"It's just part of who I am " Living with chronic headache: voices from the CHESS trial, a qualitative study.

BACKGROUND: Between 2015 and 2019 the Chronic Headache Education and Self-management Study (CHESS) developed and tested a supportive self-management approach that aimed to improve outcomes for people with chronic migraine or chronic tension type headache with/without episodic migraine. However, a paucity of qualitative research which explored the lived experiences of people with chronic headache was evidenced. In response, we undertook to explore the experiences of living with chronic headaches of people who participated in the CHESS study. METHODS: We adopted qualitative methodologies, inviting participants in the CHESS study to participate in semi-structured interviews. In phase 1 (feasibility study), a thematic analysis was conducted. In phase 2 (main CHESS trial), interviews were informed by topic guides developed from our learning from the phase 1 interviews. Pen portrait methodology and thematic analysis was employed allowing us to explore the data longitudinally. RESULTS: Phase 1, 15 interviews (10 female) age range 29 to 69 years (median 47 years) revealed the complexities of living with chronic headache. Six overarching themes were identified including the emotional impact and the nature of their headaches. Phase 2, included 66 interviews (26 participants; median age group 50s (range 20s-60s); 20 females. 14 were interviewed at three points in time (baseline, 4 and 12 months) Through an iterative process four overlapping categories of headache impact emerged from the data and were agreed: i) 'I will not let headaches rule my life'; ii) 'Headaches rule my life'; iii) 'Headaches out of control-something needs to change'; and iv) 'Headaches controlled-not ruling my life'. One of these categories was assigned to each pen portrait at each timepoint. The remaining 12 participants were interviewed at two time points during a year; pen portraits were again produced. Analysis revealed that the headache impact categories developed above held true in this sample also providing some validation of the categories. CONCLUSIONS: These data give an insight into the complexities of living with chronic headache. Chronic headache is unpredictable, permeating all aspects of an individual's life; even when an individual feels that their headache is controlled and not interfering, this situation can rapidly change. It shows us that more work needs to be done both medically and societally to help people living with this often-hidden condition. TRIAL REGISTRATION: ISRCTN79708100.

Initial validation of the 12-item Tampa Scale of Kinesiophobia in a retrospective sample of adults with chronic headache.

INTRODUCTION: An area of emerging interest in chronic pain populations concerns fear of pain and associated fear of movement (kinesiophobia)-a cognitive appraisal pattern that is well-validated in non-headache chronic pain. However, there is limited research on whether this construct can be measured in a similar manner in headache populations. METHODS: The current project details a confirmatory factor analysis of the 12-Item Tampa Scale of Kinesiophobia (TSK-12) using a clinical data set from 210 adults with diverse headache diagnoses presenting for care at a multidisciplinary pain clinic. One item (concerning an "accident" that initiated the pain condition) was excluded from analysis. RESULTS: Results of the confirmatory factor analysis for the remaining 12 items indicated adequate model fit for the previously established 2-factor structure (activity avoidance and bodily harm/somatic focus subscales). In line with previous literature, total TSK-12 scores showed moderate correlations with pain severity, pain-related interference, positive and negative affect, depressive and anxious symptoms, and pain catastrophizing. DISCUSSION: The current study is the first to examine the factor structure of the TSK-12 in an adult headache population. The results support the relevance of pain-related fear to the functional and psychosocial status of adults with chronic headache, although model fit of the TSK-12 could be characterized as adequate rather than optimal. Limitations of the study include heterogeneity in headache diagnosis and rates of comorbid non-headache chronic pain in the sample. Future studies should replicate these findings in more homogenous headache groups (eg, chronic migraine) and examine associations with behavioral indices and treatment response.

The Ethical Stewardship of Artificial Intelligence in Chronic Pain and Headache: A Narrative Review.

