Obesity as a risk factor for temporomandibular disorders.

We conducted a clinical cross-sectional study to evaluate the association between obesity and the presence of painful temporomandibular disorders (TMD), controlling for age, gender, presence of migraine, depression, non-specific somatic symptoms and obstructive sleep apnoea syndrome (OSAS) in an adult population. A total of 299 individuals (76·6% women) with a mean age of 36·8 ± 12·8 years were evaluated. TMD were classified using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Depression and non-specific somatic symptoms were scored by the Symptom Checklist-90, while pain and disability was rated by the Graded Chronic Pain Scale. Bioimpedanciometry (BIA) was used to assess obesity through total body fat percentage. Migraine was diagnosed according to the criteria of the International Classification of Headache Disorders-2 (ICHD-2). OSAS was classified according to the Berlin Questionnaire. We performed univariate and multivariate models, chi-square tests and odds ratios (OR) with 95% confidence intervals (CI). In the single regression analysis, TMD-pain was significantly associated with total body fat percentage (P = 0·01). In the multivariate analysis, migraine, age, non-specific somatic symptoms and OSAS showed to be stronger predictors of TMD-pain, and obesity did not retain in the regression model. The initial association found between obesity and TMD-pain is lost when it was corrected for gender, migraine, non-specific somatic symptoms and OSAS.

Reduced thermal threshold in patients with Temporomandibular Disorders.

BACKGROUND: Many studies have demonstrated the presence of somatosensory modulation changes at different sites in patients with temporomandibular disorders (TMDs) using different modalities. However, the neck area, a well-know condition related to TMD, remains unexplored. OBJECTIVE: To assess the thermal pain threshold in patients with TMD and controls at cephalic and extra-cephalic areas, including the neck. METHODS: Twenty female patients with TMDs diagnosed by the Research Diagnostic Criteria for TMD (RDC/TMD) and twenty age-matched controls underwent a first interview about neck pain and disability (NDI questionnaire). A blinded evaluator assessed the thermal pain threshold for cold (CPT) and heat (HPT) stimuli in accordance with an ascending method of limits of the Quantitative Sensory Testing at the following sites: periorbital, masseter, cervical posterior and ventral forearm. The groups were compared using a t-test with α = 5%. RESULTS: Patients with TMDs reported pain at higher temperature for cold stimuli in all sites (P < 0·05) and at lower temperature for heat stimuli in the right periorbital site (P < 0·05) than controls. Pain and disability due tothis symptom were reported more often in the TMD group (P < 0·05). CONCLUSION: Patients with TMD have pain modulation changes in the neck area as well, especially for cold stimuli, associated with higher disability and a higher report of neck pain than controls. These findings reinforce the evidence regarding the relationship between TMDs and neck pain.

Cervical muscle parameters and allodynia in migraine and cervical pain-A controlled study.

BACKGROUND: Neck pain is common among individuals with migraine, but there is a lack of information of how this comorbidity can be associated with cervical muscle function. This controlled cross-sectional study aimed to compare cervical muscle function, activity, and sensitization in women with migraine, neck pain, both, and neither. METHODS: This study included women, between 18 and 55 years old, with either episodic migraine with or without aura, without any concomitant headache diagnosis; chronic neck pain, with at least moderate intensity and mild disability; or neither headache nor neck pain. Pain pressure threshold, allodynia, muscle strength, and endurance and cervical muscles activity were evaluated. RESULTS: One hundred subjects, with mean age of 30.4 years old, were stratified by diagnosis (n = 25 per group) and by self-reported pain during tests. Lower endurance during flexion was observed for migraine and neck pain (34s) relative to neck pain alone (45s), migraine (40s), and controls (58s) (p = 0.04). For extensor endurance, means were 142s, 166s, 215s, and 270s, respectively (p < 0.001). Endurance times were impacted by the presence of test-induced pain decreasing about 40%-53% of the performance. Diagnostic groups did not differ significantly in strength (p > 0.05), but all pain groups presented significantly higher proportion of test-induced pain, lower muscle activity during the maximal isometric voluntary contractions, and lower pressure pain thresholds. CONCLUSION: Patients with migraine, chronic neck pain, and the association of both present altered cervical muscle function and activity. Also, test-induced pain impacts significantly on neck muscles endurance. SIGNIFICANCE: The diagnosis of migraine and chronic neck pain is associated with altered function and activity of the cervical muscles. However, the test-induced pain had an important contribution to worse cervical muscle endurance. This suggests that the therapeutic approach should focus on de-sensitization of the trigeminal-cervical complex when dealing with the comorbidity of migraine and cervical pain.

