SUNCT/SUNA: Case series presenting in an orofacial pain clinic.

AIM: Little is known about short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). We present our experience with SUNCT/SUNA patients to aid identification and management of these disorders. METHODS: A retrospective review of patient records of one orofacial pain clinic was performed. Inclusion criteria was a diagnosis of SUNCT/SUNA confirmed with at least one follow-up visit. RESULTS: Six of the 2464 new patients seen between 2015-2018 met the selection criteria (SUNCT n = 2, SUNA n = 4). Gender distribution was one male to one female and average age of diagnosis was 52 years (range 26-62). Attacks were located in the V1/V2 trigeminal distributions, and five patients reported associated intraoral pain. Pain quality was sharp, shooting, and burning with two patients reporting "numbness". Pain was moderate-severe in intensity, with daily episodes that typically lasted for seconds. Common autonomic features were lacrimation, conjunctival injection, rhinorrhea, and flushing. Frequent triggers were touching the nose or a specific intraoral area. Lamotrigine and gabapentin were commonly used as initial therapy. CONCLUSIONS: Differentiating between SUNCT/SUNA does not appear to be clinically relevant. Presenting symptoms were consistent with those published, except 5/6 patients describing intraoral pain and two patients describing paresthesia.

Chronic orofacial pain.

While pain chronicity in general has been defined as pain lasting for more than 3 months, this definition is not useful in orofacial pain (OFP) and headache (HA). Instead, chronicity in OFP and HA is defined as pain occurring on more than 15 days per month and lasting for more than 4 h daily for at least the last 3 months. This definition excludes the periodic shortlasting pains that often recur in the face and head, but are not essentially chronic. Although the headache field has adopted this definition, chronic orofacial pain is still poorly defined. In this article, we discuss current thinking of chronicity in pain and examine the term 'chronic orofacial pain' (COFP). We discuss the entities that make up COFP and analyze the term's usefulness in clinical practice and epidemiology.

Physical therapist clinical reasoning and classification inconsistencies in headache disorders: a United States survey.

Objective: The purpose of this study was to investigate the decision-making processes of physical therapists relating to evaluation and categorization of patients with headaches, including consistency with criteria proposed by the International Headache Society (IHS).Methods: A national online survey was distributed in cooperation with the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Three hypothetical patient case vignettes featuring headache disorders were used as assessment instruments. Additionally, data on physical therapist education, clinical experience, manual therapy training, self-efficacy, and familiarity & consistency with IHS criteria were collected. Physical therapist identification and valuation of clinical features of headache disorders were also examined in the decision-making processes.Results: Among the 384 respondents, 32.3% classified the tension-type headache case consistent with IHS criteria. The cervicogenic and migraine headache cases were classified at 54.8% and 41.7% consistent with IHS categories, respectively. Experienced clinicians and those with formal manual training categorized patient presentations with greater consistency. Clinician familiarity with IHS classification criteria was low with 73.6% collectively somewhat and not familiar, while 26.4% of physical therapists were self-described as very or moderately familiar.Discussion: Clinicians' headache categorization was significantly affected by symptom misattribution and weighting of individual examination findings. Weighting by practitioners of clinical features varied markedly with greatest emphasis being placed on detailed manual examination procedures, including passive intervertebral movements. Inconsistencies in valuation of clinical features in headache categorization suggest a need for further formal education in physical therapy educational curricula and in post-graduate education, including of IHS criteria and classification.Level of Evidence: 2a.

Chronic Headache Education and Self-management Study (CHESS) - a mixed method feasibility study to inform the design of a randomised controlled trial.