PURPOSE OF REVIEW: As artificial intelligence (AI) and machine learning (ML) are becoming more pervasive in medicine, understanding their ethical considerations for chronic pain and headache management is crucial for optimizing their safety. RECENT FINDINGS: We reviewed thirty-eight editorial and original research articles published between 2018 and 2023, focusing on the application of AI and ML to chronic pain or headache. The core medical principles of beneficence, non-maleficence, autonomy, and justice constituted the evaluation framework. The AI applications addressed topics such as pain intensity prediction, diagnostic aides, risk assessment for medication misuse, empowering patients to self-manage their conditions, and optimizing access to care. Virtually all AI applications aligned both positively and negatively with specific medical ethics principles. This review highlights the potential of AI to enhance patient outcomes and physicians' experiences in managing chronic pain and headache. We emphasize the importance of carefully considering the advantages, disadvantages, and unintended consequences of utilizing AI tools in chronic pain and headache, and propose the four core principles of medical ethics as an evaluation framework.

The role of environmental sensitivity, traumatic experiences, defense mechanisms and mental pain on central sensitivity: testing a path analysis model in chronic headache on quality of life.

Central pain sensitivity (CS) is defined as an increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold inputs. The main aim of this paper is to investigate if and how specific psychological constructs are related with CS burden in patients with chronic headache (CH). Specifically, research question 1 explores the association of temperament, personality, childhood adversities, defense mechanisms and mental pain with CS burden. Research question 2 aims to test the role of the best predictors of CS burden in affecting the quality of life (QoL) using path analysis. A total of 508 women with CH completed a psycho-diagnostic survey. Results showed that higher levels of low sensory threshold (ß = 0.200), bodily threat traumatic experiences (ß = 0.156), neurotic defenses (ß = 0.109) and mental pain (ß = 0.343) emerged as the best predictors of higher CS burden. The model presented demonstrated a satisfactory fit (GFI = 0.984; NFI = 0.966; CFI = 0.979; RMSEA = 0.056 [95% CI 0.028-0.085]) with large and medium effect sizes on physical (-0.654) and psychological QoL (-0.246). The study showed a key role of psychological dimensions in CS burden levels and their relationships with QoL in CH patients. From a clinical perspective, these results suggest the importance of evaluating the level of CS burden during the clinical assessment for chronic pain conditions such as CH, since it may contribute to guide patients to tailored psychological and medical treatments, thereby saving time and costs on diagnostic procedures for chronic pain.

Facial recognition, laterality judgement, alexithymia and resulting central nervous system adaptations in chronic primary headache and facial pain-A systematic review and meta-analysis.

INTRODUCTION: Patients with chronic headaches and chronic oro-facial pain commonly present psychosocial issues that can affect social interactions. A possible reason could be that patients with these disorders might present impairments in facial recognition, laterality judgement and also alexithymia. However, a systematic review summarizing the effects of facial emotion recognition, laterality judgement and alexithymia in individuals with headaches and oro-facial pain is still not available. AIM: The main objective of this systematic review (SR) and meta-analysis (MA) was to compile and synthesize the evidence on the occurrence of alexithymia, deficits in laterality or left-right (LR) recognition and/or facial emotion recognition (FER) in patients with chronic headache and facial pain. METHODS: Electronic searches were conducted in five databases (up to September 2023) and a manual search to identify relevant studies. The outcomes of interest were alexithymia scores, speed and accuracy in LR and/or FER, or any other quantitative data assessing body image distortions. The screening process, data extraction, risk of bias and data analysis were performed by two independent assessors following standards for systematic reviews. RESULTS: From 1395 manuscripts found, only 34 studies met the criteria. The overall quality/certainty of the evidence was very low. Although the results should be interpreted carefully, individuals with chronic headaches showed significantly higher levels of alexithymia when compared to healthy individuals. No conclusive results were found for the other variables of interest. CONCLUSION: Although the overall evidence from this review is very low, people with chronic primary headaches and oro-facial pain could be regularly screened for alexithymia to guarantee appropriate management.