Temporomandibular disorders and cutaneous allodynia are associated in individuals with migraine.

The objective of this study was to estimate and contrast the occurrence of ictal and interictal cutaneous allodynia (CA) in individuals with migraine with and without temporomandibular disorders (TMD). Both TMD and CA are common in migraine and may be associated with migraine transformation from episodic into a chronic form. Herein we hypothesize that TMD contributes to the development of CA and to more severe headaches. In a clinic-based sample of individuals with episodic migraine, the presence of TMD was assessed using the research diagnostic criteria for myofascial or mixed (myofascial and arthralgic) TMD. Ictal CA was quantified using the validated Allodynia Symptom Checklist (ASC-12). The ASC-12 measures CA over the preceding month by asking 12 questions about the frequency of allodynia symptoms during headaches. Interictal CA was assessed in the domains of heat, cold and mechanical static allodynia using quantitative sensory testing. Our sample consists of 55 individuals; 40 (73%) had TMD (23 with myofascial TMD and 17 with the mixed type). CA of any severity (as assessed by ASC-12) occurred in 40% of those without TMD (reference group), 86.9% of those with myofascial TMD (P = 0.041, RR = 3.2, 95% CI = 1.5-7.0) and in 82.3% of those with mixed TMD (P = 0.02, RR = 2.5, 95% CI = 1.2-5.3). Individuals with TMD were more likely to have moderate or severe CA associated with their headaches. Interictally (quantitative sensory testing), thresholds for heat and mechanical nociception were significantly lower in individuals with TMD. Cold nociceptive thresholds were not significantly different in migraine patients with and without TMD. TMDs were also associated with change in extra-cephalic pain thresholds. In logistical regression, TMD remained associated with CA after adjusting for aura, gender and age. TMD and CA are associated in individuals with migraine.

Guidelines for controlled trials of drugs in tension-type headache: second edition.

The Clinical Trials Subcommittee of the International Headache Society published its first edition of the guidelines on controlled trials of drugs in tension-type headache in 1995. These aimed 'to improve the quality of controlled clinical trials in tension-type headache', because 'good quality controlled trials are the only way to convincingly demonstrate the efficacy of a drug, and form the basis for international agreement on drug therapy'. The Committee published similar guidelines for clinical trials in migraine and cluster headache. Since 1995 several studies on the treatment of episodic and chronic tension-type headache have been published, providing new information on trial methodology for this disorder. Furthermore, the classification of the headaches, including tension-type headache, has been revised. These developments support the need for also revising the guidelines for drug treatments in tension-type headache. These Guidelines are intended to assist in the design of well-controlled clinical trials in tension-type headache.

Chronic migraine and medication overuse headache: clarifying the current International Headache Society classification criteria.

Despite the recent advances in the understanding and classification of the chronic daily headaches, considerable controversy still exists regarding the classification of individual headaches, including chronic migraine (CM) and medication overuse headache (MOH). The original criteria, published in 2004, were difficult to apply to most patients with these disorders and were subsequently revised, resulting in broader clinical applicability. Nonetheless, they remain a topic of debate, and the revisions to the criteria have further added to the confusion. Even some prominent headache specialists are unsure which criteria to use. We aimed to explain the nature of the controversies surrounding the entities of CM and MOH. A clinical case will be used to illustrate some of the problems faced by clinicians in diagnosing patients with chronic daily headache.

The acute treatment of episodic and chronic migraine in the USA.

Understanding the patterns of acute treatment of migraine in the population is a necessary step in evaluating treatment in relation to guidelines, and in improving care. Herein we assess the specific medication used for the acute treatment of migraine and chronic migraine (CM) in the population. We identified 24 000 headache sufferers, drawn from over 165 000 individuals representative of the US population. This sample has been followed with annual surveys using validated questionnaires. As part of the survey, subjects were asked to report the specific medications currently used for their most severe headaches, dose, and number of days per month using medication. Complete responses were obtained from 14 540 individuals, including 9128 with episodic migraine and 503 with CM. For episodic migraine, specific treatment was used by 19.2% of subjects (triptans 18.7%; compounds with ergotamine 0.5%). A total of 11.1% routinely used opiates, whereas 6% used compounds with barbiturates. For CM, 22% used migraine-specific treatment, whereas 34.3% used opiates and barbiturates. Non-prescribed medications were frequently used in both groups. Opiates were more commonly used by those with CM [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.69, 2.65], as were butalbital-containing compounds (OR 2.46, 95% CI 1.88, 3.22). The minority of migraineurs in the USA use specific medication, and one-fifth use opiates or barbiturates. For CM, > 34% use opiates or barbiturates. Accordingly, a sizable proportion use medications that are not firstline according to the US Headache Consortium Guidelines.

