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PubMed2001

International Headache Society headache diagnostic patterns in pain facility patients.

OBJECTIVE: Previous studies have indicated that many patients with chronic pain (PWCP) referred to pain facilities for the treatment of neck and/or low back pain complain of associated headaches. The purpose of this study was to characterize the nature of these headaches according to International Headache Society (IHS) headache diagnostic criteria. DESIGN: In preparation for this study, a questionnaire that reflected IHS headache diagnostic criteria was developed. All consecutive patients admitted to our pain facility complaining of headache completed this questionnaire and received a physical and neurologic examination focused on key aspects of headache. A headache interview was also conducted, using the questionnaire as a question guide. All questionnaires were entered in a computerized database, and IHS diagnoses were arrived at for each patient. As many IHS diagnoses as possible were assigned to each PWCP as long as IHS criteria were fulfilled. In addition, a frequency distribution for headache precipitants and neck-associated symptoms was developed and evaluated by discriminant analysis to determine the diagnostic value of these factors in relation to each IHS diagnostic group. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive PWCP. RESULTS: Of 1,466 PWCP, 154 (10.5%) were identified as suffering from severe headache interfering with function. Of these, 55.8% indicated that their headaches were related to an injury for which they were seeking treatment and 83.7% had neck pain. Migraine headache represented the most common diagnostic group (90.3%), with cervicogenic headache representing the second most common (33.8%). Of the total group, 44.2% had more than one headache diagnosis, that is, there was overlap. Cervicogenic headache patients had the greatest percentage of overlap (94.2%), with migraine patients being second (68.3%). The most frequent headache precipitant was mental stress, followed by neck position and activity/exercise. The migraine and cervicogenic headache groups had a statistically significant greater number of neck-associated symptoms when compared with the remaining patients. Of the total headache group, 74.6% complained that they had a tender point at the back of their neck. Cervicogenic, migraine, and tension PWCP had the greatest frequency of head or neck tender points. The discriminant analysis for neck-associated symptoms yielded the following symptoms as the most common predictors of headache across IHS diagnostic groups: clues to onset were severe headache beginning at the neck or tender point and numbness in arms and legs; headache brought on by neck position and arms overhead; and neck symptoms consisting of a tender point in the neck and feeling severe headache in the neck. CONCLUSIONS: Headache can and should be considered a frequent comorbid condition in PWCP. Because of the overlap data, more precise diagnostic criteria may be required to separate cervicogenic headache from migraine headache. Neck-associated symptoms seem to be important even to those PWCP diagnosed with migraine headache.

Headache↗
PubMed2004

Quantifying headache symptoms and other headache features from chart notes.

OBJECTIVES: To describe a method for quantifying headache symptoms/features in family practice charts for patients diagnosed with headache NOS (not otherwise specified, ICD-9: 784) and to determine the share of NOS headache diagnoses with clinical data strongly suggestive of migraine or probable migraine headache. BACKGROUND: Headache is one of the most common pain symptoms that brings patients to a family physician. However, the majority of headache sufferers do not receive a specific headache diagnosis when they visit physicians. METHODS: We examined the chart notes of 454 patients exclusively diagnosed with one or more ICD-9 coded headache NOS diagnoses from July 1, 1995 through December 31, 1999 at a large suburban, university-affiliated practice. We developed a template containing 20 headache items combining International Headache Society diagnostic criteria and additional headache symptoms/features, and decision rules for coding symptoms/features and collected data from patient charts. We then developed decision rules and reclassified NOS headaches into categories strongly suggestive of migraine, probable migraine headache, or other diagnosis. Our main outcome measure is the consistency in the application of decision rules and diagnostic criteria. RESULTS: With this method we estimate 3 in 10 (29%) headache NOS patients may have had migraine (8%) or probable migraine headache (21%). Reclassified migraine visits averaged 6.5 migraine symptoms and reclassified probable migraine headache visits 4.7 migraine symptoms. Logistic regression analysis supports the consistency of diagnostic criteria for classifying headache based on coded symptoms/features--our model correctly predicted 96% of visits. Evidence of physical examination was recorded at 75% of visits suggesting that physician attention is focused on elimination of secondary headache. CONCLUSIONS: We think the use of our rigorous procedures reveals that a substantial amount of migraine and probable migraine headache may be missed in everyday practice. We hope our findings will provide a basis for the development of diagnostic methods more closely suited to the needs of nonspecialists, and contribute to a better standard of care for headache patients seen in primary care practice. Finally, we are hopeful that other researchers will consider using our template and guideline procedures in their efforts to identify diagnostic patterns and study headache and other health problems.

