Virtual Issues
Virtual issues are collections of articles on a particular subject, published in Headache: The Journal of Head and Face Pain. They are selected by a guest editor to provide a rapid overview of the activity in a particular aspect of headache medicine. The virtual issues will be updated on a regular basis by the editor, but will not be available as a paper publication.
The following virtual issues are available:
- Occipital Nerve Block for Headache
- Psychiatric Comorbidity and Migraine
- Chronic Migraine: Transformation and Reversion Factors
- Vestibular Migraine
Vestibular Migraine
Guest Editor: Joshua M. Cohen, MD, MPH
Joshua M. Cohen, MD, MPH, is an Assistant Clinical Professor of Neurology at Columbia University and Headache Fellowship Program Director at the Headache Institute and Adolescent Headache Center in New York. He serves as a frequent reviewer for Headache and Cephalalgia, Secretary of the New York County Medical Society, and a member of the American Academy of Neurology Delegation to the American Medical Association.
Vestibular Migraine
Joshua M. Cohen, MD, MPH
Researchers and clinicians have long recognized an association between migraine and a variety of vestibular symptoms. First reported by Liveing in 1873, the connection of migraine and vestibular symptoms has been studied by researchers in the fields of neurology, neurootology, otolaryngology, and others to determine to what extent, if any, the two processes are related. Recent studies have shown that dizziness may accompany migraine in more than half of all migraine episodes. For more than 10 years, there has been increasing interest in defining a syndrome marked by both migraine and "dizzy" symptoms, often known as "vestibular migraine."
This virtual issue includes papers published in Headache which examine migraine and dizziness/vertigo. Beginning with the epidemiology and features of migraine and dizziness, progressing through studies evaluating the pathophysiology and underlying genetics of the disorder, examining the results of objective testing in affected patients, and finally evaluating the utility of therapeutics in this population, the issue seeks to provide an overview of the contributions of researchers in this area and stimulate further investigation into this fascinating syndrome.
EPIDEMIOLOGY, FEATURES AND SYMPTOMS
Interview with Dr. Calhoun: http://www.headachejournal.org/view/0/podcastsForHealthProf.html#calhoun
Kuritzky et al. "Vertigo, Motion Sickness and Migraine." Headache 1981; 21: 227-231
PATHOPHYSIOLOGY AND GENETICS
Cutrer and Baloh. "Migraine-associated Dizziness." Headache 1992; 32: 300-304
Baloh, Robert W. "Neurotology of Migraine." Headache 1997; 37: 615-621
TESTING AND OBJECTIVE FINDINGS
Kurtizky et al. "Vestibular Function in Migraine." Headache 1981; 21: 110-112
THERAPEUTICS
Chronic Migraine: Transformation and Reversion Factors
Guest Editor: Todd J. Schwedt, MD
Chronic Migraine: Transformation and Reversion Factors
Todd J. Schwedt, MD
Chronic migraine is defined by the International Classification of Headache Disorders as a migraine pattern in which there are at least 15 days per month with headache, including 8 days per month on which there are full-blown migraine attacks and/or attacks successfully treated with triptans or ergots prior to expression of full-blown migraine symptoms. Two to three percent of the general population has chronic migraine. Chronic migraine exerts substantial impact on patients; impact that is felt physically, emotionally, professionally, and socially. Furthermore, chronic migraine is costly to society due to direct medical expenses (e.g. doctor visits, medications) and indirect medical expenses (e.g. lost productivity).
Patients with chronic migraine typically transition from episodic migraine (less than 15 headache days/month) to chronic migraine and often eventually revert from chronic migraine back to episodic migraine. Identification and study of risk factors for the transformation to chronic migraine and for the reversion to episodic migraine could lead to important advancements for the diagnosis and treatment of migraine. This virtual issue consists of manuscripts published within Headache and other American Headache Society assets (podcast, video, handouts, patient education pages) that address the transformation to and reversion from chronic migraine.
Overviews
Concepts and Mechanisms of Migraine Chronification
Bigal ME, Lipton RB
Headache 2008;48;1:7-15.
From Migraine To Chronic Daily Headache: The Biological Basis of Headache Transformation
Meng ID, Cao L
Headache 2007;47;8:1251-1258
How Pain, Including Headache, Becomes Chronic
Dodick DW.
Headache 2007;47;8:1272-1274.
Is migraine a progressive disorder?
Bigal ME
American Headache Society – Information for Health Care Professionals
http://www.americanheadachesociety.org/assets/1/7/Bigalprogressive.pdf
Risk Factors
Risk Factors for Headache Chronification
Scher AI, Midgette L, Lipton RB
Headache 2008;48;1: 16-25.