Genetic Evidence for Causal Association Between Hypertension and Chronic Pain: A Bidirectional Two-Sample Mendelian Randomization Study.

OBJECTIVES: The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed. In the present study, Mendelian randomization (MR) was employed to examine the potential causal relationship between hypertension and risk of chronic pain. METHODS: The study data were derived from the pooled dataset of the genome-wide association study (GWAS), enabling the evaluation of the causal effects of hypertension on various types of chronic pain including chronic headache as well as chest, abdominal, joint, back, limb, and multisite chronic pain. We performed a bidirectional two-sample MR analysis using random effect inverse variance weighting (IVW), MR-Egger, weighted median, and weighted mode, quantified by odds ratio (OR). RESULTS: Genetically predicted essential hypertension was associated with an increased risk of chronic headache (OR = 1.007, 95% CI: 1.003‒|1.011, P = 0.002) and limb pain (OR = 1.219, 95% CI: 1.033|‒|1.439, P = 0.019). No potential causal associations were identified between chronic pain and essential hypertension in the reverse direction MR ( P > 0.05). In addition, there was no potential causal association between secondary hypertension and chronic pain (P > 0.05). CONCLUSIONS: This study provided genetic evidence that a unidirectional causal relationship exists between essential hypertension and the increased risks of chronic headache and limb pain, and no causal relationship was found between secondary hypertension and chronic pain. These findings offer theoretical underpinnings for future research on managing hypertension and chronic pain.

Oral and dental health status in patients with chronic headache.

INTRODUCTION: Headache is an illness with high prevalence and adverse effects on quality of life. As oral or dental problems such as pain can trigger or aggravate it, we aimed to investigate and compare oral and dental health status in patients affected with chronic headaches and healthy individuals. METHODS: The present case-control study included 60 patients with chronic headaches (case) and 60 healthy individuals (control) in Rasht, Iran. The demographic characteristics and clinical examinations, including decayed/missing/filled teeth (DMF-T) and community periodontal index of treatment needs (CPITN) indices, as well as bruxism, frequency of tooth brushing and flossing, and maxillary and mandibular tooth wear were recorded in a checklist. Data analysis was performed using the IBM SPSS version 28 at a significance level of 0.05. RESULTS: The case group consisted of 25 men (41.7%) and 35 women (58.3%) with an average age of 32.55 ± 6.62 years, while the control group had 27 men (45%) and 33 women (55%) with an average age of 30.95 ± 6.33 years. The study groups were not significantly different in bruxism, frequency of tooth brushing and flossing, DMFT, CPTIN, and maxillary and mandibular tooth wear. CONCLUSION: It seems that chronic headaches do not significantly affect the oral and dental health of the sufferers. Moreover, it appears that these patients are well aware of the role of oral and dental hygiene in triggering or aggravating the episodes of headaches.

Household income is associated with attack frequency, but not with the prevalence of headache: an analysis of self-reported headache in the general population in Germany.

BACKGROUND: Headache disorders are among the most prevalent neurological disorders worldwide. However, whether groups differing in socioeconomic position (SEP) are disproportionately affected by headache disorders has not yet been adequately clarified. Our aim was to analyse (1) the headache prevalence by socioeconomic position (SEP) and (2) the attack frequency by SEP in a German population-based adult sample. METHODS: Cross-sectional data from a random general population were used. The sample included N = 2,189 participants aged ≥ 18 years. SEP was measured using net equivalised income (NEI) and education. A binary logistic regression model tested the effect of SEP in predicting the prevalence of headache in general. Ordinal logistic regressions were modeled to predict the effect of SEP on the likelihood of attack frequency. Attack frequency was categorized in low frequency episodic headache (LFEH: 0-3 days per month), moderate frequency episodic headache (MFEH: 4-14 days per month) and chronic headache (CH: ≥ 15 days per month). RESULTS: Of the 2,189 participants, 891 reported headache in the last six months. Neither income nor education was associated with headache prevalence. However, significant differences between income groups were found for attack frequency. Compared to participants with NEI > 150%, those with NEI < 60% were 5.21 times more likely (95%CI 2.03, 13.36) to experience higher headache frequency, and those with NEI between 60 and 150% were 2.29 times more likely (95%CI 1.02, 5.11), with adjustments made for a set of potential confounders, including depressive symptoms. CONCLUSIONS: To reduce headache attacks, it is essential to address both low- and middle-income groups affected by headaches. Universal public health prevention campaigns are particularly appropriate.

