Management of primary headache: serendipity and science.

Most patients find some relief with current agents, even though a poor understanding of the causes of chronic primary headache limits prophylaxis and treatment. The author reviews current preventive and treatment strategies for migraine, chronic tension headache, cluster headache, and substance withdrawal headache.

Impact of migraine and migraine therapy on productivity and quality of life.

Migraine is an expensive disorder in terms of lost productivity and its deleterious impact on health-related quality of life (QOL). In addition to lost wages and productivity due to absenteeism, many patients with migraine also experience reduced productivity while at work and disruption of their family, social, and leisure activities. Even a migraine of moderate intensity can impair function and productivity, which emphasizes the importance of therapy that achieves complete, as opposed to partial, pain relief. Rapid onset of complete relief with abatement of migraine-associated symptoms has been reported to be most relevant for patient QOL and satisfaction with migraine therapy. Several instruments have been developed for measuring health-related QOL. Both general and migraine-specific instruments have been useful in assessing the impact of migraine and migraine therapy on health-related QOL; migraine-specific instruments may be more sensitive in measuring the effects of pharmacologic intervention. Compared with placebo, rizatriptan improved productivity in migraine patients. Compared with usual care, rizatriptan had favorable effects on all five domains of the 24-Hour Migraine Quality of Life questionnaire.

Impact of headache education program in the workplace.

We evaluated the impact of a headache education program in a workplace setting. A 45-minute standardized educational program was delivered to 492 participants at eight companies. Participants completed questionnaires regarding their headaches and headache management techniques, the Short Form (SF)-36, and the Headache Disability Inventory (HDI) before and 1 month after the presentation. The intervention significantly improved health-related quality of life, decreased headache-related disability, and promoted the use of self-management techniques.

Effect of guided imagery on quality of life for patients with chronic tension-type headache.

OBJECTIVE: To determine the effect of adjuvant guided imagery on patients with chronic tension-type headache. BACKGROUND: Management of chronic tension-type headache often requires a combination of pharmacological and nonpharmacological therapies. Guided imagery is a relaxation technique based on visualizing pleasant images and body awareness. METHODS: One hundred twenty-nine patients with chronic tension-type headache completed the Headache Disability Inventory and the Medical Outcomes Study Short Form (SF-36) at their initial visit to a specialty headache center and again 1 month after the visit. In addition to individualized headache therapy, patients listened to a guided imagery audiocassette tape daily for the month. One hundred thirty-one control subjects received individualized therapy without guided imagery. RESULTS: Controls and the patients who listened to the guided imagery tape improved in headache frequency, headache severity, patient global assessment, quality of life, and disability caused by headache. More guided imagery patients (21.7%) than controls (7.6%) reported that their headaches were much better (P = .004). The guided imagery patients had significantly more improvement than the controls in three of the SF-36 domains: bodily pain (95% CI; guided imagery patients 11.0, controls 0.2), vitality (95% CI; guided imagery patients 10.9, controls 1.7), and mental health (95% CI; guided imagery patients 7.8, controls 0.4). CONCLUSIONS: Guided imagery is an effective adjunct therapy for the management of chronic tension-type headache.

Dosing of oral sumatriptan: a review of our first 104 patients.

BACKGROUND: The introduction of oral sumatriptan in the United States at doses of 25 and 50 mg, compared with 100-mg tablets worldwide, has created the need to develop a protocol for appropriate dosing. METHODS: We evaluated the first 104 patients in our practice to treat two migraine attacks with oral sumatriptan. For their first treatment with oral sumatriptan, patients were evaluated on their response to 25-mg tablets and the total number of tablets taken. For their second treatment, patients were evaluated on their response to sumatriptan, number of 25-mg tablets taken, and dosage prescribed for future migraines. RESULTS: [table see text] After the second treatment, 41 patients (40%) continued therapy with 25-mg tablets, 54 (53%) were prescribed 50-mg tablets, 2 patients (2%) were prescribed two 50-mg tablets, and 5 patients (5%) were prescribed injectable sumatriptan. Seventy patients had previously used injectable sumatriptan, while 34 had not previously used sumatriptan. There were no significant differences in their response to oral sumatriptan. CONCLUSION: Oral sumatriptan was effective in clinical practice at doses of 25 and 50 mg. The majority of patients required more than one 25-mg tablet for a migraine attack, reflecting both inadequacy of dosing for some migraines and recurrence of headache, yet 40% of patients continued on treatment with 25-mg tablets. There were no significant differences in response to therapy in patients being switched from injectable to oral sumatriptan compared with those initiating therapy with oral sumatriptan. Both tablet strengths of oral sumatriptan are useful in clinical practice.