From transformed migraine to episodic migraine: reversions factors
Seok J, Cho H, Chung C.
Headache 2006;46:1186-1190.
Modifiable risk factors for migraine progression
Bigal ME, Lipton RB
Headache 2006;46:1334-1343.
Migraine: Epidemiology, impact, and risk factors for progression
Lipton RB, Bigal ME
Headache 2005;45(Suppl. 1):S3-S13.
Transformed or evolutive migraine
Mathew NT, Reuveni U, Perez F
Headache 1987;27:102-106.
Transformation of episodic migraine into daily headache: Analysis of factors
Mathew NT, Stubits E, Nigam MP
Headache 1982;22:66-68.
Risk Factors - Genetic
Frequency of Headaches in Children is Influenced by Headache Status in the Mother
Arruda MA, Guidetti V, Galli F, Albuquerque RC, Bigal ME
Headache 2010;50;6:973-980.
Family History for Chronic Headache and Drug Overuse as a Risk Factor for Headache Chronification
Cevoli S, Sancisi E, Grimaldi D, Pierangeli G, Zanigni S, Nicodemo M, Cortelli P, Montagna P
Headache 2009;49;3:412-418.
Risk Factors - Medication Overuse
Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study
Bigal ME, Serrano D, Buse D, Scher A, Stewart WF, Lipton RB
Headache 2008;48;8:1157-1168.
Screening And Behavioral Management: Medication Overuse Headache – The Complex Case
Lake AE
Headache 2008;48;issue 1: 26-31.
Does chronic daily headache arise de novo in association with regular use of analgesics?
Bahra A, Walsh M, Menon S, Goadsby PJ
Headache 2003;43:179-190.
Medication Overuse Headache
Silberstein SD
American Headache Society – Information for Health Care Professionals
http://www.americanheadachesociety.org/assets/1/7/AHS_Silberstein.pdf
Brainstorm – Medication Overuse
Silberstein SD, Loder E, Dodick D, Litin S.
American Headache Society video
http://www.youtube.com/watch?v=SG10phfr2fo
Risk Factors - Sleep
Chronic Headache and Potentially Modifiable Risk Factors: Screening and Behavioral Management of Sleep Disorders
Rains JC
Headache 2008;48;1: 32-39.
Behavioral sleep modification may revert transformed migraine to episodic migraine
Calhoun AH, Ford S.
Headache 2007;47:1178-1183.
Risk Factors - Psychological
Childhood Maltreatment and Migraine (Part II). Emotional Abuse as a Risk Factor for Headache Chronification
Tietjen GE
Headache 2010;50;1:32-41.
The stress and migraine interaction
Sauro KM, Becker WJ
Headache 2009;49:1378-1386.
Stress and Headache Chronification
Houle T, Nash J
Headache 2008;48;1:40-44.
Headache Chronification: Screening and Behavioral Management of Comorbid Depressive and Anxiety Disorders
Smitherman TA, Maizels M, Penzien DB
Headache 2008;48;1:48-50.
The association of frequent headaches with personality and life events
Passchier J, Schouten J, van der DJ, Van Romunde LK
Headache 1991;31(2):116-121.
Risk Factors - Menstrual Migraine
Elimination of menstrual-related migraine beneficially impacts chronification and medication overuse
Calhoun A, Ford S
Headache 2008;48:1186-1193.
Risk Factors - Obesity
Migraine and obesity: epidemiology, mechanisms, and implications
Peterlin BL, Rapoport AM, Kurth T.
Headache 2010;50:631-648.
Migraine and obesity: epidemiology, mechanisms, and implications.
Peterlin BL.
Podcasts for Health Professionals – Headache online.
http://www.headachejournal.org/view/0/podcastsForHealthProf.html#Migraine___Obesity
Research Design
Looking to the Future: Research Designs for Study of Headache Disease Progression
Lipton RB, Bigal ME
Headache 2008 ;48;1: 58-66.
Patient Education Pages
Migraine “Chronification”: What You Can Do
Rothrock JF
Headache 2009;49;1:155-156.
Migraine “Chronification”
Rothrock JF
Headache 2008;48;1: 181-182.
Psychiatric Comorbidity and Migraine
Guest Editor: Todd A. Smitherman, Ph.D.+
+Dr. Smitherman is Assistant Professor in the Department of Psychology at the University of Mississippi. His research focuses on psychiatric comorbidities in migraine and other behavioral issues in headache management.
Psychiatric Comorbidity and Migraine
The relationship between migraine and psychiatric disorders remains of growing interest to headache researchers and clinicians alike. Headache has been at the forefront of many publications on this topic, and as recently as 2006 sponsored a special issue and special series devoted to research on psychiatric comorbidities. The present issue briefly summarizes and provides links to relevant articles published in Headache.
