Alvin E. Lake

Double‐Blind Trial of Fluoxetine: Chronic Daily Headache and Migraine

SYNOPSIS

Chronic Daily Headache Prophylaxis With Tizanidine: A Double‐Blind, Placebo‐Controlled, Multicenter Outcome Study

Objective.—To assess the efficacy of tizanidine hydrochloride versus placebo as adjunctive prophylactic therapy for chronic daily headache (chronic migraine, migrainous headache, or tension‐type headache).

Headache and Psychiatric Comorbidity: Historical Context, Clinical Implications, and Research Relevance

The comorbidity of headache and psychiatric disorders is a well‐recognized clinical phenomenon warranting further systematic research. Affective disorders occur with at least three‐fold greater frequency among migraineurs than among the general population, and the prevalence increases in clinical populations, especially with chronic daily headache. When present, psychiatric comorbidity complicates headache management and portends a poorer prognosis for headache treatment. However, the relationship between headache and psychopathology has historically been misunderstood, and measures of psychopathology have not always met the standard of formal Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM‐IV) criteria. In some cases, headache has been inappropriately attributed to psychological or psychiatric features, based on anecdotal observations. The challenge for future studies is to employ research methods and designs that accurately identify and classify the subset of headache patients with psychiatric disorders, evaluate their impact on headache symptoms and treatment, and identify optimal behavioral and pharmacologic treatment strategies. This article offers methodological considerations and recommendations for future research including: (i) ascribing dual‐International Classification of Headache Disorders, 2nd ed. (ICHD‐2) headache and DSM‐IV psychiatric diagnoses according to reliable and valid diagnostic criteria, (ii) differentiating subclinical levels of depression and anxiety from major psychiatric disorders, (iii) encouraging validation studies of the recently published ICHD‐2 diagnoses for “headache attributed to psychiatric disorder,” (iv) expanding epidemiological research to address the range of DSM‐IV Axis I and II psychiatric diagnoses among various headache populations, (v) identifying relevant psychiatric and behavioral mediator/moderator variables, and (vi) developing empirically based screening and treatment algorithms.

Medication Overuse Headache: Biobehavioral Issues and Solutions

This article reviews current research on medication‐overuse headache (MOH), and provides clinical suggestions for effective treatment programs. Epidemiological research has identified reliance on analgesics as a predictive factor in headache chronicity. MOH can be distinguished as simple (Type I) or complex (Type II). Simple cases involve relatively short‐term drug overuse, relatively modest amounts of overused medications, minimal psychiatric contribution, and no history of relapse after drug withdrawal. In contrast, complex cases often present with multiple psychiatric comorbidities and a history of relapse. Although limited, current research suggests that comorbid psychiatric disorders are more prevalent in MOH than in control headache conditions, and may precede the onset of MOH. There appears to be an elevated risk of family history of substance use disorders in MOH patients, and an increased risk of MOH in patients with diagnosed personality disorders. Current studies suggest a high rate of relapse at 3 to 4 years after drug withdrawal and pharmacological treatment, with most relapse occurring during the first year of treatment. Relapse is a greater problem with analgesics than ergots or triptans. The addition of behavioral treatment to prophylactic medication may significantly reduce the risk of relapse over a period of several years. Clinical recommendations include assessment and modification of psychological factors that may underlie MOH, provision of detailed educational information, and combining behavioral treatment with the current standard of drug withdrawal and use of prophylactic pharmacotherapy.

Guidelines for Trials of Behavioral Treatments for Recurrent Headache, First Edition: American Headache Society Behavioral Clinical Trials Workgroup

Guidelines for design of clinical trials evaluating behavioral headache treatments were developed to facilitate production of quality research evaluating behavioral therapies for management of primary headache disorders. These guidelines were produced by a Workgroup of headache researchers under auspices of the American Headache Society. The guidelines are complementary to and modeled after guidelines for pharmacological trials published by the International Headache Society, but they address methodologic considerations unique to behavioral and other nonpharmacological treatments. Explicit guidelines for evaluating behavioral headache therapies are needed as the optimal methodology for behavioral (and other nonpharmacologic) trials necessarily differs from the preferred methodology for drug trials. In addition, trials comparing and integrating drug and behavioral therapies present methodological challenges not addressed by guidelines for pharmacologic research. These guidelines address patient selection, trial design for behavioral treatments and for comparisons across multiple treatment modalities (eg, behavioral vs pharmacologic), evaluation of results, and research ethics. Although developed specifically for behavioral therapies, the guidelines may apply to the design of clinical trials evaluating many forms of nonpharmacologic therapies for headache.

Defining Refractory Migraine and Refractory Chronic Migraine: Proposed Criteria From the Refractory Headache Special Interest Section of the American Headache Society

Certain migraines are labeled as refractory, but the entity lacks a well‐accepted operational definition. This article summarizes the results of a survey sent to American Headache Society members to evaluate interest in a definition for RM and what were considered necessary criteria. Review of the literature, collaborative discussions and results of the survey contributed to the proposed definition for RM. We also comment on our considerations in formulating the criteria and any issues in making the criteria operational. For the proposed definition for RM and refractory chronic migraine, patients must meet the International Classification of Headache Disorders, Second Edition criteria for migraine or chronic migraine, respectively. Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. The definition requires that patients fail adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta‐blockers, anticonvulsants, tricyclics, and calcium channel blockers. Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulation and either nonsteroidal anti‐inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated. An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least 2 months at optimal or maximum‐tolerated dose, unless terminated early due to adverse effects. The definition also employs modifiers for the presence or absence of medication overuse, and with or without significant disability.

Borderline personality disorder and the chronic headache patient: Review and management recommendations

Background.—Physicians and psychologists who treat headache not infrequently encounter patients with borderline personality disorder (BPD). BPD patients frequently suffer from headache, and often pose special problems in treatment. Few guidelines exist for the management of the BPD headache patient.

Comprehensive/tertiary care for headache: a 6-month outcome study.

Objective.—To assess programwide (outpatient plus inpatient) outcome using prospective measures for the first 6 months of treatment at a comprehensive headache center.

Comprehensive Inpatient Treatment for Intractable Migraine: A Prospective Long‐Term Outcome Study

SYNOPSIS

Comprehensive inpatient treatment of refractory chronic daily headache.

Objective.— (1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors.