Headache in Multiple Sclerosis: A Narrative Review.

Background: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system characterized by autoimmune-mediated damage to oligodendrocytes and subsequent myelin destruction. Clinical implications: Clinically, the disease presents with many symptoms, often evolving over time. The insidious onset of MS often manifests with non-specific symptoms (prodromal phase), which may precede a clinical diagnosis by several years. Among them, headache is a prominent early indicator, affecting a significant number of MS patients (50-60%). Results: Headache manifests as migraine or tension-type headache with a clear female predilection (female-male ratio 2-3:1). Additionally, some disease-modifying therapies in MS can also induce headache. For instance, teriflunomide, interferons, ponesimod, alemtuzumab and cladribine are associated with an increased incidence of headache. Conclusions: The present review analyzed the literature data on the relationship between headache and MS to provide clinicians with valuable insights for optimized patient management and the therapeutic decision-making process.

Prevalence of primary headaches in multiple sclerosis patients.

BACKGROUND: Multiple sclerosis (MS) is the most common immune-mediated inflammatory disease of the central nervous system. It is characterized by symptoms such as visual disturbances, paresis with spasticity, paresthesia, numbness, and fatigue. However, several studies have shown a high prevalence of headaches in individuals with MS. Migraine and tension-type headaches are the most frequent types of headaches experienced by those with MS. Additionally, the role of MS disease-modifying agents must be considered. These agents have different modes of action and side effect profiles, and their use may sometimes trigger headaches in patients with MS. OBJECTIVES: This study aimed to explore the prevalence and clinical characteristics of primary headaches in MS patients. The relationship between headache and clinical features of MS (Course of MS, duration, EDSS, brain imaging and DMD) are also investigated. SUBJECTS AND METHODS: Two hundred and eighty-one MS patients diagnosed according to according to the 2017 revisions to the McDonald Criteria were included in the study. Data was collected from the MS unit medical records and from the interview with the patients. Patients with reported headaches are asked to recall their headache characteristics and patterns using an interviewer administered Arabic language-structured validated questionnaire. RESULTS: The median age of patients was 33 years old, with a range of 22-55. Tension-type headache (TTH) was more common in males, patients with more severe disability (EDSS ≥ 3), and those with SPMS and PPMS phenotypes. Additionally, patients on rituximab or cyclophosphamide therapy were more likely to have TTH. On the other hand, females, patients with milder disability (EDSS < 3), and those with RRMS phenotype were more likely to have migraine. This was also true for patients with MRI lesions involving the periaqueductal gray, and those receiving INF or fingolimod (P < 0.05). Periaqueductal gray matter lesions were found in the MRI of 48 patients (40 %) who experienced headaches on more than 10 days per month. Sensorimotor lesions in the brain were found in 55 patients (53.4 %) with severe headaches (p-value < 0.001). Interferons were associated with an increased risk of worsening preexisting headaches and the appearance of de novo headaches related to its intake (odds ratio: 2.84, 3.72; relative risk: 1.63, 2.04; p-value = 0.03, < 0.001, respectively). On the other hand, rituximab was associated with a decreased risk of worsening preexisting headaches and the appearance of de novo headaches related to its intake (odds ratio: 0.04, 0.09; relative risk: 0.11, 0.18; p-value = < 0.001, < 0.001, respectively). CONCLUSION: Primary headaches are a common occurrence in patients with MS. Migraines and tension-type headaches (TTH) are among the most prevalent types. It has been observed that interferon can exacerbate preexisting headaches and even cause new ones. Additionally, the location of MS plaques may play a role in the frequency and severity of headaches.

Effects on temporomandibular disorder in the treatment of tension-type headache with acupuncture and therapeutic exercises. A secondary analysis from a randomized controlled trial.

OBJECTIVES: To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment. DESIGN: Pre-planned secondary analysis of a randomized controlled, non-blinded trial. SETTING: Outpatient clinic of a German university hospital. SUBJECTS: Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups. INTERVENTIONS: Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months. MAIN MEASURES: Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed. RESULTS: Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: -5 [SD 1.436]; therapeutic exercise: -4 [SD 1.798]; combination: -3 [SD 1.504]; P = 0.03). After 6 months, only acupuncture (-6 [SD 1.736]) showed a significant improvement compared to the usual care group (P < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment. CONCLUSIONS: Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache.

Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report.

BACKGROUND: Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary treatment for a patient with chronic tension-type headache who suffered from chronic headache refractory to treatment. CASE PRESENTATION: The patient was a 45-year-old Japanese male suffering from 20 years of headache. As his headache had worsened recently, he visited a local clinic. With the diagnosis of suspected tension-type headache, its treatment was unsuccessful and he was referred to our hospital. The neurology department confirmed the tension-type headache and prescribed another medication, but he showed no improvement. Then, the patient was referred to the rehabilitation medicine department for consultation. At the initial visit, we identified multiple myofascial trigger points in his bilateral posterior neck and upper back regions. At the initial visit, he was prescribed 10 mL of 1% lidocaine injected into the muscles in these areas. In addition, he received 2000 extracorporeal shock wave therapy into bilateral trapezius muscles, and was instructed to take oral Kakkonto extract granules, benfotiamine, pyridoxine hydrochloride, and cyanocobalamin. Cervical muscle and shoulder girdle stretches and exercises were also recommended. At follow-up treatment visits, we used extracorporeal shock wave therapy to bilateral trapezius muscles, which led to immediate pain relief. After 11 weeks, he was not taking any medication and his headache was subjectively improved and his medical treatment ended. CONCLUSION: A patient with chronic tension-type headache refractory to regular treatment was successfully treated with a multimodal approach including extracorporeal shock wave therapy in addition to standard treatment. For patients with tension-type headache accompanied by myofascial trigger points, it may be recommended to promptly consider aggressive multimodal treatment that includes extracorporeal shock wave therapy.

Does Tension Headache Have a Central or Peripheral Origin? Current State of Affairs.

PURPOSE OF REVIEW: The aim of this narrative review is to analyze the evidence about a peripheral or central origin of a tension headache attack in order to provide a further clarification for an appropriate approach. RECENT FINDINGS: Tension headache is a complex and multifactorial pathology, in which both peripheral and central factors could play an important role in the initiation of an attack. Although the exact origin of a tension headache attack has not been conclusively established, correlations have been identified between certain structural parameters of the craniomandibular region and craniocervical muscle activity. Future research should focus on improving our understanding of the pathology with the ultimate goal of improving diagnosis. The pathogenesis of tension-type headache involves both central and peripheral mechanisms, being the perpetuation over time of the headache attacks what would favor the evolution of an episodic tension-type headache to a chronic tension-type headache. The unresolved question is what factors would be involved in the initial activation in a tension headache attack. The evidence that favors a peripheral origin of the tension headache attacks, that is, the initial events occur outside the brain barrier, which suggests the action of vascular and musculoskeletal factors at the beginning of a tension headache attack, factors that would favor the sensitization of the peripheral nervous system as a result of sustained sensory input.

Clinical Profile of Tension Type Headache in a Medical College with Special Emphasis on Triggering Factors.

Background and Objectives: Tension type headache is one of the costliest primary headaches which can cause a significant impact on an individual's life. Healthcare professionals are exposed to multiple trigger factors which give rise to an increase in headache frequency, most notable reasons being sleep disturbances, stress and untimely food habits. With this background, we conducted this study of detailed clinical profile and trigger factors among the 2050 subjects (MBBS students: 909, BDS students: 323, nursing students: 268, postgraduates students and staff: 550) in our medical institute. Materials and Methods: Subjects were given questionnaires on headache and were instructed to give the details of their clinical symptoms along with relevant questions on trigger factors. The assessment tools used were the Visual Analogue Scale (VAS) and Migraine Disability Assessment Scale (MIDAS). Results: Out of 2050 subjects, 464 patients suffered from tension type headache. Overall prevalence of tension type headache was 22.6%. Prevalence was higher in females (57.9%) as compared to males (42.1%). Headache experienced by majority of the student population was unilateral (31.4%), pulsating type (51.6%) and of moderate intensity (77.1%). Common associated symptoms were nausea associated with other factors (40%) and photophobia and phonophobia (18.6%). Stress (72.1%) and decreased sleep (49.4%) were the most common triggering factors. Practice of self-medication was reported by 80.2% of subjects. Conclusion: Our study noted a high frequency of trigger factors in medical professionals, the most common triggering factors being stress and disturbed sleep. To our knowledge this is the first large study to evaluate headache and specifically tension type headache among medical professionals.