Epidemiologic and Clinical Studies
Although many headache patients will not suffer from clinically significant psychopathology, a large body of literature confirms that patients with migraine are significantly more likely to suffer from a psychiatric disorder than are those without headache. Though variability exists among studies regarding prevalence rates, most indicate that migraineurs are 2 to 5 times more likely to be diagnosed with a depressive or anxiety disorder, even after controlling for age and gender.1-6 Comorbid psychiatric disorders are most prevalent among migraine patients presenting to clinical settings and those with chronic (versus episodic) migraine. Major depression and bipolar disorder are the most commonly-studied mood disorders, and the anxiety disorders studied most frequently are panic disorder, generalized anxiety disorder, and phobias.
Longitudinal studies indicate that the relationship between depression and migraine is bidirectional, such that some patients develop depression subsequent to migraine and others have a history of depression prior to migraine onset.7 Though limited by comparison, longitudinal studies of anxiety disorders also suggest a bidirectional relationship. In some patients anxiety precedes migraine, which in turn is followed by depression. Psychiatric comorbidity among children and adolescents is also a well-recognized phenomenon,8-11 though this body of literature is far smaller than that on adults.
Most research on psychiatric comorbidities has focused on depression, despite data that anxiety disorders remain the most prevalent class of psychiatric disorder in the general population, are almost twice as common in migraineurs, and likely portend a greater prognostic challenge. Other Axis I psychiatric disorders have been studied less frequently. Studies assessing substance use have obtained mixed results, with some finding higher rates of abuse/dependence among migraineurs and others finding no differences between groups. Consistently, though, psychiatric comorbidity is associated with medication overuse.12 A newer and growing body of literature attests to the connection between posttraumatic stress disorder and migraine.13-15
Axis II personality disorders are studied more infrequently by comparison, but occur in 26% of chronic headache inpatients.16 Borderline personality disorder has been described most frequently in the empirical literature,17,18 but epidemiologic and further clinic-based studies are needed to better understand the relationship of various personality disorders to migraine.
Impact of Psychiatric Comorbidities
Psychiatric comorbidities do not occur in a vacuum; instead they negatively impact patient quality of life and headache management. Comorbid depression and anxiety disorders are associated with reduced quality of life, poorer long-term outcomes and response to headache treatments, and increased risk of medication overuse.19,20 In terms of costs, migraineurs with comorbid depression or anxiety accrue nearly $5,000 more in medical expenses each year than do migraine patients without depression or anxiety.21 Even otherwise healthy college students with infrequent migraines (<1 per week) evidence more symptoms of depression and anxiety, report reduced quality of life, and miss more days of school than do students without migraine.22
Importantly, psychiatric disorders are now identified as factors influencing the progression of migraine from episodic into chronic forms (“chronification”).23 Because they are amenable to treatment and thus can potentially reduce chronification, treatment studies focusing on these comorbidities are sorely needed.
Mechanisms
The high co-occurrence of psychiatric disorders and migraine, as well as their bidirectional relationship, suggests that these disorders likely are comorbid because they share pathophysiologic mechanisms. Potential mechanisms include dysfunctions in central serotonergic availability, fluctuations in ovarian hormone levels (for women), dysregulation of the hypothalamic-pituitary adrenal (HPA), and sensitization of both sensory and affective neural networks. Depression and anxiety also appear important in the connection between obesity and migraine.24 Recent twin studies attempting to model the genetic architecture of these comorbidities suggest that a significant proportion of their variance is due to shared genetic influences.25,26
Clinical Implications: Assessment and Treatment
The present state-of-affairs is such that epidemiologic and basic science research is only beginning to be applied to clinical settings. No studies exist that assess the effects of treating psychiatric comorbidity on migraine symptoms, and clinical trials of pharmacologic migraine interventions typically exclude individuals with significant depression or anxiety. Drug studies that have included depressed patients have produced mixed results as to whether headache agents favorably impact depression or whether concurrent depression predicts response to treatment. As a result, implications for treatment are largely based on clinical experience and extrapolations from related literatures.27
The high rates of comorbidity between migraine and psychiatric disorders suggest that all migraine patients should be screened for depression and anxiety at a minimum. This may range from brief verbal screening about core symptoms in the infrequent migraineur to more formal questionnaire and/or interview assessment in a chronic migraine patient or a patient presenting to a specialty clinic. Assessment should focus primarily on cognitive and emotional symptoms, as transdiagnostic physical symptoms often obscure accurate psychiatric diagnosis.28 Patients with high levels of depression and anxiety should also be assessed for medication overuse. Recommended assessment strategies are provided in Maizels et al.29
Regarding treatment, pharmacologic interventions (eg, antidepressants, anticonvulsants) that simultaneously treat both migraine and the psychiatric disorder offer some promise, but they are often better in theory than practice due to differential dosing requirements and resulting side effect profiles.30-32 Treating the comorbid psychiatric disorder may thus require use of a separate agent and/or behavioral interventions including cognitive-behavioral therapy (CBT). Individual CBT techniques may be adapted within the context of physician practice settings and include activity scheduling, relaxation training, and exposure exercises. These approaches may be combined with a standard pharmacologic or behavioral regimen specific to headache and are described in more detail in the accompanying articles.33-35
The subsequent decades of research on this topic offer promise for better understanding the underlying mechanisms and clinical implications. Future studies should focus on studying these topics using precise diagnostic criteria, differentiating clinical from subclinical psychiatric symptomatology, investigating psychiatric disorders as moderator and mediator variables, and developing treatment algorithms that are specific to particular psychiatric disorders.5 Ultimately, however, whether treating depression or anxiety improves headache symptoms is unknown and should become a priority of future research.
