Healthcare resource utilization and associated costs among patients with migraine in Finland: A retrospective register-based study.

Migraine is a common chronic brain disorder, characterized by recurring and often disabling attacks of severe headache, with additional symptoms such as photophobia, phonophobia and nausea. Migraine affects especially the working age population. The objective of this retrospective observational register-based study was to analyze the use of healthcare services and associated costs in Finnish migraine patients. Study was based on aggregate data from January 1st, 2020, to December 31st, 2021, from the Finnish Institute for Health and Welfare's national registries. Patients were grouped into nine patient groups according to medication prescriptions and diagnoses. Healthcare resource utilization in specialty, primary, and occupational healthcare was assessed and analyzed separately for all-cause and migraine related healthcare contacts from a one-year period. The total number of patients was 175 711, and most (45%) of the patients belonged to a group that had used only one triptan. Migraine related total healthcare resource utilization was greater for patients that had used two or more triptans compared to those that had used only one. The patients with three or more preventive medications had the highest total migraine related healthcare resource utilization of the studied patient cohorts. Of the total annual healthcare costs 11.5% (50.6 million €) was associated to be migraine related costs. Total per patient per year healthcare costs were highest with patients that had used three or more preventive medications (5 626 €) and lowest in those with only one triptan (2 257 €). Our findings are in line with the recent European Headache Federation consensus statement regarding the unmet need in patients who have had inadequate response to two or more triptans. When assessing the patient access and cost-effectiveness of novel treatments for the treatment of migraine within different healthcare systems, a holistic analysis of the current disease burden along with potential gains for patients and healthcare service providers are essential information in guiding decision-making.

Preliminary exploration of a multidimensional sleep health composite in adolescent females with frequent migraine.

OBJECTIVE: This observational study aimed to: (i) describe and explore preliminary psychometric properties of a multidimensional sleep health composite score in adolescent females with frequent migraine; and (ii) examine associations between the composite score, headache characteristics, and emotional health. BACKGROUND: Sleep health is a multidimensional construct comprised of various dimensions of sleep and circadian functioning, including Regularity, Satisfaction, Alertness, Timing, Efficiency, and Duration (Ru-SATED framework). The Ru-SATED sleep health composite score may provide a holistic perspective of sleep among adolescents with frequent migraine in the context of neurobiological and psychosocial impacts on sleep unique to this developmental period. METHODS: In all, 60 female adolescents (aged 12-18 years) with high-frequency episodic or chronic migraine completed wrist-worn actigraphy for 10 days and concurrent daily electronic surveys assessing headache, sleep, and emotional health. A sleep health composite score was derived from empirically supported "healthy" versus "unhealthy" ratings on the six Ru-SATED sleep dimensions. RESULTS: Half of participants (27/54 [50%]) had a composite score ≥4 (i.e., at least four of the six dimensions rated as poor). Convergent validity of the composite score was acceptable (rs = 0.30-0.56, all p < 0.05). Internal consistency among the dimensions was low (α = 0.45). Multivariate multiple regression models indicated that worse sleep health was associated with greater headache-related disability (B = 0.71, p = 0.018) and anxiety (B = 0.59, p = 0.010), and trended toward significance for sadness (B = 0.35, p = 0.052). The composite score was not significantly associated with headache frequency or severity. CONCLUSIONS: A multidimensional sleep health composite score may provide an alternative, more comprehensive picture of sleep disturbance among adolescent females with frequent migraine. Larger studies are needed to examine psychometric properties more rigorously and further explore the composite score as a potentially unique predictor of headache outcomes.

Acupuncture for headache in COVID-19: A protocol for systematic review and meta-analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an acute respiratory infectious disease which making people difficult to breathe and often accompanied with headache. Acupuncture have been proved the therapeutic effect on headache, but there has been no high-quality evidence on acupuncture for the headache in COVID-19. This study is designed to evaluate the effectiveness and safety of acupuncture for headache in COVID-19. METHODS: Randomized controlled trials from December 2019 to July 2021 will be included without restrictions on language or publication date. PubMed, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Databases, China National Knowledge Infrastructure, Wanfang database, and VIP database will be searched. Two researchers will independently select studies, extract data and evaluate study quality. Cochrane risk of bias tool for randomized trials will be used to assess the risk of bias of included studies. Statistical analyses will be performed using the Review Manager V.5.3 and stata 14.0. ETHICS AND DISSEMINATION: This study will not involve personal information. Ethical approval will not be required. We will publish the results in a peer-reviewed journal. PROSPERO TRIAL REGISTRATION NUMBER: CRD42021270722.

