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Headache and facial pain are among the most common, disabling and costly diseases in Europe, which demands for high quality health care on all levels within the health system. The role of the Danish Headache Society is to educate and advocate for the needs of patients with headache and facial pain. Therefore, the Danish Headache Society has launched a third version of the guideline for the diagnosis, organization and treatment of the most common types of headaches and facial pain in Denmark. The second edition was published in Danish in 2010 and has been a great success, but as new knowledge and treatments have emerged it was timely to revise the guideline. The recommendations for the primary headaches and facial pain are largely in accordance with the European guidelines produced by the European Academy of Neurology. The guideline should be used a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organized in Denmark. This description is followed by sections on the characteristics, diagnosis and treatment of each of the most common primary and secondary headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular challenges regarding migraine and female hormones as well as headache in children are addressed.

Importance Medication overuse headache (MOH) is a disabling, globally prevalent disorder representing a well-known and debated clinical problem. Evidence for the most effective treatment strategy is needed. Objective To compare 3 treatment strategies for MOH. Design, Setting, and Participants This open-label, randomized clinical trial with 6 months of follow-up was conducted in the tertiary sector at the Danish Headache Center, Glostrup, from October 25, 2016, to June 28, 2019. Of 483 patients with MOH referred during the inclusion period, 195 met the criteria consisting of migraine and/or tension-type headache, 18 years or older, eligibility for outpatient treatment, no severe physical or psychiatric disorder, no other addiction, and not pregnant or breastfeeding. Of these, 75 refused participation and 120 were included. Data were analyzed from July 3 to September 6, 2019. Interventions Random assignment (1:1:1 allocation) to 1 of the 3 outpatient treatments consisting of (1) withdrawal plus preventive treatment, (2) preventive treatment without withdrawal, or (3) withdrawal with optional preventive treatment 2 months after withdrawal. Main Outcomes and Measures The primary outcome was change in headache days per month after 6 months. Predefined secondary outcomes were change in monthly migraine days, use of short-term medication, pain intensity, number of responders, patients with remission to episodic headache, and cured MOH. Results Of 120 patients, 102 (mean [SD] age, 43.9 [11.8] years; 81 women [79.4%]) completed the 6-month follow-up. Headache days per month were reduced by 12.3 (95% CI, 9.3-15.3) in the withdrawal plus preventive group, by 9.9 (95% CI, 7.2-12.6) in the preventive group, and by 8.5 (95% CI, 5.6-11.5) in the withdrawal group (P = .20). No difference was found in reduction of migraine days per month, use of short-term medication, or headache intensity. In the withdrawal plus preventive group, 23 of 31 patients (74.2%) reverted to episodic headache, compared with 21 of 35 (60.0%) in the preventive group and 15 of 36 (41.7%) in the withdrawal group (P = .03). Moreover, 30 of 31 patients (96.8%) in the withdrawal plus preventive group were cured of MOH, compared with 26 of 35 (74.3%) in the preventive group and 32 of 36 (88.9%) in the withdrawal group (P = .03). These findings corresponded to a 30% (relative risk, 1.3; 95% CI, 1.1-1.6) increased chance of MOH cure in the withdrawal plus preventive group compared with the preventive group (P = .03). Conclusion and Relevance All 3 treatment strategies were effective, but based on these findings, withdrawal therapy combined with preventive medication from the start of withdrawal is recommended as treatment for MOH. Trial Registration ClinicalTrials.gov Identifier:NCT02993289

