Nosology and treatment of primary headache in a Swiss headache clinic

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1 J Hedche Pin (2005) 6: DOI /s ORIGINAL Stnislw Kozk Andres R. Gntenbein Hnsruedi Isler Kthleen R. Merikngs Jules Angst Alex Gmm Reto Agosti Nosology nd tretment of primry hedche in Swiss hedche clinic Received: 18 Jnury 2005 Accepted in revised form: 15 Mrch 2005 Published online: 13 My 2005 *S. Kozk *A.R. Gntenbein ( ) H. Isler Hedche nd Pin Unit, Neurology Deprtment, Zürich University Hospitl, Fruenklinikstrsse 26, 8091 Zürich, Switzerlnd e-mil: ndy.gntenbein@gmx.ch Tel.: Fx: K.R. Merikngs Ntionl Institute of Mentl Helth, NIH, Bethesd, MD, USA J. Angst A. Gmm Zurich University Psychitric Hospitl, Zurich, Switzerlnd R. Agosti Hedche Unit, Hirslnden Clinic, Zurich, Switzerlnd *Both uthors contributed eqully to this work. Abstrct We ssessed demogrphics, dignoses, course, severity, impct nd tretment of primry hedche outptients from records in the Hedche nd Pin Clinic, Neurologicl Deprtment, Zürich University Hospitl. All outptients seen from 1996 to 1998 for migrine, tension-type hedche, nd both, were included. Dignoses, drug, physicl nd lterntive tretments before nd fter referrl were listed. Descriptive sttistics were used for differences between the generl popultion nd this smple, the dignoses, nd tretments. The coexistence of migrine nd tension-type hedche, nd the high frequencies of hedche dys would hve excluded most migrine ptients from typicl drug trils: t best, only one third were eligible. The socioeconomic impct of combined nd difficult syndromes clls for comprehensive mngement beyond simple tretment with instnt relief drugs. The dignostic nd therpeutic prctices of referring physicins exposed deficit of informtion on hedche, nd need for relevnt eduction. Key words Primry hedche Tertiry cre Demogrphics Epidemiology Drug tretment Introduction Hedches without dequte structurl dmge, predominntly tension hedche nd migrine, re mjor cuse of loss of productivity [1] nd helth expenditure. The medicl sciences of our times (nd of the lst 300 yers) hve so fr not found plusible wy to ccount for these disorders of otherwise helthy persons of ll ges, constitutions nd socil situtions. Hedche problems hve been relegted mong the so-clled civilistion diseses, which mens tht deficient hbits nd fulty wys of life, nd ultimtely, sin would be responsible, but history [2] shows tht problemtic hedche ws t lest s importnt in ncient societies s it is tody, nd geogrphic differences re too vgue to interpret becuse of widely diver-

2 122 gent locl conditions nd methods. Hedche hs been norml feture of the generl humn condition (conditio humn), since its lifetime prevlence is bove 95% of the totl popultion, but problemtic hedche which fflicts t lest 10% is disese, nd needs to be treted, urgently, nd with dequte know-how. The Hedche nd Pin Clinic (HPC) in the Neurology Deprtment, Zurich University Hospitl, is service for the ssessment nd mngement of difficult hedche problems. Since its beginning in 1966, ptients hve been referred by vrious specilist physicins nd surgeons in vrious hospitls nd in privte prctice, s well s generl prctitioners. Self-referrls, usully upon recommendtion by follow-up ptients, hve lso been ccepted. These ptients hd usully been treted unsuccessfully by severl physicins nd lymen. They required time-consuming, individulised cre. Therefore, systemtic review of dt hd to be limited to smll smples of the clinic popultion [3, 4]. Menwhile Merikngs nd co-workers found surprising dt on hedche nd migrine in their Zurich cohort study [1], where they followed smple of the generl popultion over 20 yers. Migrine nd tension-type hedche were shown to be mjor problems in the Zurich popultion t lrge. The need for corresponding lrger studies of the hedche clinic popultion becme obvious. In order to ssess the chrcteristics of the popultion nd s preprtion for pproprite prospective studies, we investigted retrospectively smple of 1625 ptients of our clinic. Ptients nd methods From the files of the clinic we selected those ptients with migrine, tension-type hedche nd combintions of migrine nd tension-type hedche who hd been seen in the yers (n=1625). The following dt were collected in questionnire designed for this purpose. Sex, ge nd ntive lnguge; mritl sttus; children; eductionl sttus; occuption; referrl; dignosis before nd fter