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Tension-type headache is one of the problematic classes of the IHS classification of headache. Based on the data of 211 cases of chronic tension-type headache modified criteria are proposed for the diagnosis of chronic tension-type headache. In order to provide optimal discrimination between migraine and tension-type headache it is recommended that the severity of characteristic migraine symptoms, which also frequently occur at a mild level of intensity among patients with tension-type headache, be incorporated into the diagnostic criteria for this headache. Specifically, mild photophobia and phonophobia, and headache aggravation by physical activity should not be used as exclusion criteria for tension-type headache.

Atypical facial pain is a residual category for otherwise unclassifiable pain syndromes in the facial region. In 35 patients (31F, 4M) with a mean age of 53.2 +/- 14.9 years and a chronic facial pain syndrome we tested the new diagnostic criteria of the International Headache Society (IHS). There was a marked female preponderance, vague description of symptoms and a long history of incorrect diagnoses. A high number of invasive procedures (3.5 +/- 3.0 (1-13)) were performed in this group. In agreement with the IHS criteria, an operation or injury to the face was a suspected cause in 43%. In contrast to the IHS criteria, our patient sample had dysaesthesiae (63%), bilateral occurrence (37%), remission periods (57%), pain attacks (23%) and superficial as well as deep pain. The IHS classification is insufficient to separate atypical facial pain from other primary headache and facial pain syndromes. We suggest a modified version of the IHS criteria for atypical facial pain.

Tricyclic antidepressants, especially amitriptyline, are the medication of first choice in the treatment of chronic tension headache. Few previous studies meet modern standards of study design and statistical analysis. Tolerability and efficacy of 60-90 mg amitriptyline oxide (AO) as a single dose in the evening were compared with 50-75 mg amitriptyline (AM) and placebo (PL) in a double-blind, parallel-group trial consisting of a 4-week baseline phase and 12 weeks of treatment. The 3-armed study was conducted in 7 centers. The inclusion criterion was tension-type headache on at least 15 days monthly with a duration of at least 6 months. Exclusion criteria were a migraine history, previous participation in another clinical trial within the last 3 months, drug abuse, medication with other antidepressants or tranquilizers, current use of other acknowledged prophylactic headache medication, lack of compliance, major psychiatric disorder according to DSM-III and medical contra-indications against tricyclic antidepressants. The primary study endpoint was a reduction at least 50% of the product of headache duration and frequency and a reduction at least 50% in headache intensity. Statistics used were Fisher's Exact Test and an analysis of variance. A total of 211 patients were included in this trial. One hundred ninety-seven cases, 87 males and 110 females, with a mean age of 38 +/- 13 (18-68) years, could be analysed completely (66 AO, 67 AM, 64 PL). With regard to the strictly defined primary study endpoint, no significant difference emerged between AO, AM and PL: treatment responders were 30.3% with AO, 22.4% with AM and 21.9% with PL (PAO-PL = 0.3210, PAM-PL = 1.000, PAO-AM = 0.3299 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Atypical facial pain is generally an unclearly defined pain syndrome. We tested in 35 patients (31 women, 4 men) with a mean age of 53.2 +/- 14.9 years and a chronic facial pain syndrome the quality of the new diagnostic criteria of the International Headache Society (IHS), at the same time using the SCL-90-R (Self-Report Symptom Inventory), to identify any associated psychopathology. In accordance with the literature there is a marked female preponderance, an altogether vague description of symptoms and a long history of incorrect diagnoses. Of note is the high number of invasive procedures (3.5 +/- 3.0). In agreement with the IHS commentary, an operation or injury to the face was a suspected cause in 43%. In contrast to the IHS criteria, we found in our patient sample dysaesthesia (63%), bilateral occurrence (37%), remission periods (57%), pain attacks (23%) and presence of superficial as well as deep pain. Depression is by no means the only psychopathological abnormality in atypical facial pain; a broad spectrum of complaints is seen. The IHS classification appears insufficient to separate atypical facial pain from other primary headache and facial pain syndromes. We therefore suggest a modified version of the IHS criteria for atypical facial pain.

The role of cerebrovascular risk factors such as mitral valve prolapse, platelet aggregation, platelet activation and cardiac arrythmias in migraine was investigated in a total of 44 migraineurs (32 migraineurs without aura and 12 with prolonged aura) and 32 controls. Comparing the total of migraineurs and the two subgroups with controls, mitral valve prolapse, a raised thromboxane B2 level, at least one platelet aggregation dysfunction or an abnormality in 24-h ECG was statistically seen no more often than in the control group. Neither did combinations of the variables occur more frequently. Altogether, this study showed no increased coincidence of migraine with prolonged aura and migraine without aura with the above parameters. The absence of cardiac and haematological abnormalities in migraine with prolonged aura focuses attention on the control of the cortical microcirculation.

