The burden of headache: global and regional prevalence of headache and its impact.

Headache is a universal symptom. However, despite its prevalence and implications for daily living, headache epidemiology and its public health impact have only been partially documented. Most research has focused on migraine, with data on tension-type headache (TTH) being relatively sparse, especially for countries outside Western Europe and North America.

Headache in essential thrombocythaemia.

Headache is frequently reported as one of the neurological manifestations of essential thrombocythaemia (ET) and other myeloproliferative neoplasms. It is associated with considerable morbidity; yet, it is a frequently under-recognised symptom. In patients with ET, headaches may be attributable to the disease, to the prescribed ET treatment, or unrelated to ET. The majority of headaches in ET are self-limiting and can be managed with standard headache therapies such as paracetamol, but it is vital that the clinician managing these conditions is able to recognise the headaches with a more sinister pathology. In this article, we will review the incidence and management of headaches in ET, whether they are primarily related to the disease or a result of its treatment. Identification of specific headache types in patients with ET may enable physicians to employ the most effective headache medication. This would enhance the patient-physician relationship, increasing patient compliance and thus reducing the risk of adverse outcomes.

Clinical and economic issues associated with switching between triptans in clinical practice.

Seven oral triptans are now generally available for the acute treatment of migraine, and physicians may sometimes feel under pressure to switch patients from one triptan to another for nonclinical reasons. This commentary article provides advice on what information should be taken into account by the physician before they consider switching one triptan for another. We review recommendations on switching triptans from international guidelines for migraine management and relate these to data from a recently published study on the economic implications of switching triptans in the UK. Controlled clinical studies reveal that most of the oral triptans have broadly similar efficacy profiles. Switching triptans can therefore only be recommended if the patient experiences problems such as lack of efficacy or intolerable side effects following repeated use of the initial triptan. The retrospective database study revealed that most patients who had their triptan switched were subsequently switched again during a 15 month review period, most usually back to their original triptan. Overall, switching a patient's triptan led to increased costs (analysed as costs of medication and the GP consultation) to the healthcare provider. These data indicate that patients should only be switched from one triptan for another for clinical reasons and not for perceived economic reasons, i.e. cost of the medication.

311C90: patient profiles and typical case histories of migraine management.

The 311C90 (Zomig; zolmitriptan) long-term safety and efficacy study includes data from > 30,000 treated migraine attacks across > 2,000 patients. A review of the database identified individuals who were representative of the population studied within this trial to illustrate the findings from a patient perspective. Five case histories are described here. These patients were identified on the basis of lying at the midpoint of the trial population sample with reference to certain baseline characteristics, and therefore representing a "typical" patient. The case histories represent a "typical" man and woman patient, a patient who has migraine with aura, a patient with frequent migraine accompanied by a high frequency of adverse events, and a patient with frequent migraine attacks, some of which were related to menses. The results show that 311C90 was consistently effective for these individual patients across a number of treated attacks in the acute treatment of migraine. It is concluded that consideration of data at the individual patient level allows appreciation of clinical benefit from a different but valuable perspective.

Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability.

The MIDAS Questionnaire was developed to assess headache-related disability with the aim of improving migraine care. Headache sufferers answer five questions, scoring the number of days, in the past 3 months, of activity limitations due to migraine. The internal consistency, test-retest reliability, and validity (accuracy) of the questionnaire were assessed in separate population-based studies of migraine sufferers. In addition, the face validity, ease of use, and clinical utility of the questionnaire were evaluated in a group of 49 physicians who independently rated disease severity and need for care in a diverse sample of migraine case histories. The test-retest Pearson correlation coefficient for the total MIDAS score was approximately 0.8. The MIDAS score was valid when compared with a reference diary-based measure of disability; the overall correlation between MIDAS and the diary-based measure was 0.63. The MIDAS score was also correlated with physicians' assessments of need for medical care (r = 0.69). From studies completed to date, the MIDAS Questionnaire has been shown to be internally consistent, highly reliable, valid, and correlates with physicians' clinical judgment. These features support its suitability for use in clinical practice. Use of the MIDAS Questionnaire may improve physician-patient communication about headache-related disability and may favorably influence health-care delivery for migraine patients.

An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score.

