semnificativ(11-15%), pe cnd prevalena CTT(79-87%) n special CTT frecvent(29-37%) a crescut semnificativ. Prevalena CTT cronice(2-5%) tinde spre cretere. Proporia migrenoilor cu migren de 14 zile i mai mult pe an e n cretere(12-38%). Genul feminin a fost un factor de risc pentru ambele tipuri de cefalei primare. Majoritatea migrenoilor(92-94%) de asemenea au raportat coexistena CTT(asocierea). Concluzii: Prevalena CTT, dar nu i al migrenei este n cretere.

Creterea frecvenei migrenei i a CTT sugereaz un nalt impact individual i social al cefaleelor primare acum, ca i 12 ani n urm.

J. Headache Pain(2003)4: S 55-S 58 General disease costing principles. Amalia Donia sofio, Franco Mazzuca, Francesco S Mennini Studiile recente au demonstrat, c n rile UE(Uniunii Europene)zilele pierdute de lucru n rezultatul migrenei( din cauza migrenei) variaz de la 1,9 la 3,2 la pacient pe an. n toate studiile, indiferent de naionalitate femeile au ntietatea net fa de brbai( women stay away from worc more often than men). Capacitatea muncii scade cu 70% la aceti subieci. Costul spitalizrii peste tot (universally)reprezint doar o mic parte din costul total de management al migrnei: rata spitalizrii e mai mic de 10% i variaz de la 2% n Danemarca la 7% n SUA.

Pentru introducere: Cefaleea este un simptom foarte cunoscut, care poate avea un impact profund asupra calitii vieii. Dou patologii, cele mai cunoscute cefalei primare, migrena i cefaleea de tip tensional au o prevalen unianual 11%i 40% la populaia adult. Patologiile au condiii heterogene, care rezult ntr-un spectru al disabilitii n interiorul i printre diferii indivizi. Dei exist tratamente eficiente pentru muli pacieni cu migren, ea este acum slab cunoscut i slab tratat. Evaluarea dizabilitii la cefalee e important pentru formarea prerii privind terapia acut i preventiv. Cteva chestionare standartizate pentru migren i impactul cefaleei au fost descoperite. Acest tip de chestionare au cel puin 2 utilizri poteniale: 1.Evaluarea grupurilor, rezultatul evalurii studiilor clinice.

*+

Surse la sfrit: Cefaleea este un simptom extrem de rspndit, care poate avea un impact profund asupra funcionrii oamenilor i asupra calitii vieiilor. Dou cele mai frecvent ntlnite cefalei primare: migrena i cefaleea de tip tensional cu o prevalen de 1 an de 11%*Breslau N, Rasmussen BK. The impact of migraine:Epidemiology, risk factors, and comorbidities. Neurology 2001; 56: S4-S12+ i 40% *Schwarz BS, Stewart WF, Simon D, Lipton RB: Epidemiology of tension- type headache. JAMA 1998; 279: 381-383+ n populaia adult. Patologiile, ce au condiii heterogene, rezult n spectru de dizabiliti n interiorul i printre diferite persoane[Stewart WF,Shechter A, Lipton RB. Migraine heterogenity.Disability, pain intensity, and attack frequency and duration. Neurology 1994; 44. S 24-39 ].

Dei exist tratamente eficiente pentru majoritatea pacienilor cu migren, ea mai rmine nediagnosticat i netratat ndeajuns. n evaluarea patologiei cefalalgice este important luarea deciziilor privind tratamentul acut i preventiv. Chestionarul HIT[Headache Impact Test] include ntrebri privind durerea, funcionarea pesonal, social, oboseala, suprarea emoional, capacitatea de nsuire i sntate mintal. n MIDAS se include informaia despre timpul de munc pierdut, munca casnic sau ntreruperea activitii n ultimele 3 luni. Criterii de selectare: 1.Vrsta 18-65 ani. 2.Reedin permanent(ca s poat fi contactai) 3. A avut o cefalee cu 4 sptmni nainte de interviu(nu din cauza mahmurelii, rcelii sau gripei). Respondenii trebuia s poat: 1. S poat liber conversa n englez; 2. S poat fi intervievai fizic i mental. Rata de participare- 71%. Prevalena cefaleei n 4 sptmni precedente a fost de 45,7%. Durata interviului a fost 21,5 min.(17-27 min.). Din persoanele, ce nu au raportat, c au avut cefalee n cele 4 sptmni precedente, 35% au spus, c au avut cefalee n ultimele 3 luni. Quality of life research 12: 913-933, 2003 Calibration of an item pool for assesing the burden of headaches: An application of item response theory to the Headache Impact Test(HIT TM).

Nippon Rinsho.2005.oct; 63(10):1705-11 Epidemiology of headache Ocuma H, Kitagawa Y. n articol s-a discutat epidemiologia cefaleelor cronice. Cefaleea e omniprezent(wide spread i o problem costisitoare al sntii publice Rar cine n-a suferit de cefalee: La brbai prevalena pe via e de 93%, iar la femei de 99%. Aproximativ 8,4 mln oameni n Japonia sufer de migren i 22 mln. Au cefalee de tip tensional. Nectnd la dauna, costul i dizabilitatea cauzat de cefalee, muli pacieni cu cefalei nu se adreseaz dup servicii medicale. E important s se recunoasc incidena variatelor tipuri de cef. Cronice, diagnosticarea i tratarea lor corect. n acest articol a fost elucidat incidena, factorii provocatori, prevalena regional i dependena de vrst al incidenei fiecrui tip de cefalee cronic.

Neurology.2003; 383-385( De gsit autorii!) Pacienii cu cefalee de tip tensional(CTT)cronic au fost gsii ca semnificativ mai muli dect cei cu CTT episodic(media de vrstSD pentru tipul cronic i episodic al cefaleei de tip tensional: 41,1115,57; 35,8512,91,P>0,01)cu respectarea (datelor)studiilor, tipul cronic al cefaleei a fost gsit ca cel mai prevalent( 6,83, P<0,05) la persoanele cu nivelul cel mai jos de studii. Frecvena atacurilor de cefalee. Aproximativ 73,4% din pacienii cu migren au 1-4 atacuri pe lun, pe cnd restul trec prin> 4 atacuri pe lun. 55 pacieni migrenoi(38,5% din toi pacienii cu migren; 21- cu (MWA)migren cu aur, 14- (MWOA) migren fr aur au cel puin 180 atacuri pe an.

Lund n consideraie, c la CTT, 31,9% au 1-3 atacuri de cefalee pe lun i 68,1% din pacieni sufer de cefalee minim 1 dat pe sptmn; 33,3% din pacieni au cel puin 180 atacuri de cefalee de tip tensional pe an. Durata cefaleei. n acord cu criteriile Societii Internaionale de Cefalee(IHS), durata acceptabil a atacului de migren la pacientul netratat e de 4-72 ore. 22 pacieni (15,4%)cu migren au avut durata atacurilor < 4ore. Dar toi aceti pacieni au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu arat(demostreaz, c cea mai rspndit(comun durat al atacurilor de migren(71,3%) a fost ntre 4 i 24 ore. n CTT atacurile s-au sfrit n cadrul(dup)mai multor ore(51,9%), au continuat pe parcursul zilei(22,2%), au durat 1-3 zile(14,8%) i 3-7 zile la (11%)din pacieni. CTT episodic difer de tipul cronic prin aceea, c atacurile de obicei au o durat mai scurt, 15 min.cteva ore( 10,52, P<0,05). Caracterul cefaleei. Pulsaia a fost observat la 88,8% din migrenoi pe cnd la 62,0% din pacienii cu CTT aveau senzaie de presiune, ncordare(Tab.2); 53,1% din pacienii cu migren au avut cefalee unilateral. Cefaleea bilateral a fost raportat n 72,7% din pacienii cu CTT. La 82,5% din pacienii cu migren i 43,5% din pacienii cu CTT, cefaleea a fost agravat de activiti fizice de rutin. Caracteristicele tipurilor migrenei cu aur i fr aur au fost demonstrate n Tab.2 Compararea acestor caracteristici cu test a demonstrat caracterul pulsatil, care a fost gsit mai frecvent n migrena cu aur( Caracteristicele CTT cronic i episodic au fost prezentate n Tab.3. N-au fost diferene statistice( test) ntre cele 2 tipuri de cefalei tensionale. Simptome nsoitoare.(concomitente, asociate). Fonofobia(85,3%) a fost cel mai frecvent simptom al migrenei, nsoit de grea(80,4%) i fotofobie(77,6%). Voma a fost observat la 44,8% din pacienii cu migren, n( MWA)- migrena cu aur , cea mai comun aur au fost manifestrile vizuale, incluznd scintilaia sau distorsia (modificarea ) imaginii, hemianopsia i ntunecarea vederii(81,8%), urmat (nsoit) de tinitus/vertije(67,1%), simptome senzoriale(34,3%) i afazia(15,4%). n cazurile de CTT, fonofobia a fost de asemenea cel mai des simptom nsoitor. Greaa a fost observat la 40,7%, iar fotofobia la 14,4% din pacieni. Simptomele nsoitoare ale migrenei cu i fr aur au fost artate(prezentate, demonstrate) n Tab.4, iar cele de cefalee de tip tensional episodic i cronic n Tab. 5 Cu respectarea acestor constatri, n-a fost difereniat statistica ntre migrena cu i fr aur. Totui, cnd comparaia similar a fost fcut ntre subtipurile cefaleei de tip tensional, simptomele de grea ( ( au fost gsite ca cele mai frecvente n cefaleea cronic de tip

tensional. Tab.3 Caracteristicele cefaleei de tip tensional cronice i episodice

Tipurile CTT

Bilateralitatea%

Natura de presiune, strangulare%

Agravarea la efort fizic

Impactul asupra activitii zilnice

CTT cronic

73,6

34,7

45,8

33,3

CTT episodic

70,1

39,6

45,1

38,2

Caracteristicile epidemiologice si clinice a migrenei si cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia

Kseoglu E., Naar M., Talaslioglu A., etinkaya F.

