Establishment of an Italian chronic migraine database: a multicenter pilot study.

To optimize chronic migraine (CM) ascertainment and phenotype definition, provide adequate clinical management and health care procedures, and rationalize economic resources allocation, we performed an exploratory multicenter pilot study aimed at establishing a CM database, the first step for developing a future Italian CM registry. We enrolled 63 consecutive CM patients in four tertiary headache centers screened with face-to-face interviews using an ad hoc dedicated semi-structured questionnaire gathering detailed information on life-style, behavioral and socio-demographic factors, comorbidities, and migraine features before and after chronicization and healthcare resource use. Our pilot study provided useful insights revealing that CM patients (1) presented in most cases symptoms of peripheral trigeminal sensitization, a relatively unexpected feature which could be useful to unravel different CM endophenotypes and to predict trigeminal-targeted treatments' responsiveness; (2) had been frequently admitted to emergency departments; (3) had undergone, sometime repeatedly, unnecessary or inappropriate investigations; (4) got rarely illness benefit exemption or disability allowance only. We deem that the expansion of the database-shortly including many other Italian headache centers-will contribute to more precisely outline CM endophenotypes, hence improving management, treatment, and economic resource allocation, ultimately reducing CM burden on both patients and health system.

Chronic headaches: a clinician's experience of ICHD-3 beta.

The International Classification of Headache Disorders, 3rd edition (beta version) has significantly improved the categorization of chronic headaches. From a clinical standpoint, however, it still has a few limitations, both general and specific. Among the former is the fact that international headache classifications are aimed less at defining the disease than at characterizing the features of attacks, meaning that their structure is ill suited to dealing with chronic headaches where the patient must be the focus of the discussion. Among the latter is the fact that the diagnostic criteria for chronic migraine do not distinguish between cases differing widely in severity and that the issue of whether medication overuse headache can be considered an autonomous entity is still unsolved. We propose that changes be made in the systematizations of chronic migraine and medication overuse headache to make them more consistent with clinical practice.

The PACE study: past-year prevalence of tension-type headache and its subtypes in Parma's adult general population.

The mean global prevalence of tension-type headache (TTH) in adult is 42 %. To date, there have been no Italian studies on TTH prevalence in the adult general population. Therefore, we conducted a cross-sectional study, called PACE, aimed at detecting the prevalence of primary headaches in the city of Parma's adult general population. 904 subjects representative of Parma's adult general population were interviewed face to face by a physician of our Headache Centre. Crude past-year prevalence for definite TTH was 19.4 % (95 % CI 16.8-21.9; 18.4 %, 95 % CI 14.6-22.3 in men, and 20.1 %, 95 % CI 16.6-23.6 in women), namely, 9.0 % (95 % CI 7.1-10.8) for infrequent TTH, 9.8 % (95 % CI 7.9-11.8) for frequent TTH, and 0.6 % (95 % CI 0.1-1) for chronic TTH. Crude prevalence for probable TTH was 2.3 % (95 % CI 1.3-3.3; 2 %, 95 % CI 0.6-3.4 in men, and 2.6 %, 95 % CI 1.2-3.9 in women). Our results indicate a TTH prevalence (19.4 %) at the lower limit of data ranges for Western countries, and prevalence rates for infrequent forms (9 %) do not appear different from those of frequent forms (9.8 %).

Prevalence of tension-type headache in adult general population: the PACE study and review of the literature.

The mean global prevalence of tension-type headache (TTH) in adult is 42 %. To date, there have been no Italian studies on TTH prevalence in the adult general population. Therefore, we conducted a cross-sectional study, called PACE (PArma CEfalea, or "Headache in Parma"), aimed at detecting the prevalence and clinical features of primary headaches in the city of Parma's adult general population. Crude past-year prevalence for definite TTH was 19.4 % (95 % CI 16.8-21.9), namely 9.0 % (95 % CI 7.1-10.8) for infrequent TTH, 9.8 % (95 % CI 7.9-11.8) for frequent TTH, and 0.6 % (95 % CI 0.1-1) for chronic TTH. Crude prevalence for probable TTH was 2.3 % (95 % CI 1.3-3.3). Our study results indicate a TTH prevalence rate (19.4 %) at the lower limit of data ranges currently available for Western countries, and prevalence rates for infrequent forms (9 %) do not appear much different from those of frequent forms (9.8 %).

New prospects in the taxonomic classification of primary headaches.