Migraine (Shaqeeqa) and its management in Unani medicine.

Out of many disease conditions suffered by mankind since ancient ages, Migraine holds a significant position. It is derived from the word "hemi-crania" and is a type of primary headache. This disease is mentioned in the ancient scriptures dating back to the Mesopotamian era. It has been documented by Hippocrates (460-377 BC) in his treatise, further explored and explained on the basis of cause and location by Galen (131-201 AD). Later its etiopathogenesis clinical features and management was described by Al-Razi (850-923 AD), an eminent Unani physician. Migraine is a disease majorly affecting one side of the head and characterized by recurrent attacks of pulsating headache, mostly associated with nausea, vomiting, photophobia and phonophobia, with or without an aura. It is triggered by noise and light, based on the brightness, intensity, wavelengths or type of light that is being emitted. According to Unani physicians, the word Shaqeeqa is derived from Arabic word 'Shiq', meaning 'a part' or 'a side', hence the name Shaqeeqa. They describe it as a type of headache (Suda) in which pain occurs only in one side of head, and the causative factors for it are the morbid matters and morbid vapours (Bukharat e Radiya) arising from morbid humours which are either excessive in amount, too hot or too cold. It often results due to abnormal substantial temperament (Su-e-Mizaj Maddi) giving two variants acute (Shaqeeqa haar) and chronic (Shaqeeqa barid). The treatment mainly consists of elimination of morbid matter which is accumulated in the body, and strengthening the brain using brain tonics (Muqawwiyat-e-Dimagh).

Craniofacial neuralgias.

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.

Vitamin D3 might improve headache characteristics and protect against inflammation in migraine: a randomized clinical trial.

INTRODUCTION: Due to anti-inflammatory effects of vitamin D3, we aimed to explore the effects of supplementation with this vitamin on headache characteristics and serum levels of pro/anti-inflammatory markers in migraineurs. METHODS AND MATERIALS: This placebo-controlled, double-blind study included 80 episodic migraineurs who randomly assigned into two equal groups to receive either daily dose of vitamin D3 2000 IU (50 µg) or placebo for 12 weeks. At baseline and after the trial, headache characteristics were determined using diaries and serum levels of interleukin (IL)-10, IL-6, inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (Cox-2) were assessed via ELISA method. RESULTS: At the end of trial, analysis of covariance (ANCOVA) adjusted for baseline values, and confounders revealed that vitamin D3 supplemented group experienced significantly lower headache days per month (4.71), reduced attacks duration (12.99 h/attack), less severe headaches (5.47, visual analog scale), and lower analgesics use/month (2.85) than placebo group (6.43, 18.32, 6.38 and 4.87, respectively) (P values < 0.05). Using ANCOVA adjusted for baseline levels and confounding variables, it was found that serum levels of IL-10 and Cox-2 did not significantly differ between groups after the experiment; whereas, iNOS serum level was significantly reduced in the intervention group (106.06 U/L) comparing to the controls (156.18 U/L P : 0.001). Also, the patients receiving vitamin D3 yielded a marginally significant lower IL-6 serum concentration (76.43 ng/L) compared to placebo (93.10 ng/L) (P value:0.055). CONCLUSION: Based on the results of this study, we found that 2000 IU (50 µg)/day vitamin D3 supplementation for 12 weeks could improve headache characteristics and might reduce neuro-inflammation in episodic migraine.

Migraine associated with gastrointestinal disorders: A pathophysiological explanation.