New daily persistent headache in the paediatric population.

We conducted a clinic-based study focusing on the clinical features of new-onset chronic daily headaches (CDH) in children and adolescents. The clinical records and headache diaries of 306 children and adolescents were reviewed, to identify 187 with CDH. Relevant information was transferred to a standardized form that included operational criteria for the diagnoses of the headaches. Since we were interested in describing the clinical features of these headaches, we followed the criteria A and B of the 2nd edn of the International Classification of Headache Disorders (ICHD-2) and refer to them as new daily persistent headaches (NDPH) regardless of the presence of migraine features (therefore, this is a modified version of the ICHD-2 criteria). From the 56 adolescents with NDPH, most (91.8%) did not overuse medications. Nearly half (48.1%) reported they could recall the month when their headaches started. NDPH was more common than chronic tension-type headache in both adolescents overusing and not overusing medication. Individuals with NDPH had headaches fulfilling criteria for migraine on an average of 18.5 days per month. On most days, they had migraine-associated symptoms (one of nausea, photophobia or phonophobia)). NDPH is common in children and adolescents with CDH. Most subjects do not overuse medication. Migraine features are common.

Weight change and clinical markers of cardiovascular disease risk during preventive treatment of migraine.

Migraine, particularly migraine with aura, and increased body weight are independent risk factors for cardiovascular disease (CVD). The association of weight change and clinical markers of CVD risk was evaluated in subjects participating in a randomized double-blind, parallel-group study of migraine-preventive treatment comparing 100 mg/day of topiramate and amitriptyline. Individuals from both treatment groups were pooled and stratified into three groups. The 'major weight gain' group gained > or = 5% of their baseline body weight at the conclusion of the study; the 'major weight loss' group lost > or = 5% of their baseline body weight. The third group had < 5% of weight change. The influence of weight change in headache outcomes, as well as in markers of CVD (blood pressure, cholesterol, C-reactive protein), was assessed using analysis of covariance. Of 331 subjects, 52 (16%) experienced major weight gain and 56 (17%) experienced major weight loss. Weight change was not associated with differential efficacy for the treatment of headache. However, contrasted with those with major weight loss, those who gained weight experienced elevations in mean diastolic blood pressure (+2.5 vs. -1.2 mmHg), heart rate (+7.6 vs. -1.3 beats per minute), glycosylated haemoglobin (+0.09% vs. -0.04%), total cholesterol (+6.4 vs. -6.3 mg/dl), low-density lipoprotein cholesterol (+7.0 vs. -4.4 mg/dl) and triglycerides (+15.3 vs. -10.4 mg/dl) and an increase in high-sensitivity C-reactive protein (+1.8 vs. -1.9 mg/l). Both groups experienced decreases in systolic blood pressure (-4.0 vs. -1.3 mmHg) and high-density lipoprotein cholesterol (-3.7 vs. -0.8 mg/dl). Increased weight during migraine treatment is not associated with poor headache treatment outcomes, but is associated with deterioration of CVD risk markers.

Validity and reliability of the Migraine-Treatment Optimization Questionnaire.

Our aim was to establish the validity and reliability of a patient-rated Migraine Treatment Optimization Questionnaire (M-TOQ) in primary care. Patients who met International Classification of Headache Disorders, 2nd edn criteria for migraine completed a 19-item questionnaire containing candidate items for the M-TOQ, and three questionnaires designed to test convergent/construct validity [Migraine Disability Assessment Scale (MIDAS), Headache Impact Test (HIT)-6 and Migraine-Specific Quality of Life Scale (MSQoL)]. A 15-item (M-TOQ-15) and a five-item (M-TOQ-5) questionnaire were derived. Two hundred and fifty-three adult patients were recruited. Five treatment optimization domains were identified: functioning, rapid relief, consistency of relief, risk of recurrence and tolerability; with Cronbach alphas of 0.70-0.84. The Cronbach alpha for M-TOQ-15 was 0.85, and it correlated well with MIDAS, HIT-6 and MSQoL (r = 0.33-0.44). The Cronbach alpha for M-TOQ-5 was 0.66, and it also correlated well with the three questionnaires (r = 0.33-0.41). The utility of the M-TOQ for assessing treatment benefit in research (M-TOQ-15) and primary care (M-TOQ-5) should be further validated.

Utility of topiramate for the treatment of patients with chronic migraine in the presence or absence of acute medication overuse.