In the field of primary headaches, we have a very useful classification tool for the clinical characterization of individual attacks, but we lack a classification tool for the characterization of primary headache patients. Just because the reasons for this lack have been partially overcome by the knowledge that has been gained in the meantime and because clinicians and researchers are increasingly pressed to find new and reliable ways to manage certain primary headache forms, including so-called chronic migraine, we now have an imperative commitment to provide a syndrome classification.

A redefinition of primary headache: chronic migraine.

In the field of so-called chronic daily headache, it is not easy for migraine that worsens progressively until it becomes daily or almost daily to find a precise and universally recognized place within the current international headache classification systems. A proposal is advanced to differentiate between a form of high-frequency migraine without aura (10-20 days of headache per month for at least 3 months), to be considered as a migraine without aura subtype, and a form of transformed migraine (TM), to be considered as a complication of migraine. TM--a name that should be preferred to chronic migraine (CM)--would then replace the latter, from which it would distinguish itself by the more restrictive diagnostic criteria (at least 20 days of headache per month for at least 1 year, with no more than 5 consecutive days free of symptoms; same clinical features of migraine without aura for at least 10 of those 20 days).

Drug-resistant chronic migraine: the Italian GON project.

Chronic daily headache is a major problem due to severe disability and high socio-economic costs. In the last years, some trials have shown potential benefit from new therapeutic approach by occipital neurostimulation techniques, already applied with some success for the treatment of chronic cluster headache. Due to the extremely heterogeneous population suffering from refractory chronic daily headaches, we propose a national multicenter experimental study involving Italian ANIRCEF Headache Centres with the aim to evaluate the efficacy of occipital neurostimulation in a selected group representative for the drug-resistant chronic migraine. Patients with chronic migraine according to Manzoni's modified IHS criteria-2011, with or without medication overuse headache, will be selected. Duration of illness should be at least 2 years and pharmacological refractoriness defined strictly for experimental-surgical purposes as those patients who have properly tried without success almost all available classes of prophylactic medications. Those presenting with medication overuse should have tried at least two previous detoxification treatments. A full psychopathological assessment will be performed by a psychiatrist, to exclude mainly psychotic disorder, ongoing severe status of an affective disorder, severe post traumatic stress disorder. Headache characteristics and abortive treatments used will be reported daily on a predisposed diary during 3-month baseline and continuously through the post implant follow up, while disability and QoL scale (MIDAS, SF-12) will be completed baseline, 6 and 12 months after implant.

Late-onset cluster headache: some considerations about 73 cases.

Data in the literature on cluster headache (CH) indicate a mean age at onset of about 29-30 years; recently, however, cases have been reported with onset in old age. A review of age at onset in all CH patients (n = 693) followed at the University of Parma Headache Centre between 1976 and 2011 shows that 73 (10.5 %) patients began to suffer from CH after age 50. In these 73 patient, the gender (M:F) ratio was 1.4:1, while in the 620 patients with CH onset before age 50, it was 2.5:1. In the patients with CH onset after and before age 50, respectively, the distribution by CH subtype shows that the episodic-to-chronic ratio was 7.6:1 and 7.9:1 in men and 1.5:1 and 7.8:1 in women. In episodic CH men with onset after 50 the average duration of active periods was 60 versus 39 days for those with onset before 50. In women, the duration was 80 and 42 days, respectively. In conclusion, our case review suggests that CH onset after age 50 is not rare, especially in women. Additionally, late onset represents a negative prognostic factor because, particularly in women, CH will more likely be a chronic form and even in episodic forms active periods will last longer.

Detection of possible factors favouring the evolution of migraine without aura into chronic migraine.

In a minority of cases, the natural history of migraine without aura (MO) is characterised over time by its evolution into a form of chronic migraine (CM). In order to detect the possible factors predicting this negative evolution of MO, we searched in our Headache Centre files for all clinical records that met the following criteria: (a) first visit between 1976 and 1998; (b) diagnosis of MO or of common migraine at the first observation, with or without association with other primary headache types; (c) <15 days per month of migraine at the first observation; and (d) at least one follow-up visit at least 10 years after the first visit. The patients thus identified were then divided into two groups based on a favourable/steady evolution (Group A: n = 243, 195 women and 48 men) or an unfavourable evolution (Group B: n = 72, 62 women and 10 men) of their migraine over time. In the two groups, we compared various clinical parameters that were present at the first observation or emerged at the subsequent follow-up visits. The parameters that were statistically significantly more frequent in Group B--and can therefore be considered possible negative prognostic factors--were: (a) ≥ 10 days per month of migraine at the first observation; (b) presence of depression at the first visit in males; and (c) onset of depression or arterial hypertension after the first observation but before transformation to CM in females. Based on these findings, in MO patients the high frequency of migraine attacks, comorbidity with depression, and the tendency to develop arterial hypertension should require particular attention and careful management to prevent evolution into CM.

