Federica Galli

Risk factors in medication‐overuse headache: a 1‐year follow‐up study (care II protocol)

To investigate factors influencing prognosis in medication-overuse headache (MOH), we conducted a 12-month follow-up of patients with probable MOH. We recruited 215 patients consecutively admitted to our headache centre for an inpatient detoxification treatment. We analysed likely predictor factors for headache resolution (sex, age, primary headache, psychiatric comorbidity, type and timing of overuse). Mann–Whitney U-test and chi-squared test were used. One year after withdrawal, we had complete data on 172 patients (80%): 38 of these patients (22%) had relapsed into overuse and 134 (78%) had not. The negative prognostic factors for relapse were: intake of more than 30 doses/month (P = 0.004), smoking (P = 0.012), alcohol consumption (P = 0.037), non-confirmation of MOH diagnosis 2 months after detoxification (P = 0.000), and return to overused drug(s) (P = 0.000). The 1-year relapse rate was 22%. The existence of sub-groups of MOH patients with such risk factors could influence treatment strategies.

Medication Overuse Headache and Applicability of the ICHD-II Diagnostic Criteria: 1-Year Follow-Up Study (CARE I Protocol)

Medication overuse headache (MOH) is a growing problem worldwide and a challenge for clinicians and investigators. This study aims to contribute to the ongoing debate surrounding the classification of MOH. Applying the revised diagnostic criteria for MOH contained in the updated International Classification of Headache Disorders (ICHD-II), we enrolled 140 probable MOH (p-MOH) patients. They were submitted to an in-patient detoxification protocol and re-examined 2, 6 and 12 months later to confirm, or otherwise, the diagnosis of MOH and to observe the evolution of their headache. MOH diagnosis was confirmed 2 months after detoxification in 71% of patients, who reverted to an episodic headache pattern and stopped their drug overuse The overall clinical situation at 2 months closely reflected the 1-year trend. The 2-month period after drug withdrawal should be retained as a diagnostic criterion in the ICHD-II because it is useful not only as a diagnostic parameter, but also as predictor of a good outcome of 1-year drug withdrawal. In addition, the present findings point to the need for a more objective criterion to quantify headache frequency after drug withdrawal.

Role of psychological factors in burning mouth syndrome: A systematic review and meta-analysis:

Background Burning mouth syndrome (BMS) is a chronic medical condition characterised by hot, painful sensations in the lips, oral mucosa, and/or tongue mucosa. On examination, these appear healthy, and organic causes for the pain cannot be found. Several studies have yielded scant evidence of the involvement of psychological and/or psychopathological factors, and several have outlined a model for the classification of BMS. Aim This review aims to provide a systematic review of research examining the psychological, psychiatric, and/or personality factors linked to BMS. Findings Fourteen controlled studies conducted between 2000 and the present were selected based on stringent inclusion/exclusion criteria. All studies but one reported at least some evidence for the involvement of psychological factors in BMS. Anxiety and depression were the most common and the most frequently studied psychopathological disorders among BMS patients. Discussion and conclusion Anxiety and depression play critical roles in this condition. Evidence on the role of personality characteristics of BMS patients has also been produced by a few studies. Further studies on the role of specific psychological factors in BMS are warranted, but the importance of a multidisciplinary approach (medical and psychological) to BMS is no matter of discussion.

Psychological factors associated with failure of detoxification treatment in chronic headache associated with medication overuse

Aim The aim of this study was to evaluate the psychological factors associated with a negative outcome following detoxification in a 2-month follow-up in medication-overuse headache. Methods All consecutive patients entering the detoxification program were analysed in a prospective, non-randomised fashion. Psychiatric conditions and personality characteristics were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID-I) and the Minnesota Multiphasic Personality Inventory (MMPI)-2. χ2 tests, one-way analyses of variance, and odds ratios (ORs) were used. Results A total of 248 patients completed the follow-up: 156 stopped overuse and their headaches reverted to an episodic pattern (Group A); 23 kept overusing without any benefit on headache frequency (Group B); and 51 stopped overuse without any benefit on headache frequency (Group C). The prognostic factors for the outcome of Group B were higher scores on the correction (OR 1.128; p = 0.036), depression (OR 1.071; p = 0.05), hysteria (OR 1.106; p = 0.023), and overcontrolled hostility (OR 1.182; p = 0.04) MMPI-2 scales, whereas those for Group C were psychiatric comorbidities (OR 1.502; p = 0.021) and higher scores on the hysteria scale (OR 1.125; p = 0.004). Conclusions The outcome of detoxification is influenced by psychological factors that should be considered when considering treatment strategies.