DNA-methylation and immunological response in medication overuse headache.

OBJECTIVE: To investigate whether medication-overuse headache patients have differential DNA-methylation pattern. METHODS: We collected blood samples from 120 medication-overuse headache-patients, 57 controls (29 episodic migraine patients and 28 healthy controls) in a hypothesis-generating cross-sectional case-control pilot study; 100 of the medication-overuse headache-patients were followed for six months and samples were collected at two and six months for the longitudinal methylation analyses. Blood cell proportions of leucocytes (neutrophils, NK-cells, monocytes, CD8+ and CD4+ T-cells, and B-cells) and the neutrophile-lymphocyte ratio were estimated using methylation data as a measure for immunological analysis and a cell type-specific epigenome wide association study was conducted between medication-overuse headache-patients and controls, and longitudinally for reduction in headache days/month among medication-overuse headache-patients. RESULTS: We found a higher neutrophile-lymphocyte ratio in medication-overuse headache-patients compared to controls, indicating a higher immunological response in medication-overuse headache-patients (false discovery rate (adjusted p-value)<0.001). Reduction in headache days/month (9.8; 95% CI 8.1-11.5) was associated with lower neutrophile-lymphocyte ratio (false discovery rate adjusted p-value = 0.041).Three genes (CORIN, CCKBR and CLDN9) were hypermethylated in specific cell types in medication-overuse headache-patients compared to controls. No methylation differences were associated with reduction in headache days in medication-overuse headache-patients after six months. CONCLUSION: This pilot study was consistent with higher immunological response in medication-overuse headache-patients which decreased with a reduction in headache days in longitudinal analysis. medication-overuse headache-patients exhibited differential methylation in innate immune cells but did not exhibit longitudinal differences with alterations in headache days. Our study creates hypotheses for further biomarker searches.ClinicalTrials.gov Identifier: NCT02993289.

Association of preoperative aneurysmal wall enhancement with relief of chronic headache after surgical clipping of unruptured intracranial aneurysms.

OBJECTIVE: To investigate the association between chronic headache outcome and aneurysmal wall enhancement (AWE) on high-resolution vessel wall imaging (HR-VWI) in patients with unruptured intracranial aneurysms (UIAs) who underwent microsurgical clipping. METHODS: Two hundred seventy-four UIA patients were retrospectively analyzed. Patients were grouped according to presence of AWE. AWE was subclassified as focal or uniform. Clinical and imaging data were recorded. Headache was evaluated using the 10-point numerical rating scale and Headache Impact Test-6 before and 6 months after surgery. RESULTS: The proportions of patients reporting chronic headache in the no AWE, focal wall enhancement (FWE), and uniform wall enhancement (UWE) groups were 5.7%, 24.8%, and 41.8%, respectively. All patients in the UWE group who reported headache before surgery experienced headache improvement after surgery. Decrease in headache severity was greater in the UWE group than in the FWE group. Multivariate binary logistic regression showed that FWE (odds ratio (OR) 0.490; 95% confidence interval (CI), 0.262-0.917; p = 0.026) and small intraluminal thrombus (OR 0.336; 95% CI, 0.142-0.795; p = 0.013) were independent factors protective against preoperative headache. FWE (OR 0.377; 95% CI, 0.195-0.728; p = 0.004) and small intraluminal thrombus (OR 0.235; 95% CI, 0.088-0.630; p = 0.004) were independent predictors of no headache relief after surgery. CONCLUSIONS: AWE on HR-VWI is associated with relief of chronic headache after surgical clipping in patients with UIAs. Incidence of chronic headache was highest in patients exhibiting UWE. These patients also experienced the greatest improvement in headache after surgical clipping. CLINICAL RELEVANCE STATEMENT: This study revealed that high-resolution vessel wall imaging can demonstrate aneurysmal wall plaque and intraluminal thrombus, which may be prognostic imaging markers for chronic headache in patients with unruptured intracranial aneurysms. KEY POINTS: • Aneurysmal wall enhancement may be associated with chronic headache. • Incidence of chronic headache was highest in patients with aneurysms exhibiting uniform wall enhancement. • Patients with aneurysms exhibiting uniform wall enhancement experienced the greatest improvement in headache after clipping.

Chronic Headache Education and Self-Management Study (CHESS): a process evaluation.

BACKGROUND: The Chronic Headache Education and Self-Management Study (CHESS) multicentre randomised trial evaluated the impact a group education and self-management support intervention with a best usual care plus relaxation control for people living with chronic headache disorders (tension type headaches or chronic migraine, with or without medication overuse headache). Here we report the process evaluation exploring potential explanations for the lack of positive effects from the CHESS intervention. METHODS: The CHESS trial included 736 (380 intervention: 356 control) people across the Midlands and London UK. We used a mixed methods approach. Our extensive process evaluation looked at context, reach, recruitment, dose delivered, dose received, fidelity and experiences of participating in the trial, and included participants and trial staff. We also looked for evidence in our qualitative data to investigate whether the original causal assumptions underpinning the intervention were realised. RESULTS: The CHESS trial reached out to a large diverse population and recruited a representative sample. Few people with chronic tension type headaches without migraine were identified and recruited. The expected 'dose'of the intervention was delivered to participants and intervention fidelity was high. Attendance ("dose received") fell below expectation, although 261/380 (69%) received at least at least the pre-identified minimum dose. Intervention participants generally enjoyed being in the groups but there was little evidence to support the causal assumptions underpinning the intervention were realised. CONCLUSIONS: From a process evaluation perspective despite our extensive data collection and analysis, we do not have a clear understanding of why the trial outcome was negative as the intervention was delivered as planned. However, the lack of evidence that the intervention causal assumptions brought about the planned behaviour change may provide some insight. Our data suggests only modest changes in managing headache behaviours and some disparity in how participants engaged with components of the intervention within the timeframe of the study. Moving forwards, we need a better understanding of how those who live with chronic headache can be helped to manage this disabling condition more effectively over time. TRIAL REGISTRATION: ISRCTN79708100 .

Serological Biomarkers of Chronic Migraine.

PURPOSE OF REVIEW: Chronic migraine (CM) is a chronic form of migraine that differs from episodic migraine (EM) in terms of prevalence, comorbidities, response to treatment, and biomarkers. The aim of this review was to summarize the recent findings on serological biomarkers of CM. RECENT FINDINGS: Neuronal, inflammatory, and vascular markers have been investigated to assess their diagnostic and prognostic ability and treatment effectiveness. Several markers showed significant alterations according to disease status and treatment response in CM. Calcitonin gene-related peptide (CGRP), glutamate, and adiponectin appear to be the most promising blood biomarkers for CM. Most studies have shown altered ictal and interictal levels of these markers in CM compared with those in EM and controls. Additionally, they showed a significant association with treatment outcomes. Total adiponectin and high-molecular-weight adiponectin levels were less studied as biomarkers of CM than CGRP and glutamate levels but showed promising results. The development of suitable biomarkers could revolutionize the diagnosis and treatment of CM and ultimately decrease the disability and societal costs of the disease.

A multicenter, longitudinal survey of headaches and concussions among youth athletes in the United States from 2009 to 2019.