BACKGROUND AND AIM: Monoclonal antibodies acting on the calcitonin gene-related peptide or on its receptor are new drugs to prevent migraine. Four monoclonal antibodies have been developed: one targeting the calcitonin gene-related peptide receptor (erenumab) and three targeting the calcitonin gene-related peptide (eptinezumab, fremanezumab, and galcanezumab). The aim of this document by the European Headache Federation (EHF) is to provide an evidence-based and expert-based guideline on the use of the monoclonal antibodies acting on the calcitonin gene-related peptide for migraine prevention.METHODS: The guideline was developed following the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic review and analysis of the literature, assessed the quality of available evidence, and wrote recommendations. Where the GRADE approach was not applicable, expert opinion was provided.RESULTS: We found low to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in patients with episodic migraine and medium to high quality of evidence to recommend erenumab, fremanezumab, and galcanezumab in patients with chronic migraine. For several clinical questions, there was not enough evidence to provide recommendations using the GRADE approach and recommendations relied on experts' opinion.CONCLUSION: Monoclonal antibodies acting on the calcitonin gene-related peptide are new drugs which can be recommended for migraine prevention. Real life data will be useful to improve the use of those drugs in clinical practice.

BACKGROUND: This study aimed to describe recruitment challenges encountered during a phase IIa study of vixotrigine, a state and use-dependent Nav1.7 channel blocker, in individuals with trigeminal neuralgia.METHODS: This was an international, multicenter, placebo-controlled, randomized withdrawal study that included a 7-day run-in period, a 21-day open-label phase, and a 28-day double-blind phase in which patients (planned n = 30) were randomized to vixotrigine or placebo. Before recruitment, all antiepileptic drugs had to be stopped, except for gabapentin or pregabalin. After the trial, patients returned to their original medications. Patient recruitment was expanded beyond the original five planned (core) centers in order to meet target enrollment (total recruiting sites N = 25). Core sites contributed data related to patient identification for study participation (prescreening data). Data related to screening failures and study withdrawal were also analyzed using descriptive statistics.RESULTS: Approximately half (322/636; 50.6%) of the patients who were prescreened at core sites were considered eligible for the study and 56/322 (17.4%) were screened. Of those considered eligible, 26/322 (8.1%) enrolled in the study and 6/322 (1.9%) completed the study. In total, 125 patients were screened across all study sites and 67/125 (53.6%) were enrolled. At prescreening, reasons for noneligibility varied by site and were most commonly diagnosis change (78/314; 24.8%), age > 80 years (75/314; 23.9%), language/distance/mobility (61/314; 19.4%), and noncardiac medical problems (53/314; 16.9%). At screening, frequently cited reasons for noneligibility included failure based on electrocardiogram, insufficient pain, and diagnosis change.CONCLUSIONS: Factors contributing to recruitment challenges encountered in this study included diagnosis changes, anxiety over treatment changes, and issues relating to distance, language, and mobility. Wherever possible, future studies should be designed to address these challenges.TRIAL REGISTRATION: ClinicalTrials.gov, NCT01540630 . EudraCT, 2010-023963-16. 07 Aug 2015.