Caracteristici epidemiologice si clinice ale migrenei si a cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia. Cephalalgia 2003 ; 23 :381-338. London ISSN 0333-1024

In populatia feminina a Turciei (1146 de femei adulte), au fost investigate unele caracteristici epidemiologice si clinice ale migrenei si cefaleei de tip tensional si unele subtipuri ale lor. Relatia intre severitatea durerii de cap si caracteristicile clinice au fost investigate amanuntit. Statisticile arata o raspandire mai mare a migrenei la grupul de varsta intre 35 si 44 de ani (P<0.01), la cei cu studii superioare (P<0.001), la cei casatoriti (P<0.01) precum si la persoanele care locuiesc in localitati urbane. Cefaleea de tip tensional a fost apreciata ca fiind mai inalta la grupul de varsta cuprins intre 45 si 64 de ani (P<0.05). S-a constatat ca pacientii cu cefalee cronica (P<0.01) sunt mult mai avansati in varsta comparativ celor cu cefalee de tip tensional de tip episodic si deseori sunt cu un nivel de educatie scazut (P<0.05). Prezenta impactului asupra activitatii lor zilnice datorat severitatii durerilor de cap a fost legata de agravarea starii fizice (P=0.001) in cazul cefaleei de tip tensional, fara caracteristici clinice ale durerii de cap migrenoase si considerand toti pacientii cu dureri de cap pulsatile (P<0.05), agravarea starii fizice (P=0.001), greturi (P<0.01), vome (P<0.05), si phonofobie (P<0.05). Migrena, cefalee de tip tensional, populatia feminina, Turcia.

Introducere

Exista multe studii epidemiologice a durerilor de cap, dar relativ putine sunt efectuate in tarile asiatice. Aceasta relateaza faptul ca factorii de risc de ordin rasial, cultural si cel al mediului inconjurator joaca un rol important in cercetarile epidemiologice(1). Acest studiu a fost efectuat intr-o tara asiatica, a carei populatie apartine rasei Caucaziene. Studiile, in special cele cu privire la femei, sunt si ele relativ putine la numar. Un studiu epidemiologic a durerilor de cap din Turcia, publicat sub forma de rezumat, efectuat in cazul a 2007 de persoane, arata o raspandire a migrenei si cefaleei de tip tensional (CTT) in decursul unui an de 16.4% si respectiv 31.7%(2). Dar caracteristicile clinice ale cefaleelor n-au fost evaluate. Acesta este primul studiu detaliat, bazat pe cercetari masive a cefaleei si caracteristicile sale clinice bazate pe Sistemul International al Cefaleei (criteriul IHS) in populatia feminina a Turciei. Prevalenta de 1 an, date socio-demografice si caracteristicile migrenei, CTT si subtipurile cefaleei de tip tensional au fost investigate. De asemenea, a fost apreciata si corelatia dintre caracteristicile clinice si severitatea cefaleei.

Materiale si metode

Studiul a fost efectuat in provincia Kayseri avand ca obiect de cercetare femei in varsta mai mare de 14 ani, in cazul a 375 441 de persoane. Marimea-mostra minima a fost calculata ca fiind cea de 1100 de persoane (95% interval confidential, SD: 1.6%) prevalenta migrenei estimata la 8%. 1300 de femei intre varsta de 15 si 87 de ani au fost selectate la intamplare dupa grup si metodele de sistematizare din regiune, folosind registrul civil in centrele de sanatate primare, care au inregistrari a tuturor locuitorilor a regiunilor; 1146 din aceste femei a putut fi contactate pentru studiu. Simptomele durerii de cap au fost evaluate prin intervievarea structurata fata-n fata, bazata pe criteriul IHS (3) . Inaintea fiecarui interviu era descris obiectivul studiului si era primit acordul verbal de a participa. Studiul a fost aprobat de Comitetul Etic al Universitatii Erciyes. In urma unor intrebari introductive cu privire la varsta, nivelul educational si economic, statutul marital si profesional, indivizii au fost intrebati daca medicii generalisti au depistat vre-o boala cronica si cel mai important, daca au avut dureri de cap bine resimtite (discomfortante) pe parcursul anului trecut. In cazul in care durerea de cap era raportata, li se puneau intrebari pe marginea caracteristicilor durerilor de cap si intrebari legate de cele din urma, cum ar fi frecventa, durata, factorii declansatori, simptomele concomitente, dereglari ale somnului, istoricul familiei, tratamentele facute, etc. Intervievarile erau executate de studentii la medicina, antrenati in acest subiect prin lucrul la policlinicile de studiere a cefaleelor. Dupa intervievare, tipurile de dureri de cap au fost determinate dupa criteriul IHS in interviurile dintre neurologi si studenti. Diagnosticile altor boli erau bazate pe deciziile generalistilor din centrul primar al sanatatii.

Alte cauze ale durerii de cap, ca sinusitele si hipertensiunea au fost luate in consideratie si evaluate ca posibilitate a existentei cauzei migrenei. In 15 (1,31 %) dintre cazuri durerea de cap era gasita de a fi cauzata de aceste boli. Proportia prevalentei migrenei cu aura (MWA) si a migrenei fara aura (MWOA), tipul episodic si cel cronic CTT au fost depistate. Evaluarea relatiei dintre prevalenta tipurilor de cefalee si proprietatile pacientilor cu cefalee, cum ar fi varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala si comparatia caracteristicilor clinice dintre severitatea durerii de cap au fost evaluate folosind sirul Spearman al analizelor corelative.

Rezultatele

Proprietatile socio-demografice ale pacientilor CTT si pacientilor migrenosi: varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala sunt prezentate in Tabelul nr.1

Tebelul 1 Particularitatile socio-demografice a tuturor persoanelor intervievate si pacientilor cu cefalee

Persoane intervievate (n=1146) Varsta (ani) 15-24 25-34 35-44 45-64 >65 Nivelul educational <5 ani 5 ani 8 ani 312 526 99 289 311 253 228 65

Pacienti cu migrena (n=143)

Pacientii CTT (n=216)

23 (8.0%) 48 (15.4%) 41 (16.2%) 29 (12.7%) 2 (3.0%)

46 (15.9%) 55 (17,7%) 47 (18.5%) 59 (25.9%) 9 (13.8%)

33 (10.5%) 72 (13.7%) 6 (6.0%)

57 (18.2%) 96 (18.2%) 19 (19.2%)

11 ani >11 ani Statutul marital Casatorite Celibatare Divortate Statutul profesional Femei de casa Lucratoare Resedinta Urban Rural

126 83

11 (8,7%) 21 (25.8%)

22 (17.4%) 22 (26.5%)

853 178 115

118 (13.8%) 17 (9.5%) 8 (7.0%)

160 (18.7%) 28 (15.7%) 28 (24.3%)

975 171

116 (11.9%) 27 (15.8%)

180 (18.4%) 36 (21.0%)

636 510

97 (15.2%) 46 (9.0%)

123 (19.3%) 93 (18.2%)

Durerea de cap de tip migrenos si aspectele socio-demografice

1146 de femei au fost intervievate. 359 (31.1%) dintre ele au suportat migrena sau cefaleea de tip tensional pe parcursul ultimului an. Prevalenta migrenei timp de un an a fost de 12.5% (143 de pacienti), inclunzand 7,3 % (84) MWA si 5.2% (59) MWOA. Prevalenta migrenei a fost gasita ca fiind statistic mai inalta in grupul de persoane cuprinse intre 35-44 de ani si mai joasa in grupul de persoane cu varsta mai mare de 65 de ani, comparativ cu alte grupe ( 2: 16.38, P<0.01). O prevalenta mai mare a durerii de cap migrenoase a fost determinata la persoanele cu un nivel educational relativ mai inalt, universitar (2: 6.04, P<0.05) precum si la cei care au locuit in zonele urbane (2: 9.5, P<0.01). Totusi, in cazul statutului profesional si situatia economica nu au fost gasite tangente semnificative cu prezenta durerilor de cap de tip migrenos.

Cefaleea de tip tensional si aspectele socio-demografice

Prevalenta de un an al CCT a fost gasita de 18.8% (216 persoane) incluzand 144 (12.5%) tip episodic si 72 (6.3%) cu tip cronic al cefaleei. Prevalenta CTT a fost gasita mai inalta la grupul de varsta 45-64 de ani (2: 10.34, P<0.05). Cefaleea de tip tensional cronica a fost gasita semnificativ mai mare decat cea de tip episodic (media de varsta SD pentru tipul cronic si episodic al cefaceei de tip tensional: 41.11 15.57,

35.85, 12.91, P<0.01). Cu respectarea studiilor, tipul cronic al cefaleei a fost gasit cel mai prevalent (2: 6.83, P<0.05). La persoanele cu nivel cel mai scazut de studii.

