Sara Schramm

Epidemiological profiles of patients with chronic migraine and chronic tension-type headache

BackgroundWe evaluated risk factors associated with chronic headache (CH) such as age, gender, smoking, frequent drinking of alcoholic beverages (drinking), obesity, education and frequent intake of acute pain drugs to test their usefulness in clinical differentiation between chronic migraine (CM) and chronic tension-type headache (CTTH).MethodsWe used baseline data from the population-based German Headache Consortium Study including 9,944 participants aged 18–65 years, screened 2003–2005, using validated questionnaires. CM and CTTH were defined according to IHS criteria. Multinominal logistic regression analyses were used to investigate the association of CM or CTTH with risk factors by estimating odds ratios (OR) and 95% confidence intervals (95%CI).ResultsThe prevalence of CH was 2.6% (N = 255, mean age 46 ± 14.1 years, 65.1% women), CM 1.1% (N = 108, 45 ± 12.9 years, 73.1%), CTTH 0.5% (N = 50, 49 ± 13.9 years, 48.0%). Participants with CM compared to CTTH were more likely to be female (OR: 2.34, 95%CI: 1.00-5.49) and less likely to drink alcohol (0.31, 0.09-1.04). By trend they seemed more likely to smoke (1.81, 0.76-4.34), to be obese (1.85, 0.54-6.27), to report frequent intake of acute pain drugs (1.68, 0.73-3.88) and less likely to be low educated (0.72, 0.27-1.97).ConclusionsWe concluded that the careful assessment of different risk factors might aid in the clinical differentiation between CM and CTTH.

The association between stress and headache: A longitudinal population-based study

Introduction We studied the association between stress intensity and headache frequency for tension-type headache (TTH), migraine and migraine with coexisting TTH (MigTTH). Method We studied a population-based sample of 5159 participants (21–71 years) who were asked quarterly between March 2010 and April 2012 about headache and stress. Log-linear regression in the framework of generalized estimating equations was used to estimate regression coefficients presented as percent changes to describe the association between stress intensity (modified visual analog scale (VAS) from 0 to 100) and headache frequency (days/month) stratified by headache subtypes and age groups and adjusted for sex, age, frequent intake of acute pain drugs, drinking, smoking, BMI and education. Results TTH was reported in 31% participants (48.1 ± 12.5years, 51.5% women, 2.2 ± 3.9 mean headache days/month, 52.3 ± 26.7 mean stress), migraine in 14% (44.8 ± 11.3years, 73.3%, 4.5 ± 5.2 days/month, 62.4 ± 23.3), MigTTH in 10.6% (43.5 ± 11.5 years, 61.0%, 3.6 ± 4.8 days/month, 58.6 ± 24.1), 23.6% were unclassifiable, and 20.8% had no headache. In participants with TTH an increase of 10 points on VAS was associated with an increase of headaches days/month of 6.0% (adjusted). Higher effects were observed in younger age groups (21–30/31–40/41–50/51–60/61–71 years: 9.8/10.2/7.0/6.5/3.5%). Slightly lower effects were observed for migraine (4.3%, 8.1/5.1/3.4/6.3/0.3%) and MigTTH (4.2%, 5.5/6.8/6.9/5.8/–0.7%). Conclusion Our study provides evidence for an association between stress intensity and headache frequency.

Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: Results of the German Headache Consortium study