References
Empirical Associations between Psychopathology and Migraine
1. Breslau N, Andreski P. Migraine, personality, and psychiatric comorbidity. Headache. 1995;35:382-386.
2. Hamelsky SW, Lipton RB. Psychiatric comorbidity of migraine. Headache. 2006;46:1327- 1333.
3. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders—A national population-based study. Headache. 2008;48:501-516.
4. Juang KD, Wang SJ, Fuh JL, Lu SR, Su TP. Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache. 2000;40:818-823.
5. Lake AE III, Rains JC, Penzien DB, Lipchik GL. Headache and psychiatric comorbidity: Historical context, clinical implications, and research relevance. Headache. 2005;45:493-506.
6. Merikangas KR, Stevens DE, Angst J. Psychopathology and headache syndromes in the community. Headache. 1994;34:S17-S22.
7. Breslau N, Davis GG, Schultz LR, Paterson EL. Migraine and major depression: A longitudinal study. Headache. 1994;34:387-393.
8. Cunningham SJ, McGrath PJ, Ferguson HB, et al. Personality and behavioural characteristics in pediatric migraine. Headache. 1987;27:16-20.
9. Kaiser RS. Depression in adolescent headache patients. Headache. 1992;32:340-344.
10. Pakalnis A, Gibson J, Colvin A. Comorbidity of psychiatric and behavioral disorders in pediatric migraine. Headache. 2005;45:590-596.
11. Powers SW, Kruglak Gilman D, Hershey A. Headache and psychological functioning in children and adolescents. Headache. 2006;46:1404-1415.
12. Radat F, Sakh D, Lutz G, El Amrani M, Ferreri M, Bousser MG. Psychiatric comorbidity is related to headache induced by chronic substance use in migraineurs. Headache.1999; 39:477–80.
13. de Leeuw R, Schmidt JE, Carlson CR. Traumatic stressors and post-traumatic stress disorder symptoms in headache patients. Headache. 2005;45:1365-1374.
14. Peterlin BL, Tietjen GE, Brandes JL, et al. Posttraumatic stress disorder in migraine. Headache. 2009;49:541-551.
15. Peterlin BL, Tietjen G, Meng S, Likicker J, Bigal M. Post-traumatic stress disorder in episodic and chronic migraine. Headache. 2008;48:517-522.
16. Lake AE III, Saper JR, Hamel RL. Comprehensive inpatient treatment of refractory chronic daily headache. Headache. 2009;49:555-562.
17. Rothrock J, Lopez I, Zweilfer R, et al. Borderline personality disorder and migraine. Headache. 2007;47:22-26.
18. Saper JR, Lake AE III. Borderline personality disorder and the chronic headache patient: Review and management recommendations. Headache. 2002;42:663-674.
Impact of Psychiatric Comorbidities
19. Fichtel A, Larsson B. Psychosocial impact of headache and comorbidity with other pains among Swedish school adolescents. Headache. 2002;42:766-775.
20. Lake AE III. Medication overuse headache: biobehavioral issues and solutions. Headache. 2006;46 (Suppl. 3):S88-S97.
21. Pesa J, Lage MJ. The medical costs of migraine and comorbid anxiety and depression. Headache. 2004;44:562-570.
22. Smitherman TA, McDermott MJ, Buchanan EM. Negative impact of episodic migraine on a university population: Quality of life, functional impairment, and comorbid psychiatric symptoms. Headache. In press.