Frecventa atacurilor de cefalee

Aproximativ 73.4% din pacientii cu migrena au 1-4 atacuri pe luna, pe cand restul trec prin >4 atacuri pe luna. 55 de pacienti migrenosi (38.5% din toti migrenosii; 21 MWA, 14 MWOA) au cel putin 180 de atacuri pe an. Luand in consideratie, ca la cefalee de tip tensional 31.9% de pacienti au 1-3 cefaleei pe luna si 68.1% din pacienti sufera de cefalee minim 1 data pe saptamana; 33.3% din pacienti au cel putin 180 de atacuri pe an, de cefalee de tip tensional.

Durata cefaleei

In acord cu criteriile Societatii Internationale ale Cefaleei, durata acceptata a atacului de migrena la pacientul netratat e de 4-72 ore. 22 de pacienti (15.4%) cu migrena au avut durata <4 ore, dar toti acesti pacienti au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu demonstreaza ca cea mai raspandita durata a atacurilor de migrena (71.3%) a fost intre 4-24 ore. In cefalee de tip tensional, atacurile s-au sfarsit in cadrul mai multor ore (51.9%, au continuat pe parcursul zilei 22.2%, au durat de la 13 zile (14.8%) si de la 3-7 zile la 11.1% din pacienti). Cefalee de tip tensional episodica difera de tipul cronic prin aceea ca atacurile de obicei au durata mai scurta, 15 min. - cateva ore (2: 10.52, P<0.05).

Caracteristica cefaleei

Pulsatia a fost observata la 88.8% din migrenosi si 62.0% din pacientii cu cefalee de tip tensional, pe cand pacientii aveau senzatii de presiune/inclestare.

Tabelul 2 Caracteristicile migrenei cu aura si fara aura

Unilateralitatea Caracterul pulsatil

Agravarea la efort fizic

Impactul asupra activitatilor zilnice % 78.6 76.2

% % MWA MWOA 54.8 49.2 83.3 96.6

% 78.6 89.8

Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

53.1% din pacientii cu migrena au avut cefalee unilaterala. Cefalee bilaterala a fost raportata la 72.7% din pacientii cu cefalee de tip tensional. La 82.5% din pacientii cu migrena si 43.3% din pacientii cu cefalee de tip tensional, cefaleea a fost agravata de activitati fizice de rutina. Caracteristicile tipurilor migrenei cu aura si fara aura au fost demonstrate in Tabelul 2. Compararea acestor caracteristici cu 2 test a demonstrat caracterul pulsativ, care a fost gasit mai frecvent in migrena cu aura. (2: 4.88, P<0.005). Caracteristicile cefaleei de tip tensional cronica si episodica au fost prezentate in Tabelul 3. N-au fost diferente statistice (2 test) intre cele doua tipuri de cefalei tensionale.

Tabelul 3 Caracteristicile cefaleei de tip tensional cronice si episodice

Bilateralitatea

Caracterul de presiune/inclestare

Agravarea la efort fizic

Impactul asupra activitatilor zilnice % 33.3

% Cronica 73.6

% 34.7

% 45.8

Episodica

70.1

39.6

45.1

38.2

Simptome insotitoare

Phonofobia 85.3% a fost cel mai frecvent simptom al migrenei insotit de greata (80.4%) si photofobia 177.6%. Voma a fost observata la 44.8% din pacientii cu migrena in MWA, cea mai comuna aura au fost dereglarile vizuale, incluzind scintilatia sau distorsia imaginii, hemianopsia si intunecarea vederii (81.8%), insotita de tinitus/vertije (67.1%), simptome senzoriale (34.3%) si afazie (15.4%). In cazurile de cefalee de tip tensional, phofobia a fost de asemenea cel mai des simptom insotitor. Greata a fost observata la 40.7% din pacienti, iar photofobia la 14.4% din pacienti. Simptomele insotioare ale migrenei cu si fara aura, au fost demonstrate in Tabelul 4, iar cele de cefalee de tip tensional episodice si cronice in Tabelul 5. In ceea ce priveste aceste constatari, n-a fost diferenta statistica intre migrena cu si fara aura. Totusi, cand comparatia similara a fost facuta intre subtipurile cefaleei de tip tensional, simptomele de greata (2: 6.48, P<0.001), voma (2: 5.12, P<0.05) si phonofobie (2: 4.48, P<0.005), au fost gasite ca cele mai frecvente in cefaleea cronica de tip tensional.

Tabelul 4 Simptomele insotitoare ale migrenei cu si fara aura

Greata % MWA MWOA 81.0 83.1

Voma % 47.6 40.7

Phofobia % 89.2 79.6

Photofobia % 82.1 71.2

Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

Factorii trigger (declansatori)

Cei mai frecventi factori declansatori ai atacurilor de cefalee au fost stresul (la migrena 81.8%; la cefalee de tip tensional 83.3%), privarea de somn (la migrena 37.1%, cefalee de tip tenional 39.4%), factorii hormonali

ca menstruatia (la migrena 35.6%, cefalee de tip tensional 24.5%), sarcina (la migrena 16.1%, cefalee de tip tensional 6.0%). Diverse alimente nu joaca vre-un rol semnificativ ca factor declansator la pacientii cu migrena (cascavalul 0%, ciocolata 1.4%). 32.2% a migrenei cu aura si 42.4% a migrenei fara aura au fost raportate ca cefalei provocate de menstruatie. Cand comparam aceste frecvente, ele au fost gasite din punct de vedere statistic neschimbate. 5 pacienti (3.5% migrenosi; 3 MWA, 2 MWOA) au fost raportati cu cefalee de tip migrenos, relatate doar la menstruatie, iata de ce ei sunt considerati pacienti cu migrena menstruala pura.

Impactul asupra activitatilor zilnice

Activitatile zilnice de rutina au fost afectate in 76.6% de migrena 37.5% din pacientii cu cefalee de tip tensional, din cauza severitatii cefaleei. In ceea ce priveste acest factor, o diferenta nesemnificativa a fost gasita intre migrena cu si fara aura sau intre cefalee de tip tensional cronica si episodica. La pacientii cu cefalee de tip tensional comparand prezenta impactului asupra activitatilor zilnice cu caracteristicile cefaleei si simptomele insotitoare a fost gasita legatura intre impactul asupra activitatilor si agravarea lor la efort fizic (Spearman p:0.27, P=0.001). Cand o comparatie asemanatoare a fost efectuata la pacientii cu cefalee de tip migrenos n-a fost gasita vre-o relatie. In cazul altor pacienti cu cefalee, caracterul pulsatil (P<0.005), agravarea la eforturi fizice (P<0.01), simptomele insotitoare de greata (P<0.001), voma (P<0.05), si photofobia (P<0.05) au fost gasite pentru a relata impactul cefaleei asupra activitatilor zilnice in analizele gradului de corelatie al lui Spearman.

Tabelul 5 Simptomele insotitoare ale cefaleei de tip tensional cronice si episodice

Greata % Cronica Episodica 52.8 34.7

Voma % 13.0 10.0

Phofobia % 61.1 45.8

Photofobia % 19.4 12.5

Somnul si cefaleea In studiul nostru lipsa somnului a fost raportata la 23% de migrenosi si 20.8% de pacienti de tip tensional.

Relatiile pacient medic 75.5% din pacientii cu migrena si 56.7% din cei cu cefalee de tip tensional au fost consultati de medicul generalist in privinta durerii lor de cap. 51% din migrenosi stiu despre migrena lor.

Masuri de tratament Partea utilizarii medicamentelor la pacientii migrenosi a fost identificata pana la 90.9%, in timp ce la pacientii cu cefalee de tip tensional 63.4%. O alta masura importanta este aflarea in singuratate intr-o odaie si somnul (la migrena 86.0%, CTT 66.7%), masajul (migrena 38.5%, CTT 31.0%), compresele reci sau fierbinti (migrena 10.5%, CTT 6.0%).

Istoricul familial 43.4% din migrenosi aveau un istoric familial cu cefalei similare (48.8% migrena cu aura, 35.6% migrena fara aura), in timp ce istoricul pozitiv familial a fost raportat la 32.9% din pacientii cu CTT. Reisend din acestea, nu a fost gasita o diferenta semnificativa intre tipurile de cefalee.