BACKGROUND: Migraine is a highly prevalent, disabling, and costly disorder worldwide. From a long time ago, headaches have been known to be associated with gastrointestinal (GI) disorders. Headaches originating from gastric complaints were appreciated by Persian Medicine (PM) scholars. Today, functional GI disorders are shown to have high comorbidity with migraines; however, a causal relationship is not accepted today and pathophysiological explanations for this comorbidity are scarce. Therefore, based on the PM philosophy and the existing evidence, we aimed to propose an explanation for the co-morbidity of migraine and GI disorders. SUMMARY: Noxious stimuli from the GI tract are relayed to the nucleus tractus solitarius (NTS) in the brain stem, which is located close to the trigeminal nucleus caudalis (TNC). TNC has shown projections to (NTS) through which frequent GI stimuli may antidromically reach the TNC and finally result in neurogenic inflammation. In addition, immune products, particularly histamine, are released in the submucosa of the GI tract and absorbed into the systemic circulation, which renders migraineurs more prone to attacks.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

OBJECTIVES: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). METHODS: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. RESULTS: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. CONCLUSIONS: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. SIGNIFICANCE: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Current understanding of photophobia, visual networks and headaches.

OBJECTIVE: To review clinical and pre-clinical evidence supporting the role of visual pathways, from the eye to the cortex, in the development of photophobia in headache disorders. BACKGROUND: Photophobia is a poorly understood light-induced phenomenon that emerges in a variety of neurological and ophthalmological conditions. Over the years, multiple mechanisms have been proposed to explain its causes; however, scarce research and lack of systematic assessment of photophobia in patients has made the search for answers quite challenging. In the field of headaches, significant progress has been made recently on how specific visual networks contribute to photophobia features such as light-induced intensification of headache, increased perception of brightness and visual discomfort, which are frequently experienced by migraineurs. Such progress improved our understanding of the phenomenon and points to abnormal processing of light by both cone/rod-mediated image-forming and melanopsin-mediated non-image-forming visual pathways, and the consequential transfer of photic signals to multiple brain regions involved in sensory, autonomic and emotional regulation. CONCLUSION: Photophobia phenotype is diverse, and the relative contribution of visual, trigeminal and autonomic systems may depend on the disease it emerges from. In migraine, photophobia could result from photic activation of retina-driven pathways involved in the regulation of homeostasis, making its association with headache more complex than previously thought.

Bath-Related Headache.

PURPOSE OF REVIEW: The purpose of this review is to summarize the most up-to-date literature on bath-related headache, a rare disorder. RECENT FINDINGS: Initially described in middle-aged Asian women, it is now reported in a wider demographic. More information is available about the pathophysiology of bath-related headache, including its classification as a subtype of reversible cerebral vasoconstriction syndrome (RCVS). Nimodipine can be effective in patients both with and without vasospasm. Bath-related headache is a rare form of thunderclap headache. Although its mechanism is still unclear, it is associated with vasospasm and RCVS. Controlled trials investigating the use of nimodipine and other agents may be useful in furthering our understanding of and treatment of this phenomenon.

Vitamin D status in children with headache: A case-control study.

BACKGROUND: Vitamin D is a fat soluble vitamin with hormonal properties, plays crucial functions in bone and mineral metabolism and has important regulatory functions in brain development, cell differentiation and apoptosis. Some studies have shown a link between vitamin D deficiency and headache. MATERIAL AND METHODS: In this study, 147 patients with headache (migraine or either tension-type headache (TTH)) and 69 healthy controls, aged 5 to 16 years, were evaluated. Each group was also divided into two separate sub-groups based on presentation to the clinic in either high solar-exposure (HSE) and low solar-exposure (LSE).We retrospectively evaluated the levels of calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-OH vitamin-D3. Levels below 20 ng/ml were described as vitamin D deficiency and levels of 2030 ng/ml as vitamin D insufficiency. RESULTS: The levels of 25-OH vitamin-D3 were statistically significantly lower when compared to the control group (17.1±9.4 vs. 25.8 ± 12.8 ng/mL, respectively; p < 0.001). This held true for both the HSE and LSE group compared to the control group (for the group 1; 24.6 ± 11.8 vs. 32.1 ± 10.6 ng/mL, respectively; p = 0.007, and for the group 2; 14.5 ± 6.8 vs. 19.6 ± 13.5 ng/mL, respectively; p = 0.003). Also in headache subgroups (migraine and TTH), vitamin D levels were significantly lower than the control group (17.3 ± 9.0, 16.9 ± 9.9 and 25.8 ± 12.8 ng/mL respectively; p < 0.001). CONCLUSION: There may be a relationship between vitamin D deficiency and headache, with particular significance in LSE. We suggest that this conclusion needs to be supported with randomised clinical studies containing a larger numbers of samples and controls.