Chronic migraine has been linked to the excessive use of acute headache medications. Medication overuse (MO) is commonly considered the most significant risk factor for the progression of migraine from an episodic to a chronic condition. Managing MO is a challenge. Discontinuation of the acute medication can result in withdrawal headache, nausea, vomiting and sleep disturbances. This review summarizes the results from two similarly designed, randomized, placebo-controlled, multicentre studies of chronic migraine conducted in the USA and European Union. Both studies demonstrate the efficacy and safety of the migraine preventive medication, topiramate, for the treatment of chronic migraine in patient populations both with and without MO. These studies may have important implications for the future of chronic migraine management, suggesting that detoxification prior to initiating prophylactic therapy may not be required in all patients if MO is present.

Tolerability of acute migraine medications: influence of methods of assessment and relationship with headache attributes.

Tolerability is an important attribute of patient satisfaction with, and consequence adherence to, migraine acute treatment. Nevertheless, the determinants of tolerability are poorly explored. Accordingly, our objectives were: (i) in subjects receiving triptans, to contrast two methods of assessing adverse events (AEs); and (ii) to explore the relationship between migraine features and treatment attributes with tolerability. We surveyed 365 migraineurs who had been using the same triptan for at least 3 months. After prospectively treating an attack, headache characteristics and treatment response were assessed using headache calendars. Subjects also completed a standardized questionnaire, first asking about any AE and then prompting patients with a list of possible AEs. We contrasted both sets of answers and conducted logistic regression to assess if headache attributes or response to therapy influenced tolerability. Using the unprompted method, AEs occurred in 11.5-36.4% of patients, depending on the triptan used. Using the prompted method, they ranged from 26.9 to 64.3%. Chest and neck tightness were spontaneously reported by 3.5% of the sample, vs. 7.4% when prompted (P < 0.05). Chest pain was not spontaneously reported and was elicited in nine patients (2.5%, P = 0.002). Feeling groggy occurred in 5.7 and 17.5% (P < 0.001). AEs were not a function of headache severity, disability, efficacy of the drug, time to meaningful relief with the drug or recurrence of pain. The report of AEs varies dramatically with the methods of assessment. However, tolerability is not influenced by the severity of the attacks or by medication efficacy.

Do patients with migraine experience an increased prevalence of falls and fear of falling? A cross-sectional study.

OBJECTIVE: To assess the prevalence of falls and fear of falling in patients with migraine compared with controls. DESIGN: Cross-sectional. SETTING: Tertiary headache clinic. PARTICIPANTS: This study consisted of 105 controls and 105 consecutive patients diagnosed with migraine with aura (MA, n=35), migraine without aura (MO, n=35) and chronic migraine (CM, n=35). MAIN OUTCOME MEASURES: Patients were interviewed using a questionnaire containing questions about the history of falls and impairment in balance, and completed the International Falls Efficacy Scale (FES-I). Groups were contrasted using Student's t-test and analysis of variance, and prevalence ratios were estimated. RESULTS: Falls and self-reported impairment in balance are more prevalent in patients with migraine (54% and 69%, respectively) than in controls (2% and 2%, respectively). In particular, patients with CM and MA reported a greater mean number of falls during the previous year {CM 1.4 [standard deviation (SD) 2.2]; MA 2.2 (SD 2.3)} compared with patients with MO [0.5 (SD 1.0); P <0.04] and controls [0.05 (SD 0.2); P <0.002]. The prevalence ratio of falls was greater in patients with MA (7.2; P <0.002) and CM (4.5; P <0.002) compared with controls. Patients with migraine experienced a high level of concern about falls during their daily activities compared with controls (29.8 vs 20.1 points in the FES-I questionnaire; P<0.0001). CONCLUSIONS: The balance impairment of patients with migraine may have a functional impact. Migraine is associated with risk of falling, and patients exhibit a higher prevalence of impairment in balance, falls and fear of falling.

Intravenous dipyrone for the acute treatment of episodic tension-type headache: a randomized, placebo-controlled, double-blind study.