Characterization of persistent post-traumatic headache and management strategies in adolescents and young adults following mild traumatic brain injury.

Characteristics of persistent post-traumatic headache (PTH) in young individuals are poorly known leading to diagnostic problems and diverse management. We aimed to describe headache phenotypes and self-reported management strategies in young individuals with PTH following mild traumatic brain injury (mTBI). A comprehensive structured questionnaire was used to evaluate headache phenotypes/characteristics and management strategies to relieve headache in 107, 15-30-year-old individuals with PTH. Around 4 months post-injury, migraine-like headache in combination with tension-type like headache (40%) was the most commonly encountered headache phenotype followed by migraine-like headache (36%). Around 50% reported aura-like symptoms before/during the headache attack. Medication-overuse headache was diagnosed in 10%. Stress, sleep disturbances, and bright lights were the most common trigger factors. More than 80% reported that their headache was worsened by work-related activity and alleviated by rest/lying down. Simple analgesics were commonly used (88%) whereas prophylactic drugs were rarely used (5%). Bedrest and physiotherapy were also commonly used as management strategies by 56% and 34% of the participants, respectively. In conclusion, most young individuals with PTH after mTBI presented with combined migraine-like and tension-type-like headache followed by migraine-like headache, only. Preventive headache medication was rarely used, while simple analgesics and bedrest were commonly used for short-term headache relief.

Cefalea como motivo de consulta: la visión desde atención primaria / Headache as a reason for consultation: the primary care perspective

Introducción: La cefalea es un motivo de consulta frecuente en atención primaria (AP), sin embargo, se trata de una patología infradiagnosticada e infratratada. Uno de los posibles factores es la falta de formación de los profesionales de AP en cefaleas.MétodosEstudio descriptivo transversal mediante encuesta autoadministrada a los médicos de AP de nuestro sector sanitario. Se recogieron variables sociodemográficas, variables relacionadas con la formación previa en neurología y cefaleas y variables en relación con sus necesidades formativas.ResultadosCompletaron la encuesta 104 médicos de AP, de los cuales el 53% fueron mujeres y la edad media fue 49 años. La mayoría de los encuestados trabajan en un centro de salud urbano (42,3%) y se han formado vía MIR (77,9%). El 65,4% dedica más tiempo a una consulta de cefaleas que a otras consultas y solo un 32,7% utiliza la Clasificación Internacional de Cefaleas. El 68,3% declara tener un interés alto o muy alto en cefaleas y al 75,9% le gustaría mejorar su formación, eligiendo cursos teórico-prácticos y ponencias de actualización como la herramienta más útil. Un 90% utiliza triptanes en su práctica clínica diaria y el 78% emplea tratamientos preventivos. El fármaco más utilizado es amitriptilina y solo un 22,1% elige topiramato.ConclusionesLos profesionales de AP están en contacto constante con pacientes con cefaleas y muestran interés en la formación en esta patología, lo que podría ayudarnos a diseñar programas docentes dirigidos a mejorar la calidad asistencial en este ámbito. (AU)

Introduction: Headache is a frequent reason for consultation with primary care (PC) physicians. However, the condition is underdiagnosed and undertreated. One reason for this may be the lack of specific training on headache in PC.MethodsWe conducted a descriptive cross-sectional study of data gathered with a self-administered survey that was completed by PC physicians from our health district. We collected sociodemographic data and information on previous training in neurology and headache, and training needs.ResultsThe survey was completed by 104 PC physicians, 53% of whom were women; mean age was 49 years. Most respondents worked in urban settings (42.3%) and had been trained via residency (77.9%). Although 65.4% spent more time with patients with headache than with other patients, only 32.7% used the International Classification of Headache Disorders. In our sample, 68.3% of respondents reported a high or very high interest in headache, and 75.9% wished to receive further training on the condition; theoretical and practical courses and update lectures were regarded as the most useful tools. In clinical practice, 90% used triptans and 78% used preventive treatments. The most frequently used drug was amitriptyline; only 22.1% choose topiramate.ConclusionsPC physicians are in frequent contact with patients with headache and show interest in receiving training on this condition. This could be helpful in designing training programmes aimed at improving quality of care in this area. (AU)