What Factors Contribute to Headache-Related Disability in Teens?

BACKGROUND: Our aim was to describe the relationship between risk factors, such as stress, depression, and anxiety, and potentially protective factors against pediatric headache-related disability, such as mindfulness, resilience, and self-compassion, and to determine teens' interest in mind-body skills training to help reduce headache-related disability. METHODS: This was a cross-sectional survey among adolescents seen in an academic neurology clinic reporting four or more headaches monthly using standardized instruments to determine the relationship between putative risk and protective factors as well as physiologic markers of inflammation and vagal tone and headache-related disability. RESULTS: Among the 29 participants, 31% were male, the average age was 14.8 years, average headache frequency was 11.6 per month, and the most commonly reported trigger was stress (86%). The only risk or protective factor significantly associated with headache-related disability was depression (r = 0.52, P = 0.004). Depression was negatively correlated with mindfulness, resilience, and self-compassion (P < 0.01 each) and positively correlated with stress, sleep disturbance, and anxiety (P < 0.01 each). Biomarkers of vagal tone and inflammation were correlated with each other but not with headache-related disability or depression. There was strong interest in learning skills like slow, deep breathing practices supported by a smart phone application to reduce stress and the negative impact of headaches on daily life. DISCUSSION: Among teens with frequent migraine headaches, depression is the strongest risk factor for headache-related disability. Stress is viewed as a headache trigger, and teens reported wanting to learn simple stress management strategies supported by a smart phone application to help reduce headache-related disability.

Some Non-FDA Approved Uses for Neuromodulation: A Review of the Evidence.

INTRODUCTION: Neuromodulation, including spinal cord stimulation and peripheral nerve field stimulation, has been used with success in treating several painful conditions. The FDA approved the use of neuromodulation for a few indications. We review evidence for neuromodulation in treating some important painful conditions that are not currently FDA approved. METHODS: This review included an online web search for only clinical trials testing the efficacy of neuromodulation in treating coronary artery disease, peripheral vascular disease (PVD), headache, and peripheral field stimulation. RESULTS: Our systematic literature search found 10, 6, and 3 controlled studies relating to coronary artery disease, PVD, and headache, respectively. Our review also included 5 noncontrolled studies relating to peripheral field stimulation, as no controlled studies had been completed. CONCLUSION: This review article shows compelling evidence based on clinical trials that neuromodulation can be of benefit for patients with serious painful conditions that are not currently approved by the FDA.

Methylglyoxal induces systemic symptoms of irritable bowel syndrome.

Patients with irritable bowel syndrome (IBS) show a wide range of symptoms including diarrhea, abdominal pain, changes in bowel habits, nausea, vomiting, headache, anxiety, depression and cognitive impairment. Methylglyoxal has been proved to be a potential toxic metabolite produced by intestinal bacteria. The present study was aimed at investigating the correlation between methylglyoxal and irritable bowel syndrome. Rats were treated with an enema infusion of methylglyoxal. Fecal water content, visceral sensitivity, behavioral tests and serum 5-hydroxytryptamine (5-HT) were assessed after methylglyoxal exposure. Our data showed that fecal water content was significantly higher than controls after methylglyoxal exposure except that of 30 mM group. Threshold volumes on balloon distension decreased in the treatment groups. All exposed rats showed obvious head scratching and grooming behavior and a decrease in sucrose preference. The serum 5-HT values were increased in 30, 60, 90 mM groups and decreased in 150 mM group. Our findings suggested that methylglyoxal could induce diarrhea, visceral hypersensitivity, headache as well as depression-like behaviors in rats, and might be the key role in triggering systemic symptoms of IBS.