Summary Background Current standard of care for trigeminal neuralgia is treatment with the sodium channel blockers carbamazepine and oxcarbazepine, which although effective are associated with poor tolerability and the need for titration. BIIB074, a Nav1.7-selective, state-dependent sodium-channel blocker, can be administered at therapeutic doses without titration, and has shown good tolerability in healthy individuals in phase 1 studies. We therefore assessed the safety and efficacy of BIIB074 in patients with trigeminal neuralgia in a phase 2a study. Methods We did a double-blind, multicentre, placebo-controlled, randomised withdrawal phase 2a trial in 25 secondary care centres in Denmark, Estonia, France, Germany, Italy, Latvia, Lithuania, Romania, South Africa, Spain, Switzerland, and the UK. After a 7-day run-in phase, eligible patients aged 18–80 years with confirmed trigeminal neuralgia received open-label, BIIB074 150 mg three times per day, orally, for 21 days. Patients who met at least one response criteria were then randomly assigned (1:1) to BIIB074 or placebo for up to 28 days in a double-blind phase. We used an interactive web response system to assign patients with a computer-generated schedule, with stratification (presence or absence of existing pain medication). Patients, clinicians, and assessors were masked to treatment allocation. The primary endpoint was the difference between groups in the number of patients classified as treatment failure during the double blind phase assessed in the modified intention-to-treat population. We assessed safety in all patients who received one or more doses of BIIB074. This study is registered with ClinicalTrials.gov (NCT01540630) and EudraCT (2010-023963-16). Findings The first patient was enrolled on April 23, 2012, and the last patient completed the study on February 26, 2014. We enrolled 67 patients into the open-label phase; 44 completed open-label treatment, and 29 were randomly assigned to double-blind treatment (15 to BIIB074 and 14 to placebo). During the double-blind phase, five (33%) patients assigned to BIIB074 versus nine (64%) assigned to placebo were classified as treatment failures (p=0·0974). BIIB074 was well tolerated, with similar adverse events in the double-blind phase to placebo. Headache was the most common adverse event with BIIB074 in the open-label phase (in 13 [19%] of 67 patients), followed by dizziness (in six [9%] patients). In the double-blind phase, headache, pyrexia, nasopharyngitis, sleep disorder, and tremor were the most frequent adverse events in patients assigned to BIIB074 (in one [7%] of 15 patients for each event), and headache, dizziness, diarrhoea, and vomiting were the most frequent adverse events in patients assigned to placebo (in one [7%] of 14 patients for each event). No severe or serious adverse events were reported in the BIIB074 group during the double-blind phase. One patient assigned to placebo reported intestinal adhesions with obstruction as a severe and serious adverse event, which was considered as unrelated to study medication. Interpretation The primary endpoint of treatment failure was not significantly lower in the BIIB074 group than in the placebo group. However, our findings provide a basis for continued investigation of BIIB074 in patients with trigeminal neuralgia in future clinical trials. Funding Convergence Pharmaceuticals.

Medication-overuse headache (MOH) is a debilitating condition in which frequent and prolonged use of medication for the acute treatment of pain results in the worsening of the headache. The purpose of this paper is to review the most recent literature on MOH and discuss future avenues for research. MOH accounts for a substantial share of the global burden of disease. Prevalence is often reported as 1–2% but can be as high as 7% overall, with higher proportions among women and in those with a low socioeconomic position. Management consists of withdrawing pain medication, focusing on prophylactic and nonmedical treatments, and limiting acute symptomatic medication. Stress reduction and lifestyle interventions may support the change towards rational pain medication use. Support, follow up, and education are needed to help patients through the detoxification period. There is fertile ground for research in MOH epidemiology, pathophysiology, and neuroimaging. Randomized and long-term follow-up studies on MOH treatment protocols are needed. Further focused research could be of major importance for global health.

Headache and facial pain are among the most common, disabling and costly disorders in Europe. Correct diagnosis and treatment is important for achieving a high quality of care. As a national organisation whose role is to educate and advocate for the needs of patients with primary headaches, the Danish Headache Society has set up a task force to develop a set of guidelines for the diagnosis, organisation and treatment of the most common types of headaches and for trigeminal neuralgia in Denmark. The guideline was published in Danish in 2010 and has been a great success. The Danish Headache Society decided to translate and publish our guideline in English to stimulate the discussion on optimal organisation and treatment of headache disorders and to encourage other national headache authorities to produce their own guidelines. The recommendations regarding the most common primary headaches and trigeminal neuralgia are largely in accordance with the European guidelines produced by the European Federation of Neurological Societies. The guideline provides a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organised in Denmark. This description is followed by individual sections on the characteristics, diagnosis, differential diagnosis and treatment of each of the major headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular problems regarding headache in children and headache in relation to female hormones and pregnancy are described.