Nociplastic pain: towards an understanding of prevalent pain conditions.

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognise this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

Falta de rigor científico de dos investigaciones de series de casos sobre diplomáticos estadounidenses en La Habana / Lack of scientific consistency in two investigations of case series of United States diplomats in Havana

Introducción: Con el propósito de justificar la decisión diplomática de los Estados Unidos, se publicaron dos artículos científicos en revistas médicas que intentan sostener la idea de que en La Habana hubo un ataque dirigido a personal de la embajada estadounidense. Objetivo: Demostrar la falta de rigor científico en dos investigaciones de series de casos no independientes sobre los síntomas de salud de diplomáticos de los Estados Unidos en La Habana. Método: Se realiza un análisis documental de dos publicaciones de series de casos. Se evalúan hipótesis diagnósticas. Resultados: Existe superposición amplia entre las dos series en cuanto a pacientes compartidos y en contraste se presentan algunas diferencias en los datos clínicos que superan lo esperado. Conclusiones: En ambas publicaciones se desaprovecha la riqueza semiográfica de síntomas y la información psicosocial. Se enfatiza más en argumentos asociados al fetichismo de la tecnología expresado en la interpretación de hallazgos inespecíficos. El análisis de datos clínicos permitió ver que se trata de un grupo heterogéneo de personas cuyas quejas de salud han sido reunidas por la interacción de otros factores psicosociales contextuales(AU)

Introduction: In order to justify the diplomatic decision of the United States, two scientific articles were published in medical journals that attempt to support the idea that, in Havana, there was an attack aimed at US embassy personnel. Objective: To prove the lack of scientific consistency in two investigations of non-independent case series on the health symptoms of United States diplomats in Havana. Method: A documentary analysis of two publications of case series is carried out. Diagnostic hypotheses are evaluated. Results: There is wide overlap between the two series in terms of shared patients and in contrast there are some differences in the clinical data that exceed what was expected. Conclusions: In both publications the semiographic wealth of symptoms and psychosocial information are wasted. More emphasis is placed on arguments associated with the fetishism of technology expressed in the interpretation of nonspecific findings. The analysis of clinical data allowed us to see that it is a heterogeneous group of people whose health complaints have been brought together by the interaction of other contextual psychosocial factors(AU)

Impaired neck motor control in chronic whiplash and tension-type headache.

OBJECTIVES: The purpose of this study is twofold, first to present a new method based on head laser tracking designed to measure head or hand movements and second to further investigate if patients suffering from chronic whiplash or tension-type headache have impaired motor control of neck muscles. MATERIAL AND METHODS: A new laser tracking instrument was designed to measure the ability of a test person to track a reference point moving on the wall by a laser fixed to the forehead or held in the hand. The reference point to be tracked moves in runs of a circle or a square at three different speeds 10, 20, or 30 cm/s. We used a 1 × 1 ×1 m setup geometry to provide head movements well below pain release. Groups of 22 patients diagnosed with chronic whiplash-associated disorder grade 2, 19 patients diagnosed with chronic tension-type headache, and 37 control persons were compared. RESULTS: A small but highly significant dyscoordination of head movements was observed in both patient groups and in whiplash also of the hand. CONCLUSIONS: Our study presents a new method based on laser tracking for precision quantitative measurements of head or hand movements during standardized conditions. The results confirm that motor control of head movements is impaired in both chronic whiplash and tension-type headache, and in whiplash also of the hand. This suggests involvement of the central nervous system in the pathology of these diseases.

