[Peppermint oil in the acute treatment of tension-type headache]. / Oleum menthae piperitae (Pfefferminzöl) in der Akuttherapie des Kopfschmerzes vom Spannungstyp.

Tension-type headache is the most frequent form of headache. The local topical treatment with peppermint oil (oleum menthae piperitae) has proven to be significantly more effective than placebo in controlled studies. Peppermint oil targets headache pathophysiology in multiple ways. The efficacy is comparable to that of acetylsalicylic acid or paracetamol. Solutions of 10 % peppermint oil in ethanol are licensed for the treatment of tension-type headache in adults and children above 6 years. It is included in treatment recommendations and guidelines by the respective professional societies and is regarded as a standard treatment for the acute therapy of tension-type headaches.

[Classification and therapy of medication-overuse headache: impact of the third edition of the International Classification of Headache Disorders]. / Klassifikation und Therapie des Medikamenten-Übergebrauch-Kopfschmerzes (MÜK) : Auswirkungen der 3. Auflage der internationalen Kopfschmerzklassifikation auf die Praxis.

The diagnosis of medication-overuse headache (MOH) is of central importance because this secondary headache disorder can be treated very effectively and patients do not usually respond to headache prophylaxis as long as MOH persists. The article describes important changes in the diagnostic criteria of different MOH subtypes after publication of the International Classification of Headache Disorders (ICHD-3beta) in 2013. The new classification has a crucial and direct impact on prevention and treatment of MOH. In addition interactions exist with the new criteria of chronic migraine. With a controlled medication intake scheme according to the 10-20 rule and using a medication break, MOH usually remits in most patients. If patient education and advice does not lead to remission of MOH, a specialized managed medication break or withdrawal treatment becomes necessary. This can be done on an outpatient, day clinic or inpatient basis. In uncomplicated cases, the results of these three treatment settings do not differ. From a cost-effectiveness standpoint, the outpatient treatment should be given priority. In complicated cases, a fully inpatient withdrawal treatment using a multimodal treatment concept is significantly superior.

[Integrated headache care network. Kiel Migraine and Headache Center and German National Headache Treatment Network]. / Sektorenübergreifende schmerzmedizinische Versorgung. Schmerzklinik Kiel und bundesweites Kopfschmerzbehandlungsnetz.

Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors.

[Preventive medication in migraine headache : Individualized clinical pathways]. / Medikamentöse Prophylaxe der Migräne : Individuelle Behandlungspfade.

With the introduction of the highly effective triptans in the treatment of acute migraine attacks, the significance of migraine prevention temporarily lost ground in the awareness of doctors and, even more so, patients. This was unjustified, as the increasing numbers of patients with triptan-overuse headache clearly demonstrated. Recent years have seen this trend reversed with a resurgence of migraine prevention. In daily practice the first question is whether migraine prevention is indeed indicated for the patient. If answered affirmatively, the next step is the intricate selection of the most promising agent for the patient. Treatment guidelines regularly updated by the relevant medical societies provide a general overview of the agents principally available according to the principles of evidence-based medicine. Yet, low compliance rates suggest that in practice implementation of these guidelines may have to be tailored to the patient in question. The treatment algorithm presented here tries to bridge the gulf between general treatment guidelines and the actual needs of the patient. From this, feasible clinical pathways are derived for individualized treatment.

[Development and implementation of integrated health care in pain medicine : the nationwide German headache treatment network]. / Entwicklung und Umsetzung der integrierten Versorgung in der Schmerztherapie : Das bundesweite Kopfschmerzbehandlungsnetz.

Integrated care builds interdisciplinary networks across the different healthcare sectors. A conjoint effort toward clearly defined treatment goals is crucial for medically effective and economically efficient care. Allowing creativity in the implementation of integrated care triggers competition for more effective ideas and better solutions. Based on a summary of the development of integrated care and the example of the nationwide German headache treatment network, the successful organization and implementation of this cross-sectoral care within pain medicine is illustrated. An interdisciplinary nationwide network of pain therapists working hand in hand across the sectors, both in the outpatient and inpatient setting, and employing modern treatment regimens results in optimal pain relief. The treatment quality is assessed by continuous accompanying research and sustainable cost efficiency in all sectors of healthcare is confirmed through analysis of both direct and indirect costs. The project was started in May 2007. In the meantime, almost all large statutory health insurance providers in Germany have joined this healthcare project. The large treatment network confirms the significant clinical and economic efficiency of pain medicine. It demonstrates that coordinated modern therapy effectively relieves pain, lowers costs sustainably, and reduces sick leave. Patient satisfaction is very high. The healthcare providers may directly participate in treatment success through risk-sharing.