Cough headache secondary to spontaneous intracranial hypotension complicated by cerebral venous thrombosis.

Cough headache may be the clinical manifestation, sometimes isolated, of an intracranial disease. There are several possible causes of secondary cough headache. The hypothesis that cough headache may be the expression of spontaneous intracranial hypotension has been advanced only recently. In fact, this would represent an exception to the rule that cough headache is generally secondary to conditions leading to an increase in intracranial pressure and/or volume. We report and discuss a case of cough headache secondary to spontaneous intracranial hypotension in an otherwise healthy 59-year-old man. The condition was complicated by cerebral venous thrombosis.

Does NDPH exist? Some clinical considerations.

The analysis of case series of new daily persistent headache (NDPH) reported so far in the literature and the clinical evaluation of affected patients seen at headache clinics suggest that the current International Classification of Headache Disorders (ICHD-II) diagnostic criteria for NDPH are not adequate. In particular, in several instances headache features are not consistent with those of tension-type headache, as the ICHD-II expects. Before making a diagnosis of primary NDPH, it is imperative to rule out that it may be due to any underlying systemic disease. Just as importantly, the presence of psychiatric comorbidity and the possible role played by stressful life factors in triggering NDPH onset should also be searched for. Probably, it will only be through some future improvement in the classification of headache attributed to psychiatric disorder (chapter 12 of the ICHD-II) on the one hand, and through a careful psychological evaluation of patients currently diagnosed as NDPH sufferers on the other, that we will finally know whether primary NDPH actually exists.

Proposal for a new classification of chronic headache.

Since the publication of the second edition of the International Classification of Headache Disorders (ICHD-2) in 2004, a fiery debate has been raging about chronic daily headache in general and about chronic migraine and medication overuse headache in particular. Based on a number of considerations and observations on the current state of knowledge, a proposal is advanced that suggests a few changes to ICHD-2, namely: (1) differentiation of migraine without aura at the second-digit level into infrequent, frequent and very frequent, based on frequency of attacks. (2) Inclusion of transformed migraine among the complications of migraine; this entry should be coded to 1.5.1 replacing chronic migraine and the only diagnostic criterion that needs to be changed over those already listed in the revised ICHD-2 (ICHD-2R) is its temporal pattern (more than 20 days/month for 1 year or more and never with more than 5 headache-free consecutive days). (3) Differentiation of transformed migraine at the fourth-digit level depending on the presence or absence of symptomatic medication overuse (i.e. use for more than 20 days/month) regardless of whether overuse played any role in the worsening of the headache. (4) Switching of medication overuse headache to the Appendix with other diagnostic criteria to be defined.

Clinical review of headache in pregnancy.

Headache is a common disorder in the general population. Among women, the primary headache form that is more heavily affected by the physiologic hormonal variations occurring through a woman's lifetime is migraine. Migraine without aura (MO) and migraine with aura (MA) show a different clinical pattern during pregnancy. MO improves or disappears while it is not infrequent for women to have their first attack of MA during this period; usually, during pregnancy MA do not improve. In MO women who continue to suffer from migraine during pregnancy, clinical observation and the few data currently available from the literature suggest that in the gestational period their attacks are nonetheless less disabling than those occurring outside this period. Even though the duration of the attacks is unchanged, their severity tends to be mild or moderate. Treatment of migraine during pregnancy is discussed.

Population-based pace study: lifetime and past-year prevalence of headache in adults.

Primary headache prevalence in the adult Italian general population has been little studied so far. This is an observational, cross-sectional, population-based study conducted in a subject sample that was representative of the city of Parma's general population >or=age 18. The lifetime prevalence of headache was 69.1%, i.e. 75.8% in women and 60.6% in men; the past-year prevalence of headache was 42.8%, i.e. 52.0% in women and 31.1% in men. Most people suffer from one headache subtype. Headache past-year prevalence decreases with age, both in men and in women. After 60, the likelihood of suffering from headache is low. In more than 80% of cases, headache starts before age 40 and, therefore, it is not very likely for people to develop headache at an advanced age (>50 years). This is the first population-based study conducted in Italy on a sample aged >or=18 since the publication of the IHS diagnostic criteria in 1988.

Population-based pace study: headache frequency and disease perception in adult subjects with headache.

