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Objective: To identify and disseminate research priorities for the headache field that should be areas of research focus during the next 10 years., Background: Establishing research priorities helps focus and synergize the work of headache investigators, allowing them to reach the most important research goals more efficiently and completely., Methods: The Headache Research Priorities organizing and executive committees and working group chairs led a multistakeholder and international group of experts to develop headache research priorities. The research priorities were developed and reviewed by clinicians, scientists, people with headache, representatives from headache organizations, health-care industry representatives, and the public. Priorities were revised and finalized after receiving feedback from members of the research priorities working groups and after a public comment period., Results: Twenty-five research priorities across eight categories were identified: human models, animal models, pathophysiology, diagnosis and management, treatment, inequities and disparities, research workforce development, and quality of life. The priorities address research models and methods, development and optimization of outcome measures and endpoints, pain and non-pain symptoms of primary and secondary headaches, investigations into mechanisms underlying headache attacks and chronification of headache disorders, treatment optimization, research workforce recruitment, development, expansion, and support, and inequities and disparities in the headache field. The priorities are focused enough that they help to guide headache research and broad enough that they are widely applicable to multiple headache types and various research methods., Conclusions: These research priorities serve as guidance for headache investigators when planning their research studies and as benchmarks by which the headache field can measure its progress over time. These priorities will need updating as research goals are met and new priorities arise., (© 2024 American Headache Society.)

The quality of clinical trials is essential to advance treatment, inform regulatory decisions and meta-analysis. With the increased incidence of idiopathic intracranial hypertension and the emergence of clinical trials for novel therapies in this condition, the International Headache Society Guidelines for Controlled Clinical Trials in Idiopathic Intracranial Hypertension aims to establish guidelines for designing state-of-the-art controlled clinical trials for idiopathic intracranial hypertension.

Clinic-based headache registries collect data for a wide variety of purposes including delineating disease characteristics, longitudinal natural disease courses, headache management approaches, quality of care, treatment safety and effectiveness, factors that predict treatment response, health care resource utilization, clinician adherence to guidelines, and cost-effectiveness. Registry data are valuable for numerous stakeholders, including individuals with headache disorders and their caregivers, healthcare providers, scientists, healthcare systems, regulatory authorities, pharmaceutical companies, employers, and policymakers. This International Headache Society document may serve as guidance for developing clinic-based headache registries. Use of registry data requires a formal research protocol that includes: 1) research aims; 2) methods for data collection, harmonization, analysis, privacy, and protection; 3) methods for human subject protection; and 4) publication and dissemination plans. Depending upon their objectives, headache registries should include validated headache-specific questionnaires, patient reported outcome measures, data elements that are used consistently across studies (i.e., "common data elements"), and medical record data. Amongst other data types, registries may be linked to healthcare and pharmacy claims data, biospecimens, and neuroimaging data. Headache diagnoses should be made according to the International Classification of Headache Disorders diagnostic criteria. The data from well-designed headache registries can provide wide-ranging and novel insights into the characteristics, burden, and treatment of headache disorders and ultimately lead to improvements in the management of patients with headache.

Objective: Though migraine is thought of as a symptom complex, symptoms are typically assessed one at a time. For use in clinical research, we developed a composite measure of headache day severity by combining eight well-known symptoms captured in daily diaries., Subjects and Methods: Data came from adults with a self-reported diagnosis of migraine (n  =  4380) who provided daily diary information assessed using a novel digital platform. Nine observed features theoretically linked to headache day severity were analyzed using latent variable modeling to create a psychometrically robust headache day severity score. Logistic regression was used to assess the cross-sectional relationships of headache day severity scores against an array of clinically-relevant outcomes., Results: Participants were largely females (90%), approaching middle age (mean age of 37.3) and living in the United States (49%) or United Kingdom (23%). Findings supported a single latent headache day severity construct based on eight observed headache features. Headache day severity scores were associated with an increased odds of physician visits (Odds ratio[95% CI]: 1.71[1.32-2.21]), emergency department visits (4.12[2.23-7.60]), missed school/work (2.90[2.56-3.29]), missed household work (3.37[3.06-3.72]), and missed other activities (3.29[2.97-3.64]) (p < .0001 for all)., Conclusions: Modern measurement techniques support a single headache day severity construct that reflects migraine is a symptom complex. The headache day severity scores were associated with external validators and initial visualizations showed how headache day severity scores can be applied broadly in clinical practice and research.

Background: Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history., Methods: We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia., Results: A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia., Conclusion: Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study., Competing Interests: Declaration of Competing Interest ALL is supported by NIH grant K23NS107643. JL has no conflict. CW has no conflict. NTC has no conflict. KM has no conflict. RBL has no conflict., (Copyright © 2020. Published by Elsevier Inc.)

Background: Post-traumatic headaches are a common sequela of mild traumatic brain injury (concussion). It is unclear whether or how these headaches differ phenotypically from primary headaches., Objective: Determine whether there is an overarching unobserved latent trait that drives the expression of observed features of post-traumatic headache and other headaches., Methods: Data from this post-hoc analysis come from the Warrior Strong Cohort Study conducted from 2010 through 2015. Approximately 25,000 soldiers were screened for concussion history at routine post-deployment health assessments. A random sample was invited to participate, enrolling 1567. Twelve observed headache phenotypic features were used to measure "headache complexity", the latent trait of clinical interest, using single factor confirmatory factor analysis. We compared headache complexity between groups and determined whether headache complexity predicted accessing medical care for headache., Results: Of 1094 soldiers with headaches, 198 were classified as having post-traumatic headache. These headaches were compared to those in the other soldiers (647 without concussion history and 249 with concussion history). Soldiers with post-traumatic headache had greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The confirmatory factor analysis showed good model fit (χ 2 (51) = 95.59, p  = 0.0002, RMSEA = 0.03, comparative fit index = 0.99, and Tucker-Lewis index = 0.99), providing empirical support for the headache complexity construct. Soldier groups differed in their mean headache complexity level ( p  < 0.001) such that post-traumatic headache soldiers had greater headache complexity compared to non-concussed soldiers (standardized mean difference = 0.91, 95% confidence interval: 0.72-1.09, p  < 0.001 and to concussed soldiers with coincidental headaches standardized mean difference = 0.75, 95% confidence interval: 0.53-0.96, p  < 0.001). Increasing headache complexity predicted medical encounters for headache (odds ratio = 1.87, 95% confidence interval: 1.49-2.35, p  < 0.001) and migraine (odds ratio = 3.74, 95% confidence interval: 2.33-5.98, p  < 0.001) during the year following deployment. Conclusions and relevance: The current study provided support for a single latent trait, characterized by observed headache symptoms, that differentiates between concussive and non-concussive headaches and predicts use of medical care for headache. The single trait confirmatory factor analysis suggests that post-traumatic headaches differ from non-concussive headaches by severity more than kind, based on the symptoms assessed.ClinicalTrials.gov identifier NCT01847040.

Purpose: We examined the reliability and validity of the 6-item Headache Impact Test (HIT-6) specifically on patients with chronic migraine (CM) from the PROMISE-2 clinical trial., Methods: The conceptual framework of HIT-6 was evaluated using baseline data from the PROMISE-2 study (NCT02974153; N = 1072). A unidimensional graded response model within the item response theory (IRT) framework was used to evaluate model fit and item characteristics. Using baseline and week 12 data, convergent and discriminant validity of the HIT-6 was evaluated by correlation coefficients. Sensitivity to change was assessed by evaluating correlations between HIT-6 scores and change scores for other established reference measures. All examined correlations were specified a priori with respect to direction and magnitude. Known-groups analyses were anchored using Patient Global Impression of Change and monthly headache days at week 12., Results: A unidimensional model fit the data well, supporting that the 6 items measure a single construct. All item slopes and thresholds were within acceptable ranges. In both the validity and sensitivity to change analyses, all observed correlations conformed to directional expectations, and most conformed to magnitude expectations. Known-groups analyses demonstrated that the HIT-6 total score can distinguish between clinically meaningful CM subgroups., Conclusion: The HIT-6 was successfully calibrated using IRT with data from PROMISE-2. Results from these analyses were generally consistent with previous literature and provided supportive evidence that the HIT-6 is well suited for measuring the impact of headache and migraine in the CM population.

Neck pain and headache are 2 of the most common complications of whiplash injury. Therefore, we performed a systematic literature search on PubMed and Embase for publications reporting on the prevalence of neck pain and headache after whiplash injury. The literature search identified 2709 citations of which 44 contained relevant original data. Of these, 27 studies provided data for the quantitative analysis. For non-population-based studies, the present meta-analysis showed that a pooled relative frequency of neck pain was 84% confidence interval (68%-95%) and a pooled relative frequency of headache was 60% (46%-73%), within 7 days after whiplash injury. At 12 months after injury, 38% (32%-45%) of patients with whiplash still experienced neck pain, while 38% (18%-60%) of whiplash patients reported headache at the same time interval after injury. However, we also found considerable heterogeneity among studies with I-values ranging from 89% to 98% for the aforementioned meta-analyses. We believe that the considerable heterogeneity among studies underscores the need for clear-cut definitions of whiplash injury and standardized reporting guidelines for postwhiplash sequelae such as neck pain and headache. Future studies should seek to optimize these aspects paving the way for a better understanding of the clinical characteristics and natural course of whiplash-associated sequelae.

Objective: To compare effectiveness of onabotulinumtoxinA and topiramate for chronic migraine (CM) prevention., Background: The efficacy* of onabotulinumtoxinA and topiramate has been established in placebo-controlled randomized clinical trials (*defined as the benefit of treatment under ideal conditions). The effectiveness* of the 2 preventive treatments, however, has not been established (*the benefit of treatment under real-world conditions, representing a blend of efficacy and tolerability)., Methods: In this multicenter, randomized, parallel-group, post-authorization, open-label prospective study (FORWARD; ClinicalTrials.gov, NCT02191579), we randomized adults with CM (1:1) to onabotulinumtoxinA 155 U every 12 weeks for 3 cycles or topiramate "immediate release" 50-100 mg/day to week 36. Primary outcome measure was proportion of patients achieving ≥50% reduction in headache days (weeks 29-32). Missing values were imputed using baseline observation carried forward (BOCF) methodology. After 12 weeks, patients initially randomized to topiramate could cross over to onabotulinumtoxinA treatment. We monitored and recorded all adverse events (AEs)., Results: We enrolled 282 patients (onabotulinumtoxinA, n = 140; topiramate, n = 142) and 148 patients completed randomized treatment (onabotulinumtoxinA, n = 120 [86%]; topiramate, n = 28 [20%]). Primary reasons for withdrawal were ineffective treatment (onabotulinumtoxinA, n = 7 [5%]; topiramate, n = 27 [19%]) and AEs (onabotulinumtoxinA, n = 5 [4%]; topiramate, n = 72 [51%]). Eighty topiramate patients crossed over to onabotulinumtoxinA. In the BOCF analysis, a significantly higher proportion of patients randomized to onabotulinumtoxinA experienced ≥50% reduction in headache frequency compared with those randomized to topiramate (40% [56/140] vs 12% [17/142], respectively; adjusted OR, 4.9 [95% CI, 2.7-9.1]; P < .001). OnabotulinumtoxinA was superior to topiramate in meeting secondary endpoints. In a post hoc analysis using observed data, the 50% responder rates at week 12 were 45.6% for onabotulinumtoxinA (n = 125) and 29.4% for topiramate (n = 109) (P = .015). AEs were reported by 48% (105/220) of onabotulinumtoxinA and 79% (112/142) of topiramate patients. Results were similar in those who crossed over to onabotulinumtoxinA., Conclusions: While using imputation methods of accounting for differences in discontinuation rates, we found onabotulinumtoxinA to have greater clinical utility than topiramate, largely because of tolerability issues associated with the latter and a relatively higher number of onabotulinumtoxinA patients remaining on treatment., (© 2019 The Authors. Headache: The Journal of Head and Face Pain published by Wiley Periodicals, Inc. on behalf of American Headache Society.)