Discutii Acesta este studiul epidemiologic al populatiei bazat pe femeile cu cefalee din Turcia. Noi am incercat sa evaluam caracteristicile socio-demografice si clinice ale cefaleelor de tip tensional si cele de tip migrenos. In cele ce urmeaza noi am clasificat cefaleele de tip tensional si cele de tip migrenos in episodice si cronice, iar la migrena cu aura si fara aura. Caracteristicile clinice ale simptomelor insotitoare au fost evaluate la toate subtipurile cefaleelor si comparate intre ele. Atitudinea pacientilor fata de cefalee a fost investigata si ea. Indicii de corespundere criteriului IHS in toate tipurile si subtipurile au fost considerate si comparate. Orice necorespundere semnificativa intre subtipuri a fost evaluata. Relatia dintre caracteristicile durerilor de cap si simptomele insotitoare, si impactul asupra activitatilor zilnice au fost special studiate in tipurile cefaleelor si pacientii cu dureri de cap. Ca rezultat, luand in consideratie toti pacientii cu cefalee, am identificat relatii statistice semnificative intre unele caracteristici si simptomele insotitoare cu severitatea durerii de cap. Aceste caracteristici si simptome insotitoare au fost tipic asociate cu cefaleea migrenoasa; pulsatii, agravarea starii fizice, greturi, vome, phonofobia. La cefalee de tip tensional, severitatea a fost asociata cu agravarea starii fizice. Constatarea aceasta era in conformitate cu lucrarea lui Lavados si a lui Tenhamm (4), in care ei indicau ca agravarea cefaleei cu migrarea durerii la cefalee nu sunt discriminatori specifici ai sindromurilor de cefalee, ci posibil ca erau mai mult legate de severitatea durerii. Nici o legatura de acest fel nu a fost gasita la tipul cefaleelor migrenoase.

Migrena este de obicei unilaterala, pulsatila, de la moderat pana la sever ca intensitate, si deseori asociata cu greturi, photofobie si phonofobie. Intr-un studiu realizat anterior asupra pacientilor cu migrena fara aura intr-un spital universitar din Turcia (5), 58% sufereau de dureri pulsatile, 74% aveau dureri de cap unilaterale. Agravarea prin activitati fizice de rutina a fost gasita in proportie de 96% in cadrul studiului mentionat. Rezultatele noastre (pulsatia 96.6%, dureri unilaterale 49.2% la pacienti cu MWOA) se deosebesc de acest studiu, posibil datorita diferentei de studiu a populatiei. Caracteristicile clinice a migrenei au fost gasite relativ similare cu cele din tarile vestice (6,7). Cel mai mic coeficient de cazuri unde se intalneste asa simptom ca voma, intalnit in Korea si Ungaria, nu a fost confirmat de cercetarile noastre (8,9). Am depistat un coeficient semnificativ mai mare al pulsatiei in MWOA comparativ cu MWA. Acest fapt nu a fost confirmat nicaieri in alta parte. Russell et al.(10) au declarat ca ei s-au retinut sa faca o analiza statistica comparativa intre MWOA si MWA din motivul ca exista o diferenta in criteriul de includere. Insa noi credem ca manifestarea pulsatiei la MWA se datoreaza patofiziologiei. Depresia corticala raspandita si schimbarile fluxului sanguin celebral sunt responsabile de aura migrenei. Aceste procese pot cauza dureri din ambele parti a capului prin conexiuni centrale (11). Aria rostrala a creierului are un rol central si determinant in migrena (12). Este de-a dreptul plauzibil de considerat daca proiectiile de la aceste zone centrale a creierului spre cortex participa la initierea aurei si schimbarile vasculare a migrenei (11), precum si daca ele cauzeaza o astfel de diferenta a durerii la alte subtipuri ale migrenei. Cefaleea de tip tensional este caracterizata de o prezenta bilaterala, presiune/inclestare, domoala sau moderata ca intensitate, si de obicei, nu este agravata de activitatile fizice de rutina (13). Coeficientul indicat de noi privind cefaleele insotite de presiune/inclestare (38%) a fost determinat ca fiind mai mic comparativ cu cele indicate in lucrarile anterioare (52%-73.8%) (4,8). Un coeficient inalt al caracterului unilateral a fost indicat (28.7%) pentru acest tip de cefalee. Prezenta unui inalt coeficient al exacerbarii activitatilor fizice (45.4%), fapt prezentat in cateva studii recente (7, 14-16). In studiul nostru, photofobia a fost anuntata in 14.8% de cazuri la pacienti cu CTT. Aceasta descoperire este in corespundere cu alte studii (17, 18). N-am depistat un coeficient inalt al photofobiei (82%) indicat de Vanagait si Stovner (19). In evaluarea criteriului de diagnosticare IHS, unii autori cum sunt Messinger et al. (20) au sugerat evaluarea separata a criteriului in loc de cea traditionala, a tuturor criteriilor laolalta. Ei au raportat ca suprapunerea diagnosticilor in cazul migrenei si cefaleei de tip tensional ar putea fi diminuata daca simptomele cefaleei, cum sunt intensitatea, durata, calitatea, agravarea prin activitati fizice, nu ar fi folosite impreuna pentru a construi un criteriu comun, ci fiecare simptom ar fi tratat ca un criteriu separat (21). Unii autori au propus ca intensitatea durerii sa fie cel mai important dintre cele patru caracteristici ale durerii la migrena fara aura. Astfel, aceasta poate ajuta in diferentierea migrenei fara aura si CTT (18, 21). In acest studiu, noi am gasit o relatie dintre severitatea intensitatii durerii si cateva alte caracteristici migrenoase, facand o analiza a situatiei tuturor pacientilor. Insa, n-am fi putut constata nici o relatie intre pacientii cu cefalee migrenoasa si CTT, considerate aparte una de alta. Aceasta constatare a relevat ca atunci cand durerea devine mai severa, ea capata caracteristici migrenoase, cum ar fi pulsatia, agravarea starii fizice, greturi, vome si phonofobia. Totusi, caracterul unilateral si photofobia nu au fost determinate ca fiind datorate intensitatii durerii.

Comparand CTT cronic si episodic, greturile, vomele si phonofobia au fost gasite ca mai des intalnite in cazul CTT cronice. Aceasta descoperire este considerata in corespundere cu criteriul IHS, conform caruia simptomele apar mai ales la CTT cronice. Prevalenta migrenei studiata timp de un an corespunde rezultatelor altor studii (22). Insa noi am depistat mai multi pacienti MWA decat MWOA, faptul care este surprinzator de contradictoriu fata de rezultatele altor studii (2, 10, 21, 23). Prezenta aurei face ca MWA sa fie mai usor depistata. Exista si o problema diferentiala mai cu seama intre cefaleea de tip tensional episodica si migrena fara aura (24, 25). De asemenea, uneori aceste doua tipuri de cefalee pot coexista la unul si acelasi pacient (26, 27). In asa caz, in studiul efectuat de noi, pacientii s-ar fi putut plange doar de cefaleea de tip tensional, care probabil este mai frecventa si retinuta ca cea mai deranjanta, ca raspuns la intrebarea: Aveti dureri de cap pronuntate, care deranjeaza?. Prevalenta CTT de un an a fost similara celor prezentate in alte studii (8, 28). Prevalenta cefaleei de tip tensional cronice a fost depistata in 2-3% de cazuri conform studiilor precedente (6, 28). Coeficientul de prevalenta CTT cronica prezentata de noi, a fost mai inalt (6.3%) comparativ cu cele, similare studiului efectuat mai devreme in Turcia (2). In studiul nostru, prevalenta migrenei a fost mai inalta la grupul de varsta 35-44 de ani si respectiv mai joasa la grupul de varsta mai mare de 65 de ani. Acest fapt corespunde rezultatelor multor studii (14, 29-34). Rata mai mare a migrenei la femeile de varsta reproductiva, comparativ cu femeile de alte varste a fost legata de prezenta oestrogenului (35). Inainte se sugera ideea ca migrena este asociata cu inteligenta sporita si clasa sociala (9). Mai tarziu, in unele studii, a fost regasita tot mai des la pacientii cu un nivel mai jos de educatie si o situatie economica mai slaba (1, 6, 10, 36-39). Am depistat o rata mai mare a prevalentei migrenei la pacienti cu studii si casatoriti. Totusi, statutul profesional si nivelul economic nu au fost gasite sa aiba legatura cu rata prevalentei migrenei. In studiul efectuat de noi, prevalenta a fost gasita a fi mai mare in zonele urbane, opus rezultatelor prezentate de Martin et al. (40). In majoritatea studiilor, aria rezidentiala nu a fost corelata cu prevalenta. In literatura de specialitate, multe studii prezinta teoria ca prevalenta CTT este cea mai mare intre 30 si 39 de ani si apoi scade cu inaintarea in varsta (7, 28, 41). In cercetarile noastre, prevalenta CTT a fost determinata a fi mai mare la grupul de varsta 45-64 de ani. Aceasta descoperire poate fi atribuita unur stresuri sociale in viata familiala a grupului de varsta respectiv. Nu am putut identifica nici o legatura intre alte proprietati socio-demografice si prevalenta CTT, in conformitate cu alte studii (42). Am observat ca tipul de CTT cronic se intalneste la cei varstnici si cu mai putine studii, ceea ce coincide cu descoperirea facuta de Schwartz et al. (28). In literatura, aproape jumatate din persoane care sufera de migrena si mai mult de 80% de persoane cu CTT au recunoscut ca nu au contactat un medic generalist pentru cefalee (22). In cazul femeilor si pacientilor suferinzi de migrena, procentul de prezentare la consultatii au fost declarate a fi mai mare (43). Procentul de prezentare la consultatii la medicii generalisti a fost mai mare decat cel indicat in studiile precedente, fapt datorat posibil studiului nostru care se efectueaza la femei.