Background Optimal management of patients with classical trigeminal neuralgia (TN) requires specific treatment programs and close collaboration between medical, radiological and surgical specialties. Organization of such treatment programs has never been described before. With this paper we aim to describe the implementation and feasibility of an accelerated cross-speciality management program, to describe the collaboration between the involved specialties and to report the patient flow during the first 2 years after implementation. Finally, we aim to stimulate discussions about optimal management of TN. Methods Based on collaboration between neurologists, neuroradiologists and neurosurgeons a standardized program for TN was implemented in May 2012 at the Danish Headache Center (DHC). First out-patient visit and subsequent 3.0 Tesla MRI scan was booked in an accelerated manner. The MRI scan was performed according to a special TN protocol developed for this program. Patients initially referred to neurosurgery were re-directed to DHC for pre-surgical evaluation of diagnosis and optimization of medical treatment. Follow-up was 2 years with fixed visits where medical treatment and indication for neurosurgery was continuously evaluated. Scientific data was collected in a structured and prospective manner. Results From May 2012 to April 2014, 130 patients entered the accelerated program. Waiting time for the first out-patient visit was 42 days. Ninety-four percent of the patients had a MRI performed according to the special protocol after a mean of 37 days. Within 2 years follow-up 35 % of the patients were referred to neurosurgery after a median time of 65 days. Five scientific papers describing demographics, clinical characteristics and neuroanatomical abnormalities were published. Conclusion The described cross-speciality management program proved to be feasible and to have acceptable waiting times for referral and highly specialized work-up of TN patients in a public tertiary referral centre for headache and facial pain. Early high quality MRI ensured correct diagnosis and that the neurosurgeons had a standardized basis before decision-making on impending surgery. The program ensured that referral of the subgroup of patients in need for surgery was standardized, ensured continuous evaluation of the need for adjustments in pharmacological management and formed the basis for scientific research.

Background Religious belief can be used as a pain coping strategy. Our purpose was to evaluate the relationship between headache and religious activity using prospective data from a large population-based study. Methods This longitudinal cohort study used data from two consecutive surveys in the Nord-Trøndelag Health Survey (HUNT 2 and 3) performed in 1995–1997; and 2006–2008. Among the 51,383 participants aged ≥ 20 years who answered headache questions at baseline, 41,766 were eligible approximately 11 years later. Of these, 25,177 (60%) completed the question in HUNT 3 regarding religious activity. Frequent religious attendees (fRA) (used as a marker of stronger religious belief than average) were defined as those who had been to church/prayer house at least once monthly during the last six months. Results In the multivariate analyses, adjusting for known potential confounders, individuals with headache 1–14 days/month in HUNT 2 were more likely to be fRA 11 years later than headache-free individuals. Migraine at baseline predisposed more strongly to fRA at follow-up (OR = 1.25; 95% CI 1.19-1.40) than did non-migrainous headache (OR = 1.13; 95% 1.04-1.23). The odds of being fRA was 48% increased (OR 1.48; 95% 1.19-1.83) among those with migraine 7–14 days/month at baseline compared to subjects without headache. In contrast, headache status at baseline did not influence the odds of being frequent visitors of concerts, cinema and/or theatre at follow-up 11 years later. Conclusions In this prospective study, headache, in particular migraine, at baseline slightly increased the odds of being fRA 11 years later. Open Access This article is distributed under the terms of the Creative Commons Attribution 2.0 International License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The debate on the clinical definition of refractory Chronic Migraine (rCM) is still far to be concluded. The importance to create a clinical framing of these rCM patients resides in the complete disability they show, in the high risk of serious adverse events from acute and preventative drugs and in the uncontrolled application of therapeutic techniques not yet validated. The European Headache Federation Expert Group on rCM presents hereby the updated definition criteria for this harmful subset of headache disorders. This attempt wants to be the first impulse towards the correct identification of these patients, the correct application of innovative therapeutic techniques and lastly aim to be acknowledged as clinical entity in the next definitive version of the International Classification of Headache Disorders 3 (ICHD-3 beta).