OBJECTIVE/ BACKGROUND: Chronic headaches and sports-related concussions are among the most common neurological morbidities in adolescents and young adults. Given that the two can overlap in presentation, studying the effects of one on another has proven difficult. In this longitudinal study, we sought to assess the relationship between chronic headaches and concussions, analyzing the role of historic concussions on chronic headaches, as well as that of premorbid headaches on future concussion incidence, severity, and recovery. METHODS: This multi-center, longitudinal cohort study followed 7,453 youth athletes who were administered demographic and clinical surveys as well as a total of 25,815 Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) assessments between 2009 and 2019. ImPACT was administered at baseline. Throughout the season concussions were examined by physicians and athletic trainers, followed by re-administration of ImPACT post-injury (PI), and at follow-up (FU), a median of 7 days post-concussion. Concussion incidence was calculated as the total number of concussions per patient years. Concussion severity and recovery were calculated as standardized deviations from baseline to PI and then FU in Symptom Score and the four neurocognitive composite ImPACT scores: Verbal Memory, Visual Memory, Processing Speed, and Reaction Time. Data were collected prospectively in a well-organized electronic format supervised by a national research-oriented organization with rigorous quality assurance. Analysis was preformed retrospectively. RESULTS: Of the eligible athletes, 1,147 reported chronic headaches (CH) at the start of the season and 6,306 reported no such history (NH). Median age of the cohort was 15.4 ± 1.6 years, and students were followed for an average of 1.3 ± 0.6 years. A history of concussions (OR 2.31, P < 0.0001) was associated with CH. Specifically, a greater number of past concussions (r2 = 0.95) as well as concussions characterized by a loss of consciousness (P < 0.0001) were associated with more severe headache burden. The CH cohort had a greater future incidence of concussion than the NH cohort (55.6 vs. 43.0 per 100 patient-years, P < 0.0001). However, multivariate analysis controlling for demographic, clinical, academic, and sports-related variables yielded no such effect (OR 0.99, P = 0.85). On multivariable analysis the CH cohort did have greater deviations from baseline to PI and FU in Symptom Score (PI OR per point 1.05, P = 0.01, FU OR per point 1.11, P = 0.04) and Processing Speed (OR per point 1.08, P = 0.04), suggesting greater concussion severity and impaired symptomatic recovery as compared to the NH cohort. CONCLUSION: A history of concussions was a significant contributor to headache burden among American adolescents and young adults. However, those with chronic headaches were not more likely to be diagnosed with a concussion, despite presenting with more severe concussions that had protracted recovery. Our findings not only suggest the need for conservative management among youth athletes with chronic headaches, they also indicate a potential health care gap in this population, in that those with chronic headaches may be referred for concussion diagnosis and management at lower rates than those with no such comorbidity.

[Cross-sectional analysis of libido status and risk factors in male patients with chronic headache].

OBJECTIVE: Exploring the libido status of male chronic headache patients and analyzing its relationship with headache symptoms, sleep, anxiety, and depression, providing reference for the comprehensive treatment of male chronic headache. METHODS: 179 patients with chronic headache who visited the Third Affiliated Hospital of Qiqihar Medical College from January 2022 to February 2023 were selected. The male Self Rated Libido Scale , Visual Analog Scale for Pain, Migraine Disability Assessment Scale, Pittsburgh Sleep Quality Index, Generalized Anxiety Disorder Scale-7, and Patient Health Questionnaire-9 were used to evaluate the libido status, headache severity, disability level, sleep quality, anxiety, and depression of the research subjects, respectively. RESULTS: Among 179 male chronic headache patients, 97 were chronic migraine (CM) patients and 82 were chronic tension type (CTT) patients, and 47 were screened for low libido. The influencing factors of libido in male chronic headache patients include age, smoking, frequency of exercise, course of disease, severity of pain, frequency of headache, disability score, sleep quality, anxiety and depression (all P<0.05). Compared with male CTT patients, male CM patients have higher pain severity, headache frequency, disability score, and anxiety score, while lower libido score (all P<0.05). The results of multivariate analysis showed that age, frequency of exercise, course of disease, severity of pain, frequency of headache, degree of disability, sleep quality, anxiety, and depression were the influencing factors for the decline of libido in male chronic headache patients. CONCLUSION: It is common for male chronic headache patients to experience decreased libido, with male chronic migraine (CM) patients exhibiting more severe reductions. Advanced age, decreased physical activity, longer disease duration, severe pain intensity, frequent headaches, higher disability levels, poor sleep, anxiety, and depression are risk factors for decreased libido in male chronic headache patients.

