Maria Lurenda Westergaard

Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review.

Background Case definitions of medication-overuse headache (MOH) in population-based research have changed over time. This study aims to review MOH prevalence reports with respect to these changes, and to propose a practical case definition for future studies based on the ICHD-3 beta. Methods A systematic literature search was conducted to identify MOH prevalence studies. Findings were summarized according to diagnostic criteria. Results Twenty-seven studies were included. The commonly used case definition for MOH was headache ≥15 days/month with concurrent medication overuse ≥3 months. There were varying definitions for what was considered as overuse. Studies that all used ICHD-2 criteria showed a wide range of prevalence among adults: 0.5%–7.2%. Conclusions There are limits to comparing prevalence of MOH across studies and over time. The wide range of reported prevalence might not only be due to changing criteria, but also the diversity of countries now publishing data. The criterion “headache occurring on ≥15 days per month” with concurrent medication overuse can be applied in population-based studies. However, the new requirement that a respondent must have “a preexisting headache disorder” has not been previously validated. Exclusion of other headache diagnoses by expert evaluation and ancillary examinations is not feasible in large population-based studies.

Prevalence of chronic headache with and without medication overuse: Associations with socioeconomic position and physical and mental health status

&NA; Chronic headache prevalence in Denmark was inversely related to socioeconomic position, but significant ill health was seen among persons with chronic headache in all socioeconomic strata. &NA; Near‐daily intake of acute symptomatic medication for frequent headache increases the risk for medication‐overuse headache (MOH). Chronic headache (CH) and MOH prevalences are inversely related to socioeconomic position (SEP). It is not known how SEP influences the health status of people with these headaches. This cross‐sectional study examined the prevalence of CH in Denmark; possible associations between CH and education, work status, and income; and the health status of people with CH across socioeconomic strata. A total of 129,150 individuals aged ≥16 years were invited to the 2010 Danish National Health Survey. Data on SEP indicators and purchases of prescription drugs in 2009 were retrieved from national registers. Respondents with headache ≥15 days per month over 3 months were classified as having CH. Those with concurrent over‐the‐counter analgesic intake of ≥15 days per month or prescription medication overuse (≥20 or ≥30 defined daily doses per month depending on the drug or drugs) were classified as having MOH. Associations between headache and SEP were analyzed by logistic regression, and associations between headache and health status scores, by linear regression. Physical and mental health composite scores (SF‐12) were summarized per headache group, stratified by SEP, and compared to the sample mean. Analyses were adjusted for stratified sampling and nonresponse. The response rate was 53.1%. CH prevalence was 3.3% with 53.0% of cases having concurrent medication overuse (MOH prevalence 1.8%). CH was more prevalent among those individuals with low SEP. Health status scores were significantly lower among persons with CH in all SEP categories. The burden of CH can be reduced by preventing and treating MOH.

Epidemiology of concurrent headache and sleep problems in Denmark

Aims There are no previous epidemiologic studies on concurrent headache and sleep problems (HSP). This cross-sectional study aimed to determine the prevalence of HSP in Denmark, broadly characterize those with HSP, and examine associations between HSP and socioeconomic/lifestyle factors. Methods A total of 129,150 randomly selected individuals were invited to participate in the Danish National Health Survey 2010. Respondents were asked about headache, sleep problems, depression and anxiety in the last two weeks, health-related lifestyle and quality of life (SF-12). Socioeconomic data were retrieved from national registers. Prevalence proportions were adjusted for stratified sampling and non-response. Regression analyses examined associations between HSP and socioeconomic/lifestyle factors. Results Of 68,518 respondents, 16.3% reported only headache, 21.1% only sleep problems, and 18.1% HSP with 2.6% being severely affected. Prevalence was higher among women and the middle-aged. Severe HSP was associated with low socioeconomic position, non-Western ethnicity, unhealthy lifestyle, high stress and anxiety/depression. Those with HSP had substantially reduced quality of life; more so than those having only headache or only sleep problems. Conclusions HSP is a highly prevalent condition. Lifestyle modification, stress reduction, and screening for concurrent depression and anxiety may play important roles in management. The high prevalence of HSP suggests a common pathophysiological mechanism.

