Ingrid Gralow

The incidence and prevalence of cluster headache: a meta‐analysis of population‐based studies

Cluster headache is a trigemino-autonomic cephalgia with a low prevalence. Several population-based studies on its prevalence and incidence have been performed, but with different methodology resulting in different figures. We analysed all available population-based epidemiological studies on cluster headache and compared the data in a meta-analysis. The pooled data showed a lifetime prevalence of 124 per 100 000 [confidence interval (CI) 101, 151] and a 1-year prevalence of 53 per 100 000 (CI 26, 95). The overall sex ratio was 4.3 (male to female), it was higher in chronic cluster headache (15.0) compared with episodic cluster headache (3.8). The ratio of episodic vs. chronic cluster headache was 6.0. Our analysis revealed a relatively stable lifetime prevalence, which suggests that about one in 1000 people suffers from cluster headache, the prevalence being independent of the region of the population study. The sex ratio (male to female) is higher than published in several patient-based epidemiological studies.

Drug-induced headache: long-term results of stationary versus ambulatory withdrawal therapy

Drug-induced headache is a well-known complication of the treatment of primary headache disorders, and its successful management is only possible by withdrawal therapy. However, it is unknown whether ambulatory or stationary withdrawal is the therapy preferred. We conducted a prospective study on the outcome of stationary versus ambulatory withdrawal therapy in patients with drug-induced headache according to the International Headache Society criteria. Out of 257 patients with the diagnosis of drug-induced headache during the study period, 101 patients (41 after ambulatory and 60 after stationary withdrawal therapy) could be followed up for 5.9 ± 4.0 years. The total relapse rate after successful withdrawal therapy was 20.8% (14.6% after ambulatory and 25.0% after stationary withdrawal therapy, p <0.2). The main risk factors for a relapse were male sex (OR=3.9, CI=1.3-11.6), intake of combined analgesic drugs (OR=3.8, CI=1.4-10.3), administration of naturopathy (OR=6.0, CI=1.2-29.3), and a trend to tension-type headache as the primary headache disorder (OR=1.9, CI=0.6-53.0). Our data suggest that neither the method of withdrawal therapy nor the kind of analgesic and other antimigraine drugs has a major impact on the long-term result after successful withdrawal therapy. Patients with risk factors according to our findings should be informed and monitored regularly, and combined drugs should be avoided. Furthermore, our data suggest that there is a need for research on individual psychological and behavioral risk factors for relapse after successful withdrawal therapy in drug-induced headache.

Placebo efficacy in childhood and adolescence migraine: an analysis of double-blind and placebo-controlled studies

Studies on the treatment of migraine in children and adolescents are rare and difficult to design. In particular, the high placebo response in some trials makes it difficult to prove efficacy of a verum drug. We analysed all available placebo-controlled trials on acute and on prophylactic migraine treatment in children and adolescents with respect to different placebo rates (pain free and pain relief at 2 h; rate of responders with ≥ 50% attack frequency decrease). We identified eight crossover and 11 parallel group trials on acute treatment. The placebo response rates were considerably lower in crossover trials than in parallel group trials (19.2% vs. 27.1% for pain free after 2 h and 39.4% vs. 56.9% for pain relief after 2 h). In the 10 prophylactic trials included in this analysis, only a small trend towards a lower placebo rate in crossover trials could be observed. Further significant factors associated with a lower placebo rate in childhood and adolescence trials on the acute treatment of migraine were single-centre (vs. multicentre) trials and small sample size. Age and sex were not associated with the placebo response. Our study suggests that parallel group trials on the acute treatment of migraine in children and adolescents show a very low therapeutic gain due to a high placebo rate. The verum response rates, however, are very similar to those seen in adulthood trials. In conclusion, trial designs on the acute and prophylactic treatment of migraine in children and adolescents should consider the specific findings of this analysis in order to exhibit a higher probability of showing significant differences between placebo and verum drug.

Validation of the pain sensitivity questionnaire in chronic pain patients.

Summary Pain Sensitivity Questionnaire scores correlate with results of experimental pain testing and reflect generalized enhancement of pain perception in chronic pain patients. ABSTRACT Recently, a self‐rating measure for pain perception based on imagined painful daily life situations, the Pain Sensitivity Questionnaire (PSQ), has been developed and shown to correlate with experimentally obtained pain intensity ratings in healthy subjects. Here, we assessed the validity of the PSQ for investigation of general pain perception (ie, pain perception outside the site of clinical pain) in chronic pain patients. PSQ scores were obtained in 134 chronic pain patients and compared to those of 185 healthy control subjects. In a subgroup of 46 chronic pain patients, we performed experimental pain testing outside the clinical pain site, including different modalities (heat, cold, pressure, and pinprick) and different measures (pain thresholds, pain intensity ratings). Results show that PSQ scores were significantly correlated with both experimental pain intensity ratings (Pearson’s r = 0.71, P < .001) and experimental pain thresholds (r = −0.52, P < .001). In addition, chronic pain patients exhibited significantly elevated PSQ scores as compared to healthy controls, consistent with the generalized increase of experimentally determined pain perception that has repeatedly been reported in chronic pain patients. These results demonstrate that the PSQ constitutes a valid self‐rating measure of pain perception outside the clinical pain site in chronic pain patients and might serve as an alternative to experimental assessment of pain perception outside the clinical pain site in situations where experimental pain testing is not feasible.