Técnica de inhibición de la musculatura suboccipital / Inhibition technique of the suboccipital musculature

Las técnicas de inhibición son procedimientos de tratamiento osteopático aplicado en los tejidos blandos, que buscan una inhibición en dichos tejidos, como elemento integrador del tratamiento, donde gracias a la aplicación constante de presión ejercida durante un tiempo establecido, consigue equilibrar y normalizar el tono muscular y la actividad refleja correspondiente al área lesionada. Concretamente en la musculatura suboccipital se busca la normalización del tono muscular en el segmento C0-C1-C2, para actuar directamente sobre las estructuras musculoesqueléticas del segmento cervical alto y el paquete vásculo-nervioso, teniendo gran repercusión sobre una multitud de síntomas que observamos a diario en nuestros pacientes, que describiremos, convirtiendo a esta técnica en una excelente herramienta para el tratamiento osteopático, la cual ha demostrado su utilidad (AU)

Inhibition techniques are methods of osteopathic treatmente applied to soft tissues, seeking the inhibition of these tissues, as an integral element of treatment, where, thanks to the constant application of pressure exerted during a set time, muscle tone and corresponding reflex activity are balanced and normalized. Specifically, normalization of muscle tone in the C0-C1-C2 segment is sought in the suboccipital musculature in order to act directly on the musculoskeletal structures of the high cervical segment and the vascular-nervous package, having a great effect on a multitude of symptoms that we see every day in our patients, which will be described, making this technique an excellent tool for osteopathic treatment, which has proved its usefulness (AU)

Influence of family psychiatric and headache history on migraine-related health care utilization.

OBJECTIVE: We sought to examine the relationship of family history of headache and family history of psychiatric disorders on self-reported health care utilization tendencies for migraine treatment. BACKGROUND: Familial aggregation of both migraine and depression has been well established in the literature. Family history of headache and psychiatric disorders could influence health care utilization tendencies for migraine. METHODS: This is a secondary analysis of patients with severe migraine (n = 225) who answered questions about their family history, previous headache treatment history, disability (Headache Disability Inventory), and psychiatric symptoms (Beck Depression Inventory and Beck Anxiety Inventory). Using regression, we examined the relationship between family history of headache, depression, and anxiety and reported headache-related health care utilization. RESULTS: Participants reported family histories of headache (67.6%), anxiety (15.6%), and depression (29.3%). Participants reported seeing a physician for headache an average of 3.1 (standard deviation = 3.8) times in the past 2 years. In a 2-year period, 27.6% of participants reported seeing a general practitioner and 18.5% of participants reported seeing a neurologist. Twenty-eight percent of participants went to urgent care for headaches at least once in the last 2 years. Thirty-nine percent of participants reported using non-pharmacologic treatment for headache in the prior 2 years, with the highest rates of chiropractic manipulation (27.1%) and massage (18.2%), and fewest rates of biofeedback (0.4%), relaxation training (4.4%), psychotherapy (1.8%), physical therapy (4.9%), or acupuncture (1.8%). Family history of anxiety was associated with trying non-pharmacologic treatments for headache, but no other self-reported health care utilization variable. However, neither family history of headache nor family history of depression was associated with self-reported health care utilization tendencies. Headache Disability Inventory was associated with self-reported non-pharmacologic treatments for headache. CONCLUSIONS: Family history of anxiety, but not depression, was associated with utilizing non-pharmacologic treatments for headache. Also, disability was associated with utilizing non-pharmacologic treatments for headache. However, participants reported low rates of utilization for non-pharmacologic treatments with grade-A evidence.

Improving tinnitus with mechanical treatment of the cervical spine and jaw.

BACKGROUND: Tinnitus affects approximately 30-50 million Americans. In approximately 0.5-1.0% of the population, tinnitus has a moderate to severe impact on their quality of life. Musculature and joint pathologies of the head and neck are frequently associated with tinnitus and have been hypothesized to play a contributing role in its etiology. However, specific physical therapy interventions to assist in improving tinnitus have not yet been reported. PURPOSE: To describe the examination and treatment intervention of a patient with subjective tinnitus. PATIENT DESCRIPTION: The patient was a 42-yr-old male experiencing intermittent bilateral tinnitus, headaches, blurred vision, and neck tightness. His occupation required long-term positioning into neck protraction. Examination found limitations in cervical extension, bilateral rotation, and side bending. Asymmetry was also noted with temporomandibular joint (TMJ) movements. Upon initial evaluation the patient demonstrated functional, physical, and emotional deficits per neck, headache, and dizziness self-report scales and a score on the Tinnitus Handicap Inventory (THI) of 62. Resisted muscle contractions of the cervical spine in flexion, extension, and rotation increased his tinnitus. INTERVENTION: Treatment focused on normalizing cervical spine mobility through repetitive movements, joint mobilization, and soft tissue massage. RESULTS: At 2.5 mo, the patient demonstrated a complete reversal of his tinnitus after 10 physical therapy sessions as noted by his score of 0 on the THI upon discharge. He also demonstrated objective improvements in his cervical motion. This case reflected treatment targeted at cervical and TMJ impairments and notable improvements to tinnitus. Future studies should further explore the direct and indirect treatment of tinnitus by physical therapists through clinical trials.