Adult↗
PubMed2006

Recurrent headache in chinese children: any agreement between clinician diagnosis and symptom-based diagnoses using the International Classification of Headache Disorders (Second Edition)?

There has been a lack of published data on the pattern of recurrent headache in Chinese children. The validity of the International Classification of Headache Disorders criteria has not been evaluated in Chinese children. We performed a retrospective medical record review of 124 children aged <18 years with an International Classification of Diseases coding of headache followed up in a general outpatient clinic in a university-based hospital over a 3-year period (2000-2002). The aims of our study were to (1) study the pattern of recurrent headache in Chinese children and (2) study any agreement between clinical diagnoses made by our board-certified pediatricians and symptom-based diagnoses using the second edition of the International Classification of Headache Disorders (International Classification of Headache Disorders-II). The most common type was unclassified headache (70.2%), followed by infrequent episodic tension-type headache (24.2%) and migraine without aura (5.6%). A family history of headache or migraine was more commonly found in children with infrequent episodic tension-type headache or migraine without aura (P = .0109). The co-occurrence of abdominal pain with infrequent episodic tension-type headache was 30%; for unclassified headache, it was 19.5%. Dysmenorrhea occurred in 7.1% of girls with infrequent episodic tension-type headache and 8.6% of girls with unclassified headache. However, migraine without aura was not associated with abdominal pain or dysmenorrhea. Children with migraine without aura were more frequently referred to child neurologists (P = .0207) and admitted (P = .0000). Neurologic investigations, including electroencephalography, computed tomography, or magnetic resonance imaging of the brain, were performed in less than 30% of cases. Abnormal results were found in only seven cases; with two referred to a neurosurgeon and none requiring surgical intervention. Thus, by using the clinical diagnosis of our board-certified pediatricians as the standard, the sensitivity and specificity of International Classification of Headache Disorders-II-based definition of migraine without aura was 23.1% and 93.4%, respectively, and for infrequent episodic tension-type headache, it was 37.5% and 76%, respectively. The typical characteristics of migraine tend to emerge later and might have led to underdiagnosis of the younger age group, with a higher rate of referral and inpatient management. The new edition of the International Classification of Headache Disorders criteria is still restrictive in clinical practice and might not be able to reflect current pediatric practice. Further studies with a defined study period or recurrent headache might be more useful in analyzing the use of these new International Classification of Headache Disorders criteria in the diagnosis of recurrent headache in children.

Adolescent↗
PubMedDate not supplied

Headache management program improves outcome for chronic headache.

OBJECTIVE: To determine the feasibility of developing a headache management program and to assess the outcomes of patients referred to the program for treatment of chronic headache. BACKGROUND: Effective headache treatment requires that the patient receives the correct headache diagnosis; that appropriate acute and, if indicated, preventive medications be prescribed; and that the patient receives adequate education, including headache self-management skills. DESIGN/METHODS: A headache management program was established at a northern California staff-model health maintenance organization. Fifty-four patients were enrolled in the program and followed for 6 months. Patients participated in a structured program of group and individual sessions with the program manager. Data collection at baseline and 6 months included the Migraine Disability Assessment (MIDAS), the Short Form-36 Health Survey (SF-36), a patient satisfaction survey, and 2 additional short surveys--one that assessed patient worries about their headaches and another that queried patients on their problems with headache management. RESULTS: All enrolled patients participated in the initial group visit; 74% had at least one additional visit. All but one patient suffered from more than one headache type. Sixty-one percent of patients suffered from migraine headache and 98% from tension-type headache. At baseline, patients were severely disabled, with a mean MIDAS score of 41. At 6 months, MIDAS scores decreased an average of 21.2 points (P <.005). Patients reported 14.5 fewer days with headache over the preceding 3 months (P <.0001) and experienced clinically significant improvements in 6 of the SF-36 subscales. Patients were significantly more satisfied with their headache care (P <.0001), reported less problems with their headache management (P <.0001), and were less worried about their headaches (P <.01). During the intervention, emergency department visits for headache decreased (P <.02). CONCLUSIONS: A headache management program was successfully established. Patients referred to the program experienced significant improvement in headache-related disability and functional health status and reported greater satisfaction with care. Even so, these results were obtained at one site and in a small sample that was not randomized. We currently are conducting a randomized controlled trial to better evaluate the clinical and financial impact of a headache management program for patients with chronic headache.