23. Bigal ME, Lipton RB. Modifiable risk factors for migraine progression. Headache. 2006;46:1334-1343.
Mechanisms
24. Tietjen GE, Peterlin BL, Brandes JL, et al. Depression and anxiety: effect on the migraine-obesity relationship. Headache. 2007;47:866-875.
25. Schur EA, Noonan C, Buchwald D, Goldberg J, Afari N. A twin study of depression and migraine: evidence for a shared genetic vulnerability. Headache. 2009;49:1493-1502.
26. Ligthart L, Nyholt DR, Penninx BW, Boomsma DI. The shared genetics of migraine and anxious depression. Headache. 2010;50:1549-1560.
Implications for Assessment and Treatment
27. Baskin SM, Lipchik GL, Smitherman TA. Mood and anxiety disorders in chronic headache. Headache. 2006;46(Suppl. 3):S76-S87.
28. Holm JE, Penzien DB, Holroyd KA, Brown TA. Headache and depression: confounding effects of transdiagnostic symptoms. Headache. 1994;34:418-423.
29. Maizels M, Smitherman TA, Penzien DB. A review of screening tools for psychiatric comorbidity in headache patients. Headache. 2006;46(Suppl. 3):S98-S109.
30. Griffith JL, Razavi M. Pharmacological management of mood and anxiety disorders in headache patients. Headache. 2006;46(Suppl. 3):S133-S141.
31. Sheftell FD, Atlas SJ. Migraine and psychiatric comorbidity: from theory and hypotheses to clinical application. Headache. 2002;42:934-944.
32. Silberstein SD, Dodick D, Freitag F, et al. Pharmacological approaches to managing migraine and associated comorbidities—clinical considerations for monotherapy versus polytherapy. Headache. 2007;47:585-599.
33. Lipchik GL, Smitherman TA, Penzien DB, Holroyd KA. Basic principles and techniques of cognitive-behavioral therapies for comorbid psychiatric symptoms among headache patients. Headache. 2006;46(Suppl. 3):S119-S132.
34. Powers SW, Kruglak Gilman D, Hershey AD. Suggestions for a biopsychosocial approach to treating children and adolescents who present with headache. Headache. 2006;46(Suppl. 3):S149-S150.
35. Smitherman TA, Maizels M, Penzien DB. Headache chronification: Screening and behavioral management of comorbid depressive and anxiety disorders. Headache. 2008;48:45-50.
Virtual Issue compiled online 26 January 2011
Sleep and Headache Disorders
Jeanetta Rains, PhD♦
♦Jeanetta Rains, PhD, is Clinical Director of the Center for Sleep Evaluation at Elliot Hospital in Manchester, NH. She is Fellow of: American Board of Sleep Medicine; American Academy of Sleep Medicine; American Headache Society. She has been working in the field of headache and sleep disorders medicine since 1991, including patient care, education of medical and psychology residents and fellows, and research.
The association between headache and sleep disorders was recognized well over a century ago and the last quarter century has brought a marked growth in this literature. Historically, the literature was comprised primarily of anecdotal observations, small descriptive reports and single-group treatment outcome studies. The literature is maturing with an increased number of empirical and prospective studies. Interestingly, the earliest volumes of the journal Headache included astute observations of sleep involvement in cluster and migraine headache,1 pediatric headache,2 and psychiatric comorbidity.3 Dexter and Riley4 published one of the earliest EEG studies correlating nocturnal headaches with specific sleep stages and processes. Later experimental studies have provided strong evidence for chronobiological patterns in cluster and migraine headache5-10, as well as hypnic headache. Time-series analyses and controlled studies have supported early observations of sleep-related headache triggers.11-13 Dysregulation of sleep (e.g, sleep deprivation, oversleeping, disturbed or interrupted sleep) is now recognized as one of the more commonly reported acute headache triggers among patients with migraine and tension type headache.
Chronic daily headache not otherwise specified or a pattern of awakening frequently with any headache, termed “awakening headache,” is the headache descriptor most often used in this literature and most often associated with a sleep disorder. Obstructive sleep apnea is the sleep disorder most often associated with headache14-18 although conflicting reports have been presented. For example, Idiman and colleagues16 found headache was not related to sleep apnea severity (i.e., apnea/hypopnea index, minimum oxygen saturation) in a non-headache sample of patients with sleep apnea. ‘Sleep apnea headache’ is the only formal diagnosis for headache secondary to a sleep disorder recognized by the International Classification of Headache Disorders-2nd Edition [ICHD-II]. Among clinical headache populations, obstructive sleep apnea has been identified in a sizeable percentage of patients with cluster, hypnic, and other chronic headache diagnoses refractory to standard care. There are reports that treatment of sleep apnea improved or resolved headache in at least a subset of patients,18 but there are no controlled trials.