BACKGROUND: The Migraine Disability Assessment (MIDAS) instrument is a five-item questionnaire developed to measure headache-related disability and improve doctor-patient communication about the functional consequences of migraine. OBJECTIVES: To examine the test-retest reliability and internal consistency of the five items and of the overall MIDAS score in population-based samples of migraine sufferers in two countries and to compare consistency across countries. METHODS: Using a clinically validated telephone interview, population-based samples of migraine-headache sufferers were identified in the United States (Baltimore, MD) and the United Kingdom (Merton and Sutton, Surrey). Eligible individuals completed the MIDAS questionnaire on two occasions an average of 3 weeks apart. The MIDAS score is derived from five questions about missed time from work and household work (one question each about missed days and days with at least 50% reduced productivity) and missed days of nonwork activities. RESULTS: A total of 97 migraine-headache sufferers from the United States and 100 from the United Kingdom completed the MIDAS questionnaire twice. Mean and median item values and overall MIDAS scores were similar between the United States and the United Kingdom. Test-retest Spearman correlations of individual items ranged from 0.46 to 0.78. No significant differences in item-specific correlations were observed between the United States and United Kingdom. The test-retest Pearson correlation of the MIDAS score (i.e., sum of lost days and reduced-effectiveness days in each domain) was 0.80 in the United States and 0.83 in the United Kingdom. The Cronbach alpha, a measure of internal consistency, was 0.76 in the United States and 0.73 in the United Kingdom. CONCLUSIONS: This is the first international population-based study to assess the reliability of a disability-related illness severity score for migraine. The reliability and internal consistency of the Migraine Disability Assessment score are similar to that of a previous questionnaire (Headache Impact Questionnaire). However, the Migraine Disability Assessment score requires fewer questions, is easier to score, and provides intuitively meaningful information on lost days of activity in three domains.

The UK migraine patient survey: quality of life and treatment.

This research confirms that a majority of migraine sufferers in the UK acknowledge an incidence, frequency and symptomatology that have a significant effect on quality of life (both activity-based and on personal relationships); despite this, a significant proportion self-medicate with unsuitable and ineffective agents owing to the low level of efficacy and general lack of satisfaction with recommended and prescribed therapies. 50,000 migraineurs (sample derived from the Consumer Research Bureau) in the UK were invited to self-complete a questionnaire (during Q2-Q3, 1998). 9770 questionnaires were included in the analysis. With the advent of improved diagnosis and medications, the present study was undertaken to assess the impact and severity of migraine on the normal activities, attitudes and relationships of known migraineurs. The efficacy and control achieved by a range of therapeutic interventions were also considered. In order to identify the headache characteristics of this self-selected migraine patient population, diagnosis was confirmed by information relating to quality of headache (frequency, duration and symptomatology); the extent of restrictions on specific daily activities was also used to provide severity characteristics. A majority believed that they could not control their migraine and a significant proportion believed that migraine controlled their day-to-day life. Despite this, sufferers may not consult general practitioners (GPs) owing to previous experience, expectations of inadequate therapeutic intervention and/or perceived lack of physician empathy. This study is both opinion-based and awareness-based, and confirms known statistics while also providing further clarification on the overall effect of migraine on associated emotional and physical relationships, and on migraineurs' use and opinion of a range of available medications.

Assessing the impact of migraine.

Migraine is a remarkably disabling condition, although unpredictable and heterogeneous in frequency, duration and severity. It can be difficult to manage in primary care, where it is under-recognised, under-diagnosed and under-treated. Proposals have been made that migraine care could be improved by incorporating assessments of migraine impact into management strategies. Research has shown that measuring headache-related disability, together with assessments of pain intensity, headache frequency, tiredness, mood alterations and cognition can be used to assess the impact of migraine on sufferers' lives and society. From this research, two simple and brief impact tools were developed: the Migraine Disability Assessment (MIDAS) Questionnaire and the Headache Impact Test (HIT). Both tools are scientifically valid measures of migraine severity and have the potential to improve communication between patients and their physicians, assess migraine severity and act as outcome measures to monitor treatment efficacy. Each of these tools offers its own advantages. For example, HIT was designed for greater accessibility (on the Internet at www.headachetest.com and www.amlhealthy.com, and as a paper-based form known as HIT-6) and has a wider coverage of the spectrum of headache than MIDAS. Impact tools are also being increasingly recommended as part of generalised headache management guidelines to produce an individualised treatment plan for each patient in concert with other clinical assessments. It is not possible as yet to recommend unequivocally the optimal impact tool for use in primary care, but it should be usable by GPs, pharmacists, nurses and patients, and for research purposes.