Quality of life in migraine.

Health-related quality of life (QoL) is becoming an important outcome measure in the field of migraine. Several generic and migraine-specific questionnaires have been evaluated for reliability and validity in migraine. The generic instruments demonstrate the severe impairment in the QoL of migraine patients compared to patients with other chronic diseases and to the general population. The migraine-specific instruments are designed to measure the short- and long-term impact of migraine on QoL and are responsive to changes in QoL secondary to migraine therapy. The widespread use of these standardized instruments can increase awareness of the burden of migraine and lead to improved therapeutic intervention for migraine.

Alcohol, smoking, and caffeine use among headache patients.

We reviewed the charts of 151 headache patients, seen initially in a specialty headache center between 1988 and 1994, to collect information regarding reported alcohol consumption, smoking, daily number of caffeinated beverages, and medications. Charts of 50 patients in a general medicine clinic were reviewed for the same information. No significant differences between headache patients and general medicine patients were found in consumption of alcohol, smoking, or caffeinated beverages. Thirty headache patients (20%) used caffeine-containing medications more frequently than recommended; 24 of these patients used the products daily; 18 of those had a greater caffeine intake from medications than from beverages. Over-the-counter caffeine-containing analgesics were overused by 12 of the patients compared to 21 patients who overused prescription caffeine-containing preparations. Headache patients consume minimal amounts of alcohol, tobacco, and caffeinated beverages. However, headache patients often use caffeine-containing analgesics more frequently than recommended, which may lead to rebound and withdrawal headache.

Clinical efficacy and tolerability of 2.5 mg zolmitriptan for the acute treatment of migraine. The 042 Clinical Trial Study Group.

Previous studies demonstrated that zolmitriptan at doses of 1 to 25 mg was highly effective in treating acute migraine attacks. The 2.5-mg dose had a favorable therapeutic effect with high efficacy and good tolerability. The objective of this study was to further evaluate the efficacy of a single 2.5-mg dose of zolmitriptan (Zomig, formerly known as 311C90) for acute treatment of a single moderate or severe migraine attack. The study was a randomized, double-blind, placebo-controlled clinical trial. Female and male patients, 12 to 65 years old, with migraine (with or without aura) for > or = 1 year, one to six migraines per month, and age at onset < 50 years were included; 327 patients were screened and randomized to receive either zolmitriptan (n = 219) or placebo (n = 108). Patients treated a single moderate or severe migraine headache with 2.5 mg zolmitriptan or placebo and recorded clinical efficacy and adverse events on a diary form. Headache response at 2 hours was 62% for zolmitriptan compared with 36% for placebo (p < 0.001); at 4 hours, headache response was 70% with zolmitriptan and 37% with placebo (p < 0.001). Headache recurrence in patients treated with 2.5 mg zolmitriptan was 22% (versus placebo 30%). The headache response at 4 hours, pain-free rate, and response rate of nonheadache symptoms favored zolmitriptan over placebo. No serious adverse events were associated with zolmitriptan treatment. A 2.5-mg dose of zolmitriptan is clinically effective and well tolerated for the acute treatment of migraine.

Standards of care for treating headache in primary care practice. National Headache Foundation.

The following is a summary of guidelines created under the auspices of the National Headache Foundation, in an effort to improve the care of headache patients in primary care practice. The guidelines represent the consensus of an advisory panel of practitioners chosen by the NHF for their expertise in four specialty areas. A complete set of guidelines can be obtained by calling the National Headache Foundation at 1-800-843-2256 or by writing to them at 428 W. St. James Pl., 2nd Floor, Chicago, IL 60614-2750; the cost is $10.

Evolution of the measurement of quality of life in migraine.