Summary Frequent low back pain is associated with chronic migraine and chronic tension‐type headache, contributing to understanding of chronic pain and developing prevention strategies. ABSTRACT The objective of this study was to evaluate the association between low and frequent low back pain and chronic migraine (CM) and chronic tension‐type headache (CTTH) in a large, German population‐based sample. Headaches were diagnosed according to International Classification of Headache Disorders‐2 criteria and categorized according to frequency (episodic 1–14 days/month or chronic ⩽15 days/month) and headache type (migraine or TTH). We defined frequent low back pain as self‐reported low back pain on ⩾15 days/month. We calculated odds ratios and 95% confidence intervals (CI) using logistic regression analyses, adjusting for sociodemographic covariates. There were 5605 respondents who reported headache in the previous year, of whom 255 (4.5%) had Chronic Headache. Migraine was diagnosed in 2933 respondents, of whom 182 (6.2%) had CM. TTH was diagnosed in 1253 respondents, of whom 50 (4.0%) had CTTH. Among 9944 respondents, 6030 reported low back pain, of whom 1267 (21.0%) reported frequent low back pain. In adjusted models, the odds of having frequent low back pain were between 2.1 (95% CI 1.7‐2.6) and 2.7 (95% CI 2.3‐3.2) times higher in all episodic headache subtypes when compared to No Headache. The odds of having frequent low back pain were between 13.7 (95% CI 7.4‐25.3) and 18.3 (95% CI 11.9‐28.0) times higher in all chronic headache subtypes when compared to No Headache. Low and frequent low back pain was associated with CM and CTTH. Multiple explanations may contribute to the association of headache and back pain, including the notion that the neurobiology of chronic headache, independent of primary headache type, not only involves the trigeminal pain pathway, but is also a part of abnormal general pain processing.

Impact of season and different vitamin D thresholds on prevalence of vitamin D deficiency in epidemiological cohorts—a note of caution

PurposeWe investigated the impact of different cut-offs on the prevalence of 25-hydroxyvitamin D [25-(OH)D] deficiency.MethodsWe used baseline data of 4149 participants (45–75 years, 50% women) of the population-based Heinz Nixdorf Recall study. Serum 25-(OH)D was measured with the Roche Cobas assay. Quartiles (p25, p50, and p75) were calculated. Data were stratified by months, sex, and age. According to the recommendations of ‘Dachverband Osteologie’, Endocrine Society and National Institute of Health we used 25-(OH)D thresholds of 12, 20, and 30 ng/ml to estimate vitamin D deficiency.ResultsOverall the median of 25-(OH)D was 19.8 ng/ml (p25 = 14.4 ng/ml, p75 = 26.6 ng/ml), with highest concentrations in July (p50 = 23.8 ng/ml, p25 = 18.2 ng/ml, and p75 = 31.2 ng/ml) and lowest in March (p50 = 15.8 ng/ml, p25 = 11.5 ng/ml, and p75 = 20.6 ng/ml). Prevalence of vitamin D deficiency rose from 16, 51 up to 83% using the cut-offs of <12, <20 ng/ml, and <30 ng/ml, respectively. With respect to seasonal variance, prevalence of vitamin D deficiency rose to 92% in February/March using the cut-off <30 ng/ml (<12: 28%, <20 ng/ml: 71%) whereas in June/July prevalence of vitamin D deficiency decreased to 71% (<12: 6%, <20 ng/ml: 30%). The chance to attest the diagnosis of vitamin D deficiency for cut-off 12 ng/ml in March is 6.4-fold higher than in June, for cut-off 20 ng/ml, 5.5-fold higher and for cut-off 30 ng/ml, 3.1-fold higher.ConclusionsGuidelines to define vitamin D deficiency revealed extremely different prevalence rates ranging between 6 and 92%. Accounting for collection time and antecedent sun exposure are important to reduce bias in research studies and improve decision-making in clinical care. Vitamin D thresholds have to be rethought.

Use of aspirin combinations with caffeine and increasing headache frequency: a prospective population-based study.