Are largely beneficial, but a lack of research leaves important clinical questions unanswered

In the present study we used high-density EEG brain mapping to investigate spatio-temporal aspects of brain activity in response to experimentally induced muscle pain in 17 patients with migraine without aura and 15 healthy controls. Painful electrical stimuli were applied to the trapezius muscle and somatosensory-evoked potentials were recorded with 128-channel EEG with and without concurrent induced tonic neck/shoulder muscle pain. At baseline, the calculated P300 dipole for single stimuli was localized in the cingulate cortex. In patients, but not in controls, the dipole changed position from baseline to the tonic muscle pain condition (z = 29 mm vs. z = −13 mm, P

Chronic tension-type headache (CTTH) affects 3% of the population. Directly and indirectly it causes high costs and considerable loss of quality of life. The mechanisms of this disorder are poorly understood and the treatment possibilities are therefore limited. The blink reflex (BR) reflects neuronal excitability due to nociceptive input in the brainstem. The aim of this study was to investigate nociceptive processing at the level of the brainstem in an experimental pain model of CTTH symptoms.The effect of conditioning pain, 5 min infusion of hypertonic saline into the neck muscles, was investigated in 20 patients with CTTH and 20 healthy controls. In addition, a pilot study with isotonic saline was performed with 5 subjects in each group. The BR was elicited by electrical stimuli with an intensity of four times the pain threshold, with a superficial concentric electrode. We measured the BR, sensibility to pressure and electrical pain scores before, during and 25 min after the saline infusion.The pain rating of the electrical stimuli and the pain score of the hypertonic saline infusion were significantly higher in CTTH patients than in healthy volunteers. The primary endpoint was the relative change of the blink reflex integral immediately after hypertonic saline infusion. It was significantly smaller in CTTH patients on the contralateral side (-24.5% +/-7.0 (sem)) compared to healthy volunteers (0.4% +/-6.8), (p0.05, Holm-Sidak), while there was no significant difference on the ipsilateral side (-5.9% +/-3.2 vs. -3.4% +/-3.0, n.s., Holm-Sidak).There was no robust difference in BR integral after conditioning tonic neck pain between CTTH patients and healthy volunteers, but CTTH patients were more sensitive to nociceptive stimuli.A combined homotopic and heterotopic effect of the conditioning pain onto the blink reflex could account for this finding.

Neurovascular contact (NVC) is considered a frequent cause of classical trigeminal neuralgia (TN) and transposition of a blood vessel in the potentially dangerous procedure of microvascular decompression is considered over other surgical options in medically refractory TN. However, prevalence of NVC has not been investigated in a representative neurological TN patient cohort using high-quality imaging and blinded evaluator.

Results Mental vulnerability scores (mean ± SD) were highest for chronic headache (migraine +/TTH) headache (6.1 ± 1.9), followed by chronic TTH (5.7 ± 2.1), episodic migraine +/TTH (4.2 ± 1.9), episodic TTH (4.2 ± 1.6), no headache (3.1 ± 1.4),(p

Tension headache is known by virtually everyone. Most people have mild and infrequent attacks, but about 3% of the population have frequent attacks–chronic tension headache.1 Chronic tension headache often affects patients for a major part of their lives, causing considerable personal and socioeconomic expense.2 The aetiology of chronic tension headache remains largely unknown. A genetic factor has not previously been suspected, although patients suffering from chronic tension headache commonly report a family history of the condition. We examined the familial occurrence of chronic tension headache in spouses and first degree relatives of probands with chronic tension headache in order to evaluate …

Background Previously, central sensitization has been found in chronic, primary headaches but pain perception in MOH patients has only scarcely been studied. Aim To investigate pain perception before and during detoxification in patients with medication overuse headache (MOH). Methods 35 patients with MOH following structured detoxification programmes were tested before and 2, 6 and 12 months after withdrawal and 40 age and sex matched, healthy volunteers were tested for comparison. We measured cephalic and extra cephalic pressure pain thresholds (PPT) and supra-threshold pressure pain (STPP) as well as extra cephalic pain thresholds, supra-threshold pain and wind-up for electrical stimulation. Results At baseline, cephalic and extra cephalic PPTs were significantly lower in patients with MOH compared with healthy volunteers. Cephalic STPP was significantly higher in MOH patients compared with healthy volunteers but decreased significantly from baseline to the 6-month and 12-month follow-up. Supra-threshold pain for a single electrical stimulus was significantly higher in MOH patients compared with healthy volunteers. In contrast to healthy volunteers, patients with MOH did not exhibit wind-up before withdrawal. After 2 months, MOH patients had regained ability to wind-up and this persisted at 6-month and 12-month follow-up. Conclusions Patients with MOH have altered pain sensation and exhibit both allodynia and hyperalgesia indicating central sensitization. Withdrawal from medication overuse causes significant decrease in central sensitization. The ability to wind-up is altered in MOH patients, probably as a consequence of medication overuse, but it can be regained after withdrawal. These findings emphasize the need for detoxification in MOH.