BACKGROUND: Self-management support programmes are effective in a range of chronic conditions however there is limited evidence for their use in the treatment of chronic headaches. The aim of this study was to test the feasibility of four key aspects of a planned, future evaluative trial of a new education and self-management intervention for people with chronic headache: 1) recruiting people with chronic headache from primary care; 2) a telephone interview for the classification of chronic headaches; 3) the education and self-management intervention itself; and 4) the most appropriate patient reported outcomes (PROMS). METHODS: Participants were identified and recruited from general practices in the West Midlands of the UK. We developed a nurse-led chronic headache classification interview and assessed agreement with an interview with headache specialists. We developed and tested a group based education and self-management intervention to assess training and delivery receipt using observation, facilitator, and participant feedback. We explored the acceptability and relevance of PROMs using postal questionnaires, interviews and a smartphone app. RESULTS: Fourteen practices took part in the study and participant recruitment equated to 1.0/1000 registered patients. Challenges to recruitment were identified. We did 107 paired headache classification interviews. The level of agreement between nurse and doctor interviews was very good. We piloted the intervention in four groups with 18 participants. Qualitative feedback from participants and facilitators helped refine the intervention including shortening the overall intervention and increasing the facilitator training time. Participants completed 131 baseline questionnaires, measurement data quality, reliability and validity for headache-specific and generic measures was acceptable. CONCLUSION: This study indicated that recruiting people with chronic headache from primary care is feasible but challenging, our headache classification interview is fit for purpose, our study intervention is viable, and that our choice of outcome measures is acceptable to participants in a future randomised controlled trial (RCT). TRIAL REGISTRATION: ISRCTN, ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100.

Development and validation of a telephone classification interview for common chronic headache disorders.

BACKGROUND: For a trial of supportive self-management for people with chronic headache we needed to develop and validate a telephone classification interview that can be used by a non-headache specialist to classify common chronic headache types in primary care. We aimed to specifically: exclude secondary headaches other than medication overuse, exclude primary headache disorders other than migraine and tension type headache (TTH), distinguish between chronic migraine and chronic TTH, and identify medication overuse headache. METHODS: We held a headache classification consensus conference to draw on evidence and expertise to inform the content of a logic model underpinning the classification interview. Nurses trained to use the logic model did telephone classification interviews with participants recruited from primary care. Doctors specialising in headache did a second validation interview. RESULTS: Twenty-six delegates attended the headache classification conference including headache specialist doctors, nurses and lay representatives (with chronic headache). We trained six nurses to do the classification interviews and completed 107 paired interviews, median days between interviews was 32 days (interquartile range 21-48 days). We measured level of agreement between the nurse and doctor interviews using proportion of concordance, simple kappa and prevalence-adjusted bias-adjusted kappa (PABAK). Proportion of concordance of agreement between nurse and doctor interviews was 0.76, simple kappa coefficient κ 0.31 (95% CI, 0.09 to 0.52), and PABAK 0.51 (95% CI, 0.35 to 0.68), a moderate agreement. In a sensitivity test following review of headache characteristics recorded, concordance was 0.91, κ = 0.53 (95% CI, 0.28 to 0.79), and PABAK = 0.81 (95% CI, 0.70 to 0.92), a very good agreement. CONCLUSION: We developed and validated a new evidence-based telephone classification interview that can be used by a non-headache specialist to classify common chronic headache types in primary care.

Headache in young patients: Clinical characteristics of a series of 651 cases. / Cefalea en jóvenes: características clínicas en una serie de 651 casos.

INTRODUCTION: Headache has a negative impact on health-related quality of life in young patients. We aim to analyse the characteristics of a series of young patients visiting a headache clinic and estimate the burden of different types of headaches listed by the International Classification of Headache Disorders (ICHD). METHODS: We prospectively recruited patients aged 14 to 25 years who were treated at our clinic during a period of 6.5 years. We recorded each patient's sex, complementary test results, and previous treatment. We subsequently compared the characteristics of our sample to those of patients older than 25. RESULTS: During the study period, we treated 651 patients aged 14 to 25 years; 95.6% had received symptomatic treatment, and 30.1% had received preventive treatment. A total of 755 headaches were recorded. Only 80 were secondary headaches, most of which were included in Group 8; 77.2% were included in Group 1, 3.1% in Group 2, 1.2% in Group 3, 5% in Group 4, 0.6% in Group 13, and 0.9% in Group 14. According to Headache Impact Test (HIT-6) scores, headache had at least a moderate impact on the quality of life of 449 patients. CONCLUSION: Most headaches in young patients can be classified according to ICHD criteria. Migraine was the most frequent diagnosis in our sample. Although headache was commonly associated with a negative impact on quality of life, most patients had received little preventive treatment before being referred to our clinic.

Diagnostic and classification tools for chronic headache disorders: A systematic review.

