DOCTORS' BLOG

Archive for March, 2010

A study was conducted to describe the consulting behavior and clinical outcomes of children, aged 5 to 17, presenting with headache in primary care. These headaches were described as migraine, tension-type headache, cluster headache or headache with no further descriptor.

The impact of headache on the quality of life of sufferers is significant both at school and at home. Headache has a high risk of persisting into adulthood. The needs of adult headache sufferers are often unmet, and the situation may be worse in the pediatric population, where sufferers are less likely to articulate their problem or seek help. Little is understood about current practice in managing headache in children.

The incidence of brain tumor, a major concern for parents, patients and practitioners, is very low, particularly if headache is the primary diagnosis. However, children with headache have higher levels of anxiety and depression and demonstrate different behavioral characteristics when compare with children not having headache.

Cases receiving a diagnosis of migraine were examined for specific migraine treatment in subsequent year. Drugs were identified that were most likely to be used exclusively for the management of migraine. For the acute attack nasal sumatriptan is the only licensed triptan in the age groups studied.

It is important to identify, diagnose and treat the headache once more serious causes have been excluded. Research is needed to explore why General Practitioners find difficulty in diagnosing headaches, particularly in the younger age group, and to develop strategies to facilitate diagnosis. GPs should be encouraged to make a positive diagnosis in their headache patients as the first step to successful management.

A study in nearly 70,000 pregnant women has found no link between migraine drugs called triptans and the risk of birth defects.

Triptans are among the most powerful drugs used for migraine; others include aspirin, Excedrin, and ibuprofen.

The study, conducted by Katerina Nezvalova-Henriksen of the University of Oslo in Norway, noted that while as many as three in 10 women may develop migraines during their childbearing years, women often shy away from using such drugs during pregnancy because of safety concerns.

The study found that the percentage of birth defects was the same for those who took triptans during pregnancy as those who were not migraine sufferers: 5 percent.

The authors of the study noted, “While it is important to exert caution when using any medications during pregnancy, this study indicates that pregnant women can either start or continue taking triptans without “any major risk” of miscarriage, premature delivery, or other bad outcomes”.

However, the researchers did find that women who used triptans in their second or third trimester were more likely to develop a condition called atonic uterus, in which the uterus fails to contract back to its normal size after delivery. They were also more likely to lose significant amounts of blood during labor and delivery.

Many women who suffer from migraines will experience improvements in their symptoms after their first trimester, Nezvalova-Henriksen and her team note, yet those whose symptoms don’t improve by then aren’t likely to get better.

“Although the findings are reassuring, confirmation in independent studies is warranted,” the researchers conclude.

 Migraine headaches frequently are characterized by symptoms such as nausea, dull or severe head pain and sensitivity to light.

In some sufferers, certain foods may help trigger migraines. The U.S. National Library of Medicine offers this list:

• Processed, marinated, fermented or pickled foods.
• Baked goods.
• Chocolate or dairy foods.
• Foods that contain MSG (monosodium glutamate).
• Foods that contain tyramine, including red wine, aged cheese, smoked fish, chicken liver, figs or certain beans.
• Citrus fruits, bananas or avocados.
• Processed meats containing nitrates, such as hot dogs, salami or bacon.
• Onions.
• Nuts or peanut butter.

Researchers believe they know why light exacerbates the already debilitating pain of migraines, even in some blind people.

A report published in Nature Neuroscience reveals how visual and pain pathways in the brain converge to produce this phenomenon.

The Boston-based researchers report there are cells in a part of the brain called the thalamus “where information from the visual system and information from the pain system converge, and that anatomic convergence provides the first available explanation for how it could be that light makes pain worse,” said Dr. Richard Lipton, director of the Montefiore Headache Center and professor of neurology and epidemiology at Albert Einstein College of Medicine in New York City.

According to the study, about 85 percent to 90 percent of all migraine sufferers report having photophobia, which is when light makes the pain worse.

To solve the paradox, the team studied 20 blind individuals, all of whom suffered from migraines. Six participants had no light perception at all and no functioning optic nerve. These individuals also experienced no photophobia.

The remaining 14 people could sense light and dark and also experienced photophobia.

The study showed that the optic nerve is critically needed in order to produce photophobia or exacerbation of the headache by light.