Alexithymia in chronic and episodic migraine: a comparative study

Abstract Background: Alexithymia is a term used to describe a disorder where patients have difficulty in expressing their own feelings in words. Aims: The analysis of alexithymia in patients suffering from chronic migraine (CM) or episodic migraine (EM) compared to healthy controls. Methods: Two clinical samples formed by 80 CM patients (21 males and 59 females, mean age: 44.65) and 44 EM patients (8 males and 36 females, mean age: 42.18) were enrolled. A group of 67 healthy subjects served as controls (26 males and 41 females, mean age: 41.21). All subjects were requested to fill in the 20-item version of the Toronto Alexithymia Scale (TAS-20). Results: We found a statistically significant difference between groups in Factor 1 (difficulty in describing feelings), F(2, 191) = 7.96, p < 0.001, and in TAS total, F(2, 191) = 5.37, p = 0.005. Post-hoc analyses revealed that CM patients had higher scores in TAS factor 1 and in TAS total than healthy controls. There were no significant differences between CM and EM patients, even if CM sufferers reported a trend towards higher scores in each TAS factor as well as in TAS total. Conclusions: Alexithymia emerges as a potential characteristic trait of migraine, regardless of disease severity.

Headache and anxiety/mood disorders: are we trapped in a cul-de-sac ?

After the nth papers on the relationship between migraine and depression [1–3], I think it is the time to open a debate on the meaning of making research on the comorbidity of headache, anxiety and depression. It was 1990, when K. Merikangas published the first pioneering paper on the relationship of migraine, anxiety and depression, outlining the existence of a comorbid association with a bidirectional influence from one disorder to the other(s) and advancing several hypotheses to explain such a comorbidity. Conclusions after 26 years of research on the issue remain the same [1], with the additional complication that comorbid anxiety and depression seems not to be a prerogative of migraine, but of all kind of chronic headache (more frequent and severe are headache attacks more probable the presence of comorbid anxiety and depression-worse is the clinical situation of headache higher the probability of comorbid anxiety and depression). I think the time is mature to admit that we are in a cul-de-sac, and we need a way out. If we look to the literature on the issue anxiety/ depression and pain other than headache (neck, back, abdominal, musculoskeletal pain, and so on), we will find the same strong comorbid association. Even in rarer clinical disorders (e.g. Burning Mouth Syndrome), we found that anxiety and depression are the most represented comorbid disorders [4]. To complicate the scene, if we look to other common or uncommon, severe or not severe non-painful disorders or diseases (e.g. hearth failure, chronic kidney disease, chronic obstructive pulmonary disease, gastritis and so on) we find again the same strong comorbid association (and I do not open the door on the comorbidity of anxiety and mood disorders with other psychiatric disorders). So, it is the time to advance some consideration on the matter, because the bias of considering anxiety/depression as specifically related to headache (and not strongly related to many different medical conditions as well) constrained us in a no way out. Fruitful lines of research are related to aspects that might help in explaining anxiety and depression components of headache, as personality characteristics, child trauma, abnormal illness behavior, recent life-events, allostatic load (the failure of an organism to achieve stability through change), and so on. New insights could be gained crossing clinical psychological factors with data from imaging studies. A final warning on the use of the Hospital Anxiety and Depression Scale (HADS) to assess psychiatric comorbidity [2, 3], because we risk misapplication and misinterpretation of findings. The HADS is a useful screening test for detecting symptoms of anxiety and depression one week before a probable hospitalization. Symptoms do not mean diagnoses, which need ad hoc structured questionnaire and/or clinical interview. Any conclusion based on the HADS is at best speculative, because it does not allow a clear-cut diagnosis of “anxiety” and/or “depression”.