Natural History of Abortive Medication Withdrawal in the Management of Pediatric Medication Overuse Headache.

OBJECTIVE: The objective of this study is to document pain scores during withdrawal of abortive medication in patients diagnosed with medication overuse headache. DESIGN: Cross-sectional study. SETTING: Children's National Hospital's Headache Program. SUBJECTS: Patients 6-18 years of age who presented to the Headache Clinic at Children's National Hospital with presumed medication overuse headache between March 2017 and March 2019 were invited to participate. METHODS: Patients were instructed to abruptly discontinue overused medications and record their headache characteristics daily in a diary for 8 weeks. RESULTS: Fourteen diaries were returned and analyzed at a 4-week follow-up visit. Ninety-three percent of the patients were females, with a median age of 14.9 years (standard deviation [SD] = 2.0). The average headache intensity upon study entry was 4.7 out of 10 (SD = 2.5), and the average headache intensity upon study completion was 3.1 (SD = 2.5). Of the patients, 57% had daily headaches upon study entry, 71% had improved pain intensity from the first diary entry to the last diary entry, and 57% had complete headache resolution at an average of 7.6 days from medication discontinuation (SD = 5.1). Ibuprofen was the most overused medication (71%). CONCLUSIONS: Our findings suggest that medication overuse headache will improve in the majority of pediatric patients who abruptly stop the offending medication(s) in an average of 8 days from withdrawal. Average pain intensity was reduced by more than one point among all patients who stopped taking abortive medications. Further larger-scale studies on medication withdrawal in pediatric patients with medication overuse headache could help us better understand whether this management strategy is effective.

Questionnaire-based survey on the prevalence of medication-overuse headache in Japanese one city-Itoigawa study.

OBJECTIVE: The medication-overuse headache (MOH) prevalence has not been investigated in a general Japanese population. We performed questionnaire-based survey and revealed MOH prevalence and its characteristics. We also performed clustering to obtain insight for MOH subgrouping. METHODS: In this cross-sectional study, the 15-64-year-old population was investigated in Itoigawa during their COVID-19 vaccination under the national policy. MOH was defined as ≥ 15 days/month plus self-report of use of pain medications ≥ 10 or 15 days/month in the last 3 months. Ward method and k-means + + were used to perform clustering MOH patients. RESULTS: Among 5865 valid responses, MOH prevalence was 2.32%. MOH was common among females and the middle-aged. Combination-analgesic is the most overused as 50%. MOH had aggravation by routine physical activity, moderate or severe pain, and migraine-like, compared to non-MOH. The 136 MOH patients could be grouped into 3 clusters. Age and frequency of acute medication use were essential factors for clustering. CONCLUSIONS: This is the first study of MOH prevalence in Japan. Most MOH characteristics were similar to previous reports worldwide. Public awareness of proper headache treatment knowledge is still needed. Clustering results may be important for subtype grouping from a social perspective apart from existing clinical subtypes.

OnabotulinumtoxinA for the treatment of headache: an updated review.

Botulinum toxin (BT) is a neurotoxin produced by Clostridium botulinum, a gram-positive anaerobic bacterium. Systemic human intoxication from BT following oral ingestion results in acute and life-threatening muscle paralysis called botulism. BT has a wide scope of therapeutic uses, including conditions associated with increased muscle tone, smooth muscle hyperactivity, salivation, sweating, and allergies, as well as for cosmetic purposes. Several commercial forms of BT are available for medical use, including Botox (onabotulinumtoxinA). Multiple studies have found evidence of an analgesic effect of onabotulinumtoxinA and demonstrated the benefits of its use for the treatment of various chronic pain disorders. In this review, we provide an update on the use of onabotulinumtoxinA for the treatment of headache disorders.