Watermelon and others plant foods that trigger headache in migraine patients.

Background: Food is already recognized as a trigger for migraine, but its mechanism of action has not been fully clarified. There is evidence that they act on the pathogenesis of migraine, interfering with meningeal inflammation, vasodilation and cerebral glucose metabolism.Aim: The aim of this study was to know which plant foods are triggers for migraine and the latency time for the onset of pain.Method: We interviewed patients with migraine and tension-type headache about plant foods that trigger headache and onset time of the headache. We studied 3,935 migraine patients and 1,163 with tension-type headache.Results: There were headaches triggered by plant foods after 90.5 ± 7.9 minutes of ingestion in 40.3% (1,584/3,935) of migraine patients and none with tension-type headache. Headaches triggered by plant foods intake are distributed in the following order of frequency: watermelon (29.5%), passion fruit (3.73%), orange (2.01%), pineapple (1.52%), grape (0.51%), banana (0.46%), cucumber (0.43%), acerola (0.25%) and papaya (0.25%).Conclusions: Many plant foods, especially watermelon, may trigger headache attacks in migraine patients within a few minutes.

Photophobia and allodynia in persistent post-traumatic headache are associated with higher disease burden.

OBJECTIVE: To assess photophobia and allodynia in subjects with post-traumatic headache and examine how these sensory hypersensitivities associate with clinical measures of disease burden. BACKGROUND: Post-traumatic headache is the most frequent and disabling long-term consequence of mild traumatic brain injury. There is evidence of sensory dysfunction in acute post-traumatic headache, and it is known from other headache conditions that sensory amplifications correlate with more severe disease. However, systematic studies in post-traumatic headache are surprisingly scarce. METHODS: We tested light and tactile sensitivity, along with measures of disease burden, in 30 persistent post-traumatic headache subjects and 35 controls. RESULTS: In all, 79% of post-traumatic headache subjects exhibited sensory hypersensitivity based on psychophysical assessment. Of those exhibiting hypersensitivity, 54% exhibited both light and tactile sensitivity. Finally, sensory thresholds were correlated across modalities, as well as with headache attack frequency. CONCLUSIONS: In this study, post-traumatic headache subjects with both light and tactile sensitivity had significantly higher headache frequencies and lower sensitivity thresholds to both modalities, compared to those with single or no sensory hypersensitivity. This pattern suggests that hypersensitivity across multiple modalities may be functionally synergistic, reflect a higher disease burden, and may serve as candidate markers of disease.

Tension-type headache.

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

Efecto de las técnicas neuromusculares y de jones en pacientes bruxistas con cefaleas tensionales episódicas y crónicas / No disponible

INTRODUCCIÓN: El bruxismo es una disfunción temporomandibular que tensa los músculos de la masticación, especialmente los músculos temporales y maseteros, y que a su vez puede causar cefaleas tensionales episódicas o crónicas. OBJETIVOS: Valorar el efecto de las técnicas neuromusculares y de Jones aplicadas sobre el músculo temporal en la amplitud de la apertura vertical de la boca, el umbral del dolor a la presión y la extensión craneocervical, en pacientes bruxistas con cefaleas tensionales episódicas y crónicas. MATERIAL Y MÉTODOS: Estudio experimental, tipo ensayo clínico aleatorizado y doble ciego. Se realizaron con cada paciente tres sesiones de osteopatía. La muestra estuvo formada por 52 pacientes diagnosticados de bruxismo y cefaleas tensionales episódicas y crónicas, a los que se aplicó las técnicas neuromuscular y técnica de Jones en el músculo temporal (grupo experimental), o una intervención control (contacto occipital). Se llevaron a cabo mediciones antes de hacer la intervención, inmediatamente después de realizar las técnicas y tres días después de realizar las técnicas con algometría de los puntos gatillos de la musculatura temporal, inclinometría para el movimiento craneocervical, así como mediciones de la apertura vertical de la boca con pie del rey. RESULTADOS: El grupo experimental obtuvo mejoras significativas en la apertura vertical de la boca (p < 0,001), en el umbral del dolor a la presión sobre el punto seleccionado del músculo temporal (p < 0,001) y en la en extensión craneocervical (p < 0,001). CONCLUSIONES: Las técnicas neuromusculares y de Jones aplicadas sobre el músculo temporal en pacientes bruxistas con cefaleas tensionales son útiles de cara a obtener mejoras en aspectos de interés en patologías álgicas diversas a nivel craneocervical

No disponible

Impact of 24-Hour On-Call Shifts on Headache in Medical Residents: A Cohort Study.