Adult↗
PubMed1991

Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis.

There is a definite relationship between the vascular type of benign sexual headache and benign exertional headache. Forty five patients with benign vascular sexual headache were reviewed. Twenty seven (60%) experienced benign vascular sexual headache alone and eighteen (40%) had experienced both benign vascular sexual headache and benign exertional headache on at least one occasion. The mean age was 34.3 years with a male:female ratio of 5.4:1. Thirty patients with a history of benign vascular sexual headache were followed for an average of 74 months. A personal history of migraine was found in 47% of cases and a family history of migraine in 30%. Forty one per cent of patients with benign vascular sexual headache alone had recurrences after diagnosis, and stress and fatigue were considered major contributing factors to the initial and recurrent headache. Nine patients had experienced benign vascular sexual headache and benign exertional headache within 72 hours of each other on at least one occasion, often with a residual headache between the two. Four patients experienced their benign vascular sexual headache and benign exertional headache separated by months to years. The prognosis of benign vascular sexual headache and the clinical and possible pathophysiological relationships between benign vascular sexual headache and benign exertional headache are discussed. Knowledge of the interrelationships of these varieties of headache is valuable in the counselling of patients.

Adult↗
PubMed2004

Headache induced by chronic substance use: analysis of medication overused and minimum dose required to induce headache.

BACKGROUND: The International Headache Society has defined the diagnostic criteria for headache induced by substance use. Recently, a revision to these criteria has been proposed. OBJECTIVE: To consider whether the International Headache Society criteria for headache induced by substance use and the proposed revisions for the classification of daily and near-daily headache with medication abuse permit classification of patients commonly seen in a headache center. METHODS: One hundred fourteen consecutive patients (96 women [84.2%] and 18 men [15.8%]; mean age, 54.2 years [SD, 14]) with headache and chronic overuse of medications, admitted for detoxification to the inpatient unit of a headache center, participated in the study. The initial headache, medications and doses used, duration of daily medication use, and means of medication administration were studied. RESULTS: Eighty-one patients (71%) had an initial headache of migraine without aura, 13 patients (11.4%) had migraine without aura and coexistent tension-type headache, 11 (9.7%) patients had migraine with and without aura, and 9 patients (7.9%) had episodic tension-type headache. Medications overused by patients included analgesics combined with barbiturates or other nonnarcotic substances in 39.5%, simple analgesics in 38.6%, triptans in 11.4%, and ergotamine in 10.5%. Using the International Headache Society diagnostic criteria, we were able to classify only 28.1% of our patients; the proposed revised criteria for daily and near-daily headaches with medication abuse permitted the classification of 46.4% of patients. CONCLUSION: The minimum dose of medication required to induce chronic headache should be revised because a high proportion of patients are not classifiable using either the International Headache Society diagnostic criteria or the revised criteria recently proposed. A more comprehensive definition for the required minimum dose might be used. Triptan abuse can cause chronic headache and should be included in the International Headache Society classification.

Analgesics, Non-Narcotic↗
PubMed2002

Chronic daily headache in children and adolescents presenting to tertiary headache clinics.