Comparison of a fixed combination of domperidone and paracetamol (Domperamol) with sumatriptan 50 mg in moderate to severe migraine: a randomised UK primary care study.

Migraine is a common and debilitating condition routinely managed in primary care. A number of treatment options--both acute and prophylactic--are currently available but may differ in terms of efficacy, tolerability and cost. The aim of this study was to compare the effectiveness and tolerability of a fixed combination of domperidone and paracetamol (Domperamol; Servier), which has anti-nauseant and anti-emetic activity, with sumatriptan 50 mg in moderate to severe migraine. To do this, 120 patients were recruited from 23 primary care practices throughout the UK and were enrolled into the six-month trial. Patients were randomised at entry to one of the comparator regimens (used to treat their first migraine attack) and then crossed over to the alternative treatment for their second attack. Detailed diary cards were completed for each attack using a scale of pain severity. At two hours and four hours post-dose, the two treatments showed comparable efficacy (< or = 15% difference) in relieving headache and reducing nausea and vomiting. Both were well tolerated and there were no serious adverse effects. In the management of migraine patients typically seen in routine general practice, this trial showed that the effects of Domperamol and sumatriptan 50 mg were broadly comparable. Since Domperamol is considerably less expensive than sumatriptan (and other triptans), a first-line role for this agent appears appropriate.

Management by nurses of primary headache: a pilot study.

Primary headache is a very common condition and one that nurses encounter in many different care settings. Yet there is a lack of evidence as to whether advice given to sufferers is effective and what improvements may be expected in the condition. The aim of this study was to evaluate the advice given by a nurse to primary headache sufferers. The design was quasi-experimental. An experimental group (n = 19) and a control group (n = 25) of primary headache sufferers had their headache parameters of frequency, severity duration and disability (Migraine Disability Assessment) over the previous six months assessed. The experimental group then received advice in the form of health education from a nurse. Both groups kept a headache diary for six months. After six months both groups had their headache parameters assessed again. Compared to the control group, there was a significant reduction in the severity of headaches experienced by the experimental group (p = 0.006). Although there were reductions in frequency and duration of headaches experienced by the experimental group compared to the control group, these were not significant (p = 0.664 and p = 0.235, respectively). The Migraine Disability Assessment showed a trend towards reduced scores in the experimental group compared to controls which were not significant (p = 0.535). This pilot study suggests that health education can be effective in reducing the severity of headaches. However, a larger study over a longer period is needed to evaluate improvements in headache parameters.

New guidelines for the management of migraine in primary care.

Despite repeated initiatives over the past decade, migraine remains under-recognised, under-diagnosed and under-treated in everyday clinical practice. The Migraine in Primary Care Advisors (MIPCA) group has produced new guidelines for migraine management to attempt to rectify this situation. MIPCA is a group of physicians, nurses, pharmacists and other healthcare professionals dedicated to the improvement of headache management in primary care, who have also worked closely with the Migraine Action Association (the UK patients' group) in the development of these guidelines. The principles of the new MIPCA guidelines are: To arrange specific consultations for headache. To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation. To utilise a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary. To institute a process of management that is individualised for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management. To prescribe only treatments that have objective evidence of favourable efficacy and tolerability. To utilise prospective follow-up procedures to monitor the success of treatment. To organise a team approach to headache management in primary care.

Identifying patients who require a change in their current acute migraine treatment: the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire.