Although headache is among the most common pain complaints seen by physicians, the measurement of health-related quality of life (HRQoL) in headache patients is in its earliest stages. Two types of questionnaire have been used to measure HRQoL in headache sufferers: general and disease-specific instruments. General quality-of-life (QoL) instruments use scales to assess QoL with respect to a number of activities within physical, social, psychological, and behavioral life domains. Disease-specific instruments reflect particular limitations or restrictions associated with specific disease states. These instruments are designed to be most sensitive in determining the effects of treatment or the longitudinal course of disease. Data from the Medical Outcomes Study Short Form (SF)-20 and SF-36 generic QoL instruments demonstrated that chronic headache disorders were associated with significant limitations in all eight health domains of patient wellbeing and functioning. The SF-20 outcomes profiles for each of the common benign headache disorders (migraine, tension-type headache, mixed headache, and cluster headache) appear to be unique for the specific headache diagnosis. The SF-20 and SF-36 were also used to compare headache disorders with other chronic illnesses. Chronic headache disorders, including migraine, were found to cause significantly more impairment of function than diabetes, hypertension, osteoarthritis, and low back pain. Preliminary studies of QoL during pharmacologic therapy have suggested that disease specific instruments may be more sensitive than generic instruments for evaluating the longitudinal impact of treatment. Generic QoL instruments, such as the SF-20 or SF-36, may be more useful to define populations being studied than to measure changes in the population over time. The publication of headache-specific QoL instruments, which have been widely used in clinical trials and have been validated, is awaited. Until such time, the SF-36 will remain the standard measure of QoL in headache.

The impact of drug therapy on quality of life in headache and migraine.

Although headache is among the most common and costly disorders in primary care, our understanding of its direct impact on the quality of life of affected individuals is incomplete. While studies evaluating the role of headache on health-related quality of life and healthcare economics are starting to appear in the medical literature, the effect of pharmacotherapy in improving quality of life is only beginning to be studied. At present, studies evaluating health-related quality of life in patients with migraine who are undergoing treatment are limited to 3 agents: sumatriptan, flurbiprofen and diclofenac. Several studies have consistently indicated that these drugs benefit patients by improving key dimensions of health-related quality of life or patients' sense of well-being to a significant extent. Given the magnitude of functional and emotional impairment associated with chronic headache disorders, assessing patients' perceptions of their quality of life makes a useful contribution to the evaluation of therapeutic interventions and should supplement traditional clinical endpoints in determining the effectiveness of new drugs.

Using pretreatment quality of life perceptions to predict response to sumatriptan in migraineurs.

Quality of life perceptions vary for individuals with similar medical conditions and reflect disease impact. When correlated with subsequent response to treatment, such data may contribute useful insights in understanding the determinants of therapeutic effectiveness in selected medical conditions. Two hundred thirty-five migraine patients never previously treated with injectable sumatriptan completed a Short Form-36 questionnaire before receiving a supervised test dose and a prescription for the medication. Medical records were examined to determine the number of comorbid conditions, headache characteristics (age at onset, headache frequency, duration of disease, aura, association with menses, unilaterality, and emesis), and documentation of sumatriptan's effect in relieving migraine during 12 months of follow-up. Logistic regression was used to identify patient- and disease-specific features most closely associated with the dependent variable, clinical response. One hundred eighty-four patients (78%) reported both relief of symptoms and continued usage of sumatriptan. Patients who experienced emesis with headaches (OR = 2.05 [1.07, 3.91]) and those with higher pretreatment Physical Functioning scores (OR = 3.27 [1.28, 8.37]) were more likely to respond to sumatriptan. Response to sumatriptan therapy was associated with specific pretreatment quality of life domains and headache features. These results may be useful in improving the efficiency of disease management strategies for patients with migraine.

Burden of migraine. A review of its socioeconomic impact.