Headache has been linked to a wide range of sleep disorders in adults,19-20 adolescents21 and children.22 Among patients with migraine and tension type headache, insomnia is the most common sleep complaint, reported by one-half to two-thirds of headache clinic patients. One of the largest clinical studies published to date reported sleep complaints among 1,283 migraineurs presenting for headache treatment.20 Morning headaches were reported by 71% of migraineurs. Though insomnia was not systematically assessed, the majority of patients reported difficulty initiating sleep (53%) and maintaining sleep (61%). Chronically shortened sleep patterns suggestive of insomnia were observed in 38% of migraineurs (< 6 hours sleep per night) and shorter sleep was associated with greater migraine frequency and severity.
Sleep complaints have been identified as risk factors for frequent and severe headache conditions.23-26 In a United Kingdom cross sectional study, Boardman24 identified a dose-response relationship between headache severity and sleep complaints (i.e., trouble falling asleep, wake up several times, trouble staying asleep, or waking after usual amount of sleep feeling tired or worn out). Among 2662 respondents, headache frequency was associated with slight [age/gender adjusted OR=2.4 (1.7-3.2)], moderate [OR=3.6 (2.6-5.0)], and severe [OR=7.5 (4.2-13.4)] sleep complaints.[12] The study also identified an association with anxiety.
A common clinical scenario is for episodic headache to “transform” to chronic headache over the span of months or years. It has been postulated that migraine, chronic daily headache, and perhaps other forms of chronic headache are progressive disorders.25-26 Sleep-related variables including snoring, insomnia, daytime sleepiness, circadian rhythm disorders and parasomnias have been identified as potential risk factors for chronic headache.23-26 Thus, sleep and other modifiable risk factors may become clinical targets for headache prevention.27
Psychiatric disorders are comorbid with both headache and sleep disorders.23,28-30 Affective disorders occur with at least three-fold greater frequency in migraineurs than in the general population, and the prevalence increases in clinical populations, especially with chronic daily headache.28 Sleep disturbance (increased or decreased sleep) is a diagnostic symptom of a number of psychiatric disorders, and occurs in the majority of patients with affective disorders. Most often the sleep complaint is “insomnia” but the complaint of “hypersomnia” occurs as well.
Recent studies have controlled for psychiatric disorders. Sleep disturbance in headache patients is not explained solely by the presence of a psychiatric disorder29 and insomnia is an independent risk factor for chronic headache.23,30
Several papers have been published offering recommendations for evaluation and treatment of sleep-related headache.31-33 While at the present time there are no evidence-based guidelines for clinical practice, these recommendations draw broadly from the scientific literature and take into consideration the full constellation of headache-sleep-mood symptoms commonly encountered in more severe and complex headache conditions. While there have been precious few controlled treatment studies, a recent randomized controlled trial34 has demonstrated marked improvement in chronic migraine following a behavioral sleep intervention with headache change proportionate to the number of sleep behaviors changed (dose-response relationship)—providing compelling evidence for sleep regulation in chronic headache sufferers.
The relationship between sleep and headache disorders and the association with mood/anxiety disorders implicates common neuro-anatomic systems. Expert reviews of mechanisms have been published recently in Headache.35-36 It is expected that the next decade of empirical research will yield prospective and controlled studies of sleep related headache that may not only facilitate clinical management but possibly yield measures to prevent or limit progression to chronic headache.
Classic Contributions in Headache
1. Graham JR. Cluster headache. Headache. 1972;11(4):175-85.
2. Choa D, McGovern JP, Haywood TJ, Knight JA. Headaches in children: The Migraine syndrome. Headache. 1963;3(1):13-20.
3. Diamond S. Depressive headaches. Headache. 1964;4:255-9.
4. Dexter JD, Riley TL. Studies in nocturnal migraine. Headache. 1975;15(1):51-62.
Chronobiological Patterns in Headache
5. Terzaghi M, Ghiotto N, Sances G, Rustioni V, Nappi G, Manni R. Episodic cluster headache: NREM prevalence of nocturnal attacks. Time to look beyond macrostructural analysis? Headache. 2010;50(6):1050-4.
6. Alstadhaug K, Salvesen R, Bekkelund S. 24-hour distribution of migraine attacks. Headache. 2008;48(1):95-100.
7. Vetrugno R, Pierangeli G, Leone M, Bussone G, Franzini A, Brogli G, D'Angelo R, Cortelli P, Montagna P. Effect on sleep of posterior hypothalamus stimulation in cluster headache. Headache. 2007;47(7):1085-90.