Background: OnabotulinumtoxinA is effective in preventing chronic migraine (CM); however, the benefit of onabotulinumtoxinA in patients with CM with daily headache is unknown because these patients are typically excluded from clinical trials. This subanalysis of the COMPEL Study assessed the efficacy and safety of onabotulinumtoxinA in people with CM with and without daily headache., Methods: In total, 715 patients received onabotulinumtoxinA 155 U with or without concomitant oral preventive treatment. Patients who had complete daily diary records for the 28 days of the baseline period were stratified based on daily headache status. The primary outcome variable was reduction in headache-day frequency per 28-day period at 108 weeks (after 9 treatment cycles) relative to baseline. Exploratory outcomes included moderate to severe headache days, migraine disability (using the Migraine Disability Assessment [MIDAS] questionnaire), and health-related quality of life (Migraine-Specific Quality-of-Life Questionnaire v2 [MSQ]). Adverse events and their relatedness were recorded., Results: Overall, 641 patients had complete daily diary records at baseline. In patients with daily headache (n = 138) versus without (n = 503), treatment with onabotulinumtoxinA was associated with a significant mean (SD) reduction in 28-day headache-day frequency relative to baseline at week 108 (- 10.5 [9.2] vs - 12.2 [6.7], respectively; both P < 0.001) with no significant between-group difference (P = 0.132). The mean (SD) reduction in moderate to severe headache days at week 108 was significant in patients with and without daily headache (- 11.5 [9.4] and - 9.9 [6.4]; P < 0.001) with no significant between-group difference (P = 0.153). Mean (SD) MIDAS scores significantly improved from baseline at week 108 (- 43.3 [73.4] and - 43.6 [46.7]; both P < 0.001), with no significant between-group difference (P = 0.962). Similarly, mean (SD) MSQ subscale scores significantly improved from baseline at week 108 for patients with and without daily headache. OnabotulinumtoxinA was well tolerated in patients with and without daily headache., Conclusion: Results indicate that onabotulinumtoxinA is associated with reductions from baseline in headache-day frequency and improvements in disability and quality of life for up to 108 weeks in people with CM with daily headache; however, a longer duration of treatment was required to fully realize the treatment effect on headache. No new safety concerns were identified.

Objective: To evaluate the frequency with which migraine patients initiated behavioral migraine treatment following a headache specialist recommendation and the predictors for initiating behavioral migraine treatment., Methods: We conducted a prospective cohort study of consecutive patients diagnosed with migraine to examine whether the patients initiated behavioral migraine treatment following a provider recommendation. The primary outcome was scheduling the initial visit for behavioral migraine treatment. Patients who initiated behavioral migraine treatment were compared with those who did not (demographics, migraine characteristics, and locus of control) with analysis of variance and chi-square tests., Results: Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were reached by phone. The mean duration from time of referral to follow-up was 76  (median 76, SD = 45) days. Thirty (56.6%) patients initiated behavioral migraine treatment. There was no difference in initiation of behavioral migraine treatment with regard to sex, age, age of diagnosis, years suffered with headaches, health care utilization visits, Migraine Disability Assessment Screen, and locus of control (P > 0.05). Patients who had previously seen a psychologist for migraine were more likely to initiate behavioral migraine treatment than patients who had not. Time constraints were the most common barrier cited for not initiating behavioral migraine treatment., Conclusions: Less than one-third of eligible patients were referred for behavioral treatment, and only about half initiated behavioral migraine treatment. Future research should further assess patients' decisions regarding behavioral treatment initiation and methods for behavioral treatment delivery to overcome barriers to initiating behavioral migraine treatment.

Background: Emergency department (ED) visits for migraine are burdensome to patients and to the larger healthcare system and society. Thus, it is important to determine strategies used to prevent ED visits and the common communication patterns between headache specialists and the ED team., Objective: We sought to understand: (1) Whether headache specialists use headache management protocols. (2) The strategies they use to try and reduce the number of ED visits for headache. (3) Whether protocols are used in the EDs with which they are affiliated. (4) The level of satisfaction with the coordination of care between headache physicians and the ED., Methods: We surveyed via SurveyMonkey members of the American Headache Society Emergency Department/Refractory/Inpatient (EDRI) Section to understand their practice regarding patients who call their office to be seen urgently, and to understand their communication with their local EDs., Results: There were 96 eligible AHS members, 50 of whom responded to questionnaires either by email or in person (52%). Of these, 59% of respondents reported giving rescue treatment to their patients to manage acute attacks. Fifty-four percent reported using standard protocols for outpatients not responding to usual acute treatments. In the event of a request for urgent care, 12% of specialists reported bringing patients into the office most or all of the time, and 20% reported sending patients to the ED some or most of the time for headache management. Thirty-six percent reported prescribing a new medicine and 30% reported providing telephone counseling some/most/all of the time. Sixty percent reported that their ED has a protocol for migraine management. Overall, 38% were usually or very satisfied with the headache care in the ED., Conclusions: A substantial number of headache specialists are dissatisfied with the care their patients receive in the ED. More standardized protocols for ED visits by patients with known headache disorders, and clear guidelines for communication between ED providers and treating physicians, along with better methods for follow-up following discharge from the ED, might appear to improve this issue., (© 2018 American Headache Society.)

Background: The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0-18 years) and to suggest changes, additions, and amendments., Methods: Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents., Results: Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults., Conclusions: Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.

Aim This study charts the growth of the scientific journal literature on headache for 30+ years (1983-2014). Methods Using the Web of Science, articles published in four two-year periods (1983-1984, 1993-1994, 2003-2004, 2013-2014) from journals indexed in the Science Citation Index Expanded database were retrieved and analyzed. Results From 1983-1984 to 2013-2014, the scientific literature on headache increased nearly fourfold (3.8) from 468 to 1776 articles; the number of participating countries more than doubled (26 to 67); and the two most prolific countries in each period were the USA and Italy. While several European countries (Italy, Germany, UK and Denmark) were among the top 10 in each period, the notable appearance of Turkey, China and Brazil among the top 10 in 2013-2014 indicates the growing geographic spread of publications on headache research. Meanwhile, the comet-like distribution of journals has not changed: two journals, Headache and Cephalalgia, persist throughout as the nucleus, with the tail increasing more than threefold from 141 journals in 1983-1984 to 462 in 2013-2014. Conclusion Our study follows the recent growth and spread of the scientific literature on headache research and should stimulate further bibliometric investigation in this field.