BACKGROUND: Adults with chronic daily headache often describe a transformation from episodic migraine and partial retention of migrainous features. Although chronic daily headache has not been investigated as carefully in the pediatric population, one study showed a predominance of coexisting daily headache and episodic migraine, without a clear history of transformation. OBJECTIVE: To identify the clinical features of chronic daily headache in children and adolescents, to evaluate the efficacy of current headache classification criteria, and to compare the features of coexistent daily and episodic headaches so as to determine whether they represent separate syndromes or different stages in the "transformation" process. DESIGN: We surveyed 189 consecutive patients, 18 years of age or younger, who presented for initial evaluation of daily or near daily headache at one of 9 tertiary headache clinics. Data were collected in semistructured interviews employing a standard questionnaire and analyzed using Statistical Analysis Systems and Stata statistical software computer programs. RESULTS: Of the patients enrolled, 70% were female and 87% were white. Mean age was 13.0 +/- 3.1 years. Male gender was associated with a higher degree of reported disability. A family history of headache (typically migraine) was described in 79%. Use of nonsteroidal anti-inflammatory drugs 5 days per week or more was reported by 44% of patients. The International Headache Society (IHS) criteria failed to classify 64% of patients and criteria proposed by Silberstein et al failed to classify 31% of patients. Participating physicians misclassified patients according to criteria of the IHS and Silberstein et al in one third of cases. Nearly one quarter of patients reported two separate headache types with distinguishing characteristics. "Baseline" headache was present 27.3 +/- 4.1 days per month with a mean pain intensity of 5.9 +/- 2.1 on a 10-point scale. Superimposed episodic headache occurred 4.7 +/- 3.8 days per month with a mean pain intensity of 8.4 +/- 1.4, and was more often accompanied by other migrainous symptoms. After logistic regression to control for pain intensity, the only statistically significant difference between the two headache types was a lower prevalence of tension-type head pain with the superimposed headache. CONCLUSIONS: Our data suggest that rather than having two coexistent headache types, children and adolescents with chronic daily headache have a single syndrome that, in many cases, will paroxysmally worsen and gather migrainous features.

Adolescent↗
PubMed2006

Headache and sleep disorders: review and clinical implications for headache management.

Review of epidemiological and clinical studies suggests that sleep disorders are disproportionately observed in specific headache diagnoses (eg, migraine, tension-type, cluster) and other nonspecific headache patterns (ie, chronic daily headache, "awakening" or morning headache). Interestingly, the sleep disorders associated with headache are of varied types, including obstructive sleep apnea (OSA), periodic limb movement disorder, circadian rhythm disorder, insomnia, and hypersomnia. Headache, particularly morning headache and chronic headache, may be consequent to, or aggravated by, a sleep disorder, and management of the sleep disorder may improve or resolve the headache. Sleep-disordered breathing is the best example of this relationship. Insomnia is the sleep disorder most often cited by clinical headache populations. Depression and anxiety are comorbid with both headache and sleep disorders (especially insomnia) and consideration of the full headache-sleep-affective symptom constellation may yield opportunities to maximize treatment. This paper reviews the comorbidity of headache and sleep disorders (including coexisting psychiatric symptoms where available). Clinical implications for headache evaluation are presented. Sleep screening strategies conducive to headache practice are described. Consideration of the spectrum of sleep-disordered breathing is encouraged in the headache population, including awareness of potential upper airway resistance syndrome in headache patients lacking traditional risk factors for OSA. Pharmacologic and behavioral sleep regulation strategies are offered that are also compatible with treatment of primary headache.

Depressive Disorder↗
PubMed2005

Serial headache drawings by children with migraine: correlation with clinical headache status.