Am avut cateva limitari in studiul nostru. Rasmussen et al.(29) a indicat ca modul in care sunt puse intrebarile despre cefalee, cum ar fi Suferiti de dureri de cap? sau Ati avut vre-odata dureri de cap? ar putea influenta rezultatele studiilor epidemiologice. Presupunem ca utilizarea cuvintelor a suferi de a fost indicata sa aiba o prevalenta mai mica decat utilizarea verbului aveti. Aceeasi idee este aplicata, in studiul nostru, si intrebarii Aveti dureri de cap pronuntate, care deranjeaza?. Am pus intrebari detaliate despre caracterul celor mai suparatoare dureri de cap subiectilor. Aceasta exprimare ar putea fi confundata de unii pacienti, care sufera de mai multe tipuri de dureri de cap si ar putea influenta prevalentele. Aceasta insa este o problema generala in incercarile de a face o clasificare a pacientilor in grupuri, conform tipurilor de cefalee. Intervievarile sunt o metoda preferata in cercetarile masive (44). In acest studiu, studentii la medicina, antrenati de neurologi, au efectuat intervievari, iar deciziile finale asupra cazurilor intalnite au fost luate atat de neurologi cat si de studenti. Totusi, ar fi fost mai bine daca cei care intervievau pacientii sa fi fost neurologi specializati in obiectul cefaleelor. Studiul a fost efectuat in exclusivitate la femei, deoarece stabilirea unui contact cu ele a fost mai usoar decat in cazul barbatilor si pentru ca ele pot fi mai usor gasite acasa. De altfel, femeile sunt o categorie speciala si importanta in studierea cefaleelor.

Concluzie Aceste cercetari, bazate pe cercetari masive, a avut ca obiect de studiu caracteristicile clinice si factorii socio-demografici in manifestarea migrenei, CTT si a subtipurilor lor. Credem ca aceste cercetari sunt de asemenea interesante, deoarece discutarea simptomelor clinice si relatia lor cu severitatea durerii este actuala.

Tension-type, the forgotten headache How to recognize this common but undertreated condition Loretta Mueller, DO VOL 111 / NO 4 / APRIL 2002 / POSTGRADUATE MEDICINE Up to 88% of women and 69% of men experience tension-type headache during their lifetime (1). The word "tension" implies that this type of headache can be attributed entirely to tension or stress, which may make people with this type of headache reluctant to consult a physician. Physician misperceptions that tension-type headaches are mild, benign, self-treatable conditions due solely to stress may further trivialize the problem. Epidemiologic factors Nearly 80% of the population will experience a tension-type headache at some time. An estimated 1-year prevalence of 86% in women and 63% in men means that it is more probable to have experienced a tension-type headache than not (1). Headache is one of the 10 chief complaints of patients seen in primary care practices, and 47% of headaches are tension-type (3). During childhood there is no male or female predominance for tensiontype headache, but during adulthood it is more commonly experienced by women (female-male ratio, 5:4) (4). First onset of tension-type headache is before age 20 in 40% of affected persons, between ages 20 and 40 in 40%, and between ages 40 and 50 in 18% (3). Three percent of the general population (5% of women and 2% of men) experience chronic tension-type headache, defined as more than 180 headache days per year (1). Prevalence of chronic tension-type headache increases with age; the inverse is true for episodic tension-type headache.

Societal impact Because of its high prevalence and wide spectrum of disability, tension-type headache has greater socioeconomic impact than any other headache type. About 820 annual workdays for every 1,000 persons are lost on account of tension-type headache (versus 270 days on account of migraine) (5). The reduced productivity of those who remain at work despite headache has an even greater impact. Overall, tension-type headaches have a negative effect on the emotional life of affected persons, resulting in marked reductions in quality of life and frequency of social and family activities. Despite this, less than 15% of people with tension-type headache seek medical attention (3). Proposed reasons for this disparity are lack of respect, empathy, and understanding by physicians; fear of not being taken seriously; trivialization of the disorder by media advertising and jokes; and the widespread misperception that the headaches have a purely psychological basis. Physical examination is rarely helpful in diagnosis but should focus on detailed funduscopic and neurologic evaluations. Diagnostic studies are not required unless the history or physical examination reveals features that suggest an organic cause: atypical headache features not meeting IHS criteria, sudden onset of or change in headache, late first onset of headache (after age 50), or abnormal physical examination findings. Generally, a severe headache of sudden onset is best evaluated by computed tomography of the head without contrast and, possibly, lumbar puncture to rule out subarachnoid hemorrhage. Magnetic resonance imaging (MRI) of the brain is preferred for evaluating chronic progressive headaches because it has higher sensitivity for tumors, aneurysms, and posterior fossa lesions. Interestingly, nonspecific white matter abnormalities are an incidental finding on MRI scans in many patients with tension-type headache as well as in patients with migraine (32% and 34%, respectively, versus 7.4% in controls) (6). Laboratory studies may be indicated to identify suspected secondary causes of headache (eg, temporal arteritis, anemia, thyroid or metabolic abnormalities, Lyme disease) or to monitor for toxic effects from headache medication. Electrocardiography may be performed before prescribing of drugs that potentially alter conduction times (ie, tricyclic antidepressants) or cause vasoconstriction. Standardized psychometric testing may identify comorbid psychiatric disorders, but these abnormalities may be the result of chronic headache pain. Precipitating factors Tension-type headache triggers are not always identifiable or consistent, and multiple triggers may have the additive effect of lowering the threshold of headache activation. In the past, studies have demonstrated few tension-type headache triggers other than emotional stress; more recent studies have found similar headache precipitants for both tension-type headache and migraine (table 3). Table 3. Potential triggers of tension-type headache Stress (eg, everyday hassles, family crises, heavy workloads, unpleasant work or social situations) Change in sleep regimen (eg, shift work, oversleeping) Skipping meals Certain foods (eg, caffeine, alcohol, cheese, chocolate) Physical exertion Environmental factors (eg, sun glare, odors, smoke, ambient noise, fluorescent lighting, sustained postures at video terminals or while driving) Female hormonal changes (eg, menses, menopause, pregnancy, exogenous hormone use) Medications used for concomitant medical conditions (eg, nitrates, selective serotonin reuptake inhibitors, antihypertensives) Overuse of headache medication (eg, analgesic and caffeine combinations, butalbital compounds, opiates, ergot) Information from Rasmussen (7).

Various medical conditions may exacerbate tension-type headache but rarely are an underlying cause. Tension-type headaches may be aggravated by barosinusitis from allergic or structural turbinate congestion or by functional disturbances of the masticatory muscles around the temporomandibular joint from clenching, bruxism, or malocclusion. Head trauma--even a mild whiplash injury not associated with a blow to the head or loss of consciousness--may initiate or exacerbate tension-type headache, possibly on a chronic basis. That patients with first onset of tension-type headache after trauma have a genetic predisposition for the disorder is suspected but unproven (8).

Stress is undoubtedly the most common precipitant, triggering up to 80% of tension-type headaches. Emotions have biochemical effects in the body, and mental stress alone can elicit muscle contraction through the limbic system. Studies have demonstrated that, compared with control groups, patients with tension-type headache have similar major stressful life events but perceive more events as "hassles" and have less effective coping strategies (eg, avoidance, self-criticism, lack of use of social supports) (9). The increased prevalence of comorbid anxiety, depression, and somatoform disorders among people with tension-type headache is still debated. It is uncertain whether these disorders can initiate, contribute to, or maintain tension-type headaches; whether they are the result of a chronic pain condition; or whether they are due to a genetic susceptibility and serotonin abnormalities. Treatment Few people with tension-type headache consult a physician for treatment; a recent study (15) found that 60% of those reporting severe headaches used only over-the-counter medications. Many get adequate relief with overthe-counter abortive medications, but others experience a marked reduction in function and quality of life. Daily or nearly daily use of over-the-counter analgesics at recommended or higher-than-recommended dosages can lead to gastrointestinal toxicity, renal toxicity, and hepatotoxicity; analgesic nephropathy is the leading cause of drug-induced renal failure. Inappropriately frequent use (>2 days a week) of over-the-counter or prescription abortive medications--especially simple analgesics containing caffeine, caffeinated beverages, butalbital combination products, narcotics, or ergotamines--may cause or maintain a chronic daily headache pattern called analgesic rebound (16). In analgesic rebound, headache frequency and severity typically increase, and patients require regular dosing of the offending medication to avoid becoming incapacitated by headache. Conclusion Recent advances in the treatment and understanding of migraine have overshadowed concerns about tension-type headache, the most prevalent headache disorder. Because of its high prevalence and wide spectrum of disability, tensiontype headache is the most important headache type in regard to reduction in work productivity, quality of life, and socioeconomic impact. Future research endeavors will address the pathophysiology of tension-type headache, whether peripheral, central, psychological, or multifactorial. Well-controlled clinical trials are needed to clarify the best treatment approaches and determine whether standard migraine medications may be used for tension-type headache. Patient education and more aggressive treatment regimens would likely increase use of the healthcare system and decrease the large indirect economic cost attributable to this often inadequately treated disorder.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. Rasmussen BK, Jensen R, Schroll M, et al. Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol 1991;44(11):1147-57 Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(Suppl 7):29-34 A study of headache in North American primary care: report from the Ambulatory Sentinel Practice Network. J R Coll Gen Pract 1987;37(302):400-3 Friedman AP, de Sola Pool N, von Storch TJ. Tension headache. JAMA 1953;151:174-7 Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J Epidemiol Community Health 1992;46(4):443-6 De Benedittis G, Lorenzetti A, Sina C, et al. Magnetic resonance imaging in migraine and tension-type headache. Headache 1995;35(5):264-8 Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993;53(1):65-72 Yamaguchi M. Incidence of headache and severity of head injury. Headache 1992;32(9):427-31 Glass DE. Tension headache and some psychiatric aspects of headache. Headache Q 1992;3(3):262-9