referrl; ge of onset of hedche; frequency of hedche (hedche dys per month); loss of working dys per month nd per yer; other diseses, nd drugs tken for them; specil investigtions: CT scn, MRI nd EEG before nd fter referrl; longterm prophylctic drugs for hedche before nd fter referrl; drugs for cute hedche (ttcks) before nd fter referrl; drugs discontinued becuse of dverse effects, or lck of effect; lterntive, or complementry tretment before nd fter referrl; specil remrks. Where necessry, missing dt were obtined by telephone interview using the sme form. However it ws not possible to rech every ptient for this purpose. The following dt hve not been obtined: onset of hedche in 17.9%, eduction nd profession in less thn 5%; bsence from school/work in less thn 2%; frequency of hedches nd mritl stte in 1%. Missing dt ws excluded for the nlysis. Dt were nlysed using SPSS (version 8.0) nd SAS 8.2 for Windows. χ 2 - nd U-tests were used to ssess the sttisticl significnce of differences between hedche subtypes. Results Demogrphy nd clinicl chrcteristics According to the IHS criteri [5], 47.3% of the ptients hd migrines, 20% hd tension-type hedches nd 32.7% hd migrines combined with tension-type hedches. The distribution of demogrphic chrcteristics in this clinicl smple (n=1625) ws typicl of tretment smples: women were over-represented by 72% s ginst 28% men, nerly 3:1, the proportion usully found in migrine. See lso Tble 1. The ge rnge of the migrine ptients ws 8 74 yers, with men ge of 39.3 yers. Tension-type hedche ptients were between 7 nd 82 yers, with men ge The men ge of onset ws 20.5 yers for migrine nd 30.2 yers for tension-type hedche (Fig. 1). On verge, migrine ptients hd lower frequency of hedche dys per month thn tension-type hedche ptients. There were more ptients with less thn 4 hedche dys per month in migrine (28% s ginst 5% in tensiontype hedche) nd more ptients with dily hedche in tension-type hedche (61% s ginst 9.3% in migrine). A lrge mjority of tension-type hedche ptients hd dily hedche (61%). Altogether 82.4% fulfilled the criteri of chronic tension-type hedche. This clerly outweighs the incidence of chronic tension-type hedche found in the generl popultion of Germny nd Denmrk (3%) [6, 7]. Nerly one third of ll migrine ptients fulfilled the criteri for chronic migrine, wheres in the generl Germn popultion only 2% of the migrine sufferers hd 15 or more hedche dys per month [8]. See lso Tble 2. Impct 57.8% of 748 ptients with migrine, nd 83.4% of 314 ptients with tension-type hedche hd no loss of school or work dys. 28.8% of the migrine ptients, nd 9% of the ptients with tension-type hedche hd lost up to 30 dys per yer. 13.4% of the migrine ptients, nd 7.6% of the tension-type hedche ptients reported work loss of more thn one month per yer. Some hd not been ble to work t ll.

3 123 Tble 1 Demogrphics. Numbers in prentheses re vlues expected in the popultion of Switzerlnd Women Men Totl p FM Ptients, n Ptients, % 71.8 (51.2) 28.2 (48.8) 100 Age distribution (yers) Medin ge , % , % , % , % , % Mritl sttus Single, % (42.0) Mrried, % (46.6) Divorced, % (5.5) Widowed, % (5.9) Eduction (25 64 yers) Bsic eduction, % 24.7 (25.7) 12.8 (12.9) 21.3 (19.3) Trde school, % 68.1 (61.5) 71.0 (54.0) 68.9 (57.8) Tertiry eduction, % 7.2 (12.8) 16.2 (33.1) 9.8 (22.9) Foreign lnguge spekers (19) 0.05 U-tests nd χ 2 -tests, respectively, compring femles vs. mles Fig. 1 The ge of onset-curve hs shrp pek t 13 yers in the migrine group (puberty, prepuberty) Dignosis nd specil investigtions Mjor differences were encountered in dignoses nd tretment before nd fter ssessment in the hedche clinic. The dignoses of migrine nd tht of tension-type hedche were estblished much more often in the clinic thn by referring physicins. Of hedches finlly dignosed s migrine, 57% were referred s migrine, 6% s tension-type hedche with or without migrine nd 37% s hedche without further specifiction. The sitution ws even more incongruous in tension-type hedche where 79% were referred s unspecified hedche, 17% s tension-type hedche with or without migrine nd 4% s migrine (Fig. 2). The most frequent specil investigtions were: CT scn (18.2% before, 7.6% fter first consulttion), EEG (10% before, 2.3% fter first consulttion) nd MRI (5.5% before, 3.8% fter first consulttion). No pthology ws found which would hve led to further investigtions, interventions or chnge of tretment.