Background While pain intensity during migraine headache attacks is known to be a determinant of interference with daily activities, no study has evaluated: (a) the pain intensity-interference association in real-time on a per-headache basis, (b) multiple interference domains, and (c) factors that modify the association. Methods Participants were 116 women with overweight/obesity and migraine seeking behavioral treatment to lose weight and decrease headaches in the Women's Health and Migraine trial. Ecological momentary assessment, via smartphone-based 28-day headache diary, and linear mixed-effects models were used to study associations between pain intensity and total- and domain-specific interference scores using the Brief Pain Inventory. Multiple factors (e.g. pain catastrophizing (PC) and headache management self-efficacy (HMSE)) were evaluated either as independent predictors or moderators of the pain intensity-interference relationship. Results Pain intensity predicted degree of pain interference across all domains either as a main effect (coeff = 0.61-0.78, p < 0.001) or interaction with PC, allodynia, and HMSE ( p < 0.05). Older age and greater allodynia consistently predicted higher interference, regardless of pain intensity (coeff = 0.04-0.19, p < 0.05). Conclusions Pain intensity is a consistent predictor of pain interference on migraine headache days. Allodynia, PC, and HMSE moderated the pain intensity-interference relationship, and may be promising targets for interventions to reduce pain interference.

Objective: To characterize demographic and clinical features in pregnant women presenting with acute headache, and to identify clinical features associated with secondary headache., Methods: We conducted a 5-year, single-center, retrospective study of consecutive pregnant women presenting to acute care with headache receiving neurologic consultation., Results: The 140 women had a mean age of 29 ± 6.4 years and often presented in the third trimester (56.4%). Diagnoses were divided into primary (65.0%) and secondary (35.0%) disorders. The most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%). The groups were similar in demographics, gestational ages, and most headache features. In univariate analysis, secondary headaches were associated with a lack of headache history (36.7% vs 13.2%, p = 0.0012), seizures (12.2% vs 0.0%, p = 0.0015), elevated blood pressure (55.1% vs 8.8%, p < 0.0001), fever (8.2% vs 0.0%, p = 0.014), and an abnormal neurologic examination (34.7% vs 16.5%, p = 0.014). In multivariate logistic regression, elevated blood pressure (odds ratio [OR] 17.0, 95% confidence interval [CI] 4.2-56.0) and a lack of headache history (OR 4.9, 95% CI 1.7-14.5) had an increased association with secondary headache, while psychiatric comorbidity (OR 0.13, 95% CI 0.021-0.78) and phonophobia (OR 0.29, 95% CI 0.09-0.91) had a reduced association with secondary headache., Conclusions: Among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache. Diagnostic vigilance should be heightened in the absence of a headache history and if seizures, hypertension, or fever are present. Attack features may not adequately distinguish primary vs secondary disorders, and low thresholds for neuroimaging and monitoring for preeclampsia are justified., (© 2015 American Academy of Neurology.)

Objective/background: The role of diet in migraine is not well understood. We sought to characterize usual dietary intake patterns and diet quality in a nationally representative sample of women with and without severe headache or migraine. We also examined whether the relationship between migraine and diet differs by weight status., Methods: In this analysis, women with migraine or severe headache status was determined by questionnaire for 3069 women, ages 20-50 years, who participated in the National Health and Nutrition Examination Study, 1999-2004. Women who experienced severe headaches or migraines were classified as migraine for the purposes of this analysis. Dietary intake patterns (micro- and macronutrient intake and eating frequency) and diet quality, measured by the Healthy Eating Index, 2005, were determined using one 24-hour dietary recall., Results: Dietary intake patterns did not significantly differ between women with and without migraine. Normal weight women with migraine had significantly lower diet quality (Healthy Eating Index, 2005 total scores) than women without migraine (52.5 ± 0.9 vs. 45.9 ± 1.0; P < .0001)., Conclusions: Whereas findings suggest no differences in dietary intake patterns among women with and without migraine, dietary quality differs by migraine status in normal weight women. Prospective analyses are needed to establish how diet relates to migraine onset, characteristics, and clinical features in individuals of varying weight status., (© 2015 American Headache Society.)

Background: Studies of the difference between menstrually associated and non-menstrually associated migraine are somewhat controversial. The majority of studies have focused on comparing menstrual to non-menstrual attacks rather than comparing study groups with different migraine diagnoses with respect to menstruation. As there is limited knowledge available on the overall impact and burden of migraine among groups of women with and without menstrually associated migraine our goal was to examine differences between these groups. We hypothesized that there would be greater burden of migraine related to menstruation and headache frequency in a population study across groups of women., Methods: We analyzed data from the American Migraine Prevalence and Prevention (AMPP) Study, a longitudinal, US, population-based study. We included female respondents to the 2009 survey, aged 18 to 60, who met modified ICHD-2 criteria for migraine, were actively menstruating and fit one of three definitions based on the self-reported association of menses and migraine attacks: self-reported predominantly menstrual migraine (MM, attacks that only or predominantly occur at the time of menses), self-reported menstrually-associated migraine (MAM, attacks commonly associated with menses, but that also occur at other times of the month), and self-reported menstrually-unrelated migraine (MUM). These three groups were compared on characteristics and measures of headache impact and burden (Headache Impact Test- 6 item (HIT-6) and Migraine Disability Assessment Scale (MIDAS)., Results: There were 1,697 eligible subjects for this study in the following categories: MM (5.5%), MAM (53.8%), or MUM (40.7%). Women with MM had an older age of migraine onset. Those with predominantly menstrually-related attacks (MM) had fewer headache-days but appeared to be more impaired by attacks. HIT-6 and MIDAS scores were significantly higher for both the MM and MAM groups compared with the MUM groups; however, effects were more robust for MM than MAM., Conclusions: Nearly 60% of women with migraine reported an association between migraine and menses. These women reported greater headache impact and migraine-related burden on functioning than those in whom migraines were not related to menstruation. Women with MM were more impaired by attacks while women with MAM had overall highest burden, likely due to experiencing migraines on additional days.