The association between candidate migraine susceptibility loci and severe migraine phenotype in a clinical sample.

Introduction The objective of the study was to follow up and to test whether 12 previously identified migraine-associated single nucleotide polymorphisms were associated as risk factors and/or modifying factors for severe migraine traits in a Danish clinic-based population. Methods Semi-structured migraine interviews, blood sampling and genotyping were performed on 1806 unrelated migraineurs recruited from the Danish Headache Center. Genotyping was also performed on a control group of 6415 people with no history of migraine. Association analyses were carried out using logistic regression and odds ratios were calculated assuming an additive model for risk. The proxies for severe migraine traits (early onset of migraine; many lifetime attacks, prolonged migraine and tendency to chronification of migraine) were tested against the 12 single nucleotide polymorphisms and a combined genetic score in both a case-control and case-only logistic regression model. Results We successfully replicated five out of the 12 previously reported loci and confirmed the same direction of effects for all the 12 single nucleotide polymorphisms. In line with the recently published genome-wide association meta-analysis, the associations were significant for all migraine and migraine without aura but not for migraine with typical aura. Two single nucleotide polymorphisms (rs2274316 and rs11172113) conferred risk of many lifetime attacks inthe case-control analysis. In the case-only analysis, only three single nucleotide polymorphisms showed nominal association with many lifetime attacks and prolonged migraine attacks. Conclusion Our study supports previously reported findings on the association of several single nucleotide polymorphisms with migraine. It also suggests that the migraine susceptibility loci may be risk factors for severe migraine traits.

Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey:

Aim This cross-sectional study investigated associations between chronic headache (CH) with and without medication overuse, healthy lifestyle behaviour, and stress. Methods Questionnaires were sent to 129,150 adults. Those with headache ≥15 days per month for three months were classified as having CH then further described as having medication-overuse headache (MOH) or CH without medication overuse. Associations between headache and daily smoking, physical inactivity, obesity, excessive drinking, illicit drug use, and high stress were analysed by logistic regression. Results CH with and without medication overuse (prevalence 1.8% and 1.6%, respectively) had strong, graded associations with stress. Associations with daily smoking, physical inactivity, and obesity were significant only for MOH. Odds for MOH were highest among people who had all three factors compared to those who had none (OR 2.8 in women and 5.1 in men). High stress plus any of these three factors had synergistic effects in MOH but not clearly in those who had CH without overuse. Associations between CH subtypes and excessive drinking or illicit drug use were not statistically significant. Conclusion Results suggest strong links between healthy lifestyle behaviour and stress in MOH. Stress reduction and promoting healthy behaviour are highly relevant in MOH management.

The Headache Under-Response to Treatment (HURT) Questionnaire: Assessment of utility in headache specialist care

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 rs = 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.

Medication-overuse headache: a perspective review

Medication-overuse headache (MOH) is a debilitating condition in which frequent and prolonged use of medication for the acute treatment of pain results in the worsening of the headache. The purpose of this paper is to review the most recent literature on MOH and discuss future avenues for research. MOH accounts for a substantial share of the global burden of disease. Prevalence is often reported as 1–2% but can be as high as 7% overall, with higher proportions among women and in those with a low socioeconomic position. Management consists of withdrawing pain medication, focusing on prophylactic and nonmedical treatments, and limiting acute symptomatic medication. Stress reduction and lifestyle interventions may support the change towards rational pain medication use. Support, follow up, and education are needed to help patients through the detoxification period. There is fertile ground for research in MOH epidemiology, pathophysiology, and neuroimaging. Randomized and long-term follow-up studies on MOH treatment protocols are needed. Further focused research could be of major importance for global health.

Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain

BackgroundThe prevalence of migraine with co-existing tension-type headache and neck pain is high in the general population. However, there is very little literature on the characteristics of these combined conditions. The aim of this study was to investigate a) the prevalence of migraine with co-existing tension-type headache and neck pain in a clinic-based sample, b) the level of physical activity, psychological well-being, perceived stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain compared to healthy controls, c) the perceived ability of persons with migraine and co-existing tension-type headache and neck pain to perform physical activity, and d) which among the three conditions (migraine, tension-type headache or neck pain) is rated as the most burdensome condition.MethodsThe study was conducted at a tertiary referral specialised headache centre where questionnaires on physical activity, psychological well-being, perceived stress and self-rated health were completed by 148 persons with migraine and 100 healthy controls matched by sex and average age. Semi-structured interviews were conducted to assess characteristics of migraine, tension-type headache and neck pain.ResultsOut of 148 persons with migraine, 100 (67%) suffered from co-existing tension-type headache and neck pain. Only 11% suffered from migraine only. Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress and poorer self-rated health compared to healthy controls. They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.ConclusionsMigraine with co-existing tension-type headache and neck pain was highly prevalent in a clinic-based sample. Persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity, and to improve psychological well-being, perceived stress and self-rated health.

National awareness campaign to prevent medication-overuse headache in Denmark

Background Medication-overuse headache is prevalent, but in principle preventable. Objective To describe the Danish national awareness campaign for medication-overuse headache. Methods The Danish Headache Center, the Association of Danish Pharmacies, and headache patient organizations implemented a four-month medication-overuse headache awareness campaign in 2016. Target groups were the general public, general practitioners, and pharmacists. Key messages were: Overuse of pain-medication can worsen headaches; pain-medication should be used rationally; and medication-overuse headache is treatable. A range of communication technologies was used. A survey on the public’s awareness of medication-overuse headache was conducted. Results The Danish adult population is 4.2 million. Online videos were viewed 297,000 times in three weeks. All 400 pharmacies received campaign materials. Over 28,000 leaflets were distributed. Two radio interviews were conducted. A television broadcast about headache reached an audience of 520,000. Forty articles were published in print media. Information was accessible at 32 reputable websites and five online news agencies. Three scientific papers were published. Information was available at an annual conference of general practitioners, including a headache lecture. The survey showed an increase in percentage of the public who knew about medication-overuse headache (from 31% to 38%). Conclusion A concerted campaign to prevent medication-overuse headache can be implemented through involvement of key stakeholders.

The DoloTest® in a specialized headache center among patients receiving psychological treatment. A pilot study

Abstract Background The DoloTest is a newer health-related quality of life (HRQoL) monitoring instrument for pain, not yet validated for headache. Aims To examine the usefulness of the DoloTest in a specialized headache center. Methods The sample consisted of patients referred to psychologists from the Danish Headache Center (DHC) for whom the test was carried out at start of, end of, and 6 months after treatment. Points on eight scales of the test were measured (values ranged from 0 to 100), then totaled (0 to 800). Scores were analyzed using Wilcoxon Signed Ranks test. The correlation between headache days and DoloTest scores were computed using linear regression adjusted for age. Qualitative feedback on usefulness of the test were gathered from psychologists. Results Of 135 patients included, 105 completed treatment. On average, headache days decreased from 22 days per month at start of treatment (SD 9.0, median 29) to 18 days at end of treatment (SD 10.8, median 19) (p<0.001). At end of treatment, DoloTest scores improved for pain (p=0.015) and reduced energy and strength (p=0.034). At 6 months’ follow-up, total scores improved (p=0.034), as well as component scores for pain (p=0.010), problems with strenuous activity (p=0.045) and reduced energy and strength (p=0.012). Correlation between reduced headache days and improved DoloTest scores was 0.303 (p=0.028). Psychologists found the test useful in monitoring and evaluating patients. Conclusions The DoloTest was useful for psychoeducation and for monitoring the effect of headache treatment. Implications The DoloTest is a potential HRQoL monitoring instrument for headache patients. We recommend further validation studies.