The differential diagnosis of chronic daily headaches: an algorithm-based approach

Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for “red flags” that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is ≥4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review

Intravenous dipyrone for the acute treatment of episodic tension-type headache: A randomized, placebo-controlled, double-blind study

Acute headaches are responsible for a significant percentage of the case load at primary care units and emergency rooms in Brazil. Dipyrone (metamizol) is easily available in these settings, being the most frequently used drug. We conducted a randomized, placebo-controlled, double-blind study to assess the effect of dipyrone in the acute treatment of episodic tension-type headache. Sixty patients were randomized to receive placebo (intravenous injection of 10 ml saline) or 1 g dipyrone in 10 ml saline. We used seven parameters of analgesic evaluation. The patients receiving dipyrone showed a statistically significant improvement (P<0.05) of pain compared to placebo up to 30 min after drug administration. The therapeutic gain was 30% in 30 min and 40% in 60 min. The number of patients needed to be treated for at least one to have benefit was 3.3 in 30 min and 2.2 in 60 min. There were statistically significant reductions in the recurrence (dipyrone = 25%, placebo = 50%) and use of rescue medication (dipyrone = 20%, placebo = 47.6%) for the dipyrone group. Intravenous dipyrone is an effective drug for the relief of pain in tension-type headache and its use is justified in the emergency room setting

Frequent headaches in the preadolescent pediatric population: a population-based study

Objectives: To estimate the prevalence of chronic daily headaches (CDH) and of high-frequency episodic headaches (HFEH) in preadolescent children from the general population. Background: Early-onset cases of neurologic diseases often reflect increased biologic predisposition, specific risk factors, or both. Methods: Of 2,173 children identified as the target sample, consents were obtained from 1,870 (86.0%), and analyzable data were provided by 1,547 (71.2%). Parents and children were interviewed using a questionnaire consisting of 97 questions, with a validated headache module (10 questions). Crude and adjusted prevalences of HFEH (10-14 headache days per month) and CDH (15 or more headache days per month) were calculated. Results: The prevalence of CDH was 1.68% (girls 2.09%, boys 1.33%). The overall prevalence of HFEH was 2.52% (girls 2.8%, boys 2.3%). After adjusting for gender, age, parental history of headaches, income, and school of origin, the prevalence of CDH was higher in girls than in boys (2.2% vs 1.1%, p < 0.01) and in nonwhite vs white children (2.2% vs 1.2%, p < 0.01). Similar differences were seen for HFEH (girls 3.1%, boys 2.0%, p < 0.01), (nonwhite 3.1%, white 1.9%, p < 0.01). Income significantly contributed to the model. Conclusion: High-frequency episodic headaches and chronic daily headaches are common in the preadolescent pediatric population. Health care providers and educators should be aware of the magnitude of the problem to properly identify and treat children with headaches

Prenatal exposure to tobacco and alcohol are associated with chronic daily headaches at childhood: a population-based study

The influence of prenatal events on the development of headaches at childhood has not been investigated and is the scope of our study. Of 2,173 children identified as the target sample, consents and analyzable data were provided by 1,440 (77%). Parents responded to a standardized questionnaire with a validated headache module and specific questions about prenatal exposures. Odds of chronic daily headache (CDH) were significantly higher when maternal tabagism was reported. When active and passive smoking were reported, odds ratio (OR) of CDH were 2.29 [95% confidence intervals (CI)=1.6 vs. 3.6)]; for active tabagism, OR=4.2 (95% CI=2.1-8.5). Alcohol use more than doubled the chance of CDH (24% vs. 11%, OR=2.3, 95% CI=1.2-4.7). In multivariate analyses, adjustments did not substantially change the smoking/CDH association. Prenatal exposure to tobacco and alcohol are associated with increased rates of CDH onset in preadolescent children

Migraine, tension-type headache, and attention-deficit/hyperactivity disorder in childhood: a population-based study