Background: The strikingly higher prevalence of migraine in females compared with males is one of the hallmarks of migraine. A large global body of evidence exists on the sex differences in the prevalence of migraine with female to male ratios ranging from 2:1 to 3:1 and peaking in midlife. Some data are available on sex differences in associated symptoms, headache-related disability and impairment, and healthcare resource utilization in migraine. Few data are available on corresponding sex differences in probable migraine (PM) and other severe headache (ie, nonmigraine-spectrum severe headache). Gaining a clear understanding of sex differences in a range of severe headache disorders may help differentiate the range of headache types. Herein, we compare sexes on prevalence and a range of clinical variables for migraine, PM, and other severe headache in a large sample from the US population., Methods: This study analyzed data from the 2004 American Migraine Prevalence and Prevention Study. Total and demographic-stratified sex-specific, prevalence estimates of headache subtypes (migraine, PM, and other severe headache) are reported. Log-binomial models are used to calculate sex-specific adjusted prevalence ratios and 95% confidence intervals for each across demographic strata. A smoothed sex prevalence ratio (female to male) figure is presented for migraine and PM., Results: One hundred sixty-two thousand seven hundred fifty-six individuals aged 12 and older responded to the 2004 American Migraine Prevalence and Prevention Study survey (64.9% response rate). Twenty-eight thousand two hundred sixty-one (17.4%) reported "severe headache" in the preceding year (23.5% of females and 10.6% of males), 11.8% met International Classification of Headache Disorders-2 criteria for migraine (17.3% of females and 5.7% of males), 4.6% met criteria for PM (5.3% of females and 3.9% of males), and 1.0% were categorized with other severe headache (0.9% of females and 1.0% of males). Sex differences were observed in the prevalence of migraine and PM, but not for other severe headache. Adjusted female to male prevalence ratios ranged from 1.48 to 3.25 across the lifetime for migraine and from 1.22 to 1.53 for PM. Sex differences were also observed in associated symptomology, aura, headache-related disability, healthcare resource utilization, and diagnosis for migraine and PM. Despite higher rates of migraine diagnosis by a healthcare professional, females with migraine were less likely than males to be using preventive pharmacologic treatment for headache., Conclusions: In this large, US population sample, both migraine and PM were more common among females, but a sex difference was not observed in the prevalence of other severe headache. The sex difference in migraine and PM held true across age and for most other sociodemographic variables with the exception of race for PM. Females with migraine and PM had higher rates of most migraine symptoms, aura, greater associated impairment, and higher healthcare resource utilization than males. Corresponding sex differences were not observed among individuals with other severe headache on the majority of these comparisons. Results suggest that PM is part of the migraine spectrum whereas other severe headache types are not. Results also substantiate existing literature on sex differences in primary headaches and extend results to additional headache types and related factors., (© 2013 American Headache Society.)

Acute headache medication overuse (MO) is common in patients with chronic migraine (CM). We evaluated safety and efficacy of onabotulinumtoxinA as preventive treatment of headache in CM patients with baseline MO (CM+MO) in a planned secondary analysis from two similarly designed, randomized, placebo-controlled, parallel, Phase III trials. Patients were randomized to treatment groups (155-195 U of onabotulinumtoxinA or placebo) using MO (patient-reported and diary-captured frequency of intake) as a stratifying variable. Of 1384 patients, 65.3% (n=904) met MO criteria (onabotulinumtoxinA: n=445, placebo: n=459). For the CM+MO subgroup at Week 24, statistically significant between-treatment group mean changes from baseline favoring onabotulinumtoxinA versus placebo were observed for headache days (primary endpoint: -8.2 vs. -6.2; p<0.001) and other secondary endpoints: frequencies of migraine days (p<0.001), moderate/severe headache days (p<0.001), cumulative headache hours on headache days (p<0.001), headache episodes (p=0.028), and migraine episodes (p=0.018) and the percentage of patients with severe Headache Impact Test-6 category (p<0.001). At Week 24, change from baseline in frequency of acute headache medication intakes (secondary endpoint) was not statistically significant (p=0.210) between groups, except for triptan intakes (p<0.001), where the onabotulinumtoxinA-treated group was favored. OnabotulinumtoxinA was effective and well tolerated as headache prophylaxis in CM+MO patients., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objectives: To characterize the extent of measurement error arising from rounding in headache frequency reporting (days per month) in a population sample of headache sufferers., Background: When reporting numerical health information, individuals tend to round their estimates. The tendency to round to the nearest 5 days when reporting headache frequency can distort distributions and engender unreliability in frequency estimates in both clinical and research contexts., Methods: This secondary analysis of the 2005 American Migraine Prevalence and Prevention study survey characterized the population distribution of 30-day headache frequency among community headache sufferers and determined the extent of numerical rounding ("heaping") in self-reported data. Headache frequency distributions (days per month) were examined using a simplified version of Wang and Heitjan's approach to heaping to estimate the probability that headache sufferers round to a multiple of 5 when providing frequency reports. Multiple imputation was used to estimate a theoretical "true" headache frequency., Results: Of the 24,000 surveys, headache frequency data were available for 15,976 respondents diagnosed with migraine (68.6%), probable migraine (8.3%), or episodic tension-type headache (10.0%); the remainder had other headache types. The mean number of headaches days/month was 3.7 (standard deviation = 5.6). Examination of the distribution of headache frequency reports revealed a disproportionate number of responses centered on multiples of 5 days. The odds that headache frequency was rounded to 5 increased by 24% with each 1-day increase in headache frequency (odds ratio: 1.24, 95% confidence interval: 1.23 to 1.25), indicating that heaping occurs most commonly at higher headache frequencies. Women were more likely to round than men, and rounding decreased with increasing age and increased with symptoms of depression., Conclusions: Because of the coarsening induced by rounding, caution should be used when distinguishing between episodic and chronic headache sufferers using self-reported estimates of headache frequency. Unreliability in frequency estimates is of particular concern among individuals with high-frequency (chronic) headache. Employing shorter recall intervals when assessing headache frequency, preferably using daily diaries, may improve accuracy and allow more precise estimation of chronic migraine onset and remission., (© 2013 American Headache Society.)