BACKGROUND OR AIM: Despite guidelines and the International Classification of Headache Disorders (ICHD-III beta) criteria, the diagnosis of common chronic headache disorders can be challenging for non-expert clinicians. The aim of the review was to identify headache classification tools that could be used by a non-expert clinician to classify common chronic disorders in primary care. METHODS: We conducted a systematic literature review of studies validating diagnostic and classification headache tools published between Jan 1988 and June 2016 from key databases: MEDLINE, ASSIA, Embase, Web of Knowledge and PsycINFO. Quality assessment was assessed using items of the Quality of Diagnostic Accuracy Studies (QUADAS-2). RESULTS: The search identified 38 papers reporting the validation of 30 tools designed to diagnose, classify or screen for headache disorders; nine for multiple headache types, and 21 for one headache type only. We did not identify a tool validated in a primary care that can be used by a non-expert clinician to classify common chronic headache disorders and screen for primary headaches other than migraine and tension-type headache in primary care. CONCLUSIONS: Despite the availability of many headache classification tools we propose the need for a tool that could support primary care clinicians in diagnosing and managing chronic headache disorders within primary care, and allow more targeted referral to headache specialists.

Cardiac cephalalgia: severe, non-exertional headache presenting as unstable angina.

Cardiac cephalalgia is a migraine-like headache that occurs during episodes of myocardial ischaemia. Clinical characteristics of the headache vary widely but are often severe in intensity, worsen with reduced myocardial perfusion and resolve with reperfusion. It can present along with typical symptoms of angina pectoris, although not always. We present a 64-year-old man with a 6-month history of severe, non-exertional headaches occurring with increasing frequency. A resting ECG showed ST elevation in the inferior leads. His serum troponin I was not elevated. Coronary angiography showed severe stenosis of his right coronary artery, which was successfully stented by percutaneous coronary intervention. He remains headache free at 2-year follow-up.

What Are We Missing in the Diagnostic Criteria for Migraine?

PURPOSE OF REVIEW: This review is intended to examine how the diagnostic criteria for migraine have evolved over the past 45 years and to evaluate the strengths and weaknesses of the current diagnostic criteria promulgated by the International Classification of Headache Disorders (ICHD). RECENT FINDINGS: The ICHD is a comprehensive and systematic classification system for headache disorders. As the pathophysiology of migraine is more fully elucidated and more sophisticated diagnostic technologies are developed (e.g., the identification of biomarkers), the current diagnostic criteria for migraine will likely be further refined. The ICHD has allowed for more precise research study design in the field of headache medicine. The current diagnostic criteria for migraine outlined in the 3rd version of the ICHD are far more sensitive and specific than the clinical criteria proposed in 1962. In future iterations, dividing episodic and chronic migraine into subtypes based on frequency (i.e., low frequency vs high frequency; near-daily vs daily) potentially could assist in guiding clinical management. In addition, a better understanding of aura, vestibular migraine, migrainous infarction, and hemiplegic migraine likely will lead to more refined diagnostic criteria for those entities.

Unusual Headache Disorders.

PURPOSE OF REVIEW: Unusual headache disorders are less commonly discussed and may be misdiagnosed. These headache disorders frequently have a benign natural history; however, without reassurance, therapeutic education, and treatment, they can negatively affect the health and function of patients. RECENT FINDINGS: This article reviews the clinical features, diagnosis, workup, and proposed treatments for several unusual headache disorders including primary cough headache, primary headache associated with sexual activity, primary exercise headache, cold-stimulus headache, primary stabbing headache, nummular headache, hypnic headache, and headache attributed to travel in space. Exploding head syndrome is also discussed, which is a sleep disorder commonly confused with a headache disorder. SUMMARY: Unusual headache disorders are usually benign, yet without the correct diagnosis can be very worrisome for many patients. Through greater awareness of these headache disorders, neurologists can evaluate and effectively manage unusual headache disorders, which offers significant benefits to patients and practice satisfaction to neurologists.

A Narrative Review of Persistent Post-Stroke Headache - A New Entry in the International Classification of Headache Disorders, 3rd Edition.

BACKGROUND: Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed. METHODS: We summarize the literature describing persistent headache attributed to stroke. RESULTS: Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology. CONCLUSION: Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies.

A New Subtype of Chronic Daily Headache Presenting in Older Women.