Objectives: Primary headache syndromes (eg, migraine and tension-type headache [TTH]) and attention-deficit/hyperactivity disorder (ADHD) are prevalent in childhood and may cause impairment in social and academic functioning. We tested if ADHD or its symptoms are associated with specific headache syndromes or with headache frequency. Study design: Cross-sectional epidemiological study with direct interviews to parents and teachers using validated and standardized questionnaires. Setting: Populational study. Participants: Children aged 5 to 11 years (n = 1856). Outcome measures: Prevalence of ADHD as a function of headache status in crude and adjusted analyses. Results: The prevalence of migraine was 3.76%. Infrequent episodic TTH occurred in 2.3% of the sample, and frequent episodic TTH occurred in 1.6%. The prevalence of ADHD was 6.1%. The prevalence of ADHD was not significantly different by headache category. For hyperactivity-impulsivity symptoms, the prevalence was 8.1% in children without headache, 23.7% in children with migraine (relative risk [RR], 2.6; 95% confidence interval [CI], 1.6-4.2), and 18.4% in children with probable migraine (RR, 2.1; 95% CI, 1.4-3.2). For inattention, no significant differences were seen. In multivariate analyses, ADHD or inattention symptoms were not predicted by headache subtypes or headache frequency. Hyperactivity-impulsivity symptoms were significantly associated with any headache (P < 0.01), TTH (P < 0.01), or migraine (P < 0.001). Conclusion: Migraine and TTH are not comorbid to ADHD overall, but are comorbid to hyperactive-impulsive behavior. Providers and educators should be aware of the association

Frequency of headaches in children is influenced by headache status in the mother

Background. - Migraine aggregates within families. Nonetheless the familial aggregation of chronic daily headaches (CDH) and of episodic headaches of different frequencies has been very poorly studied. Accordingly herein we test the hypothesis that frequency of primary headaches aggregates in the family. Methods. - Sample consisted of 1994 children (5-12 years) identified in the population. Validated questionnaires were used to interview the parents. Crude and adjusted prevalences of low-frequency (1-4 headache days/month), intermediate-frequency (5-9 days/month), high-frequency (10-14 headache days/month), and CDH (15 or more headache days/month) in children were calculated as a function of headaches in the mother. Results. - Frequency of headaches in the mother predicted frequency of headaches in the children; when the mother had low frequency headaches, the children had an increased chance to have low or intermediate headache frequency (relative risk = 1.4, 1.2-1.6) but not CDH. When the mother had CDH, risk of CDH in the children was increased by almost 13-fold, but the risk of infrequent headaches was not increased. In multivariate models, headaches in the children were independently predicted by headaches in the mother (P <.001); headache frequency in the children was also predicted by frequency in the mother (P <.001). Conclusions. - Frequency of headaches in children is influenced by frequency of headaches in the mother and seems to aggregate in families. Future studies should focus on the determinants of headache aggregation, including genetic and non-genetic factors

Obesity as a risk factor for temporomandibular disorders

We conducted a clinical cross-sectional study to evaluate the association between obesity and the presence of painful temporomandibular disorders (TMD), controlling for age, gender, presence of migraine, depression, non-specific somatic symptoms and obstructive sleep apnoea syndrome (OSAS) in an adult population. A total of 299 individuals (76·6% women) with a mean age of 36·8 ± 12·8 years were evaluated. TMD were classified using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Depression and non-specific somatic symptoms were scored by the Symptom Checklist-90, while pain and disability was rated by the Graded Chronic Pain Scale. Bioimpedanciometry (BIA) was used to assess obesity through total body fat percentage. Migraine was diagnosed according to the criteria of the International Classification of Headache Disorders-2 (ICHD-2). OSAS was classified according to the Berlin Questionnaire. We performed univariate and multivariate models, chi-square tests and odds ratios (OR) with 95% confidence intervals (CI). In the single regression analysis, TMD-pain was significantly associated with total body fat percentage (P = 0·01). In the multivariate analysis, migraine, age, non-specific somatic symptoms and OSAS showed to be stronger predictors of TMD-pain, and obesity did not retain in the regression model. The initial association found between obesity and TMD-pain is lost when it was corrected for gender, migraine, non-specific somatic symptoms and OSAS