The objective of this series is to examine several threats to the interpretation of headache chronification studies that arise from methodological issues. The study of headache chronification has extensively used longitudinal designs with 2 or more measurement occasions. Unfortunately, application of these designs, when combined with the common practice of extreme score selection as well as the extant challenges in measuring headache frequency rates (eg, unreliability, regression to the mean), induces substantive threats to accurate interpretation of findings. Partitioning the amount of observed variance in rates of chronification and remission attributable to regression artifacts is a critical yet previously overlooked step to learning more about headache as a potentially progressive disease. In this series on rethinking headache chronification, we provide an overview of methodological issues in this area (this paper), highlight the influence of rounding error on estimates of headache frequency (second paper), examine the influence of random error and regression artifacts on estimates of chronification and remission (third paper), and consider future directions for this line of research (fourth paper)., (© 2013 American Headache Society.)

The HURT Questionnaire consists of eight questions which the patient answers as a measure of effectiveness of intervention against headache. This first assessment of clinical utility was conducted in headache specialist centres in three countries in order to demonstrate that HURT was responsive to change induced by effective management. We administered HURT on three occasions to 159 consecutive patients seeking non-urgent care from centres in Denmark and the United Kingdom: the first before the initial visit to the centres; the second at the initial visit; and the third when the specialist judged that the best possible outcome had been achieved in each patient. Questionnaires were also answered by 42 patients at initial and final visits to a centre in Italy. Internal consistency reliability was very good (α = 0.85) while test-retest reliability was fair to low (κ = 0.38-0.62 and r (s) = 0.49-0.76), possibly because headache was unstable prior to start of management. There were significant changes in responses post-intervention compared with baseline (p < 0.01), indicating a favourable outcome overall in up to 77% of patients, and responsiveness to change, but there was no improvement in patients' concerns about side effects of medication (p = 0.18). We conclude that the questionnaire has utility across headache disorders. It can help patients describe headache frequency and headache-attributed disability, medication use/efficacy/tolerability, self-efficacy and knowledge about headache. It may guide physicians in assessment of disability of individual patients, how to proceed with management towards the best possible outcome, and in evaluating the quality of management.

Objectives: Patients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores, lower socioeconomic status, and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1 month after the ED visit., Methods:   This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the research team reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to the institution's headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1 month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and use of migraine-specific medication within that 1-month period., Results:   Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3 = -5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1% = -22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43% = 20 to 63%) 1 month later., Conclusions: A comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on one's daily life) 1 month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care., (© 2012 by the Society for Academic Emergency Medicine.)

The Global Campaign against Headache, directed by the non-governmental organization Lifting The Burden (LTB) in official relations with the World Health Organization (WHO), aspires to reduce the global burden of headache. Ultimately this calls for improvements in headache management, largely in primary care, where most people with headache receive medical care. In support, LTB is developing a range of headache management aids for primary care. Presently, no single instrument covers the range of assessment and decision-making necessary for successful headache management, and few make the important link between assessment and clinical advice. Expressly to fill this gap, LTB has developed a new instrument: the Headache Under-Response to Treatment (HURT) Questionnaire, an eight-item, self-administered questionnaire addressing headache frequency, disability, medication use and effect, perceptions of headache "control" and knowledge of diagnosis. This instrument is intended not only to evaluate current headache outcomes and assess the need for and response to treatment, but also to provide guidance on appropriate actions towards treatment optimization. The first draft of the HURT was created by an expert consensus group, meeting at WHO headquarters in Geneva, Switzerland. The final version came about through multiple refinements following psychometric testing. Assessment of clinical utility is ongoing in multiple countries.

Headaches are a common reason for visiting a health care provider. Headaches are at times symptomatic of an underlying process that requires prompt diagnosis and urgent treatment to reduce threats to life or limb. In this article, the authors review the 6 most common presentations for worrisome headache and discuss the differential diagnosis. Careful attention to patients' history and physical examination and a thoughtful approach to the differential diagnosis will guide diagnostic work-up and management. Although benign causes of headache are much more common than malignant secondary processes, thorough management of the acute headache requires excluding malignant secondary processes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To determine whether change in headache-days over 1-year is associated with change in lost productive time (LPT) among a population sample of migraineurs., Methods: Data are from migraine sufferers who participated in at least two consecutive annual American Migraine Prevalence and Prevention surveys between 2005 and 2008. LPT was estimated using two questions from the validated Migraine Disability Assessment survey about missed workdays and number of days at work., Results: The reduction in LPT (ie, missed workdays + reduced productive time) from 1 year to the next had a nonlinear relationship with reduction in headache-days. The relationship was directly linear, however, when change in employment status was considered in the regression model., Conclusion: A reduction in headache days over time translates into a linear reduction in LPT, including an increased likelihood of employment.

Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure- and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Study Objective: Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache., Methods: This was a randomized, double-blind efficacy trial. We randomized patients to either naproxen 500 mg or sumatriptan 100 mg for headache recurrence after ED discharge. Patients were eligible if they received parenteral therapy for an acute exacerbation of a primary headache in the ED. Patients who met established criteria for migraine without aura were designated a priori as a homogenous subgroup of interest. We followed all patients by telephone 48 hours after ED discharge. The primary endpoint was the between-group difference in change in pain intensity during the 2-hour period after ingestion of either 500 mg naproxen or 100 mg sumatriptan. This difference was measured on a validated 11-point (0 to 10) verbal numeric rating scale (NRS). Satisfaction with the medication and adverse effects were also assessed. Patients who met criteria for migraine without aura were analyzed twice according to a priori design: once as a homogenous subgroup and then again combined with all other primary headaches., Results: Of 410 patients randomized, 383 (93%) had outcome data available for analysis. Two hundred eighty (73%; 95% confidence interval [CI] 68% to 77%) reported headache post-ED discharge and 196 (51%; 95% CI 44% to 58%), including 88 with migraine, took the investigational medication provided to them. The naproxen group improved by a mean of 4.3 NRS points, whereas the sumatriptan group improved by 4.1 points (95% CI for difference of 0.2 points: -0.7 to 1.1 points). Findings were virtually identical among the migraine subset (4.3 versus 4.2 NRS points; 95% CI for difference of 0.1 points: -1.3 to 1.5 points). Seventy-one percent (95% CI 62% to 80%) of naproxen patients and 75% (95% CI 66% to 84%) of sumatriptan patients would want to take the same medication the next time. Adverse effect profiles were also comparable., Conclusion: In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication., (Copyright 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Headache is one of the most common neurological symptoms reported by patients with thrombotic thrombocytopenic purpura (TTP). Reports of headache characteristics in patients with TTP are rare. We report 2 cases of headache in a setting of TTP and review previous reports. Headache in TTP can have features in common with both migraine and tension-type headache. Although the pathophysiology of headache in TTP is not certain, platelet aggregation and activation may play a key role.