Measuring health-related quality of life in chronic headache: A comparative evaluation of the Chronic Headache Quality of Life Questionnaire and Headache Impact Test (HIT-6).

OBJECTIVE: To compare the quality and acceptability of a new headache-specific patient-reported measure, the Chronic Headache Quality of Life Questionnaire (CHQLQ) with the six-item Headache Impact Test (HIT-6), in people meeting an epidemiological definition of chronic headaches. METHODS: Participants in the feasibility stage of the Chronic Headache Education and Self-management Study (CHESS) (n = 130) completed measures three times during a 12-week prospective cohort study. Data quality, measurement acceptability, reliability, validity, responsiveness to change, and score interpretation were determined. Semi-structured cognitive interviews explored measurement relevance, acceptability, clarity, and comprehensiveness. RESULTS: Both measures were well completed with few missing items. The CHQLQ's inclusion of emotional wellbeing items increased its relevance to participant's experience of chronic headache. End effects were present at item level only for both measures. Structural assessment supported the three and one-factor solutions of the CHQLQ and HIT-6, respectively. Both the CHQLQ (range 0.87 to 0.94) and HIT-6 (0.90) were internally consistent, with acceptable temporal stability over 2 weeks (CHQLQ range 0.74 to 0.80; HIT-6 0.86). Both measures responded to change in headache-specific health at 12 weeks (CHQLQ smallest detectable change (improvement) range 3 to 5; HIT-6 2.1). CONCLUSIONS: While both measures are structurally valid, internally consistent, temporally stable, and responsive to change, the CHQLQ has greater relevance to the patient experience of chronic headache.Trial registration number: ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100.

Poor social support and loneliness in chronic headache: Prevalence and effect modifiers.

OBJECTIVE: To explore the prevalence of poor social support and loneliness among people with chronic headache, and how these might be effect modifiers in the relationships between chronic headache and stress, medication overuse, and self-rated health. BACKGROUND: Poor social support and loneliness are consistently linked to worse health outcomes. There are few epidemiologic studies on their effect on headache. METHODS: The Danish Capital Region Health Survey, a cross-sectional survey, was conducted in 2017. Participants were asked about headache, pain medication use, social support, loneliness, perceived stress, and self-rated health. Data were accessed from sociodemographic registers. Logistic regression analyses were performed to test for effect modification. RESULTS: The response rate was 52.6% (55,185 respondents) and was representative of the target population. People with chronic headache were more likely to report poor social support and loneliness compared to those without chronic headache (p < 0.0001 for both). Odds ratios for the combination of chronic headache and poor social support were very high for stress (odds ratio 8.1), medication overuse (odds ratio 21.9), and poor self-rated health (odds ratio 10.2) compared to those without chronic headache and with good social support. Those who reported both chronic headache and loneliness had a very high odds ratio for stress (odds ratio 14.4), medication overuse (odds ratio 20.1), and poor self-rated health (odds ratio 15.9) compared to those without chronic headache and low loneliness score. When adjusted for sociodemographic factors, poor social support and loneliness were not significant effect modifiers in almost all these associations. Loneliness was a significant effect modifier in the association between chronic headache and medication overuse, but exerted greater effect among those who did not report they were lonely. CONCLUSION: Poor social support and loneliness were prevalent among people with chronic headache. The combination of chronic headache and poor social support or loneliness showed higher odds ratios for stress, medication overuse, and poor self-rated health compared to those with good social support and low loneliness scores. The effect of loneliness in the relationship between chronic headache and medication overuse warrants further study.

Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture.

OBJECTIVE: This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle. BACKGROUND: Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP. METHODS: We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population. RESULTS: In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer. CONCLUSION: Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.