Background and aims Low physical activity has been associated with higher prevalence of headaches. The primary aim of the study was to assess the association of pure migraine, pure tension-type headache (TTH) and coexistent headache with the level of leisure-related physical activity. The secondary aim was to study the association between the level of leisure-related physical activity and episodic and chronic mixed headache. Methods Total of 1300 subjects was invited to participate in a crosssectional population study. A total of 805 eligible subjects completed a diagnostic headache interview, provided selfreported data on neck pain and back pain, leisure-related physical activity, demographics and self-rated health. Levels of leisure-related physical activity were classified according to activities performed as low, medium and high (reference). Results Multinomial logistic regression analysis adjusted for gender, age, education, neck pain, back pain, poor self-rated health demonstrated that primary headache (mixed headache ) was associated low physical activity (OR=2.54, 95% CI=1.47-4.39, p=0.001) followed by medium physical activity (OR=1.62, 95% CI=1.05-2.52, p=0.03). Low physical activity was significantly associated with pure TTH (OR=2.80, 95%CI=1.38-5.68, p=0.004) and coexistent headache (OR=2.97, 95%CI=1.27-6.99, p=0.01) in the adjusted analysis. Association of pure migraine with low (OR=1.95, 95% CI=0.86-4.43, p=0.11) and medium physical activity, and coexistent headache and pure TTH with medium physical activity did not reach statistical significance. Low activity level is highest in chronic headache (OR=2.97, 95%CI=0.94-9.44, p=0.07) compared to episodic headache (OR=2.42, 95%CI=1.37-4.28, p=0.002). Conclusions Lower level of leisure-related physical activity is associated with primary headaches. Furthermore, the association is strongest for coexistent headache followed by pure TTH and pure migraine. The causal relationship of low activity level to headache chronicit yc annot be assessed in this cross-sectional study.

The aim of the present study was to compare the late exteroceptive suppression period (ES2) of temporalis muscle activity between patients with chronic tension-type headache and healthy controls, and to investigate the influence, if any, of actual headache on ES2. ES2 was recorded in 55 patients and in 55 controls with a previously evaluated methodology and analysed by a blinded observer. The first 20 patients were randomly studied on 2 additional days, 1 day with and 1 day without headache. The duration of ES2 did not differ between patients and controls and did not differ on days with headache compared with days without headache. ES2 duration was not related to the frequency of headache, headache intensity, age, pericranial muscle tenderness or electrical pain threshold. Our results strongly indicate that ES2 is normal in chronic tension-type headache and therefore may not be related to the pathophysiology of this disorder.

The purpose of the study is to test the cross-cultural adaptation and psychometric properties of a Danish version of the Headache-Specific Locus of Control Scale (HSLC) and the Headache Management Self-Efficacy Scale (HMSE) in a tertiary headache centre. HSLC and HMSE are headache-specific measures of locus of control (LOC) and SE. The Danish versions of the HSLC and the HMSE were created according to the guidelines for cross-cultural adaptation of self-report measures. The HSLC and HMSE were administered to 135 consecutively referred headache patients in a tertiary headache centre together with other self-report measures concerning general distress, anxiety, depression, and health-related quality of life. Internal stability of the HSLC subscales and the HMSE were analysed using Chronbach's alpha coefficient. The psychometric properties of the Danish version of the HSLC and the HMSE were analysed using Spearman's rank correlation test. Cronbach's alpha ranged from 0.71 to 0.88 and the corrected item-total correlations were acceptable. The mean corrected item-total correlations for the three subscales of HSLC (health-care LOC, internal LOC, and chance LOC) were 0.40, 0.59, and 0.40 respectively. The mean corrected item-total correlation for HMSE was 0.42. High HMSE scores were found to be associated with high scores on internal LOC and low scores on chance LOC. High scores on chance LOC were positively associated with low scores on social functioning independently of headache frequency. The results are consistent with the earlier findings of the original American versions of HMSE and HSLC. These scales seem to be valid and valuable tools for testing of psychological aspects related to level of functioning and quality of life for headache patients across different cultures of Western society. The HMSE and the HSLC proved valuable in clinical headache research. Since scores on HSLC and HMSE were associated with measures of physical and social functioning the HSLC and HMSE may be of particular interest for intervention studies aimed at enhancing level of functioning for headache patients.