Background: Many clinicians use peripheral nerve blocks (NBs) and trigger point injections (TPIs) for the treatment of headaches. Little is known, however, about the patterns of use of these procedures among practitioners in the USA., Objectives: The aim of this study was to obtain information on patterns of office-based use of peripheral NBs and TPIs by headache practitioners in the USA., Methods: Using an Internet-based questionnaire, the Interventional Procedures Special Interest Section of the American Headache Society (AHS) conducted a survey among practitioners who were members of AHS on patterns of use of NBs and TPIs for headache treatment., Results: Electronic invitations were sent to 1230 AHS members and 161 provided usable data (13.1%). Of the responders, 69% performed NBs and 75% performed TPIs. The most common indications for the use of NBs were occipital neuralgia and chronic migraine (CM), and the most common indications for the use of TPIs were chronic tension-type headache and CM. The most common symptom prompting the clinician to perform these procedures was local tenderness at the intended injection site. The most common local anesthetics used for these procedures were lidocaine and bupivacaine. Dosing regimens, volumes of injection, and injection schedules varied greatly. There was also a wide variation in the use of corticosteroids when performing the injections. Both NBs and TPIs were generally well tolerated., Conclusions: Nerve blocks and TPIs are commonly used by headache practitioners in the USA for the treatment of various headache disorders, although the patterns of their use vary greatly.

Interventional procedures such as peripheral nerve blocks (PNBs) and trigger point injections (TPIs) have long been used in the treatment of various headache disorders. There are, however, little data on their efficacy for the treatment of specific headache syndromes. Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens. The role of corticosteroids in this setting is also debated. We performed a PubMed search of the literature to find studies on PNBs and TPIs for headache treatment. We classified the abstracted studies based on the procedure performed and the treated condition. We found few controlled studies on the efficacy of PNBs for headaches, and virtually none on the use of TPIs for this indication. The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled. The techniques, as well as the type and doses of local anesthetics used for nerve blockade, varied greatly among studies. The specific conditions treated also varied, and included both primary (eg, migraine, cluster headache) and secondary (eg, cervicogenic, posttraumatic) headache disorders. Trigeminal (eg, supraorbital) nerve blocks were used in few studies. Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies. The procedures were generally well tolerated. Evidently, there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.

Headache associated with moyamoya disease (HAMD) is common in moyamoya disease. However, the characteristics and classification of HAMD are largely unknown. We present a case of a 39-year-old woman with HAMD. To characterize and classify the features of this syndrome, the patient was asked to complete a 4-month diagnostic headache diary. There was a total of 15 ictal days. All episodes were without aura. The headache was more commonly pressing (10/15), mild to moderate in severity (14/15), unchanged by physical activity (11/15), and associated with photophobia (10/15). The International Headache Society Classification was utilized to determine that eight episodes met criteria for probable migraine without aura, while seven episodes met criteria for probable frequent episodic tension-type headache. We identified four other case reports of HAMD with partial descriptions of the characteristics. When combined with our patient, the median age was 34 years old (range 6-49, SD 16). Four were female, while the patient with cluster headache was male. The median time from headache onset to diagnosis with moyamoya disease was 9.5 months (range 0-192, SD 88.0). Headaches were described as migraine with aura in two of five cases, hemiplegic migraine in one of five, and cluster headache in one of five. The highest intensity was described as severe in three of three cases, in which headache intensity was reported. Meanwhile, nausea, vomiting, and photophobia were present in two of three cases, where these features were reported, while nausea without vomiting was seen in one of three cases. In all five cases, patients had other neurological symptoms, such as paresis, seizures, visual disturbances, dysarthria, allodynia, ptosis, and unilateral restless leg syndrome. In conclusion, HAMD can present as migraine without aura. It can be the first presenting symptom of moyamoya disease. The headache features are not diagnostic; hence, early neurovascular imaging should be considered in patients with new onset, refractory migraine-like headache, especially in the setting of other neurological symptoms to exclude underlying moyamoya disease. Further reports using headache diaries are needed to better characterize HAMD as well as to determine whether headache with tension-type features is also part of this condition.

Objective: To evaluate the impact of incident transformed migraine on health care resource utilization, medication use, and productivity loss. In addition, the study estimates the total direct and indirect costs associated with transformed migraine., Background: Emerging evidence indicates that migraine may be a chronic progressive disorder characterized by escalating frequency of headache attacks, often termed transformed migraine. Little is known about the economic impact of transformed migraine., Methods: AMPP is a 5-year, national, longitudinal survey study of headache in the US. The study utilized data from the 2006 follow-up survey based on an initial sample of 14,544 adults identified as having migraine in either the 2004 screening or 2005 baseline survey. A diagnosis of migraine was assigned based on criteria proposed by the International Classification of Headache Disorders, 2nd Edition. Participants completed self-administered, validated questionnaires on headache features, frequency, impairment, resource use, medication use, and productivity loss. Direct and indirect headache-related costs were estimated using unit cost assumptions from the PharMetrics Patient-Centric database, wholesale acquisition costs (Red Book), and wage data from the US Bureau of Labor Statistics. Those who developed transformed migraine were compared with those who did not develop transformed migraine in the 1-2 year interval between screening/baseline and follow-up., Results: A total of 7796 (54%) identified migraine cases completed the 2006 follow-up survey. Of those cases, 359 (4.6%) developed transformed migraine. Participants who developed transformed migraine reported significantly more primary care visits, neurologist or headache specialist visits, pain clinic visits, and emergency room visits compared with participants whose migraine remained episodic. Hospital nights and urgent care visits did not reach statistical significance. Transformed migraine participants reported significantly more time missed at work or school because of headaches and more time where work or school productivity was reduced by >50% in the previous 3 months because of headaches. Average per-person annual total costs, including direct and indirect costs, were 4.4-fold greater for those who developed transformed migraine ($7750) compared with those who remained episodic ($1757)., Conclusion: Transformed migraine exacts a significantly higher economic toll on patients and health care systems compared with other forms of migraine. Our findings support the need to prevent migraine progression and to provide appropriate management and treatment of transformed migraine.