Disability and quality of life in headache: where we are now and where we are heading.

Headache disorders determine relevant personal and societal burden, and thus the use of patient-reported outcome measures (PROMs) investigating the level of disability and health-related quality of life (HRQoL) have been increasingly used in headache research. The aim of this review was to address the status of research on disability and HRQoL, by addressing results from recently published clinical trials as well as in longitudinal observational studies on headache patients. PubMed has been searched for papers in which measures of HRQoL and/or disability were used as primary or secondary outcome on adult subjects with primary headache, and published in 2010-2012. Among the 70 records retrieved, 12 papers were selected for narrative synthesis. They included data on 2,621 patients with episodic migraine with and without aura, chronic daily headache, and/or chronic migraine with and without medication overuse. The selected trials investigated the efficacy of different pharmacological prophylaxis, of some surgical approaches, of education programmes and osteopathic manipulative treatment; two studies reported longitudinal observations of patients currently under treatment. Overall, the results of our review showed that headache frequency as well as HRQoL and disability were positively impacted by treatment interventions; positive outcomes were less evident in two studies, and similar results were found in the two observational studies. Our findings confirmed that the most commonly used PROMs, including disease-specific tools to assess disability and HRQoL and SF-36, are sensitive to the beneficial effects occurring over time in functioning and quality of life domains in headache patients. They also suggest that the personal and societal costs of headache disorders are likely to be reduced when headache patients receive appropriate treatments and when continuity of care is offered. In terms of future directions, we note that the systematic use of appropriate PROMs should be encouraged both in the clinical practice and in the research field, as they offer a valid option to assess the global effect of treatments on patient-perceived sense of well-being and quality of performance.

Effects of anger awareness and expression training versus relaxation training on headaches: a randomized trial.

BACKGROUND AND PURPOSE: Stress contributes to headaches, and effective interventions for headaches routinely include relaxation training (RT) to directly reduce negative emotions and arousal. Yet, suppressing negative emotions, particularly anger, appears to augment pain, and experimental studies suggest that expressing anger may reduce pain. Therefore, we developed and tested anger awareness and expression training (AAET) on people with headaches. METHODS: Young adults with headaches (N = 147) were randomized to AAET, RT, or a wait-list control. We assessed affect during sessions, and process and outcome variables at baseline and 4 weeks after treatment. RESULTS: On process measures, both interventions increased self-efficacy to manage headaches, but only AAET reduced alexithymia and increased emotional processing and assertiveness. Yet, both interventions were equally effective at improving headache outcomes relative to controls. CONCLUSIONS: Enhancing anger awareness and expression may improve chronic headaches, although not more than RT. Researchers should study which patients are most likely to benefit from an emotional expression or emotional reduction approach to chronic pain.

Treatment of orthostatic headache without intracranial hypotension: a case report.

INTRODUCTION: Orthostatic headache is very suggestive of intracranial hypotension. It has a good prognosis as it usually responds to conservative treatment or epidural blood patches. CASE REPORT: A 36-year-old female presented with severe and prolonged orthostatic headache starting after a seizure. No stigma of intracranial hypotension was detected on brain MRI, and intracranial pressure was within normal range. No imaging evidence of a fistula was found. She was refractory to symptomatic treatment including five epidural blood patches. Progressive improvement occurred simultaneously to the introduction of vitamin A supplementation. DISCUSSION: A series of six similar patients is discussed, in which five patients remained severely symptomatic and workdisabled at an average follow-up of four years. It is proposed that the pathophysiological mechanism producing orthostatic headache might not be dependent on intracranial hypotension and could respond to vitamin A.