8. Soriani S, Fiumana E, Manfredini R, Boari B, Battistella PA, Canetta E, Pedretti S, Borgna-Pignatti C. Circadian and seasonal variation of migraine attacks in children. Headache. 2006;46(10):1571-4.
9. Fox AW. Time-series data and the "migraine generator". Headache. 2005;45(7):920-5.
10. Fox AW, Davis RL. Migraine chronobiology. Headache. 1998;38(6):436-1.
Sleep-Related Headache Triggers
11. Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. Sep 2007;47(8):1184-1188.
12. Chabriat H, Danchot J, Michel P, Joire JE, Henry P. Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and nonmigraineurs. Headache. 1999;39(5):335-8.
13. Spierings EL, Sorbi M, Maassen GH, Honkoop PC. Psychophysical precedents of migraine in relation to the time of onset of the headache: the migraine time line. Headache. 1997;37(4):217-220.
Sleep Apnea Headache
14. Pelin Z, Bozluolcay M. Cluster headache with obstructive sleep apnea and periodic limb movements during sleep: a case report. Headache. 2005;45(1):81-3.
15. Graff-Radford SB, Newman A. Obstructive sleep apnea and cluster headache. Headache. 2004;44(6):607-10.
16. Idiman F, Oztura I, Baklan B, Ozturk V, Kursad F, Pakoz B. Headache in sleep apnea syndrome. Headache. 2004;44(6):603-6.
17. Paiva T, Batista A, Martins P, Martins A. The relationship between headaches and sleep disturbances. Headache. 1995;35(10):590-6.
18. Poceta JS, Dalessio DJ. Identification and treatment of sleep apnea in patients with chronic headache. Headache. 1995;35(10):586-9.
Sleep Disturbance In Headache: Descriptive Reports of Adult, Adolescent, and Pediatric Patients
19. Calhoun AH, Ford S, Finkel AG, Kahn KA, Mann JD. The prevalence and spectrum of sleep problems in women with transformed migraine. Headache. 2006;46(4):604-10.
20. Kelman L, Rains JC. Headache and sleep: examination of sleep patterns and complaints in a large clinical sample of migraineurs. Headache. 2005;45(7):904-10.
21.Gilman DK, Palermo TM, Kabbouche MA, Hershey AD, Powers SW. Primary headache and sleep disturbances in adolescents. Headache. 2007;47(8):1189-94.
22. Miller VA, Palermo TM, Powers SW, Scher MS, Hershey AD. Migraine headaches and sleep disturbances in children. Headache. 2003;43(4):362-8.
Sleep-Related Risk Factors for Chronic Headache (“Chronification”)
23. Sancisi E, Cevoli S, Vignatelli L, Nicodemo M, Pierangeli G, Zanigni S, Grimaldi D, Cortelli P, Montagna P. Increased Prevalence of Sleep Disorders in Chronic Headache: A Case-Control Study. Headache 2010;50(9):1464-72.
24. Boardman HF, Thomas E, Millson DS, Croft PR. Psychological, sleep, lifestyle, and comorbid associations with headache. Headache 2005;45(6):657-69.
25. Bigal ME, Lipton RB. Modifiable risk factors for migraine progression (or for chronic daily headaches)—clinical lessons. Headache. 2006;46(Suppl 3):S144-6. 26. Scher, AI, Midgette, LA, Lipton, RB. Risk Factors for Headache Chronification. Headache 2008;48(1):16-25.
27. Rains, JC. Chronic Headache and Potentially Modifiable Risk Factors: Screening and Behavioral Management of Sleep Disorders. Headache 2008;48(1):32-9.
Psychiatric Comorbidity
28. Lake AE, Rains JC, Penzien DB, Lipchik GL. Headache and Psychiatric Comorbidity: Historical Context, Clinical Implications, and Research Relevance. Headache 2005;45(5): 493-506.
29. Vgontzas A, Cui L, Merikangas KR. Are sleep difficulties associated with migraine attributable to anxiety and depression? Headache. 2008;48(10):1451-9.
30. Boardman HF, Thomas E, Millson DS, Croft PR. Psychological, sleep, lifestyle, and comorbid associations with headache. Headache. 2005;45(6):657-69.
Screening and Treatment of Sleep Disorders in Headache Patients
31. Mitsikostas DD, Viskos A, Papadopoulos D. Sleep and headache: the clinical relationship. Headache. 2010;50(7):1233-45.
32. Silberstein SD, Dodick D, Freitag F, Pearlman SH, Hahn SR, Scher AI, Lipton RB. Pharmacological approaches to managing migraine and associated comorbidities—clinical considerations for monotherapy versus polytherapy. Headache. 2007;47(4):585-99.