BACKGROUND: Currently available measures of the efficacy of acute migraine medications are not frequently used in primary care. They may be too burdensome and complicated for routine use. OBJECTIVES: To design and test a new, easy to use, 4-item assessment tool, the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire for use by clinicians, to quickly evaluate how a recently prescribed acute medication is working, and to identify patients who require a change of their current acute treatment. METHODS: A 27-item Migraine-ACT questionnaire was developed by an international advisory board of headache specialists. Questions were formulated in four domains: headache impact, global assessment of relief, consistency of response and emotional response. All these are clinically important measures of migraine severity and treatment outcome. All questions were dichotomous and answered by yes or no. Patients (n = 185) attending secondary care headache clinics who were diagnosed with migraine according to International Headache Society criteria entered a multinational, prospective, observational study to investigate the test-retest reliability and construct validity of the 27-item Migraine-ACT. Patients completed the Migraine-ACT on two occasions, separated by a 1-week interval, and test-retest reliability was assessed by Pearson product moment and Spearman rank measures. Construct validity was assessed by correlating patients' answers to the 27-item Migraine-ACT with those to other questionnaires (individual domains and total scores) conceptually related to it; the Short-Form 36 quality of life questionnaire (SF-36), the Migraine Disability Assessment (MIDAS) questionnaire and the Migraine Therapy Assessment Questionnaire (MTAQ). Discriminatory t-tests were used to identify the four Migraine-ACT questions (one in each domain) which discriminated best between the domains of the SF36, MIDAS, and MTAQ. These four items constituted the final 4-item Migraine-ACT. RESULTS: The test-retest reliability of the 27 Migraine-ACT questions ranged from good to excellent, and correlation coefficients were highly significant for all items. The consistency of reporting the yes and no answers was also excellent. Correlations of Migraine-ACT items with SF-36 and MIDAS items and SF-36, MIDAS and MTAQ total scores indicated that the following were the most discriminating items, in the respective four domains, and constitute the final Migraine-ACT questionnaire: Consistency of response: Does your migraine medication work consistently, in the majority of your attacks? Global assessment of relief: Does the headache pain disappear within 2 h? IMPACT: Are you able to function normally within 2 h? Emotional response: Are you comfortable enough with your medication to be able to plan your daily activities? The 4-item Migraine-ACT was shown to be highly reliable (Spearman/Pearson measure r = 0.82). The individual questions, and the total 4-item Migraine-ACT score, showed good correlation with items of the SF-36, MIDAS and MTAQ questionnaires, particularly with the total MTAQ and SF-36 scores. CONCLUSIONS: The 4-item Migraine-ACT questionnaire is an assessment tool for use by primary care physicians to identify patients who require a change in their current acute migraine treatment. It is brief and simple to complete and score, and has demonstrated reliability, accuracy and simplicity. Migraine-ACT can therefore be recommended for everyday clinical use by clinicians.

Usage of triptans among migraine patients: an audit in nine GP practices.

A retrospective audit was carried out to investigate triptan usage over a period of one year among 360 adult patients with migraine in nine GP practices in the UK and the Republic of Ireland. Data from patient records were analysed, in conjunction with replies to a questionnaire about patients' perceptions of their migraine and its treatment. The majority of patients included in the audit were women (83%), and most patients (81%) were aged between 35 and 64 years. Most patients in the audit population (60%) were in the lowest band of triptan usage (1-36 tablets prescribed over 12 months); 7% had moderate usage (37-53 tablets). A minority of patients appeared to be taking triptans in higher quantities: about 15% of patients had been prescribed 54-94 triptan tablets over a year, 9% had received prescriptions for 95-149 tablets and 7% had received prescriptions for 150 or more tablets. These results indicated that some migraine patients were using triptans at higher than expected rates, and suggested that some patients might have been using their prescribed triptans inappropriately to treat a headache that they incorrectly perceived as migraine (e.g. chronic daily headache). Analyses were carried out to identify predictors of high usage. Predictors identified included the use of several other (non-triptan) medications to treat conditions other than migraine, one triptan dose being reported as sufficient to treat an attack, patient's perception of all headaches as migraine and lack of concern about taking too much medication. Patients identified as using triptans at a higher than expected rate can be called in for review of migraine diagnosis, identification of possible causes of any increased frequency of attacks, and investigation of suspected non-migrainous headaches, such as chronic daily headache and medication-induced headaches. For GPs, such actions would help achieve and maintain a high standard of care for their migraine patients, thus helping to contribute towards meeting the demands of the clinical governance agenda. Audit of triptan usage may also offer financial benefits for the practice, since helping patients to avoid the inappropriate use of triptans could lead to reductions in the overall costs of triptan prescribing within the practice. The high usage predictors could be developed into a checklist of potential indicators for GPs to identify patients who may become high users if prescribed triptans and who might require closer monitoring. We recommend that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Although triptans are generally safe and well tolerated, unnecessary use of any medication should be avoided.

A long-term study to maximise migraine relief with zolmitriptan.