[Classification of headache disorders]. / Klassifikation von Kopfschmerzen.

In 2003 the International Headache Society (IHS) published the second edition of the International Classification of Headache Disorders. Diagnostic criteria for no less than 206 separate headache diagnoses are presented in the parts (I) primary headaches, (II) secondary headaches and (III) cranial neuralgia, central and primary facial pain. The headaches are classified according to the etiology in case of the secondary headaches and according to the phenomenology in case of the primary headaches. It is the task of the headache specialist to identify the correct headache diagnose with the smallest effort possible. Both, the differentiation between secondary and primary headaches and the differentiation between the various primary headaches are of equal importance.

Variation of the serotonin transporter gene SLC6A4 in the susceptibility to migraine with aura.

To replicate a reported association between migraine with aura (MA) and a promoter polymorphism in the serotonin transporter gene (SLC6A4), we performed a case-control study in a large German sample comprising 472 patients with MA and 506 controls. Neither this polymorphism nor a systematic analysis with single nucleotide polymorphisms capturing the main haplotype diversity of the SLC6A4 locus provided evidence for a contribution of SLC6A4 to the predisposition of complex inherited MA.

[Prophylactic measures and acute treatment of migraine]. / Vorbeugung und Akutbehandlung der Migräne.

The treatment of migraine consists of the acute treatment of the migraine attack and prophylactic measures for either pharmacological or non-pharmacological management. Since the retreat of the ergotamines one can only choose between one of the well-established analgesics and one of seven triptans for the treatment of the migraine attack. Although neither a new triptan nor an innovative new application form has been introduced, the year 2006 will be remembered as the year when the first triptan (naratriptan) was released as a prescription-free over-the-counter drug and when the first sumatriptan generics were marketed in Germany. In addition to the beta-blockers metoprolol and propranolol and the calcium antagonist flunarizine two antiepileptic drugs, topiramate and valproic acid, have been rated as first-line prophylactic drugs in Germany. Due to an extensive and successful study program topiramate has been officially approved in Germany.

[Managing the attacks, preventing headache. Migraine therapy in 2002]. / Die Attacke abwehren, dem Kopfschmerz vorbeugen. Migränetherapie im Jahr 2002.

At the heart of every migraine treatment concept is the management of the acute attack with effective medication. Here, the triptans have been progressively replacing the ergot alkaloids with their unsatisfactory relationship between effect and side effects. Prophylactic medication is indicated when, despite every non-pharmaceutic measure, migraine attacks occur on seven or more days in a month. The beta receptor blockers metoprolol and propranolol have so far been considered the substances of first choice, but in practice there is now a trend towards substances with a lower potential for side effects. The article provides an up-to-date overview of the efficacy and tolerability of the various migraine prophylactics.

Toxina botulínica A para el tratamiento de síndromes de cefalea y síndromes de dolor pericraneal / Botulinum toxin A in the treatment of headache syndromes and pericranial pain syndromes

No disponible

Evidence-based medicine: botulinum toxin A in migraine and tension-type headache.

The therapeutic effect of botulinum toxin in headache was observed coincidentally. The rationale for this new indication initially met with a great deal of scepticism, because the toxin's mechanism of action, cholinergic chemodenervation, does not fit the pathophysiological concept of migraine and other forms of headache. Meanwhile a fair number of studies have been published which indicate efficacy for botulinum toxin and recommend its use for the treatment of tension headache and migraine. According to the evidence-based medicine criteria, grade I evidence has been demonstrated. In addition the use of botulinum toxin for cluster-headache and secondary headache is discussed. Further large scale studies will be regarded to demonstrate the long-term efficacy.

[Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]. / Botulinum-Toxin A in der Therapie von Kopfschmerzerkrankungen und perikranialen Schmerzsyndromen.

For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.