33. Rains JC, Poceta JS. Headache and sleep disorders: review and clinical implications for headache management. Headache. 2006;46(9):1344-63.
34. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-83.
Shared Mechanisms of Headache and Sleep Disorders
35. Evers S. Sleep and headache: the biological basis. Headache. 2010;50(7):1246-51.
36. Dodick DW, Eross EJ, Parish JM, Silber M. Clinical, anatomical, and physiologic relationship between sleep and headache. Headache. 2003;43(3):282-92.
Virtual Issue compiled online 4 November 2010
Occipital Nerve Block for Headache
Avi Ashkenazi, MD*, Joshua Tobin, MD+
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*The Neurologic Group of Bucks/Montgomery County, Doylestown, PA
+21st Century Neurology, Phoenix, AZ
Peripheral nerve blocks are among the most rewarding therapeutic tools in headache medicine, and have been used for this purpose for decades.1 Clinicians most frequently target the greater occipital nerve (GON), but also target various other cervical and cranial nerves to relieve both primary and secondary headache pain. Despite favorable results seen by many headache practitioners, high quality scientific data supporting their use are scarce.2,3 Most published studies on this topic are limited by a retrospective design, small sample size, heterogeneous patient groups, and lack of a control arm. Moreover, comparing studies and making generalizations is difficult because of the marked variability in the methods used in the different studies.
Recently, the American Headache Society Interventional Procedure Special Interest Section (AHS-IPS) surveyed AHS members to study their use of peripheral nerve blocks for headaches. We found that many headache practitioners use nerve blocks, but that the indications for using them and the methods used vary considerably among practitioners.
This issue’s collection of articles includes data on the efficacy of GON block for headaches. The articles suggest that GON block is effective for many headache disorders, and that its effect on head pain may be prompt and dramatic. However, many important questions remain: what is the optimal method to block the GON? What drugs should be used, and in what doses? Should corticosteroids be added to local anesthetics when performing the nerve block? What clinical parameters predict a favorable outcome after a GON block?
We need more rigorous studies to answer these questions. The goals of future studies should be to identify the patients who would benefit the most from GON block, and to determine the optimal drug combination and injection technique for this procedure. This knowledge will render GOB blocks even more beneficial to our headache patients.
Review Articles and Expert Opinions:
1. Evans RW, Yannakakis GD. Occipital nerve blocks and managed care: a review of the reviewers. Headache 2001;41:990-991
2. Young WB, Marmura M, Ashkenazi A, Evans RW. Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125
3. Tobin J, Flitman S. Occipital nerve blocks: when and what to inject? Headache 2009;49:1521-1533
4. Ashkenazi A, Blumenfeld A, Napchan U, Narouze S, Grosberg B, Nett B, DePalma T, Rosenthal B, Tepper S, Lipton RB. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Headache 2010;50:943-952
Original Research Articles and Case Reports:
1. Saadah HA, Taylor FB. Sustained headache syndrome associated with tender occipital nerve zones. Headache 1987;27:201-205
2. Rothbart P. Unilateral headache with features of hemicranias continua and cervicogenic headache – A case report. Headache 1992;32:459-460
3. Ellis BD, Kosmorsky GS. Referred ocular pain relieved by suboccipital injection. Headache 1995;35:101-103
4. Caputi CA, Firetto V. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997;37:174-179
5. Lavin PJ, Workman R. Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache 2001;41:902-904
6. Ashkenazi A, Young WB. The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine. Headache 2005;45:350-354
7. Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-919
8. Cooper W. Images from Headache: Resolution of trigeminal mediated nasal edema following greater occipital nerve blockade. Headache 2008;48:278-279
9. Young W, Cook B, Malik S, Shaw J, Oshinsky M. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1128
10. Selekler M, Kutlu A, Dundar G. Orgasmic headache responsive to greater occipital nerve blockade. Headache 2009;49:130-131
11. Tobin J, Flitman S. Occipital nerve blocks: effect of symptomatic medication overuse and headache type on failure rate. Headache 2009;49:1479-1485
12. AKIN TAKMAZ S, ÜNAL KANTEKİN C, KAYMAK Ç, BAŞAR H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache 2010;50:869-872
13. Blumenfeld A, Ashkenazi A, Grosberg B, Napchan U, Narouze S, Nett B, DePalma T, Rosenthal B, Tepper S, Lipton RB. Patterns of use of peripheral nerve blocks and trigger point injections among headache practitioners in the US: results of the American Headache Society Interventional Procedure Survey (AHS-IPS). Headache; 2009:937-942
Virtual Issue compiled online 4 June 2010
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