4 124 Tble 2 Chrcteristics of hedche types. Numbers re percentges or medins (with qurtiles in prentheses) Migrine Tension Both F M p FM F M p FM F M p MT Ptients, n Ptients, % Age 39 (30 49) 39 (31 47) (24 50) 34 (26 47) (26 49) 36 (27 45) Age of onset 19 (13 27) 16 (10 29) (19 42) 26 (20 37) (12 26) 20 (13 30) Frequency hedche 8 (4 14) 6 (4 12.5) ( ) 30 (16 30) (9 30) 17.5 (8 30) dys/month <4 hedche dys/month, % Dily hedche, % No. school/work 18 (12 48) 13.5 (6 30) (12 144) 24 (10 48) (12 42) 18 (12 57) dys lost b U-tests. p FM compres femles vs. mles; p MT compres migrine vs. tension hedche subjects b Only subjects who hve hd ny bsences re considered Fig. 2 More thn one hlf of the migrine group were referred s migrine but only one sixth of the tension-type hedches, nd one tenth of the combined hedches cme in with correct dignosis. Most of the hedches were referred s unspecific hedche Tretment before nd fter first consulttion in the HPC See Tble 3. Monotherpy ws the exception both before referrl nd in HPC prescriptions (ltogether 64). The min difference between tretment by referring doctors nd tretment in the HPC ws shift from instnt relief drugs to prophylctics, especilly to mgnesium (new: 1062), ntidepressnts (691) nd bet-blockers (461). There ws modest decrese of ergotmines, mtched by comprble increse of triptns. However most ptients kept the instnt relief drugs they were using, usully declring tht they helped them best of ll, independent of their phrmceuticl nture. Previous lterntive or complementry tretment (cupuncture, romtherpy, Atlslogy, Bch flowers, bioresonnce, chin oil, chiroprctic, colour therpy, crnioscrl therpy, electrotherpy, foot reflex mssge, homeopthy, lser tretment, lymph dringe, mgnetopthy, morphology, neurl therpy, neurolinguistics, osteopthy, phytotherpy, psychophony, Reiki, Shitsu, vitlogy, yog) ws reported by 484 ptients while 1141 did not report such tretments. The most frequently reported complementry tretments were cupuncture (338) nd homeopthy (120), while ll other methods were reported by smll minorities.

5 125 Tble 3 Drug tretment before nd fter initil consulttion t HPC (number of drugs tken by the 1625 ptients, often more thn one by ech ptient) Previous (stopped) Continued t HPC HPC prescribed (new) Acute type Benzodizepines Ergotmines Opioids Simple nlgesics Combined nlgesics Triptns Prophylctic type Anticonvulsnts Antidepressnts* Benzodizepines Bet blockers Clcium ntgonists Ergotmines Mgnesium Serotonin ntgonists** *Tricyclics nd serotonin reuptke inhibitors (SSRIs) **Methysergide nd pizotifen Discussion Demogrphy nd clinicl chrcteristics Compred to the generl popultion of Switzerlnd in 1998 [9] there ws prepondernce of the ge group from 20 to 65 yers (89% ginst 61.6%). Severe hedche problems pper to previl in the middle ge groups where worklod, fmily stresses nd competition re more likely to become unberble. The mritl sttus of the ptients presented no importnt differences to the distribution in the generl popultion. The eductionl chrcteristics showed no over-representtion of higher lerning, contrry to the populr prejudice bout migrine s disese of intellectuls. The percentge of ptients with tertiry eduction ws only hlf of tht found in the generl popultion [9]. As more thn one third of ll ptients were ntive spekers of other lnguges thn the officil Germn of the region of Zürich, this permits us to infer tht those with socilly underprivileged sttus my be over-represented in this smple. Although the onset of migrine in our smple ws 10 yers lower thn the onset of tension-type hedche, the ptients in the migrine group were on verge 2 yers older thn the tension-type hedche ptients. This could imply longer durtion of the migrine disese. There were bundnt differences in the frequency of hedche of our popultion compred to epidemiologicl dt from Germny nd Denmrk. Chronic tension-type hedche ws over-represented nerly 24 times, nd chronic dily hedche combined with migrine, though non-existent in the published Germn dt, ws found in nerly 10% of the migrine ptients, while 29.6% hd 15 or more hedche dys per month. This could well be explined with very frequent hedches s motive for seeking professionl help. We pplied the selection criteri from the revised IHS guidelines for controlled trils of drugs in migrine [10]. A mximum of 390 of 1299 (30%) ptients with migrine or migrine nd tension-type hedche would be eligible for trils with cute or prophylctic drugs, due to the high migrine frequency. Further need for medicl tretment my be gretest where the selection criteri of the IHS guidelines for migrine drug trils [10] will be lest pplicble. Impct Only one third of the whole group reported loss of work or school dys. As there were ltogether 1166 women, more thn hlf of them without ginful occuption, nd more or less ble to wit t home for the end of bd hedche ttck or bd hedche episode, the present reports re showing only prt of this problem. Merikngs nd co-workers [1] found up to 90% impirment of socil nd leisure ctivities, nd up to 75% occuptionl impirment in the migrine sufferers mong the high-risk group of the Zurich cohort study.