BACKGROUND: During 24-hour on-call shifts medical residents are exposed to diverse circumstances such as sleep deprivation and stress. OBJECTIVE: Our aim is to assess the effect of 24-hour on-call shifts on medical residents' headache-related disability. METHODS: The Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test (HIT-6), the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS) questionnaires were administered to medical residents who had never performed on-call shifts at baseline and 6 months after beginning 24-hour on-call shifts. Scores were compared. RESULTS: About 66 medical residents completed this study. About 21.2% (n = 14) had history of migraine, 42.4% (n = 28) had a history of tension-type headache (TTH) and 12.1% (n = 8) had a history of both migraine and TTH. Among medical residents with migraine, the median MIDAS score was significantly higher after starting 24-hour on-call shifts than at a baseline (4.0 vs 8.0; Wilcoxon, P = .001), meaning that, on average, disability increased from little or no disability, to moderate disability. No difference in HIT-6 scores was found. The median score of PSQI and HADS was higher at 6 months (PSQI: 7.0 vs 8.0; P = .003), (HADS: 5.0 vs 8.0; P < .001) for the general group. CONCLUSIONS: In medical residents with migraine, migraine-related disability increased after starting 24-hour on-call shifts. We also found a worsening in depression and anxiety symptoms and self-reported sleep quality in medical residents with and without headache history.

Headache at the Chronic Stage of Ischemic Stroke.

BACKGROUND: Headache in ischemic stroke survivors after the acute stage is incompletely described. OBJECTIVE: We aimed to prospectively describe the characteristics of headache and the predictors of headache at the chronic stage after ischemic stroke. METHODS: We conducted a prospective observational cohort study including 102 acute ischemic stroke patients admitted to a Stroke Unit. Patients were interviewed at the acute and the chronic stage (12 months after stroke). Characteristics of those headaches were collected using a previously validated headache questionnaire enabling headache classification following the International Headache Society criteria. Pre-stroke headache history was registered using the same instrument. RESULTS: Forty-five patients out of 89 with completed follow-up (51%) reported headache at the chronic stage. In most of the patients, headache was sporadic, mild, pressure-like, with a duration of minutes to hours, with characteristics of tension-type headache in 51% (n = 23/45). Headache was a reactivation of pre-stroke headache in 33% (n = 15/45), different from pre-stroke headache in 44% (n = 20/45), and of new-onset in 22% (n = 10/45). Only 1 patient had a new-onset headache at the acute stage that persisted with the same characteristics at the chronic stage. Pre-stroke headache (OR = 5.3; 95% CI [2.01-13.98] P = .001) and female sex (OR = 3.5; 95% CI [1.3-9.4] P = .013) predicted headache at the chronic stage after stroke, controlling for age, severity, and location of stroke. CONCLUSIONS: Headache in ischemic stroke survivors at the chronic stage is more frequent in women and in patients with pre-stroke headache. It is most frequently a headache with different characteristics of the pre-stroke headache and only rarely a new-onset headache starting at the acute stage and persisting at the chronic stage.

Appraisal of Headache Trigger Patterns Using Calendars.