Efficacy and tolerability of rizatriptan 10 mg in migraine: experience with 70 527 patient episodes.

As patients who suffer from migraine need long-term treatment, the safety and consistent efficacy of such therapy is very important. Concurrent illness and additional medication can interfere with the treatment chosen for the attacks of migraine. The objective of this open-label study was to investigate the efficacy and tolerability of rizatriptan, in the treatment of up to three attacks of migraine, in the clinical setting. From October 1998 to July 1999, 6 174 doctors enrolled 33 147 patients into the study (26 644 women, 650 men). The mean age was 42.7 years. We were able to examine standardized migraine diaries relating to 25 501 patients and 70 537 migrainous episodes. Rizatriptan scored consistently high on efficacy and showed a consistently rapid onset. There was no evidence of tolerance to repeated use. An effect was reported within 1 hour of ingestion in 79% of attacks treated. In 27.8% of attacks, remission of headache was complete at 1 hour. Two hours after ingestion, 74% of attacks had subsided completely. Repeated administration of rizatriptan was well tolerated, and few adverse effects were seen. The most common unwanted effects were dizziness, weakness, fatigue, and nausea. No cardiovascular disturbance was seen. In the clinical setting, rizatriptan, 10 mg, is an effective and well-tolerated agent for the treatment of migraine attacks. Particularly noteworthy is the rapid onset of effect, with swift disappearance of headache. Rizatriptan has a favorable side effect profile, and, provided contraindications are observed, severe adverse cardiovascular complications are extremely unlikely.

[Value of specialized pain treatment]. / Nutzen spezialisierter Schmerzbehandlung.

The paper describes new forms of specifically organized headache prevention and headache therapy in Germany with the aid of two examples. It provides an overview of the clinical and economic efficiency of facilities with new forms of organization for specialized pain therapy. Their effectiveness can be seen both in a marked reduction in individual suffering and in low-cost provision of services for the institutions bearing the costs and for society. This effectiveness can be seen not only from subjective parameters by interviewing the patients, but also from objective target parameters such as resumption of work, reduction in intake of medication, cost reductions due to reduced demands on the healthcare system, avoidance of premature pensioning. By contrast, patients who do not receive specially organized treatment despite the fact that they need it display either constant suffering or even a worsening of their symptoms and an increased need for financial compensation. In view of this clear situation, specialized headache and pain therapy with a special focus on catering for the needs of chronic headache suffering is called for, both on economic and ethical grounds.

[Epidemiology and socioeconomic consequences of migraine and headache diseases]. / Epidemiologie und sozioökonomische Konsequenzen von Migräne und Kopfschmerzerkrankungen.

The paper describes the situation of traditional headache therapy on the basis of up-to-date empirical data on headache epidemiology, the habits of the persons affected, and the economic consequences for employers, health insurance funds and society in general. It also describes for the first time the direct costs of in-patient headache therapy in a traditional treatment context without specially organized therapy on the basis of actual invoicing between hospitals and health insurance funds.

Open-labeled long-term study of the efficacy, safety, and tolerability of subcutaneous sumatriptan in acute migraine treatment.

In a multicenter study, a long-term analysis was made of the efficacy, safety, and tolerability of subcutaneous (s.c.) sumatriptan in the acute treatment of migraine attacks over a period of up to 18 months. A total of 2263 patients took part in the study, all able to perform their own acute treatment of migraine attacks at home by s.c. administration of 6 mg of sumatriptan. A headache diary was used by each patient to record the various migraine parameters before the injection and 1 h and 2 h after it. A total of 43,691 attacks were treated and analyzed during the study period from October 1991 to June 1993. Therapy was successful in 89.5% of attacks. Freedom from headache was achieved in 71.0% of cases. In 22.7% of the attacks a second injection was administered on recurrence of the headache; 82.9% of the patients achieved an intraindividual therapy success rate ranging from over 80% to 100%. In the course of treatment there was no change in either the therapy success rate or in the frequency of attacks. Some 4.9% of the patients withdrew from the study because of insufficient efficacy or adverse events. A total of 44.5% of patients reported adverse events, and these were rated serious in the case of 1.7%. S.c. administration of sumatriptan for acute migraine therapy is an effective treatment method, with reliable action, that can be used with good tolerability provided the contraindications are taken into account.