Children's artistic self-depictions of headache provide valuable insights into their experience of pain and aid in the diagnostic differentiation of headache types. In a previous study, we compared the clinical diagnosis (gold standard) and artistic diagnosis of headaches in 226 children. In approximately 90% of cases, the drawing predicted the clinical diagnosis of migraine versus nonmigraine headache correctly. In the present study, we explored whether headache drawings correlate with clinical improvement after treatment in children with migraine headaches followed longitudinally. Children seen in the Pediatric Neurology Clinic with the chief complaint of headache were asked to draw a picture of what their headache feels like. On subsequent clinic visits, children with the clinical diagnosis of migraine were asked to draw another picture depicting their current headache. The two drawings were compared to assess whether there was improvement; this "artistic response" was then correlated with the child's clinical status (ie, whether the headaches were improved clinically). One hundred eleven children (66 girls, 45 boys) participated in the study, with a mean interval of 5.3 +/- 2.3 (standard error of the mean) months between the first and second visits. The mean age at the first visit was 11.6 +/- 3.1 years. The raters agreed that serial drawings were both improved or both not improved in 99 of the 111 cases (89%; interrater reliability kappa score of 0.767). Fifty-three children had improvements in their headaches and drawings, 3 children had an improved drawing but no clinical headache improvement, 32 children had no improvement in either their drawing or clinical headaches, and 11 children had improved headaches but no improvement in their drawing. The sensitivity of the drawings for clinical improvement was 0.83, and the specificity was 0.91. The predictive value of an improved headache drawing for an improved clinical response was 0.946. There was no correlation between specific treatment modality and artistic response. We concluded that children's headache drawings are a useful adjunct for the diagnosis of headache type and provide valuable insights into their experience of pain. The present data show that headache drawings can be used longitudinally to provide additional information about the clinical course. The technique is simple, inexpensive, and enjoyable for children and can be applied in a variety of clinical settings.

Adolescent↗
PubMed2002

Self-awareness of migraine: interpreting the labels that headache sufferers apply to their headaches.

Although people with migraine are aware of their headaches they are often not aware that they have migraine. This can lead to inappropriate or ineffective use of treatments, delays in seeking appropriate care, and miscommunication during clinical encounters. This article assesses self-recognition of migraine and identifies terms used by migraine sufferers to describe their migraine headaches. Individuals were selected for telephone interview by random digit dialing in several large United States cities as a part of a clinical trials recruiting initiative. Individuals (n = 30,758) aged 18 to 65 years of age were interviewed about their headaches using a validated computer-assisted telephone interview. Among the 23,564 respondents who reported headache, their headaches were classified as migraine (with or without aura) by the criteria of the International Headache Society (IHS). The relationships among the terms subjects used for their headaches and their IHS diagnosis of migraine were assessed. Of the 23,564 respondents, 4,967 individuals called their headache migraine and 3,074 individuals reported headache that met the IHS criteria for migraine. The positive predictive value for self-assessed migraine is 33.1%; the negative predictive value for a self-assessment other than migraine is 92.3%. Therefore, individuals who called their headaches migraine were about three times more likely to meet IHS criteria for migraine. Among the 3,074 individuals meeting IHS criteria for migraine, only 53.4% recognized their headaches as migraine (sensitivity 54%; specificity 83.8%). Among migraineurs, stress headaches (n = 345) and sinus headaches (n = 365) were the most common erroneous labels reported. Age influenced the erroneous terminology. Individuals less than 40 years of age were more likely to misidentify their migraine as stress headaches, whereas individuals 40 years of age and older were more likely to misidentify their migraines as sinus headaches. In a population sample, 54% of individuals with IHS migraine did not know that their headaches are migraine. Those who called their headaches migraine were much more likely to have migraine. Migraine awareness programs that rely solely on the term "migraine" may miss individuals who urgently need to be reached. Therefore, public education should target people with severe or disabling headache and aim to create awareness of the diagnostic possibilities.

Adolescent↗
PubMed2001

Childhood headache, stress in adolescence, and primary headache in young adulthood: a longitudinal cohort study.

OBJECTIVES: To determine the association between childhood history of headache, adolescent stress, and headache syndromes (determined by International Headache Society criteria) in young adulthood. BACKGROUND: The association between stress and tension-type headache has recently been challenged. Little is known about stress and other headache subtypes, particularly among young people from the general population. DESIGN: Members of the longitudinal Dunedin Multidisciplinary Health and Development Study participated in this study. Study members were asked about headache characteristics/symptoms at aged 26 (96% of the living cohort), and historical records were examined to ascertain headache history (younger than 12 years) and the reporting of stressful life events at aged 15 years. RESULTS: Study members with childhood headache were significantly more likely to report adolescent stress than those without headache. High-intensity stress during mid adolescence increased the likelihood of migraine diagnosis. In those with combined headache (migraine as well as tension-type headache), this relation held only for those with a history of headache. Stress associated with bodily changes during mid adolescence was the only significant predictor of tension-type headache. CONCLUSIONS: Childhood headaches are related to the appraisal of life events reported during mid adolescence. Childhood headaches also appear to confer a specific risk for the development of combined headache. There was little evidence for a prospective relation between stress in mid adolescence and tension-type headache in young adulthood, supporting claims that proximal (rather than distal) stress is associated with this disorder.