OBJECTIVE: To describe a new subtype of chronic daily headache in women of a specific age group. METHODS: Case series. RESULTS: Eight patients were included in the presented case series. The average age of onset of this distinct headache condition is 57 years. All patients were either perimenopausal or in menopause when the headaches started. The syndrome is marked by bilateral head pain that starts daily from onset and is typically at its most severe intensity the first thing in the morning before arising or when in the supine position. Immediate worsening in Trendelenburg appears to be an almost diagnostic test for the syndrome and occurred in all patients. The majority of the patients had a history of episodic migraine, but the migraines were either very well controlled or had ceased by the time the new headache arose. The bulk of the patients (6/8) were either overweight or obese, although two patients were of normal body mass index (BMI). Neuroimaging showed no abnormalities. All patients responded to cerebrospinal fluid (CSF) pressure-/volume-lowering medications (acetazolamide or spironolactone), but only one patient was able to completely taper off treatment without headache recurrence. CONCLUSION: This newly defined subtype of chronic daily headache appears to be caused by a state of elevated CSF pressure. It is hypothesized that a combination of an elevated BMI and the presence of cerebral venous insufficiency leads to this form of daily headache.

Headache.

Headache, an almost universal human experience, is one of the most common complaints encountered in medicine and neurology. Described and categorized since antiquity, with the first classification by Aretaeus of Cappadocia, other classifications followed. The evaluation of this condition may be straightforward or challenging, and, though often benign, headache may prove to be an ominous symptom. This review discusses the current diagnosis and classification of headache disorders and principles of management, with a focus on migraine, tension-type headache, trigeminal autonomic cephalgias, and various types of daily headache.

Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta.

BACKGROUND: The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0-18 years) and to suggest changes, additions, and amendments. METHODS: Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents. RESULTS: Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults. CONCLUSIONS: Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.

Classification of Headache Disorders: Extending to a Multiaxial System.

This article argues for extending the International Classification of Headache Disorders to include information that goes beyond diagnosis. The obvious model is a multiaxial system as has been developed for other taxonomies. An axis for recording disability and impact on functioning, and an axis for recording the triggers of headache/migraine, are perhaps the strongest contenders for adding to the system, but there are other possibilities such as lifestyle factors relevant to headache. Extensions such as these would contribute to headache management, provide clear targets for change, and encourage adoption of a biopsychosocial perspective.

Prevalence and Features of a Probable Diagnosis in First-Visit Headache Patients Based on the Criteria of the Third Beta Edition of the International Classification of Headache Disorders: A Prospective, Cross-Sectional Multicenter Study.

OBJECTIVES: This study aimed to determine the characteristics and significance of a probable diagnostic entity for primary headache disorder (PHD). BACKGROUND: A diagnosis of probable primary headache disorder (PPHD) is given when a patient's headache fulfills all but one criteria of the third beta edition of the international classification of headache disorder (ICHD-3ß). Despite the uncertainty regarding this diagnosis, the inclusion of a probable diagnosis entity in this manual may aid in the accurate classification of headache disorders and allow effective treatment strategies to be started at the patient's initial visit. METHODS: This cross-sectional multicenter registry study assessed first-visit patients with complaints of headaches who presented at the outpatient clinics of 11 neurologists in Korea. The classification of a headache disorder was made according to the criteria of the ICHD-3ß by each investigator based on the initial evaluation of the patient or by a consensus meeting for uncertain cases. The rates of a probable diagnosis among PPHD patients were assessed and the clinical characteristics of these patients were compared with those of patients with a diagnosis of definite primary headache disorder (DPHD). RESULTS: A total of 1429 patients were diagnosed with PHD, and 305 (21.3%) of these patients had PPHD. The proportions of PPHD differed among the subtypes of DPHD as follows: migraines (16.1%), tension-type headaches (TTH; 33%), trigeminal autonomic cephalalgia (TAC; 40.9%), and other PHD (14%, P < .001). Patients with PPHD had less severe headache intensity than patients with DPHD (5.8 ± 2.2 vs. 6.5 ± 2.1, respectively, P < .001) as well as a shorter duration of headache from onset (median: 1 vs. 4 months, respectively, P < .001). The most common criteria missing for a definite diagnosis in the PPHD patients were total frequency (52.1%), duration of attack (14.4%), and accompanying symptoms (13.1%). CONCLUSIONS: A probable diagnosis was given to 21.3% of the first-visit PHD patients due to incomplete or atypical presentations of the headaches. The incorporation of a probable diagnosis into the ICHD-3ß may be useful for reducing the diagnoses of unspecified headaches.