The role of psychological factors in the course of primary headache syndromes is still controversial. Using the Minnesota Multiphasic Personality Inventory (MMPI) we investigated the personality profiles of 434 headache patients (160 migraineurs, 95 with tension type headache, 30 with cluster headache and 149 with combination headache) in accordance with the IHS criteria. In the first three MMPI scales (hypochondria, depression, hysteria) there was a slight increase in T mean values to over 60, but still in the range of two standard deviations of the normal population. There were no statistically significant differences between the four headache groups and between patients with and without analgesic abuse. It was impossible to distinguish headache groups on the basis of their personality profiles by means of reclassification with discriminant analysis. In a cluster analysis, patients with cluster headache showed the highest number (20%) of abnormalities, but also the highest percentage (13%) of completely normal results. Our findings--a cross section analysis of personality profiles--contradict many other MMPI-based studies.

In a multi-centre, randomized double-blind study, the effect and tolerance of 10 and 20 mg flunarizine i.v. versus placebo was tested on 102 migraineurs with acute migraine attacks with and/or without aura. Thirty-seven patients received 10 mg flunarizine, 32 received 20 mg and 33 received placebo. The groups were comparable. Response to treatment was defined as pain reduction of at least 50% within 60 min on a visual analogue scale after i.v. drug administration. This effect was noted on 59.4% with 20 mg flunarizine, on 24.3% with 10 mg flunarizine and on 30.3% with placebo. The tolerance of flunarizine i.v. was similar to placebo. Blood pressure and pulse rate were not affected by flunarizine. All in all, 20 mg flunarizine i.v. appeared to be a suitable alternative for treatment of acute migraine attacks.

Cervicogenic headache (CH) is a clearly defined headache syndrome and can usually be differentiated from other unilateral headaches like cluster headache, chronic paroxysmal hemicrania (CPH) and hemicrania continua by a thorough history and neurological examination. Combinations of CH with other headaches like migraine, tension headache, combination headache and drug induced headache, that occur quite frequently, can complicate the diagnosis. In our own material of 5520 headache patients the prevalence of CH was 13.8% (763). Four hundred and thirty of these patients suffered from CH in combination with one or more other headaches.

Cluster headache is a defined disorder which is often mistaken in spite of its characteristic picture. The different types of cluster headache and their clinical symptoms are reviewed in detail. Predisposing factors, frequency of other medical disorders as well as personal and psychological characteristics are described. The treatment of the attack and the prophylaxis includes ergot alkaloids, methysergide, cortisone, lithium and oxygen. Some aspects of etiology and pathogenesis are discussed.

Immunoglobulins are often used as an optimizing therapy in cases of infectious diseases of the central nervous system. To clarify the question of whether or not an intravenously administered compound of the IgG class is able to penetrate the cerebrospinal fluid barrier despite its high molecular weight, 12 anti-HBs negative patients received 20 ml each of a beta-Propiolacton treated IgG compound with a high anti-HBs titre (1 : 115 000) used as a marker. Four patients having an inconspicuous fluid condition were consulted for control. Five patients were suffering from slight disturbances and three other patients had severe disorders of the blood-cerebrospinal fluid barrier function resulting from inflammatory diseases of the central nervous systems. Cerebrospinal fluid was produced by way of lumbar puncture resp. drainage for the determination of anti-HBs. Simultaneously, the concentration of antibodies in serum was determined. In all patients having barrier disturbances, anti-HBs was evident in the cerebrospinal fluid, the transfer of intravenously administered immunoglobulins to cerebrospinal fluid increasing in correlation with the degree of the barrier disorder. The therapeutical importance of immunoglobulin therapy in treating infections of the central nervous system is pointed out.

Migraine is considered to be a primarily neurogenic disease. In this common headache syndrome beta-blockers are widely used as prophylactic drugs. In the meantime there is evidence for central beta-receptors. The effect of beta-blockers is considered to be based on a reduction of the increased sympathetic tonus and its influence on the intracerebral vessels. Beta-blockers--such as Atenolol, Metoprolol, Nadolol, Pindolol, Propranolol and Timolol which differ according to their intrinsic activity, their selectiv cardiac effects, their membran stabilizing ability, their hydro- or lipophily as well as according to their plasmaprotein binding capacity are used. Therefore, it is more likely that beta-blockers develop their effect through a stabilisation of the intrasynaptic serotonin-level in the serotonergic neurons of the brainstem.

Tension headache (TH) is an ill-defined headache syndrome, characterized by bilateral, daily headaches with fronto-occipital localisation. TH is often accompanied by a migraine and an abuse of analgesics and/or ergotamine. In the etiology of TH vascular, muscular and psychogenic factors are assumed. Floating transitions to common migraine are discussed. The increased muscle tension is not specific for TH, but more probably a consequence of TH. In addition a decrease of the pain threshold with a deficiency of the antinociceptive system is supposed. The efficacy of tricyclic antidepressives in TH is based on potentiation of serotonergic and noradrenergic mechanisms and - besides their analgetic potencies - upon an increase of the pain threshold. TH prophylaxis is indicated if patients suffer from TH more than ten times per month. Medication are tricyclic antidepressives of the amitriptyline-type. Prophylaxis of TH can only be successful if a simultaneous abuse of analgesics and/or ergotamine is discontinued. In addition, EMG-biofeedback, as well as relaxation - and vasoconstriction training might be helpful in specific cases.