Adolescent↗
PubMed2000

Prevalence of migraine, tension-type headache, and other headaches in Hong Kong.

OBJECTIVE: To assess the prevalence of migraine and other headaches in Hong Kong in 1998. BACKGROUND: A community-based prevalence survey of headache was carried out from July 1992 to March 1993, and the prevalence rates were 1% for migraine, 2% for tension-type headache, and 1% for other headaches. A similar survey was carried out in May and June 1998 to interview individuals aged 15 years or older. Recurrent headache was defined as having two or more headaches unrelated either to influenza or a common cold within the past 12 months. METHODS: Respondents with recurrent headache were offered a personal interview for clinical validation. Of 3156 randomly selected individuals, 1436 responded. RESULTS: Headache was due to influenza or a common cold in 270 (18.8%) respondents; recurrent headache affected 533 (37.1%) respondents. The overall prevalence rates were 4.7% for migraine, 26.9% for tension-type headache, and 5.5% for other headaches. Clinical validation was available for 72 respondents. After adjustment for possible misclassification, the estimated prevalence rates became 12.5% for migraine, 18.7% for tension-type headache, and 6.0% for other headaches. There was a female preponderance for all types of headache with a peak in the 25- to 34-year-age group for tension-type headache. CONCLUSIONS: All types of headache were more common in the 1998 study, and the prevalence rates were closer to those of Western communities.

Adolescent↗
PubMed2004

Primary headaches in an outpatient neurology headache clinic in East Hungary.

The majority of patients with primary headache do not seek medical help. In the present study we analyse the characteristics of those patients with primary headaches who consulted a single headache outpatient service in East Hungary. All consecutive patients with primary headaches referred to the headache center between February 2002 and April 2003 were asked to fill in a questionnaire on headache characteristics and the migraine disability score (MIDAS) form. A total of 327 patients had some form of primary headache: 42% migraine, 31% tension-type headache, 1% cluster headache and 26% had combination headache. Of the patients 95% were younger than 60 years of age. Only 16% of the patients were male. Chronic daily headache was found in 41% of patients. Although headache was the least severe in tension-type headache, reported disability occurred on much more days in this group than in migraine patients. The majority of patients with primary headache were in the active age group. Patients with tension-type headache need more attention, as disability is more severe in this patient group than generally assumed. More attention to the headaches of men and the elderly could improve the quality of life in these groups of the Hungarian population.

Activities of Daily Living↗
PubMed1990

The influence of sex and pre-traumatic headache on the incidence and severity of headache after head injury.

Pre- and post-traumatic headache of 168 individuals aged 18-60 years was registered 9-12 months after a head trauma. Headache before the trauma was reported by 39.9%, women being in the majority. After the trauma 64.3% were suffering from headache. Post-traumatic headache was reported by 64 patients (38.1%), of whom 22 patients experienced an increase of already existing headache and 42 patients complained of new headache. Patients suffering from headache before the trauma were not more at risk of having post-traumatic headache than patients who did not suffer from headache before the trauma. Patients who experienced an increase of already-existing pre-traumatic headache used more analgesics than patients first suffering from headache after the trauma. Post-traumatic headache was reported by more women than men (p less than 0.02), the corresponding relative risk being 1.6. Both the use of analgesics and the frequency of headache showed a significant increase for patients with post-traumatic headache when compared with a "control group" of 41 patients with unchanged headache and when compared with all patients with headache before the trauma. There was no significant difference in the location of pain between the groups analysed.

Adolescent↗
PubMed1999

Weekend headache: a retrospective study in migraine without aura and episodic tension-type headache.