OBJECTIVE: Using experimental, yet realistic, headache calendars, this laboratory study evaluated the ability of individuals to identify the degree of association between triggers and headaches. BACKGROUND: Individuals with headache often record daily diaries or calendars to identify their patterns of triggers. METHODS: This cross-sectional, observational study included adults with migraine, tension-type, or cluster headache who had ever experienced more than 5 attacks. Participants (N = 300) were presented with headache calendars and asked to rate the strength of the relationship (how strongly one causes the other) between 3 experimental triggers (high stress, poor sleep, and cinnamon) and headache using a 0 ("no relationship") to 10 ("perfect relationship") scale for each calendar. RESULTS: Calendars with a high positive correlation between trigger and headache had higher participant ratings than those with low correlations. The median [25th, 75th] of ratings for each correlation level was low correlation: 1 [0, 4], medium: 4 [2, 5], and high: 5 [4, 8], P < .0001. However, participants appeared to ignore negative associations (ie, trigger present with no headache) and rated calendars with more headache days as having higher associations, regardless of the true relationship. The ratings for 2, 6, and 26 headache days were 1 [0, 3], 4 [1, 6], and 8 [0, 10], respectively (P < .0001). Participants' previous beliefs about the triggers also affected their ratings (average correlation across triggers: r = 0.25, P < .0001). CONCLUSIONS: This laboratory task supports the notion that individuals with headache are able to identify the association between headaches and triggers using headache calendars. However, these judgments can be biased by the individuals' previous beliefs about the trigger and by the degree of headache activity.

Different clinical phenotypes of persistent post-traumatic headache exhibit distinct sensory profiles.

INTRODUCTION: Persistent post-traumatic headache remains a poorly understood clinical entity. Although there are currently no accepted therapies for persistent post-traumatic headache, its clinical symptoms, which primarily resemble those of migraine or tension-type headache, often serve to guide treatment. However, evidence-based justification for this treatment approach remains lacking given the paucity of knowledge regarding the characteristics of these two major persistent post-traumatic headache phenotypes and their etiology. METHODS: We compared clinical features and quantitative sensory testing profiles between two distinct cohorts of persistent post-traumatic headache subjects that exhibited symptoms resembling either migraine (n = 15) or tension-type headache (n = 13), as well as to headache-free subjects that had suffered traumatic brain injury (n = 19), and to healthy controls (n = 10). We aimed to determine whether the two persistent post-traumatic headache subgroups could be discriminated based on additional clinical features, distinct quantitative sensory testing profiles, or the interaction of pain severity with the level of post-traumatic stress disorder. RESULTS: Persistent post-traumatic headache subjects with migraine-like symptoms reported that bright light and focused attention aggravated their pain, while stress and nervousness were reported to aggravate the headache in subjects with tension-type headache-like symptoms. Quietness was better in alleviating migraine-like persistent post-traumatic headache, while anti-inflammatory medications provided better relief in tension-type headache-like persistent post-traumatic headache. The two persistent post-traumatic headache subgroups exhibited distinct quantitative sensory testing profiles with subjects exhibiting tension-type headache-like persistent post-traumatic headache displaying a more pronounced cephalic and extracephalic thermal hypoalgesia that was accompanied by cephalic mechanical hyperalgesia. While both persistent post-traumatic headache subgroups had high levels of post-traumatic stress disorder, there was a positive correlation with pain severity in subjects with tension-type headache-like symptoms, but a negative correlation in subjects with migraine-like symptoms. CONCLUSIONS: Distinct persistent post-traumatic headache symptoms and quantitative sensory testing profiles may be linked to different etiologies, potentially involving various levels of neuropathic and inflammatory pain, and if confirmed in a larger cohort, could be used to further characterize and differentiate between persistent post-traumatic headache subgroups in studies aimed to improve treatment.

Relationship between headache and Internet addiction in children

Background/aim: We aimed to investigate Internet addiction in pediatric patients with migraine- and tension-type headache in this study. Materials and methods: Among our 200 subjects, 103 had migraine-type headache and 97 had tension-type headache. Results: Headache triggered by computer use was more common in the migraine-type headache group. There was no difference between the Internet addiction scale score of the two groups. The Internet addiction scale scores of the patients were found to differ depending on the aim and duration of computer use. Internet addiction was found in six (6%) patients. Internet addiction prevalence was 3.7% and 8.5% in the two groups, respectively. Conclusion: The prevalence of Internet addiction in children with recurrent headache was lower than that found in their peers in Turkey, possibly due to avoidance of computer use as a headache trigger. This finding raises the question of whether migraine- or tension-type headaches actually prevent Internet addiction.