Sixty-five patients (51 women, 14 men), who were 41.9 years on average, suffered from combination headache (migraine and tension headache) and were under therapy with propranolol and amitriptyline-N-oxide. The following predictive factors were tested with regard to the success of therapy: age, sex, duration of the migraine and tension headache illness, and frequency of use of analgesic and ergotamine preparations. The prerequisite was a statistically valid classification of responders and non-responders. Responders were defined as patients with at least 50% reduction in their symptomatic parameters (duration and frequency of migraine attacks or tension headaches between the beginning (t(0)) and end of the 3-month treatment (t(3)). Both the migraine treatment and the tension headache were standardized and headache records were kept. The statistical procedure used permitted clear differentiation between responders and non-responders, but these predictive factors did not make it possible to distinguish a subgroup of potential responders.

Chronic paroxysmal Hemicrania (CPH) is a headache syndrome first described in 1974. Since then about 60 cases have been reported in the world literature. CPH is characterised by headache attacks occurring daily and always strictly unilaterally. The frequency of the attacks varies from 5 to 30 per 24 hours, the single attack having an usual length of 2 to 30 minutes. The prompt response to indomethacin is the decisive diagnostic criterion of this headache syndrome. The clinical picture, the treatment, some aspects of the pathogenesis and the differential diagnosis of CPH are described by means of case reports. To our knowledge these are the first four cases reported in West Germany.

In the prophylaxis of migraine beta-blockers are commonly used. In the therapy of tension headache (TH) the use of tricyclic antidepressives is widespread. Therefore, from a rational point of view, one should combine an antidepressive and a beta-blocker in the treatment of combination headache (CH), in which patients have both migraine and TH. In an open uncontrolled study, 61 patients with CH received a combination of an antidepressive (amitriptyline) or amitriptyline-N-oxide and a beta-blocker (propranolol or metoprolol) for at least 3 months. The 61 patients kept a diary in which they recorded frequency and duration of migraine attacks and tension headaches. The median migraine attack frequency decreased in the 3 months from four to two and the mean attack duration per month from 2 to 0.7 days. TH frequency was reduced from a median of 21 days to 6 days; TH duration fell from a median of 21 days to 2.7 days. At first sight, this treatment appears to be highly effective, at least when judged by the results at the group level. Nevertheless, in an open uncontrolled study like this, one must be aware of many problems, which are discussed in detail.

"Cervicogenic headache" (CEH) is a strictly unilateral constant dull, dragging, boring background pain of varying intensity which does not alternate sides and persists for a few hours to several days. It is triggered or intensified by head movements, and typically radiates from the neck to the fronto-temporal region. Occasionally, the ipsilateral shoulder and arm are also affected, with no definite radicular pattern. There is overall restriction of head movements. Ipsilateral accompanying symptoms may include conjunctival injection, lacrimation and lid edema. Migraine-like symptoms such as nausea, vomiting, sound and light sensitivity, and ipsilateral visual blurring may occur, as well as dizziness and difficulties in swallowing. A C2-blockade always leads to temporary pain relief. The possible pathophysiology of CEH, and its differential diagnosis are discussed.

There are three headaches syndromes that are typically characterized by strictly unilateral and always same-sided attacks: cluster headache, "cervicogenic" headache, and chronic paroxysmal hemicrania (CPH). In rare cases, cluster headache also occurs bilaterally; "cervicogenic" headaches probably as well. We present a patient with a probable bilateral CPH. To our knowledge no such case has previously been described.

Out of the knowledge of various headache syndromes the physician has to develop a clear diagnostical and therapeutical concept. This is especially true for migraine. Relevant pathophysiological hypotheses are presented e.g. the neurogenic-vascular model of migraine. Metoclopramide and domperidone in combination with mono-analgesics, ergotamine and nonsteroidal-antiinflammatory drugs are favoured in the treatment of the acute migraine attack. 2 to 4 mg ergotamine for the attack, respectively 16 to 20 mg per month should not be exceeded. Mixed compounds, containing ergots, analgesics, codeine, caffeine, tranquilizers and barbiturates should be avoided as these drugs may induce rebound-headache. A prophylaxis of migraine is indicated if a migraineur suffers from at least 2 attacks per month or if a migraine attack lasts longer than 4 days. In the first place, beta-blockers and flunarizine, in some cases verapamil or naproxen, should be used; the effect of dihydroergotamine is questionable. Because of its severe side effects, methysergide should only be given if all other prophylactic drugs fail. Naproxen is standard medication in the short time prophylaxis of menstrual migraine.