Adjuvant topical therapy with a cannabinoid receptor agonist in facial postherpetic neuralgia.

Background: Postherpetic neuralgia is a frequent adverse event in herpes zoster patients and difficult to treat. Conventional analgetic therapy often fails to reduce the burning pain transmitted by unmyelinated nerve fibers. These nerves express cannabinoid receptors which exert a role in modulation of nociceptive symptoms. Therefore, topical therapy with cannabinoid receptor agonist seems likely to suppress local burning pain.

Psychosoziale Beeinträchtigung durch chronische Kopfschmerzen Evaluation des Inventars zur Beeinträchtigung durch Kopfschmerzen (IBK)

ZusammenfassungChronische primäre Kopfschmerzen beeinträchtigen die Lebensqualität der Betroffenen wesentlich. Bislang ist diese Beeinträchtigung durch allgemein schmerzbezogene Instrumente erfaßt worden, während kopfschmerzspezifische Instrumente zur Erfassung der akuten Beeinträchtigung der Lebensqualität für den deutschsprachigen Raum bislang nicht vorliegen. Im amerikanischen Raum ist ein Headache Disability Inventory (HDI) evaluiert worden, der in der hier vorgelegten Studie als Grundlage zur Entwicklung eines eigenständigen deutschsprachigen „Inventar zur Beeinträchtigung durch Kopfschmerzen” (IBK) dient. Anhand von 94 konsekutiven Patienten mit primären Kopfschmerzen (59 weiblich, 35 männlich; mittleres Alter 40±12 Jahre) ist der FBK hinsichtlich der Testgütekriterien untersucht worden. Dabei zeigte sich ein hoher Wert für Cronbachs Alpha (a=0,90). Die Test-Retest-Reliabiliät nach 3 Monaten war ebenfalls hoch (r=0,87). Eine Untergliederung des FBK in Subskalen für die emotionale und funktionale Beeinträchtigung ergab ähnlich hohe Werte für die interne Konsistenz und die Test-Retest-Reliabilität dieser Subskalen. Die Scorewerte der einzelnen Kopfschmerzdiagnosen unterschieden sich nicht signifikant voneinander, jedoch zeigte der Clusterkopfschmerz im Vergleich zur Migräne in post-hoc-Analysen eine signifikant größere Beeinträchtigung in der Gesamtskala und in den Subskalen. Der Scorewert des IBK korrelierte signifikant mit den Kopfschmerztagen pro Monat (r=0,41; p<0,0003), jedoch nicht mit der Erkrankungsdauer und anderen demographischen Größen. Mit dem IBK liegt erstmals ein deutschsprachiges kopfschmerzspezifisches Instrument zur Erfassung der Lebensqualität vor, es eignet sich sowohl im klinischen Alltag zur Erhebung eines Eingangsstatus und zur Kontrolle des Therapieerfolgs als auch für wissenschaftliche Fragestellungen.SummaryChronic primary headache has a considerable impact on the quality of life. To date, this impact has been evaluated by measurements of the general pain specific impairment of the quality of life. Headache specific measurements of quality of life or of disability caused by the headache are still missing for the German language. In America, a headache specific questionnaire, the „Headache Disability Inventory” (HDI), has been evaluated which is used in the presented study to create a German version, the „Inventar zur Beeinträchtigung durch Kopfschmerzen” (IBK). 94 consecutive patients with a primary headache disorder (59 female, 35 male; mean age 40±12 years) were examined. Cronbach’s alpha was a=0.90, the test-retest-reliability after three months was r=0.87. An analysis of subscales for emotional and functional disability showed similar values for the internal consistency and the test-retest-reliability of these subscales. The scores of the different headache types did not differ significantly. In post-hoc-analyses, however, cluster headache showed higher disability scores than migraine both in the total scale and in the subscales. The total score of the IBK was significantly correlated with the number of headache days per month (r=0.41; p<0.0003) but not with the duration of disease or other demographic parameters. The IBK is the first German headache specific measurement of certain aspects of the quality of life in chronic headache patients. It can be used in clinical settings to evaluate the current state of the patient or to monitor treatment and it can be used for scientific studies.