Acute headaches are responsible for a significant percentage of the case load at primary care units and emergency rooms in Brazil. Dipyrone (metamizol) is easily available in these settings, being the most frequently used drug. We conducted a randomized, placebo-controlled, double-blind study to assess the effect of dipyrone in the acute treatment of episodic tension-type headache. Sixty patients were randomized to receive placebo (intravenous injection of 10 ml saline) or 1 g dipyrone in 10 ml saline. We used seven parameters of analgesic evaluation. The patients receiving dipyrone showed a statistically significant improvement (P<0.05) of pain compared to placebo up to 30 min after drug administration. The therapeutic gain was 30% in 30 min and 40% in 60 min. The number of patients needed to be treated for at least one to have benefit was 3.3 in 30 min and 2.2 in 60 min. There were statistically significant reductions in the recurrence (dipyrone = 25%, placebo = 50%) and use of rescue medication (dipyrone = 20%, placebo = 47.6%) for the dipyrone group. Intravenous dipyrone is an effective drug for the relief of pain in tension-type headache and its use is justified in the emergency room setting.

Alteration of the motor response to an acute painful stimulus during tonic immobility.

The motor responses caused by liminal (1.0 and 3.0 mA, applied for 3 s) and subliminal electrical stimuli (40% below the liminal value) applied to the dental pulp of the upper incisors of adult guinea pigs (N = 41) are more intense during tonic immobility (TI) than in control situations. Tonic immobility is a temporary state of profound motor inhibition elicited by some form of physical restraint in our experiment induced by maneuvers of lateral postural inversion and movement restraint. This suggests the occurrence of hyperalgesia in the trigeminal territory in situations of direct confrontation with a predator, as in the case for tonic immobility. This hyperalgesia may protect in a reflex manner vital regions of the head and neck from fatal bites inflicted by the predator, but without interrupting the state of immobility, since in our experiments the electric stimuli had no disruptive effect on TI episodes.

[Headache treatment in an emergency unit of the city of Ribeirão Preto, Brazil]. / Tratamento da cefaléia em uma unidade de emergência da cidade de Ribeirão Preto.

Headache is one of the most common symptoms observed in clinical practice. It has a considerable economic impact and overburdens emergency rooms. In Brazil, most emergency rooms have no tryptans. The present study analyses the treatment provided by the Emergency Room of the University Hospital of Ribeirão Preto. In 1996, 1254 patients were treated for headache and 64 of them required hospitalization. Of the non-hospitalized (NH) patients, 77% had primary headache, as opposed to 29.7% of hospitalized patients. Of the patients with migraine, 83.6% improved with intravenous dipyrone, 66.7% improved with intramuscular diclofenac and 81.8% improved with intravenous chlorpromazine. The percentages of patients with tension-type headache who improved with the same drugs were 77.8%, 80% and 100%, respectively. Among NH patients, 16.3% improved without any medication. We conclude that the drugs used have similar efficacy profiles and costs and can be used at basic health unities. The major drawback is parenteral administration.

[Hospital costs of acute headaches in a Brazilian public emergency room unit]. / Custos hospitalares das cefaléias agudas em uma unidade de emergência pública brasileira.

Headache is one of the most frequent complain in the medical practice and a very common cause of medical assistance searching in emergency rooms, leading to considerable high costs. The headache cases assisted during the year of 1996 of an emergency room unit (UE - USP) at Ribeirão Preto, SP, Brazil, had been retrospectively studied. During that year a number of 1254 patients searched the UE - USP with major complain of acute headache, among which 64 needed hospitalization. The estimated costs due to consultation, investigation and clinical treatment of the acute headaches was in the order of R$ 138 573.31 (US$ 76 985.17). The expenses related only to laboratorial exams were R$ 23 801.54 (US$ 13 223.07). The surgical expenses were R$ 5 817.90 (US$ 3 232.17). The total cost was R$ 144 391.21 (US$ 80 217.34) which corresponds to R$ 115.14 (US$ 63.97) per patient. This calculus instigates an additional discussion about the costs and effectiveness of the current public health policy, where the financial resources are less abundant than the State dependant population's needs.

[Migraine prevalence and impact in employees of the clinical hospital of the medical school of Ribeirão Preto-USP]. / Prevalência e impacto da migrânea em funcionários do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP.

Headache is a common symptom in the population, with a life prevalence around 90%. It results in an important impact in the life quality of sufferers. The aim of this study is to evaluate the prevalence of migraine among employees of an university hospital (HC), as well as to measure the headache intensity, interference and impact in the daily activities. A total of 1890 employees had answered to a questionnaire which made possible to carry out diagnosis of migraine. Life prevalence of this headache type was 30. 4%. Pain was considered intense, most of the time, by 86% of the migraneurs. It was verified an important impact in the daily life aspects as much during as between the headache attacks. It can be concluded that migraine represents a public health problem among the HC employees. Because migraine brings about an important impact in the life quality of those workers, it is possible that a reduction of working capacity with considerable economic burden exists. This problem deserves, thus, special attention, through a better diagnostic and treatment.