According to population-based epidemiological studies using International Headache Society diagnostic criteria, the prevalence of migraine in developed countries ranges from 8 to 14%. These prevalence figures confirm the widespread nature of the disorder. Moreover, as migraine is a chronic episodic disorder that predominantly affects people during their working lives (between the ages of 25 and 55 years), indirect costs associated with reduced productivity represent a substantial proportion of the total cost of migraine. The results of health-related quality-of-life studies demonstrate that migraine has a considerable impact on functional capacity, resulting in disrupted work and social activities. Many migraineurs, however, do not seek medical attention, have not been accurately diagnosed by a physician or do not use prescription medication. Therefore, the direct costs of treatment for migraine are relatively small compared with the indirect costs. Migraine is an important chronic illness that has a major impact on the working sector of a population. The overall cost attributable to migraine is unknown, but it is now established that the indirect costs of migraine outweigh the direct costs and therefore represent an obvious target for healthcare intervention aimed at reducing the impact of this chronic condition.

Impact of sumatriptan on clinic utilization and costs of care in migraineurs.

BACKGROUND: Although migraine headaches affect a large segment of the population, no objective measure of therapeutic success is currently available. Comparing visit frequency and associated costs of care before and after introduction of a new therapy represents an important surrogate measure of success. METHODS: One hundred four patients regularly attending a headache clinic for migraines at a tertiary care hospital were instructed in the use of a new abortive migraine therapy. Medical appointment and financial systems were searched retrospectively for visit frequency and associated patient care and institutional costs. The number of visits and mean costs 18 months before and after initiation of therapy were compared using the signed rank test and paired t-test, respectively. RESULTS: The median number of visits made by study subjects to the headache clinic fell significantly following sumatriptan test dosing (P < 0.001). Prior to the new treatment, mean total patient care and institutional costs were $228.59 and $112.81 per person, respectively, and fell to $135.93 and $78.16 (P < 0.001) after therapy began. CONCLUSIONS: These data suggest that many patients with migraine benefit from sumatriptan, seek medical attention in a headache clinic less often, and incur fewer costs following initiation of treatment with this drug.

Advances in cluster headache management.

Cluster headache, an uncommon, excruciating headache distinct from migraine, is often misdiagnosed. Until recently, therapy was difficult, but verapamil has revolutionized treatment.

Substance P concentration and history of headache in relation to postlumbar puncture headache: towards prevention.

Medical treatment of postlumbar puncture headache (post-LP HA) is often difficult and ineffective. Prevention would be preferable to more invasive procedures, including blood patch. The aim was to determine the incidence of post-LP HA in two suspected high risk groups compared with the general outpatient population. Based on previous research, it was hypothesised that a low substance P concentration, or a history of chronic headache, or both would be associated with a higher risk of post-LP HA. A total of 310 randomly selected patients undergoing diagnostic lumbar puncture in the outpatient neurology clinic over 30 consecutive months were studied. Follow up was by headache questionnaire or phone survey after diagnostic lumbar puncture. Substance P was measured by radioimmunoassay on a subset of 102 samples of CSF. The overall incidence of post-LP HA was 38%. Patients with a measured substance P value < 1.3 pg/ml were three times as likely to have post-LP HA than those with a higher value. A history of chronic or recurrent headache was reported by 57% of those who developed post-LP HA. This group was also three times as likely to experience post-LP HA as those who did not have chronic headaches.

Quality of life assessment among migraine patients treated with sumatriptan.

PURPOSE: Quality of life evaluations can enhance traditional measures of therapeutic efficacy. The purpose of our study was to evaluate the impact of sumatriptan on the quality of life of patients with migraine headaches. PATIENTS AND METHODS: Migraine patients who were given a prescription for sumatriptan completed an SF-36 questionnaire and a nine-item pain questionnaire. Six to 9 months later, patients were mailed another copy of the SF-36 and the nine-item pain questionnaire. We compared the pretreatment and posttreatment scores for the SF-36 and for each question of the nine-item pain questionnaire. RESULTS: The pretreatment SF-36 was completed by 255 patients. The pretreatment pain questionnaire was completed by 86 of these patients. Follow-up questionnaires were returned by 147 patients (58%). Three of the eight SF-36 scales: role functioning--physical, bodily pain, and social functioning showed significant (P < 0.05) improvement with treatment. On the nine-item pain-specific questionnaire, three items--pain interference with normal work, ability to walk or move about, and enjoyment of life showed statistically significant (P < 0.05) improvement after sumatriptan treatment. CONCLUSIONS: Sumatriptan caused a significant improvement in the quality of life of patients with very severe migraine. This improvement was measurable by both the general quality of life instrument and the pain-specific questionnaire.