Part 1 of this international study was a randomised, double-blind, placebo-controlled study of 2.5 mg and 5 mg zolmitriptan (Zomig) in the treatment of persistent migraine headache, two hours after an initial dose of 2.5 mg zolmitriptan. Part 2 was a non-comparative evaluation of long-term, unrestricted zolmitriptan use for treatment of initial, persistent and recurrent migraine headaches. In Part 1, following the treatment of moderate or severe persistent headache, two-hour headache response rates with 5 mg zolmitriptan (51.6%, n = 322), 2.5 mg zolmitriptan (49.7%, n = 324) and placebo (51.6%, n = 343) were not significantly different. However, the pain-free response rate following the treatment of persistent migraine headache of any intensity was significantly higher with 5 mg zolmitriptan than with placebo (36.0% vs. 25.5%; p < 0.001). This was predominantly due to effects in the subgroup of patients with mild headache. Thus, migraine relief in patients whose initial headache shows a partial response to 2.5 mg zolmitriptan may be maximised by a second 5 mg dose. In Part 2 (involving 2499 evaluable patients), 65.8% of attacks were treated with a single dose of zolmitriptan (2.5 mg or 5 mg). Of those migraine attacks initially treated with 2.5 mg zolmitriptan, 70.3% required no further dose, similarly 62.7% of migraine attacks treated initially with 5 mg zolmitriptan only required a single dose. Over the whole attack (i.e. initial and any persistent headache), headache response rates to one or two zolmitriptan doses were greater than 88.8%. 'Level of pain' was the primary factor influencing the choice of dose. Zolmitriptan provided consistent migraine headache relief in the majority of patients and was well tolerated.

The cost effectiveness of stratified care in the management of migraine.

OBJECTIVE: To examine the cost effectivess of a stratified-care regimen for patients with migraine--in which patients are stratified by severity of illness, and then prescribed differing treatments according to level of severity--compared with a conventional stepped-care approach. DESIGN AND METHODS: A decision analytic model was constructed to simulate a controlled clinical trial in which patients with migraine receiving primary medical care were randomly assigned to treatment under a stepped-care or a stratified-care regimen. A health service payer perspective was adopted and the time horizon was 1 year. Data inputs were: (i) the frequency and disability of migraine, derived from population-based studies; (ii) disability level-specific treatment response rates for over-the-counter analgesics,aspirin/metoclopramide and zolmitriptan as the representative of high-end therapy obtained from an international consensus opinion enquiry; and (iii) unit costs of healthcare obtained from UK health service sources. MAIN OUTCOME MEASURES AND RESULTS: The estimated 1-year direct healthcare costs per primary care patient with migraine were pound sterling 156.82 for stepped care and sterling pound 151.57 for stratified care. Estimates of treatment response rates were 40 and 71% for stepped and stratified care, respectively. The cost per successfully treated attack was sterling pound 23.43 for stepped care and sterling pound 12.60 for stratified care. Stratified care remained cost effective when tested in a wide range of one-way sensitivity analyses, and probabilistic sensitivity analysis showed the cost effectiveness of stratified care to be significant at the 3% level. Conditional confidence analysis showed that the level of confidence in the cost effectiveness of stratified care varied positively with the case mix, i.e. in populations where the proportion of moderate and severely disabled patients with migraine was greater than 25%, the cost effectiveness of stratified care remained statistically significant. CONCLUSION: A stratified-care treatment strategy (including zolmitriptan as the representative of high-end therapy) is a highly cost-effective method of managing migraine in the primary care setting compared with stepped care, delivering improved clinical outcomes at no additional cost.

Psychiatric morbidity and cognitive representations of illness in chronic daily headache.

OBJECTIVES: We studied patients with chronic daily headache (CDH) attending a headache clinic. Our hypothesis was that patients with anxiety or depression would have poorer functional status and differing cognitive representations of illness than would those without psychiatric morbidity. METHODS: The sample consisted of 144 consecutive new patients. Patients underwent a semistructured interview and completed a prospective headache diary, the Hospital Anxiety and Depression Scale (HADS) and other health-related questionnaires. RESULTS: Sixty patients (42%) were probable cases of anxiety or depression on the basis of their HADS score. These HADS-positive cases had longer, more severe headaches, were more worried about them, were more functionally impaired and believed that their illness would last longer. Principal components analysis revealed that the HADS-positive cases believed that psychological factors play a role in their headaches. CONCLUSIONS: Psychological morbidity is high amongst CDH patients who attend specialist clinics. In addition to identifying those with high levels of psychological distress, the HADS can be used to predict those likely to have worse headaches and poorer functional ability.