Atrial fibrillation and psychological factors: a systematic review

Background Psychological factors have been suggested to have an influence in Atrial Fibrillation (AF) onset, progression, severity and outcomes, but their role is unclear and mainly focused on anxiety and depression. Methods A systematic electronic search had been conducted to identify studies exploring different psychological factors in AF. The search retrieved 832 articles that were reviewed according to inclusion criteria: observational study with a control/comparison group; use of standardized and validated instruments for psychological assessment. Results were summarized qualitatively and quantitatively by effect size measure (Cohen’s d and its 95% confidence interval). Cochrane Collaboration guidelines and the PRISMA Statement were adopted. Results Eight studies were included in the systematic review. Depression was the most studied construct/ but only one study showed a clear link with AF. The remaining studies showed small and non-significant (95% CI [−0.25–1.00]) differences between AF and controls, no differences in frequency of depression history (95% CI [−0.14–0.22]) or in case frequency (95% CI [−0.50–0.04]). Miscellaneous results were found as far as anxiety: AF patients showed higher levels when compared to healthy subjects (95% CI [2.05–2.95]), but findings were inconsistent when compared to other heart diseases. Considering personality and life-events preceding AF, we respectively found a large (95% CI [1.87–2.49]) and a moderate to large effect (95% CI [0.48–0.98]). Discussion The small number of studies does not allow to draw clear-cut conclusions on the involvement of psychological factors in AF. Promising lines of research are related to personality and adverse life-events, and to the increase of longitudinal design studies. Some methodological problems could be overcome by including clinical psychologists in the implementation of research protocols.

Traumatic Experiences, Stressful Events, and Alexithymia in Chronic Migraine With Medication Overuse

Background: Many factors are involved in the prognosis and outcome of Chronic Migraine and Medication Overuse Headache (CM+MOH), and their understanding is a topic of interest. It is well known that CM+MOH patients experience increased psychiatric comorbidity, such as anxiety, depression, or personality disorders. Other psychological factors still need to be explored. The present study is aimed to evaluate whether early life traumatic experiences, stressful life events, and alexithymia can be associated with CM+MOH. Methods: Three hundred and thirty-one individuals were recruited for this study. They belonged to one of the two following groups: CM+MOH (N = 179; 79% females, Age: 45.2 ± 9.8) and episodic migraine (EM) (N = 152; 81% females; Age: 40.7 ± 11.0). Diagnosis was operationally defined according to the International Classification of Headache Disorders 3rd edition (ICHD-IIIβ). Data on early life (physical and emotional) traumatic experiences, recent stressful events and alexithymia were collected by means of the Childhood Trauma Questionnaire, the Stressful life-events Questionnaire, and the Toronto Alexithymia Scale (TAS-20), respectively. Results: Data showed a higher prevalence of emotional (χ2 = 6.99; d.f. = 1; p = 0.006) and physical (χ2 = 6.18; d.f. = 1; p = 0.009) childhood trauma and of current stressful events of important impact (χ2 = 4.42; d.f. = 1; p = 0.025) in CM+MOH patients than in EM ones. CM+MOH patients were characterized by higher difficulties in a specific alexithymic trait (Factor 1 subscale of TAS-20) [F(1, 326) = 6.76, p = 0.01, ηp2 = 0.02] when compared to the EM group. The role of these factors was confirmed in a multivariate analysis, which showed an association of CM+MOH with emotional (OR 2.655; 95% CI 1.153–6.115, p = 0.022) or physical trauma (OR 2.763; 95% CI 1.322–5.771, p = 0.007), and a high score at the Factor 1 (OR 1.039; 95% CI 1.002–1.078, p = 0.040). Conclusions: Our findings demonstrated a clear relationship between CM+MOH and life traumas, stressful events, and alexithymia. These observations have a relevant role in multiple fields of related to chronic headache: from the management to the nosographic framing.

A Child with Headache and Anxiety Disorder Including School Refusal

A 10-year-old girl presents with a daily headache for the past 2 months. She suffered from headache since 4–5 years of age with infrequent attacks. During the past month, her school attendance was interrupted due to symptoms of separation anxiety (nightmares, refusal to see peers and go to school, and cardiovascular symptoms). Her mother administered analgesics on rare occasions. On the basis of the clinical history, she was thought to have a probable chronic tension-type headache, and a psychological assessment was deemed necessary, which confirmed the separation anxiety disorder as the cause of her symptoms. The patient and the family have been invited to join a family psychotherapy program. After a few months, headache returned to an episodic pattern, the child returned to school, and the family reached a new “healthier” equilibrium.

P008. Alexithymia and chronic migraine with medication overuse: what relationship?

Background Alexithymia is a personality trait characterized by the inability to identify and express emotions. Neuroimaging studies showed specific neural correlates in alexithymic subjects [1] and pathological scores of alexithymia in several chronic pain populations and in episodic migraine [2,3]. There is also evidence of a positive association between alexithymia, depression, and anxiety in migraine patients. So far, no study has evaluated alexithymia in medication-overuse headache patients (MOH) (progressed by migraine) versus episodic migraine patients (MIG). The present study was aimed to evaluate whether MOH individuals differ from MIG as regards alexithymia scores and to investigate the association of alexithymia with headache characteristics.