Lack of knowledge on patients’ expectations to treatment may lead to misunderstandings and prevent successful outcome. Presently, treatment of medication overuse headache (MOH) leads to improvement in up to 75% of patients, but the relapse rate may exceed 40%. This study aimed to evaluate the preferences on information and expectations to treatment in patients entering a treatment programme for MOH. A questionnaire on patients’ needs and preferences on information and expectations was distributed to 65 MOH patients from specialized headache clinics in Italy, Germany and Denmark. A total of 75% selected personal verbal information as their primary need, significantly higher than the percentage of patients who selected leaflets and website information 35 and 35%, respectively (p

The objective was to discover possible psychological factors influencing treatment outcome for headache patients referred to psychological treatment in a tertiary headache centre by initial assessment using the Millon Clinical Multiaxial Inventory III (MCMI-III). The MCMI-III was administered to 136 referred patients. Patients with valid protocols who had completed their treatment by October 2003 were included. Multidisciplinary treatment was offered including psychological treatment, mainly pain and stress management, pharmacological treatment and physiotherapy. Medians of MCMI-III scales for patients with and without reduction in headache frequency were compared. All of the eligible 58 patients were included in the study. Patients with reduction in headache frequency after treatment had lower scores on the MCMI-III Somatoform, Major depression and Avoidant personality pattern scales and higher scores on the Alcohol Dependence, Self-Defeating personality pattern, Depressive personality pattern, Drug Dependence, Aggressive personality pattern and Bipolar: Manic scales before treatment compared to patients without effect. Patients with a positive treatment effect reported less symptoms of depression and seemed less inclined to somatisation than non-responders. Responders also appeared more likely to experience increased social or occupational distress and report difficulties with handling emotions and an enduring tendency to focus on negative aspects of the self-image. The results can give valuable information regarding treatment planning and development.

Perineural tumor invasion is a rare complication of cancer though well-reported phenomenon among patients with head and neck cancer. Multiple cranial neuropathies as an initial symptom of recurrent neoplasm have been reported in few studies. The latest study by Leach et al. [1] reported multiple cranial nerve involvement in 67% (4 out of 6 patients) of the patient in comparison to 21% (13 out of 62 patients) found in a study of Mendenhall et al. [2]. Facial pain, progressive weakness of the facial nerve and involvement of fifth cranial nerve were the symptoms most often referred by the patients in previous studies [1–5]. The similarities of the symptoms with Bell’s palsy, trigeminal neuralgia or facial pain of uncertain etiology can lead to misdiagnosis and postpone treatment of highly morbid tumors. Here we describe a patient with multiple cranial neuropathies due to perineural spread of squamous cell carcinoma (SCC), whom the diagnostic procedure establishment of a final diagnosis was a long and challenging process because of repetitive non-diagnostic biopsies and negative magnetic resonance imaging (MRI).

A 59-year-old woman referred by a neurologist to the Danish Headache Center, a tertiary headache centre, for the treatment of refractory migraine presents for the initial consultation. The patient has suffered from frequent headaches since childhood and in the last couple of years from daily headaches. She told me that she was so tired of the headaches that have ruined her life and of all the various treatments she has received during her life. None of the treatments has had any effect, several have been costly and several had bothersome side effects. She had almost given up hope. The patient did not fill out the 4-week headache diary that has been mailed to her from the headache centre prior to the initial consultation, and it was difficult for her to give a detailed headache history. She reported that her headaches could be unilateral or bilateral, of moderate to severe intensity, throbbing and at times pressing in character and could be aggravated by waking stairs. She also reports frequent nausea and sometimes sensitivity to sounds and light. The headaches are clearly provoked by psychological stress and to a lesser extent by physical activity. Sometimes headaches are preceded by visual disturbances. She had been on sick leave due to the headaches in the past 3 months. She reports being often anxious but she denies depressed mood. She works as a teacher and had some stress at work. Otherwise, she is healthy. Her mother had suffered from life-long migraines. Her paternal uncle had brain aneurysm. At the first consultation, it was obvious that the patient suffered from migraine, tension-type headache (TTH) and anxiety on the most severe headache days. General and neurological examination demonstrates increased pericranial myofascial tenderness. Her blood pressure and pulse are within normal limits. Electrocardiogram and routine blood tests are unremarkable. What to do for this severely incapacitated woman?

Background Medication-overuse headache (MOH) is a chronic, secondary headache caused by excessive intake of symptomatic medications for an underlying headache, most often tension-type headache or migraine. Previously, elevated calcitonin-gene-related peptide (CGRP) levels were found in migraine patients increasing with migraine frequency and in animal MOH models. Aim To test whether MOH patients have increased CGRP levels before withdrawal therapy compared with healthy volunteers, and further, if the CGRP level would normalize after withdrawal in parallel with the headache-frequency decrease.

In the summer of 2013 the International Headache Society (IHS) published the beta-version of the 3rd International Classification of Headache Disorders (ICHD-3 beta) with revised diagnostic criteria for classical trigeminal neuralgia (TN). The TN diagnostic criteria are based on expert opinion and IHS strongly encourages field-testing of the new diagnostic criteria.

Background In patients with idiopathic intracranial hypertension (IIH) headache often persist as a disabling symptom even after intracranial pressure (ICP) has normalized. Yet very little is known about the mechanisms of chronification. Aim To explore pain perception in patients with IIH in a controlled design at time of diagnosis and after 3 months of treatment. Materials and methods We explored pain perception in patients with newly diagnosed IIH by Quantitative Sensory Testing (QST) measuring cephalic and extra-cephalic supra-threshold pain ratings and pain thresholds for pressure and electrical stimulation. QST was performed at diagnosis and after one and three months. ICP was measured at baseline and at the 3-month follow-up. QST measurements from sex-matched controls were used for comparisons. Headache was assessed by monthly standardized interviews and headache diaries. Results At baseline IIH patients (n = 28) showed no consistent abnormalities in pain sensitivity or thresholds (p > 0.09 for all comparisons to healthy controls (n = 28). Although headache improved markedly and ICP normalized in 52%, there was no consistent change in pain sensitivity from baseline to follow-up (p > 0.09 for all variables). Patients with (54%) and without persistent chronic headache (46%) 3 months after diagnosis showed no different pain perception either at baseline or at the 3-month follow-up. Conclusions Although headache persisted as a chronic symptom in half of the patients we found no evidence of increased central pain sensitivity suggesting that headache chronification in IIH is caused by mechanisms other than central sensitization.

Background Medication overuse headache (MOH) is a very disabling and costly disorder due to indirect costs, medication and healthcare utilization. The aim of the study was to describe general demographic and clinical characteristics of MOH, along with the national referral pathways and national painkillers distribution in several European and Latin American (LA) Countries. Methods This descriptive cross-sectional observational study included 669 patients with MOH referred to headache-centers in Europe and LA as a part of the COMOESTAS project. Information about acute medication and healthcare utilization were collected by extensive questionnaires, supplemented with structured patient interviews. Results Triptans were overused by 31 % European patients and by 6 % in LA (p