Patient-selected dosing in a six-month open-label study evaluating oral sumatriptan in the acute treatment of migraine. Sumatriptan Tablets S2CM10 Study Group.

BACKGROUND: Dosing recommendations for oral sumatriptan as acute treatment for migraine have ranged from 25 mg to 100 mg. Patient dose preferences have not been studied in a setting mimicking clinical practice. METHODS: In an open-label study evaluating patient acceptance and the relative efficacy and safety of 25 mg, 50 mg, and 100 mg doses of oral sumatriptan over a period of six months, 338 patients treated three migraine attacks with 50 mg sumatriptan and then were allowed to double or halve the dose. After treating another three attacks, they were again allowed to adjust the dose by one level. RESULTS: After migraine attack 3, 37% of patients chose to continue with the 50 mg dose, 50% increased the dose to 100 mg, and 12% decreased it to 25 mg. After attack 6, 8%, 33%, and 58% of patients chose the 25 mg, 50 mg, and 100 mg doses, respectively; only 3% of those taking the 100 mg dose chose to reduce it. Overall, the mean percentages of attacks per patient in which headache relief had been obtained 4 h after dosing were 71%, 71%, and 80% for the 25 mg, 50 mg, and 100 mg doses, respectively. Patients who decreased the dose to 25 mg after attack 3 experienced decreases both in adverse events and percentage of attacks with headache relief, whereas in those who increased the dose to 100 mg, likelihood of headache relief increased but the incidence of adverse events did not. CONCLUSIONS: More patients chose the 50 mg or 100 mg dose than the 25 mg dose. All three doses had similar efficacy and tolerability.

Predictors of outcome in patients consulting their general practitioners for headache: a prospective study.

Headache is the most common neurological symptom presenting to general practitioners (GPs). Identifying factors predicting outcome in patients consulting their GPs for headache may help GPs with prognosis and choose management strategies which would improve patient care. We followed up a cohort of patients receiving standard medical care, recruited from 18 general practices in the South Thames region of England, approximately 9 months after their initial participation in the study. Of the baseline sample (N=255), 134 provided both full baseline and follow-up data on measures of interest. We determined associations between patients' follow-up scores on the Headache Impact Test-6 and baseline characteristics (including headache impact and frequency scores, mood, attributions about psychological/medical causes of their headaches, satisfaction with GP care and illness perceptions). Greater impact and stronger beliefs about the negative consequences of headaches at baseline were the strongest predictors of poor outcome at follow-up.

Influence of cold-water immersion on indices of muscle damage following prolonged intermittent shuttle running.

The aim of this study was to assess the effects of cold-water immersion (cryotherapy) on indices of muscle damage following a bout of prolonged intermittent exercise. Twenty males (mean age 22.3 years, s = 3.3; height 1.80 m, s = 0.05; body mass 83.7 kg, s = 11.9) completed a 90-min intermittent shuttle run previously shown to result in marked muscle damage and soreness. After exercise, participants were randomly assigned to either 10 min cold-water immersion (mean 10 degrees C, s = 0.5) or a non-immersion control group. Ratings of perceived soreness, changes in muscular function and efflux of intracellular proteins were monitored before exercise, during treatment, and at regular intervals up to 7 days post-exercise. Exercise resulted in severe muscle soreness, temporary muscular dysfunction, and elevated serum markers of muscle damage, all peaking within 48 h after exercise. Cryotherapy administered immediately after exercise reduced muscle soreness at 1, 24, and 48 h (P < 0.05). Decrements in isometric maximal voluntary contraction of the knee flexors were reduced after cryotherapy treatment at 24 (mean 12%, s(x) = 4) and 48 h (mean 3%, s(x) = 3) compared with the control group (mean 21%, s(x) = 5 and mean 14%, s(x) = 5 respectively; P < 0.05). Exercise-induced increases in serum myoglobin concentration and creatine kinase activity peaked at 1 and 24 h, respectively (P < 0.05). Cryotherapy had no effect on the creatine kinase response, but reduced myoglobin 1 h after exercise (P < 0.05). The results suggest that cold-water immersion immediately after prolonged intermittent shuttle running reduces some indices of exercise-induced muscle damage.