Background: Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache., Methods: As part of the American Migraine Prevalence and Prevention study, a validated self-administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, "frequent" ED use was defined as a participant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology., Results: Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension-type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache., Conclusions: Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.

Study Objective: We determine the frequency of moderate or severe headache during the first 24 hours after an emergency department (ED) visit for a primary headache disorder (such as migraine or tension-type headache), determine the burden of headache during the 3 months after the ED visit, and identify predictors of poor pain and functional outcomes after ED discharge for each of these periods., Methods: In this prospective cohort study, we enrolled headache patients during their initial ED visit, interviewed them by using a standardized questionnaire, and followed them by telephone 24 hours and 3 months after ED discharge. Two emergency physicians classified all headaches according to criteria established by the International Headache Society, using a valid questionnaire and a reproducible technique., Results: During an 18-month period, we enrolled 309 primary headache disorder patients in the cohort. The most common primary headache diagnoses assigned to patients were migraine, tension-type headache, and unclassifiable recurrent headache disorder. We successfully obtained follow-up in 94% of patients 24 hours after ED discharge and in 94% 3 months after ED discharge. Moderate or severe headache was present within 24 hours of ED discharge in 31% (95% confidence interval [CI] 25% to 38%) of migraine patients, 19% (95% CI 9% to 36%) of tension-type headache patients, and 27% (95% CI 18% to 38%) of the unclassifiable headache patients. Multiple functionally impairing headaches occurred during the 3 months after ED discharge in 37% of migraine patients (95% CI 30% to 44%), 38% of tension-type headache patients (95% CI 23% to 54%), and 26% of the unclassifiable headache patients (95% CI 17% to 37). After multivariate adjustment, independent predictors of poor 24-hour outcomes were severe baseline pain, baseline nausea, screening positive for depression, and longer duration of headache; the independent predictor of poor 3-month outcomes was Medicaid insurance., Conclusion: Regardless of type of primary headache disorder, ED headache patients frequently experience pain and functional impairment during the hours and months after discharge.

Context: Headache is a common, disabling disorder that is frequently not well managed in general clinical practice., Objective: To determine if patients cared for in a coordinated headache management program would achieve reduced headache disability compared with patients in usual care., Design: A randomized controlled trial of headache management vs usual care., Setting: Three distinctly different practice sites: an academic internal medicine practice located in a major east coast city, a staff-model managed care organization located in a major west coast city, and a community practice in a medium-sized city in the southeast. Patients.- Individuals 21 years of age or older with chronic tension-type, migraine, or mixed etiology headache and a Migraine Disability Assessment (MIDAS) score greater than 5, not receiving treatment from a neurologist or headache clinic currently or within the previous 6 months and with an intention to continue general medical care at their current location and to continue their present health insurance coverage for the next 12 months., Interventions: Active intervention is a headache management program consisting of: (1) a class specifically designed to inform patients about headache types, triggers, and treatment options; (2) diagnosis and treatment by a professional especially trained in headache care (based on US Headache Consortium guidelines); and (3) proactive follow-up by a case manager. Participation lasted 6 months. Control patients received usual care from their primary care providers., Main Outcome Measures: The primary efficacy measure reported in this article is a comparison of MIDAS scores of headache disability between the intervention group and the control group at 6 months. Secondary measures were response at 12 months, general health and quality of life, and satisfaction with headache care., Results: The intervention improved (ie, decreased) MIDAS scores by 7.0 points (95% confidence interval 2.9 to 11.1) more than the control (P = .008) at 6 months. The difference was not affected by site (P = .59 for clinic by intervention interaction), and a trend toward persistent benefit at 12 months (mean difference in improvement 6.8 points, 95% confidence interval -.3 to 13.9, P = .06) was observed. Quality of life and satisfaction with headache treatment were similarly improved., Conclusions: Coordinated headache management significantly improved outcomes for patients who, despite contact with the healthcare system for headache, had substantial unmet needs. The intervention in this trial can be implemented practically in a wide range of settings with the expectation that meaningful improvements will accrue.

Migraine and fibromyalgia are prevalent and disabling disorders with few preventive medications approved by the US Food and Drug Administration (FDA). Neuromodulators (or antiepileptic drugs; AEDs) are often effective in the treatment of these conditions. Divalproex sodium and topiramate are FDA-approved AEDs for migraine. For fibromyalgia, pregabalin has recently been approved in the United States. We review the use of AEDs in the preventive treatment of these highly prevalent disorders.

Acceptance of headache disorders as "real diseases" is now widespread due largely to advances made over the last 50 years in diagnoses, treatment, and the understanding of pathophysiology. Drs. Lipton and Bigal examine the path to acceptance and the impediments that had to be overcome.

About 4% of the adult population and about 1% to 2% of children experience chronic attacks on a daily or near daily basis. While there is uncertainty about the biological mechanisms that lead to headache "chronification," the epidemiologic literature has provided some insight into modifiable and nonmodifiable factors that appear to influence risk of headache progression. This review summarizes the evidence from population-based studies related to the chronic daily headache phenotype, natural history, and risk factors that may influence incidence, prevalence, or prognosis.

In this article, we consider the possible reasons and supporting evidence for the comorbidity of chronic pain conditions. To simplify the discussion, we primarily focus on the epidemiology of headache with other pain conditions, dividing studies into those based on children or adolescents and those based on adults. We consider exogenous and endogenous factors, and methodological challenges, in understanding whether and how 2 pain conditions may be related.