Senior author Rami Burnstein, a professor of anesthesia and neuroscience at Harvard University, said the study “identified a new pathway in the brain that originates in the eye and goes to the brain areas where neurons are found that are active during migraine attacks. The light can increase the electrical activity in neurons that are active to begin with.”

The findings should put to rest any thoughts that patients exaggerate their sensitivity to light, Lipton said. “This provides an anatomic and physiological basis for a common experience — that light makes pain worse, not because you’re a whiner, but because there is an anatomic pathway that links the visual system to the pathway that produces head pain.”

The pharmacologic treatment of migraine may be acute (abortive) or preventive (prophylactic), and patients with frequent severe headaches often require both approaches. Preventive therapy is used to try to reduce the frequency, duration, or severity of attacks. The preventive medications with the best-documented efficacy are amitriptyline, divalproex, topiramate, and the beta-blockers. Choice is made based on a drug’s proven efficacy, the physician’s informed belief about medications not yet evaluated in controlled trials, the drug’s adverse events, the patient’s preferences and headache profile, and the presence or absence of coexisting disorders. Because comorbid medical and psychologic illnesses are prevalent in patients who have migraine, one must consider comorbidity when choosing preventive drugs. Drug therapy may be beneficial for both disorders; however, it is also a potential confounder of optimal treatment of either.

Children and adolescents experience headaches as do adults and usually present with migraine and chronic daily or tension-type headaches. As some adolescents are unable to achieve headache relief after various treatment strategies, botulinum toxin type A (Botox) injections as a clinical treatment are availabe in selected cases. Botulinum toxin type A by injection has been found to be effective in the treatment of headache disorders in adults. A recent study treated 12 adolescents (aged 14 to 18 years) with Botox injections for migraine and chronic daily headache. Six patients (all female adolescents) were in long-term treatment and received Botox in the standard “migraine” and “follow-the-pain” patterns every 3 months. Effectiveness was evaluated using pain scales and a standardized quality-of-life survey at baseline and prior to each treatment session. Duration of treatment was 3-29 months. Each patient had 9-63 (average = 42) injections per treatment. All 6 long-term patients reported improvement in headache symptoms, with decreases on pain scales and an average of 33%-75% improvement in quality of life. Two long-term patients had complete relief of headaches between injection series. Four patients had only one series of injections with good results. Two patients had no improvement and refused additional injections. Consequently, Botox may be an effective treatment option for certain adolescents with intractable migraine and chronic daily headaches.

Migraine is a common and disabling brain disorder with a strong inherited component. Because patients with migraine have severe and disabling attacks usually of headache with other symptoms of sensory disturbance (eg, light and sound sensitivity), medical treatment is often required. Patients can be managed by use of acute attack therapies (eg, simple analgesics or non-steroidal anti-inflammatory drugs) or specific agents with vasoconstrictor properties (ie, triptans or ergot derivatives). Preventive therapy is probably indicated in about a third of patients with migraine, and a broad range of pharmaceutical and non-pharmaceutical options exist. Medication overuse is an important concern in migraine therapeutics and needs to be identified and managed. In most patients, migraine can be improved with careful attention to the details of therapy, and in those for whom it cannot, neuromodulation approaches, such as occipital nerve stimulation, are currently being actively studied and offer much promise.

A  study conducted by The University of Helsinki, Finnish Institute of Occupational Health and University College London, examined whether work stress, as indicated by the effort-reward imbalance models, predicts onset of newly diagnosed migraine in a cohort of female public sector employees.

The effort-reward imbalance model is a more recent stress model that focuses on a negative trade-off between ‘costs’ and ‘gains’ at work. According to this model, lack of reciprocity between effort spent on work and rewards received in return in terms of money, esteem, security and career opportunities leads to emotional distress that increases the risk of negative health consequences.

In the population studied, 6.2% of the new migraine cases detected were attributable to high effort-reward imbalance, suggesting a modest, rather than strong association between effort-reward imbalance and migraine. Although the increased risk was small, the fact that this potentially modifiable exposure is common means that attempts to find a better balance between personal efforts and rewards gained from work could reduce the burden of migraine in the workplace. However, this will be the case only if the association between effort-reward imbalance and migraine is causal.

These results provide a justification for further research to determine whether effort-reward imbalance may function as a potentially modifiable risk factor for incident migraine.