Abstract Combinations of analgesics with caffeine have been discussed as bearing a risk for headache chronicity. We investigated whether aspirin with caffeine (ASA+) increases headache frequency compared with aspirin alone in migraine, tension-type headache (TTH), and migraine + TTH (MigTTH). The population-based German Headache Consortium Study, which included participants aged 18 to 65 years, collected information about headache and analgesics at baseline (2003-2007, t0, response rate: 55.2%), first follow-up after 1.87 ± 0.39 years (t1, 37.2%), and second follow-up after 3.26 ± 0.60 years (t2, 38.8%). We included participants with headache at t0, aspirin intake, ASA+ or no analgesics at t0 and t2, and known headache frequency. Linear regression was used to estimate changes of headache frequency (&Dgr;t2−t0) and 95% confidence intervals depending on analgesic intake, stratified by headache subtypes, adjusting for sex, age, analgesics at t1, changes of headache frequency at t1, drinking, smoking, body mass index, education, headache frequency at t0. Of 509 participants (56.0% women, 42.0 ± 11.8 years [mean ± SD]), 45.2% reported aspirin intake (41.3 ± 10.9 years, 59.6% women, headache days at t0: 2.8 ± 3.1 d/mo, t2: 3.6 ± 4.1 d/mo), 11.8% ASA+ intake (46.0 ± 9.8 years, 73.3%, t0: 4.8 ± 6.1 d/mo, t2: 5.3 ± 5.1 d/mo), and 43.0% no analgesics (41.6 ± 13.1 years, 47.5%, t0: 3.8 ± 6.2 d/mo, t2: 5.3 ± 6.6 d/mo). There was no increase in headache frequency in participants with ASA+ intake compared with aspirin (adjusted, all headache: −0.34 d/mo [95% confidence intervals: −2.50 to 1.82], migraine: −1.36 d/mo [−4.76 to 2.03], TTH: −0.57 d/mo [−4.97 to 3.84], MigTTH: 2.46 d/mo [−5.19 to 10.10]) or no analgesics (all headache: −2.24 d/mo [−4.54 to 0.07], migraine: −3.77 d/mo [−9.22 to 1.68], TTH: −4.68 d/mo [−9.62 to 0.27]; MigTTH: −3.22 d/mo [−10.16 to 3.71]). In our study, ASA+ intake did not increase headache frequency compared with aspirin or no analgesics.

Headache service quality: evaluation of quality indicators in 14 specialist-care centres

BackgroundThe study was a collaboration between Lifting The Burden (LTB) and the European Headache Federation (EHF). Its aim was to evaluate the implementation of quality indicators for headache care Europe-wide in specialist headache centres (level-3 according to the EHF/LTB standard).MethodsEmploying previously-developed instruments in 14 such centres, we made enquiries, in each, of health-care providers (doctors, nurses, psychologists, physiotherapists) and 50 patients, and analysed the medical records of 50 other patients. Enquiries were in 9 domains: diagnostic accuracy, individualized management, referral pathways, patient’s education and reassurance, convenience and comfort, patient’s satisfaction, equity and efficiency of the headache care, outcome assessment and safety.ResultsOur study showed that highly experienced headache centres treated their patients in general very well. The centres were content with their work and their patients were content with their treatment. Including disability and quality-of-life evaluations in clinical assessments, and protocols regarding safety, proved problematic: better standards for these are needed. Some centres had problems with follow-up: many specialised centres operated in one-touch systems, without possibility of controlling long-term management or the success of treatments dependent on this.ConclusionsThis first Europe-wide quality study showed that the quality indicators were workable in specialist care. They demonstrated common trends, producing evidence of what is majority practice. They also uncovered deficits that might be remedied in order to improve quality. They offer the means of setting benchmarks against which service quality may be judged. The next step is to take the evaluation process into non-specialist care (EHF/LTB levels 1 and 2).

Evaluation of headache service quality indicators: pilot implementation in two specialist-care centres

BackgroundEvaluating quality of health care is increasingly recognized as an important contributor to the advancement of health-care delivery. We recently developed a set of quality indicators for headache care, intended to be applicable across countries, cultures and settings so that deficiencies in headache care worldwide might be recognized and rectified. These indicators themselves require evaluation and proof of fitness for purpose. This pilot study begins this process.MethodsWe tested the quality indicators in the tertiary headache centres of the University of Duisburg-Essen in Essen, Germany, and the Hospital da Luz in Lisbon, Portugal. Using seven previously-developed enquiry instruments, we interrogated health-care providers (HCPs), including doctors, nurses, psychologists and physiotherapists, as well as consecutive patients and their medical records.ResultsThe questionnaires were easily understood by both HCPs and patients and were not unduly time-consuming. The results from the two headache centres were comparable despite their differences in structure, staffing and language. These findings met the purpose of the study.Diagnoses were made according to ICHD criteria and critically evaluated during follow-up. However, diagnostic diaries and instruments assessing burden and response to treatment were not always in place or routinely utilised. Triage systems adjusted waiting times to urgency of need. Treatment plans included pathways to other specialities. Patients felt welcomed, reassured and educated, and were mostly satisfied. Discussion points arose over inclusion of psychological therapies in treatment plans; over recording of outcomes; over indicators of efficiency and equitability (protocols to limit wastage of resources, systems to measure input costs and means of ensuring equal access to the services); and over protocols for reporting serious adverse events.ConclusionThis pilot study to assess feasibility of the methods and acceptability of the instruments of headache service quality evaluation was successful. The project is ready to be taken into its next stages.