10. Jensen R. Pathophysiological mechanisms of tension-type headache. Cephalalgia 1999;19(6):602-21 11. Olesen J, Jensen R. Getting away from simple muscle contraction as a mechanism of tension-type headache. (Editorial) Pain 1991;46(2):123-4 12. Castillo J, Martinez F, Leira R, et al. Plasma monoamines in tension-type headache. Headache 1994;34(9):531-5 13. Olesen J. Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain 1991;46(2):125-32 14. Russell MB, Iselius L, Ostergaard S, et al. Inheritance of chronic tension-type headache investigated by complex segregation analyses. Hum Genet 1998;102(2):138-40 15. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001;41(7):638-45

16. Diener HC, Dichgans J, Scholz E, et al. Analgesic-induced chronic daily headache: long-term results of withdrawal therapy. J Neurol 1989;236(1):9-14 17. Friedman AP, DiSerio FJ. Symptomatic treatment of chronically recurring tension headache. Clin Ther 1987;10(1):69-81 18. Cady RK, Gutterman D, Saiers JA, et al. Responsiveness of non-IHS migraine and tension-type headache to sumatriptan. Cephalalgia 1997;17(5):588-90 19. Diamond ML, Solomon GD. Tension-type headache. In: Diamond ML, Solomon GD, eds. Diamond and Dalessio's the practicing physician's approach to headache. 6th ed. Philadelphia: WB Saunders, 1999:125-36 20. Lance JW, Anthony M. Cyclobenzaprine in the treatment of chronic tension headache. Med J Aust 1972;2:1409-11 21. Wheeler AH. Botulism Toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension. Headache 1998;38(6):468-71

Tension-type, the forgotten headache

How to recognize this common but undertreated condition
Loretta Mueller, DO
VOL 111 / NO 4 / APRIL 2002 / POSTGRADUATE MEDICINE

CME learning objectives To review accurate diagnosis of tension-type headache To better understand the pathophysiology, precipitating factors, and societal impact of tension-type headache

Dr Mueller has served as a clinical investigator, consultant, or speaker for Abbott Laboratories, AstraZeneca, BristolMyers Squibb, Carnrick Laboratories, Glaxo Wellcome, Innovex Marketing, Merck & Co, Novartis Pharmaceuticals, Pfizer, Pozen Inc, and Proctor & Gamble. She received a grant from Innovex Marketing for research on tension-type headache.

This page is best viewed with a browser that supports tables. Preview: Tension-type headache is the most prevalent headache type, affecting most women and men at some time in their lives, and can impair job productivity and interfere with family and social time. However, despite its impact, tension-type headache is also the most misunderstood headache type. Because of these misperceptions, many affected people are reluctant to seek medical treatment. In this article, Dr Mueller discusses possible triggers of tension-type headache, appropriate evaluation, and management with pharmacologic, nonpharmacologic, and alternative therapies. Mueller L. Tension-type, the forgotten headache: how to recognize this common but undertreated condition. Postgrad Med 2002;111(4):25-50

Up to 88% of women and 69% of men experience tension-type headache during their lifetime (1).
The word "tension" implies that this type of headache can be attributed entirely to tension or stress, which may make people with this type of headache reluctant to consult a physician. Physician misperceptions that tension-type headaches are mild, benign, self-treatable conditions due solely to stress may further trivialize the problem. "Tension-type" is a headache classification developed in 1988 by the International Headache Society (IHS) (table 1). It refers to a condition characterized by bilateral mild to moderate pain and pressure that often is described as similar to that of having "a

vise around the head." Some patients with tension-type headache may experience severe pain and marked disability. Table 1. International Headache Society diagnostic criteria for tension-type headache Primary diagnosis 1. Headache has at least two of the following characteristics: Bilateral pain Pressure Mild to moderate pain No increased pain with physical exertion 2. And no more than one of the following: Sensitivity to light Sensitivity to sound 3. And neither of the following*: Nausea Vomiting 4. And duration of 30 minutes to 7 days Subdivision diagnosis 1. Episodic (<15 days/mo) or chronic (>15 days/mo for >6 mo) 2. Associated with or not associated with coexisting pericranial muscle tenderness** *Chronic tension-type headache may include one of these symptoms. **Diagnosed by manual palpation or electromyographic studies. Adapted from Headache Classification Committee of the International Headache Society (2).

Tension-type headache usually is not associated with migrainelike symptoms, such as nausea, vomiting, increased pain with physical exertion, photophobia, and phonophobia. Stress may be one of many precipitating factors, but the underlying cause is unknown. Research advances into this nonvascular headache have not kept pace with exciting new migraine discoveries. A central mechanism that is not unlike the mechanism of the serotonin abnormalities of migraine is one likely cause of tension-type headache, with muscular tenderness being either a contributing factor or an epiphenomenon. Physician and patient education directed at addressing the reduced quality of life and work productivity due to tension-type headache may stimulate further research and increase healthcare use by the 85% of people with tension-type headache who do not seek treatment (3).

Epidemiologic factors
Nearly 80% of the population will experience a tension-type headache at some time. An estimated 1-year prevalence of 86% in women and 63% in men means that it is more probable to have experienced a tension-type headache than not (1). Headache is one of the 10 chief complaints of patients seen in primary care practices, and 47% of headaches are tension-type (3). During childhood there is no male or female predominance for tension-type headache, but during adulthood it is more commonly experienced by women (female-male ratio, 5:4) (4). First onset of tension-type headache is before age 20 in 40% of affected persons, between ages 20 and 40 in 40%, and between ages 40 and 50 in 18% (3). Three percent of the general population (5% of women and 2% of men)

experience chronic tension-type headache, defined as more than 180 headache days per year (1). Prevalence of chronic tension-type headache increases with age; the inverse is true for episodic tension-type headache.

Societal impact
Because of its high prevalence and wide spectrum of disability, tension-type headache has greater socioeconomic impact than any other headache type. About 820 annual workdays for every 1,000 persons are lost on account of tension-type headache (versus 270 days on account of migraine) (5). The reduced productivity of those who remain at work despite headache has an even greater impact. Overall, tension-type headaches have a negative effect on the emotional life of affected persons, resulting in marked reductions in quality of life and frequency of social and family activities. Despite this, less than 15% of people with tension-type headache seek medical attention (3). Proposed reasons for this disparity are lack of respect, empathy, and understanding by physicians; fear of not being taken seriously; trivialization of the disorder by media advertising and jokes; and the widespread misperception that the headaches have a purely psychological basis.

Diagnosis
There are no objective diagnostic markers for tension-type headache. An accurate diagnosis relies on comprehensive history taking, which is helpful in eliminating secondary, potentially lifethreatening diagnoses (table 2). The principal feature of tension-type headache is mild to moderate pressure-type pain, usually on both sides of the head, often described as occurring in the frontal or occipital areas or as a band around the head. Associated symptoms may include fatigue, irritability, and difficulty concentrating, but migrainelike symptoms usually are absent. Tension-type headaches typically last 30 minutes to 1 week, but some people experience them daily. Table 2. Differential diagnostic considerations in tension-type headache Primary diagnosis Nonvascular: Tension-type Vascular: Migraine or cluster Secondary (organic) diagnosis Vascular disorders Subarachnoid hemorrhage Subdural hematoma Unruptured arteriovenous malformation or aneurysm Ischemic cerebrovascular disease Temporal arteritis Arterial hypertension Cerebral venous thrombosis Nonvascular intracranial disorders Benign intracranial hypertension Intracranial hypotension after lumbar puncture Intracranial neoplasm Intracranial infection or meningitis Substances that act as triggers Medications (eg, nitrates, over-the-counter drugs) Foods (eg, monosodium glutamate, alcohol) Exposures (eg, carbon monoxide)

Rebound (eg, caffeine, analgesic, ergot) Metabolic disorders Hypoxia (eg, chronic obstructive pulmonary disease, sleep apnea) Hypercapnia Hypoglycemia Abnormalities of extracranial structures Eyes (eg, glaucoma, refractive errors) Ears and sinuses (eg, infectious sinusitis, barosinusitis) Teeth and jaws (eg, temporomandibular joint disorder) Skull (eg, Paget's disease, multiple myeloma) Neck (eg, spondylosis, cervical disk disease)

The IHS criteria further classify tension-type headaches into an episodic form (occurring on fewer than 15 days a month) and a chronic form (occurring on 15 or more days a month for more than 6 months) based on headache frequency and the presence or absence of a coexisting disorder of pericranial muscles (identified as tenderness to manual palpation or increased surface amplitude tracings on electromyography). Pericranial muscle abnormalities are not associated with any distinguishing clinical characteristics or specific treatments. Physical examination is rarely helpful in diagnosis but should focus on detailed funduscopic and neurologic evaluations. Diagnostic studies are not required unless the history or physical examination reveals features that suggest an organic cause: atypical headache features not meeting IHS criteria, sudden onset of or change in headache, late first onset of headache (after age 50), or abnormal physical examination findings. Generally, a severe headache of sudden onset is best evaluated by computed tomography of the head without contrast and, possibly, lumbar puncture to rule out subarachnoid hemorrhage. Magnetic resonance imaging (MRI) of the brain is preferred for evaluating chronic progressive headaches because it has higher sensitivity for tumors, aneurysms, and posterior fossa lesions. Interestingly, nonspecific white matter abnormalities are an incidental finding on MRI scans in many patients with tension-type headache as well as in patients with migraine (32% and 34%, respectively, versus 7.4% in controls) (6). Laboratory studies may be indicated to identify suspected secondary causes of headache (eg, temporal arteritis, anemia, thyroid or metabolic abnormalities, Lyme disease) or to monitor for toxic effects from headache medication. Electrocardiography may be performed before prescribing of drugs that potentially alter conduction times (ie, tricyclic antidepressants) or cause vasoconstriction. Standardized psychometric testing may identify comorbid psychiatric disorders, but these abnormalities may be the result of chronic headache pain.