Our retrospective study was aimed at determining the existence of weekend headache and, if so, whether it has the same clinical features as migraine without aura and episodic tension-type headache, or whether it occurs as a separate form of headache which could find its own place in the International Headache Society classification. For this study, we reviewed the clinical records of 120 patients with migraine without aura and 120 patients with episodic tension-type headache randomly selected among all those referred to the Headache Center of the University of Parma Institute of Neurology between 1985 and 1996. A review of these records suggests that weekend headache exists for both types of headache considered. Clinically, it is interesting to note that the male-to-female ratio for the weekend form of tension-type headache was 1:1, as opposed to 1:3 for general episodic tension-type headache. As regards classification, no evidence so far seems to suggest that weekend headache should be considered as an independent entity. Apart from certain features that appear to be peculiar to this form of headache-such as increased pain intensity-it thoroughly fulfills the diagnostic criteria of the primary headaches from which it evolves. Finally, a few clinical features suggest that the weekend may simply be a triggering factor in migraine without aura attacks, while playing a major role in episodic tension-type headache. However, weekend headache is a clinical entity that clearly needs further study.

Adolescent↗
PubMedDate not supplied

Triggers of headache episodes and coping responses of headache diagnostic groups.

The frequency of common headache instigators or "triggers" and the use of specific behavioral responses to headache episodes were determined using the self-reports of patients with migraine, tension-type, and combined migraine and tension-type headache. Headache diagnostic groups were compared on the nature of headache triggers identified. The diagnostic groups were also compared on the frequency with which they engaged in a set of behavioral responses during headache episodes. No diagnostic group differences were found in triggering stimuli. Emotional, dietary, physical, environmental, and hormonal factors were all reported to be equally likely to precipitate a headache episode regardless of headache diagnosis. There were, however, differences in specific behavioral responses to headache episodes depending upon headache diagnosis. Discriminant analyses were performed to determine the best predictors of headache diagnoses. Migraine patients were significantly more likely to avoid noise, light, social activity, and physical activity compared with tension-type and combined headache patients. When average headache severity was taken into account, the diagnostic group differences in coping responses disappeared. It is concluded from the results of this study that headache severity has a greater impact on coping response than does specific headache diagnosis.

Adaptation, Psychological↗
PubMedDate not supplied

Guidelines for the organization of headache education in Europe: the headache school.

According to its mission statement, one of the goals of the European Headache Federation (EHF) is to "educate Europe" about headache through the teaching of the key health personnel, such as young physicians and all those involved in headache management, about the seriousness of headache disorders. The countries of Europe share a close geographical proximity that facilitates international exchanges, particularly between university faculties. In recent years, this has, indeed, been the working basis of European educational endeavours in the field of headache. For a number of years, annual summer schools were organized in different European countries and a permanent Summer Headache School was set up in Cambridge (to be held every alternate year). The last summer headache school was held in Vilnius in 2002. In the past decade, a patronage scheme was also set up, which, combining two or more countries (one developed, one or more developing), allowed international exchanges of doctors and students for training purposes. In some centres, participants were also able to gain clinical practice and research experience by staying at the host institutions for extended periods of time. As a result of all this activity there have emerged, in Europe, "clusters" of people with a particular interest in headache. However, the rapid growth of insight into headache (new molecules, new headache categories, etc.) has contributed to a widening of the scientific gap between developing and developed countries. Moreover, in the past four years, due to the relative restriction of national/international drug company budgets, it has proved possible to organize only relatively inexpensive teaching courses. As a result, countries whose medical communities had been developing a "headache culture" now find themselves destined to be increasingly held back. Therefore, the EHF, in order to promote education on headache in Europe at national level, felt there was a need for guidelines for the organization of educational courses that meet uniform standards of excellence and in terms of code of conduct: guaranteed courses that will attract investors and those seeking to increase their knowledge, skills and understanding in the area of primary and secondary headache. The guidelines, presented here, specify the ideal length of a headache course, the number of lectures it should include, as well as the ideal number of participants and teachers. A sample course outline is provided, together with a checklist to help the organizers to meet the criteria for an EHF-approved headache school.

Curriculum↗