Remission of chronic headache: Rates, potential predictors and the role of medication, follow-up results of the German Headache Consortium (GHC) Study:

Objectives To estimate remission rates of chronic headache (CH), focusing on potential predictors of headache remission and medication. Methods We used data from the longitudinal population-based German Headache Consortium (GHC) Study (n = 9,944, 18–65 years). Validated questionnaires were used at baseline (t0, 2003–2007, response rate: 55.2%), first follow-up after 1.87 ± 0.39 years (t1, 37.2%) and second follow-up after 3.26 ± 0.60 years (t2, 38.8%) to assess headache type and frequency, use of analgesics and anti-migraine drugs, medication overuse, education, BMI, smoking and alcohol consumption. CH was defined as ≥ 15 headache days/month at t0 over three months. Outcomes were: CH remission (<15 headache days/month at both follow-ups), CH persistence (≥ 15 headache days/month at both follow-ups); all others were considered as partially remitted. To estimate predictors of remission, univariate and multiple logistic regression were calculated. Results At baseline, 255 (2.6%) participants were identified with CH. Of these, 158 (62.0%) participants responded at both follow-ups. Remission was observed in 58.2% of participants, partial remission in 17.7% and persistence in 24.1%. Remission was associated with female sex (adjusted odds ratio: 3.10, 95% confidence interval: 1.06–9.08) and no medication overuse (4.16, 1.45–11.94) compared to participants with persistent CH; participants with higher headache frequency at t0 were less likely to remit (0.90, 0.84–0.97). Medication, age, education, BMI, smoking and drinking showed no effects on remission. Similar results were observed for partial remission. Conclusion The majority of CH participants remitted from CH. Female sex, no overuse of pain medication and lower headache frequency were associated with remission.

EHMTI-0143. The association between stress and headache: a longitudinal population-based study

Methods The German Headache Consortium studied a populationbased sample of 5,159 participants (21-71years) who were asked every three months between March 2010 and April 2012 about headache and stress. Log-linear regression in the framework of Generalized Estimating Equations was used to estimate regression coefficients presented as percent changes to describe the association between stress intensity (visual analogue scale [VAS] from 0-100) and headache frequency (days/month) stratified by headache subtypes and age groups. Percent changes were adjusted for sex, age, frequent intake of acute pain drugs, drinking, smoking, body mass index and education.

Use of acute anti-migraine medication and risk of development of chronic headache: a prospective population based study

Methods We used data of the German Headache Consortium (GHC) Study which is a population-based sample of 18,000 participants aged 18 to 65 years. Information about headache features, frequency, use of medication and years of education were collected at baseline (20032005) and follow up one (t1) and two (t2) years after baseline using mailed questionnaires. Participants with prophylactic headache or other prophylactic pain medication were excluded (n=209). Primary outcome was defined as incidence of chronic headache (any headache on ≥ 15 days/month) at t1 or t2 in participants with episodic migraine (≤14 days of migraine/month) at baseline. We estimated odds ratios (OR) and 95%-confidence intervals (95%-CI), adjusting for headache days at baseline (interval scaled), education, age (interval scaled), gender and BMI classes (normal, overweight, obese). Results Of 18,000 people 9,944 (55.2%) responded at baseline, of those 6,688 (67.3%) resp. 6,975 (70.1%) responded at t1 resp. t2. At baseline 1,601 participants had episodic migraine. The incidence of chronicity was 6.2%. Use of anti-migraine medication had a protective effect compared to no intake (SA: OR=0.39, 95%-CI=0.19-0.78; CA: 0.60, 0.22-1.61; T: 0.34, 0.10-1.15). This effect was stronger for SA than for CA (OR=0.65, 95%-CI=0.281.50). Adjusting for age, gender and BMI classes did not notably change these results. Conclusion Our data indicate that use of acute anti-migraine medication irrespective of the type (SA, CA, T) reduces the risk for developing chronic headache.