Precipitating factors
Tension-type headache triggers are not always identifiable or consistent, and multiple triggers may have the additive effect of lowering the threshold of headache activation. In the past, studies have demonstrated few tension-type headache triggers other than emotional stress; more recent studies have found similar headache precipitants for both tension-type headache and migraine (table 3). Table 3. Potential triggers of tension-type headache Stress (eg, everyday hassles, family crises, heavy workloads, unpleasant work or social situations)

Change in sleep regimen (eg, shift work, oversleeping) Skipping meals Certain foods (eg, caffeine, alcohol, cheese, chocolate) Physical exertion Environmental factors (eg, sun glare, odors, smoke, ambient noise, fluorescent lighting, sustained postures at video terminals or while driving) Female hormonal changes (eg, menses, menopause, pregnancy, exogenous hormone use) Medications used for concomitant medical conditions (eg, nitrates, selective serotonin reuptake inhibitors, antihypertensives) Overuse of headache medication (eg, analgesic and caffeine combinations, butalbital compounds, opiates, ergot) Information from Rasmussen (7).

Various medical conditions may exacerbate tension-type headache but rarely are an underlying cause. Tension-type headaches may be aggravated by barosinusitis from allergic or structural turbinate congestion or by functional disturbances of the masticatory muscles around the temporomandibular joint from clenching, bruxism, or malocclusion. Head trauma--even a mild whiplash injury not associated with a blow to the head or loss of consciousness--may initiate or exacerbate tension-type headache, possibly on a chronic basis. That patients with first onset of tension-type headache after trauma have a genetic predisposition for the disorder is suspected but unproven (8). Stress is undoubtedly the most common precipitant, triggering up to 80% of tension-type headaches. Emotions have biochemical effects in the body, and mental stress alone can elicit muscle contraction through the limbic system. Studies have demonstrated that, compared with control groups, patients with tension-type headache have similar major stressful life events but perceive more events as "hassles" and have less effective coping strategies (eg, avoidance, self-criticism, lack of use of social supports) (9). The increased prevalence of comorbid anxiety, depression, and somatoform disorders among people with tension-type headache is still debated. It is uncertain whether these disorders can initiate, contribute to, or maintain tension-type headaches; whether they are the result of a chronic pain condition; or whether they are due to a genetic susceptibility and serotonin abnormalities.

Pathophysiologic mechanisms
The cause of tension-type headache is unknown, but most research has focused on a peripheral mechanism pertaining to pericranial muscle tenderness, thus explaining the previous term "muscle contraction headache." Researchers who have attempted to find correlations between subjective complaints of pericranial muscle tension and electromyographic changes during a headache have had conflicting results. In fact, electromyographic readings indicating tenderness are usually greater in patients with migraine than in patients with tension-type headache during a headache (10). Sustained muscle contraction from physical or emotional causes may compress intramuscular arterioles, causing ischemia, accumulation of noxious metabolites, or both, which results in localized tenderness (9). Another hypothesis, favored by physicians who believe migraine and tension-type headache are part of a continuum of the same underlying disorder, is that tension-type headache has a purely central

mechanism and that muscle tension is an epiphenomenon (11). Studies that suggest a shared disorder with migraine have found reductions in platelet or serum serotonin, epinephrine, norepinephrine, and dopamine levels; these findings appear to support the idea that an alteration in serotoninergic and monoaminergic central systems results in depressed pain suppression and activated pain pathways in tension-type headache (12). Chronic tension-type headache also may be associated with central opioid hypofunction with decreased cerebrospinal fluid beta-endorphin levels. The cause of tension-type headache is most likely multifactorial and best described by Olesen's vascular-myogenic-supraspinal model (13). It is the convergence of multiple pain pathways-vascular, myogenic, supraspinal, or all of these--that enter the caudate nucleus of the trigeminovascular system and, in combination with other precipitating factors in a predisposed person, determine whether the headache activation threshold is met (10). A genetic predisposition has been suggested by studies that found a threefold increased incidence of chronic tension-type headache in families (14).

Treatment
Few people with tension-type headache consult a physician for treatment; a recent study (15) found that 60% of those reporting severe headaches used only over-the-counter medications. Many get adequate relief with over-the-counter abortive medications, but others experience a marked reduction in function and quality of life. Daily or nearly daily use of over-the-counter analgesics at recommended or higher-than-recommended dosages can lead to gastrointestinal toxicity, renal toxicity, and hepatotoxicity; analgesic nephropathy is the leading cause of drug-induced renal failure. Inappropriately frequent use (>2 days a week) of over-the-counter or prescription abortive medications--especially simple analgesics containing caffeine, caffeinated beverages, butalbital combination products, narcotics, or ergotamines--may cause or maintain a chronic daily headache pattern called analgesic rebound (16). In analgesic rebound, headache frequency and severity typically increase, and patients require regular dosing of the offending medication to avoid becoming incapacitated by headache. A comprehensive therapeutic approach, incorporating both nonpharmacologic and pharmacologic means, is successful for over 90% of patients with tension-type headache. Nonpharmacologic approaches include regulation of sleep and meal schedules, avoidance of headache precipitants, and training in relaxation techniques (table 4). Many patients seek alternative therapies; however, vitamins (eg, riboflavin), minerals (eg, magnesium, calcium), and herbal therapies (eg, feverfew), which have been found to benefit people with migraine, have not been adequately studied in patients with tension-type headache. Most headache therapies have a 40% placebo response, which usually is dependent on the patient's faith in both the treatment and the physician prescribing it. Table 4. Nonpharmacologic approaches to treatment of tension-type headache Regulation of lifestyle Maintain regular sleep schedule Eat regular meals Avoid known dietary triggers Get regular aerobic exercise Minimization of emotional stressors Plan ahead and avoid stressful situations Learn biofeedback Meditate

Increase undemanding leisure activities, hobbies, social events Learn other relaxation techniques (eg, progressive muscle relaxation, visualization) Consider individual or family psychotherapy Avoidance of environmental precipitants Wear sunglasses Avoid smoke, strong odors, and noisy areas Maintain proper posture; limit sustained positions Physical therapy techniques Heat, ice, ultrasound, transcutaneous electrical nerve stimulation Massage or cervical traction Stretching and strengthening exercises for cervical musculature Trigger point stretching, compression, injection (any or all) Osteopathic or chiropractic manipulation Alternative therapies Acupuncture Acupressure Therapeutic touch Aromatherapy (eg, peppermint, green apple) Topical salves (eg, salicylic acid, piroxicam [Feldene], ketoprofen [Orudis, Oruvail]) Education and headache support groups National Headache Foundation (888-643-5552, www.headaches.org) American Council for Headache Education (800-255-ACHE, www.achenet.org)

Psychological stressors or comorbidities should be addressed for the best possible therapeutic outcome. A physician cannot change a patient's life circumstance but may be able to alter a patient's perspective about life events and the amount of stress they cause. Family or individual psychotherapy, or both, may help patients to modify perfectionistic standards, environmental demands, and maladaptive coping mechanisms; express their anger and emotions effectively; and develop a less critical self-perception. In some cases, family members should be involved in treatment to identify and address family behaviors that may unconsciously reinforce secondary gains and enabling behaviors in the patient. Generally, families should deemphasize concerns regarding headaches and encourage the patient to maintain as normal a lifestyle as possible. If pharmacologic agents are indicated, abortive medications to relieve headaches may be used alone for infrequent headaches (occurring on 1 or 2 days a week) or in addition to a daily prophylactic medication for more frequent or severe headaches. Prophylaxis should be considered if significant disability occurs with attacks, if abortive medication cannot be used because of comorbid conditions or a history of substance abuse, or if preventive medication enhances the abortive medication effect. The mainstays of abortive therapy are analgesics and muscle relaxants (table 5). Simple over-thecounter analgesics and non-steroidal antiinflammatory drugs (NSAIDs) have been found to be effective in clinical trials. Little scientific evidence is available to support the effectiveness of muscle relaxants. Butalbital analgesic combinations with or without codeine have been found to provide effective pain relief for tension-type headache (17); the barbiturate compound helps relieve the anxiety component of pain. Caffeine, used as an analgesic adjuvant in over-the-counter and prescription barbiturate combinations, increases the absorption, peak concentration, and analgesic potency of medication as much as 40%. The mild central nervous system stimulant effect of caffeine

counteracts the sedative effects of barbiturates or opioids. A combination of isometheptene, dichloralphenazone, and acetaminophen also is indicated for tension-type headache. Interestingly, sumatriptan succinate (Imitrex), which typically is used for migraine, has been found to be effective in subgroups of patients with tension-type headache who experience frequent vascular headache qualities (ie, throbbing, increased pain with exertion, photophobia, and phonophobia) (18). Sumatriptan has not been found to be effective in patients with tension-type headache who do not report these vascular qualities. Table 5. Pharmacologic treatment of tension-type headache Abortive therapy Simple analgesics without caffeine Simple analgesic combinations with caffeine Nonsteroidal anti-inflammatory drugs Muscle relaxants with or without an analgesic combination Isometheptene, dichloralphenazone, and acetaminophen compounds Barbiturate or analgesic compounds Narcotic analgesics Prophylactic therapy Nonsteroidal anti-inflammatory drugs Tricyclic antidepressants Sedating (eg, amitriptyline HCl [Elavil], doxepin HCl [Sinequan], trimipramine maleate [Surmontil]) Intermediate sedation (eg, nortriptyline HCl [Aventyl HCl Pulvules, Pamelor], imipramine HCl [Tofranil]) Nonsedating (eg, protriptyline HCl [Vivactil], desipramine [Norpramin])