Headache is a disorder that has a very negative personal and social impact. This is an observational, cross-sectional, population-based study conducted in a subject sample (n = 904) that was representative of the town of Parma's general population aged 18 and over. The aim of this study, which is a part of a larger project, was to assess the frequency of headache and the disease perception of subjects with headache during the past year (n = 387). The average number of headache days in the past year was 34.9 days and it was comparable in men and in women: 49.9% of subjects had 1-12 days of headache in the past year, 34.9% had 1-52 days, 11.9% had 53-180 days, and 3.4% had more than 180 days. Only three subjects had headache every day during the past year. Only one-third of the subjects with headache in the past year considered themselves headache sufferers. The analysis by gender showed differences between men and women: although the average number of headache days in the past year was comparable in the male and female populations, women considered their headache a disease more often than men did. In addition, the percentage of men who considered their headache a disease did not increase with the increase in the number of headache days in the past year. More in-depth studies on this important aspect are needed.

Chronic migraine and chronic tension-type headache: are they the same or different?

The question in the title of this article arises from ambiguities in the diagnostic criteria for chronic migraine (CM) included in the 2004 International Classification of Headache Disorders, 2nd Edition (ICHD-II), and in the 2006 revision. More broadly speaking, it also arises from the fact that to date the general subject of chronic daily headaches (CDH) has not been approached in a correct and appropriate way. For all its limitations, ICHD-II has unquestionable merits and remains a fundamental tool. However, it is a tool that gets a snapshot picture of headache; so, it is not applicable to a dynamic form that evolves from and is transformed by a chain of events. If these events are ignored, there will be no accurate interpretation of the final clinical picture. Today, we still do not have any classification of headache syndromes to complement ICHD-II. Currently, then, the only way to approach the CDH issue is to put patients at the center and to focus on their life histories. If we reason strictly in terms of diagnostic classification criteria, which for this headache subtype are artificial and ambiguous, we may have trouble finding an answer to the title question. However, if we reason in broader clinical terms, putting at the center of our reasoning not only headache features, but patients with all their histories, the answer can only be that CM and chronic tension-type headache are two different clinical entities.

The patient-physician relationship in the approach to therapeutic management.

Recent epidemiological investigations have demonstrated that migraine, and more generally primary headaches, are underdiagnosed and poorly treated. To tackle and resolve this problem, in addition to identifying efficient screening means and reliable disability measurement tools, it is crucial to improve communication between physicians and patients. In particular, physicians should be willing and have time to establish a relationship of active and mutual cooperation with their patients and should do so through a number of inescapable steps: listening to patients, understanding their needs, identifying with their condition, giving them explanations and information, reassuring their concerns, advising them on what should be done, making sure that they have correctly understood what they have been told, finding out whether they want to be involved in decision-making and choosing a treatment. Patients must be in a position to freely express their opinions, with no hurry and without fear. Indeed, the time spent with patients, as Graham pointed out as early as 40 years ago, is the most important ingredient of migraine therapy. Proper measures should be taken to overcome the two major obstacles that stand in the way of a good patient-physician relationship: a physician's lack of adequate skills and the organisational absurdities of the health system.

Validation of AIDA Cefalee, a computer-assisted diagnosis database for the management of headache patients.

AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.

Headache and anxiety-depressive disorder comorbidity: the HADAS study.

Psychiatric comorbidity (prevalence and types) was tested in a naturalistic sample of adult patients with pure migraine without aura, and in two control groups of patients, one experiencing pure tension-type headache and the other combined migraine and tension-type headaches. The study population included 374 patients (158, 110 and 106) from nine Italian secondary and tertiary centres. Psychiatric comorbidity was recorded through structured interview and also screened with the Mini International Neuropsychiatry Interview (MINI). Only anxiety and depression were investigated. Psychiatric disorders were reported by 49 patients (14.6%; 10.9% of patients with migraine, 12.8% of those with tension-type headache and 21.4% of those with combined migraine and tension-type headaches). The MINI interview detected a depressive episode in 59.9% of patients with migraine, 68.3% of patients with tension-type headache and 69.6% of patients with combined migraine and tension-type headaches. Depression subtypes were significantly different across groups (p=0.03). Anxiety (mostly generalised) was reported by 18.4% of patients with migraine, 19.3% of patients with tension-type headache, and 18.4% of patients with combined migraine and tension-type headaches. The values for panic disturbance were 12.7, 5.5 and 14.2, and those for obsessive-compulsive disorders were 2.3, 1.1 and 9.4% (p=0.009). Based on these results, psychopathology of primary headache can be a reflection of the burden of the disease rather than a hallmark of a specific headache category.