Pain and pain management in dermatology

It is estimated that 23 million Germans suffer from chronic pain. A recent survey has revealed that 30 % of chronic pain patients are dissatisfied with their pain management. Furthermore, five million Germans suffer from neuropathic pain, 20 % of whom are inadequately treated. Pain is also a symptom of many dermatologic diseases, which is mostly somatic and may be classified as mild in the majority of cases. Nevertheless, research on the quality of life (QoL) has increasingly shown a marked impairment of QoL by moderate pain such as in psoriatic arthritis. Severe pain is associated with herpes zoster (shingles), leg ulcers, and pyoderma gangrenosum.

Requirements for an interdisciplinary lecture on pain. Results from a survey of medical students

ZusammenfassungHintergrundSchmerztherapie ist auch nach der Neufassung der Approbationsordnung kein curricular verankerter Lehrgegenstand im Medizinstudium in Deutschland.MethodikZur Erfassung der Wünsche von Studierenden an eine fakultative Lehrveranstaltung in Schmerztherapie ist während 2 Semestern an der Medizinischen Fakultät der Universität Münster eine Befragung unter Studierenden durchgeführt worden, die freiwillig eine solche Lehrveranstaltung besuchen wollten.ErgebnisseDie Hauptinteressen richten sich auf die Vermittlung konkreter Schmerzsyndrome (Rücken-, Kopf-, Tumorschmerz), der Pharmakotherapie und der Struktur der schmerztherapeutischen Versorgung. Weibliche Studierende äußerten ein signifikant stärkeres Interesse an der Schmerztherapie für bestimmte Zielgruppen (Frauen, Kinder, alte Menschen, Menschen mit HIV-Infektion). Als wichtigste Bestandteile von Lehrveranstaltungen wurden Fallbeispiele und Patientenvorstellungen gewünscht.SchlussfolgerungDie Analyse der gegenwärtig vorgeschlagenen Curricula für eine universitäre Lehrveranstaltungen in Schmerztherapie ergibt, dass die Curricula der IASP und der EFIC zu umfangreich bzw. zu theoretisch orientiert sind. Das Curriculum der DGSS deckt sich weitgehend mit den Wünschen von Studierenden. Fakultative Lehrveranstaltungen zur Schmerztherapie sollten die ermittelten Wünsche der Studierenden in der Themenauswahl und in den didaktischen Methoden berücksichtigen.AbstractBackgroundPain therapy is not an obligatory subject of undergraduate medical education in Germany.MethodsIn order to evaluate the expectations of undergraduate medical students regarding pain therapy as a lecture, a questionnaire was distributed to students visiting a facultaty lecture on pain therapy.ResultsThe main topics voted by the students as very interesting to them were pain syndromes such as low back pain, headache, and cancer pain. Furthermore, pharmacotherapy and the structure of pain therapy units were voted as interesting. Female students were significantly more interested in pain problems of specific patient groups (women, children, older patients, HIV-infected patients). Case reports on paper or with patient presentations were regarded as the most important didactic elements of such lectures.ConclusionsAn analysis of the published undergraduate curricula in pain therapy revealed that the curriculum of the IASP and of the EFIC are too long and too theoretical, respectively. The curriculum of the DGSS meets many expectations of the students in this survey. Concepts of pain therapy education in undergraduate medical schools should consider the wishes of students regarding knowledge of pain syndromes and didactic methods.

Pain: Basics and relevance in dermatology

Scientific progress in pathophysiology and differentiation of pain, functional diagnostic of pain and emerging treatments highlight this subject. Basics of development of pain, as well as differentiation of nociceptive and neuropathic pain are depicted; the latter is illustrated with the example of postherpetic neuralgia. Complex regional pain syndromes are described as a third pain complex. Principles of differentiated pain management are given. Substance groups from the WHO scheme including antipyretic analgesics, non‐steroidal antiinflammatory drugs (NSAIDs) and opioids are discussed. Recommendations of the Drug Commission of the German Medical Association concerning NSAIDs and of the International Association for the Study of Pain (IASP) concerning new treatment options for cancer pain are cited. Overviews amongst others from the Cochrane library for local anesthetics, opioids and for the treatment of postherpetic neuralgia are included. Tables are provided to simplify use in daily practice. The goal of this overview is a conceptual development of pain diagnosis and therapy in dermatology.

Cluster headache and alpha 1‐antitrypsin deficiency

Little is known about the pathophysiology of cluster headache (CH), one of the most debilitating primary headaches. Interestingly, associations of lung affecting diseases or lifestyle habits such as smoking and sleep apnoea syndrome and CH have been described. Certain genotypes for alpha 1-antitrypsin (α1-AT) are considered risk factors for emphysema. Our aim was to investigate possible associations between common genotypes of the SERPINA1 gene and CH. Our study included 55 CH patients and 55 controls. α1-AT levels in serum and the genotype were analysed. Patients CH characteristics were documented. We could not detect any association between CH and a genotype that does not match the homozygous wild type for α1-AT. Interestingly, there is a significant difference of CH attack frequency in patients who are heterozygous or homozygous M allele carriers. We conclude that the presence of an S or Z allele is associated with higher attack frequency in CH.