Selective serotonin reuptake inhibitors (eg, fluoxetine HCl [Prozac], sertraline HCl [Zoloft], paroxetine HCl [Paxil], citalopram hydrobromide [Celexa]) Other antidepressants (eg, trazodone HCl [Desyrel], bupropion HCl [Wellbutrin], venlafaxine [Effexor], nefazodone HCl [Serzone]) Monoamine oxidase inhibitors (eg, phenelzine sulfate [Nardil], isocarboxazid [Marplan])

Abortive migraine therapy has advanced from a stepped-care to a stratified-care approach, but no such schema has been proposed for tension-type headache. Table 6 illustrates a proposed stratifiedcare approach that emphasizes choosing medications on the basis of headache frequency and disability; the stepped-care approach involves beginning treatment of all patients with the weakest medications and slowly advancing to stronger medications on the basis of response. In a stratifiedcare model, more effective medications, such as barbiturate or opioid combination analgesics, or both, may be considered first-line therapy for patients experiencing more disabling headaches; this is true as long as the headaches are not frequent (<2 days a week) and the patient is at low risk for habituation and has no history of substance abuse. Table 6. Stratified-care approach to tension-type headache management based on

frequency and degree of disability* Infrequent Low disability Nonpharmacologic approaches only Over-the-counter simple analgesics with or without caffeine (eg, Excedrin, Tylenol) Nonsteroidal anti-inflammatory drugs (eg, Anaprox, Motrin) No prophylaxis High disability Narcotic analgesics (eg, Fioricet With Codeine Capsules, Vicodan) Nonsteroidal anti-inflammatory drugs with or without analgesic adjuvant (Anaprox, Motrin) Muscle relaxants Barbiturate and analgesic compounds Isometheptene compound Anxiolytics Consider prophylaxis Frequent Low disability Nonpharmacologic approaches only Over-the-counter simple analgesics without caffeine Nonsteroidal anti-inflammatory drugs Consider prophylaxis High disability** Muscle relaxants Nonsteroidal anti-inflammatory drugs Isometheptene compounds Prophylaxis indicated *Headache frequency: infrequent, <2 days per week; frequent, >2 days per week. Low disability means no to moderate impairment in function. High disability means moderate to severe impairment. **High potential for analgesic overuse; avoid caffeine products, barbiturate compounds, anxiolytics, and narcotic analgesics.

Tricyclic antidepressants are the mainstay of prophylactic therapy for tension-type head-ache (19). Selection of a tricyclic antidepressant is usually based on the presence of sleep disturbances, with poor sleepers receiving the more sedating drugs. The average maintenance dose of most tricyclic antidepressants is 50 to 75 mg daily (except protriptyline hydrochloride [Vivactil], which is dosed differently). Effective dosage varies among patients and is unrelated to serum drug levels or antidepressant properties. Despite their improved side effect profile, selective serotonin reuptake inhibitor antidepressants are less reliable for headache prophylaxis. Atypical antidepressant classes have potential but unproven benefits. Cyclobenzaprine hydrochloride (Flexeril), a muscle relaxant, has a chemical structure similar to that of the tricyclic antidepressants and has been found to be an effective prophylactic

agent for tension-type headache but is not approved for long-term use (20). NSAIDs also may be used prophylactically. Some physicians who feel strongly that migraine and tension-type headache are common entities propose that all migraine prophylactics are also effective for tension-type headache; however, few controlled studies of beta blockers, calcium channel blockers, or anticonvulsants used for tensiontype headache are available. Botulinum toxin type A (Botox) has been studied as a potential headache treatment when injected into the frontalis muscle, but further studies are needed to identify the group of patients who are best suited for this treatment (21). Efforts to foster a collaborative relationship with patients, making them active participants in their care, are likely to achieve higher treatment success rates. Patients should be educated about realistic treatment expectations. The physician should explain that a 4- to 8-week drug trial at full therapeutic doses may be required because of delayed effectiveness, that combinations of medications may be required, and that overuse of caffeine or analgesics negates treatment effect. Preventive medications are not a cure; successful therapy is considered to be a 50% reduction in headache frequency, a reduction in headache intensity or duration, an enhancement of abortive medication effect, or all of these. Work around patient biases against certain drug classes or their potential for side effects (eg, weight gain, fatigue) while maintaining safety and efficacy. Treatment is a balance between medication efficacy and adverse effects. Headache is a dynamic condition, and routine follow-up is required to reassess the need for medication adjustments and to reinforce nonpharmacologic regimens. When patients are doing well, reduction of dosages of preventive medications should be attempted. Exacerbation of headache occurs at times regardless of potential triggers or medical regimens. The art of headache treatment is knowing when to maintain therapy and reassure patients, when to make minor adjustments in medications, and when to change the entire treatment regimen.

Conclusion
Recent advances in the treatment and understanding of migraine have overshadowed concerns about tension-type headache, the most prevalent headache disorder. Because of its high prevalence and wide spectrum of disability, tension-type headache is the most important headache type in regard to reduction in work productivity, quality of life, and socioeconomic impact. Future research endeavors will address the pathophysiology of tension-type headache, whether peripheral, central, psychological, or multifactorial. Well-controlled clinical trials are needed to clarify the best treatment approaches and determine whether standard migraine medications may be used for tension-type headache. Patient education and more aggressive treatment regimens would likely increase use of the healthcare system and decrease the large indirect economic cost attributable to this often inadequately treated disorder.

References
1. Rasmussen BK, Jensen R, Schroll M, et al. Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol 1991;44(11):1147-57 2. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(Suppl 7):29-34 3. A study of headache in North American primary care: report from the Ambulatory Sentinel Practice Network. J R Coll Gen Pract 1987;37(302):400-3 4. Friedman AP, de Sola Pool N, von Storch TJ. Tension headache. JAMA 1953;151:174-7

5. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J Epidemiol Community Health 1992;46(4):443-6 6. De Benedittis G, Lorenzetti A, Sina C, et al. Magnetic resonance imaging in migraine and tension-type headache. Headache 1995;35(5):264-8 7. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993;53(1):65-72 8. Yamaguchi M. Incidence of headache and severity of head injury. Headache 1992;32(9):427-31 9. Glass DE. Tension headache and some psychiatric aspects of headache. Headache Q 1992;3(3):262-9 10. Jensen R. Pathophysiological mechanisms of tension-type headache. Cephalalgia 1999;19(6):602-21 11. Olesen J, Jensen R. Getting away from simple muscle contraction as a mechanism of tension-type headache. (Editorial) Pain 1991;46(2):123-4 12. Castillo J, Martinez F, Leira R, et al. Plasma monoamines in tension-type headache. Headache 1994;34(9):531-5 13. Olesen J. Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain 1991;46(2):125-32 14. Russell MB, Iselius L, Ostergaard S, et al. Inheritance of chronic tension-type headache investigated by complex segregation analyses. Hum Genet 1998;102(2):138-40 15. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001;41(7):638-45 16. Diener HC, Dichgans J, Scholz E, et al. Analgesic-induced chronic daily headache: longterm results of withdrawal therapy. J Neurol 1989;236(1):9-14 17. Friedman AP, DiSerio FJ. Symptomatic treatment of chronically recurring tension headache. Clin Ther 1987;10(1):69-81 18. Cady RK, Gutterman D, Saiers JA, et al. Responsiveness of non-IHS migraine and tension-type headache to sumatriptan. Cephalalgia 1997;17(5):588-90 19. Diamond ML, Solomon GD. Tension-type headache. In: Diamond ML, Solomon GD, eds. Diamond and Dalessio's the practicing physician's approach to headache. 6th ed. Philadelphia: WB Saunders, 1999:125-36 20. Lance JW, Anthony M. Cyclobenzaprine in the treatment of chronic tension headache. Med J Aust 1972;2:1409-11 21. Wheeler AH. Botulism Toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension. Headache 1998;38(6):468-71 Dr Mueller is associate professor of family medicine and associate director of the University Headache Center, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Moorestown, New Jersey. Correspondence: Loretta Mueller, DO, University Headache Center, 513 S Lenola Rd, Moorestown, NJ 08057.