6 126 According to the IHS criteri [5] nd definitions the intensity of tension-type hedche should not be severe, tht is, not severe enough to block the usul dily ctivities. Contrry to these expecttions 16.6% of our tensiontype hedche ptients reported loss of work dys, s ginst 42.2% of the migrine ptients, which is more in keeping with the migrine criteri defining ttcks of moderte to severe hedche. In sizeble minority, disbility occurred on more thn 30 dys per yer: 11.3% of ll ptients, 13.4% of those with migrine nd 7.6% of those with tension-type hedche. These severe problems my be concentrted in the specilist clinic but they re closely relted to the encrochment on the qulity of life in the generl popultion [1]. Tretment Tretment before nd fter HPC prescriptions ws usully drug tretment, predominntly using more thn one drug, combining t lest one prophylctic nd one instnt relief type drug. Previous tretment consisted mostly of instnt relief drugs, wheres the HPC preferred prophylctic drugs for tretment. The slient feture ws the chnge from 29 ptients tking mgnesium previously to 1062 who hd it prescribed t HPC (85 continuing from before). Similr but lower increses were observed in ntidepressnts (193 to 691, 104 continuing) nd bet-blockers (239 to 461, 67 continuing). The increse in bet-blockers ws ssocited with shift from proprnolol to ndolol. In 315 cses flunrizine ws stopped nd cyclndelt ws newly prescribed in 260 ptients. Both these chnges were intended for better tolerbility. Among the instnt relief drugs, simple nlgesics showed both the highest number of users nd the highest continuity of use, with similr ptterns but lower numbers for ergotmine compounds nd triptns. Opioids nd benzodizepines were only used by mrginl minorities. One third reported vrious complementry or lterntive tretments. Conclusions The typicl ptient t the Hedche nd Pin Clinic is 35-yer-old mrried womn with both migrine without ur nd tension-type hedche with frequency of 15 hedche dys per month, resulting from both syndromes. Age distribution of migrine nd tension hedche ptients ppers to be different nd typicl for ech syndrome. The findings re more comptible with continuous spectrum of primry hedche syndromes thn with the concept of netly seprte nosologicl entities, which is in turn hrdly comptible with clinicl experience where replcement or trnsformtion of tension-type hedche by or into migrine, nd vice vers, is reported by very importnt minority of ptients. The most striking difference ws found between dignoses by referring physicins nd dignoses estblished in the clinic. Over 80% of tension-type hedches, nd over one third of migrines dignosed in the clinic hd been referred with unspecified hedche dignoses. Ptients referred to the hedche clinic reported mediction closely resembling tht of the epidemiologicl studies of Isler et l. [11] in the region of most frequent referrl, the Cnton of Zürich nd its surroundings. This consisted minly of nlgesics for cute ttcks, sometimes overused. Prophylctics were pplied rrely nd rther indiscrimintely, often without considertion of their specific indiction for migrine. As whole, our study indicted tht vilbility of informtion on current dignosis nd tretment, s it were, is still insufficient in referring generl prctitioners. References 1. Merikngs KR, Whitker AE, Isler H, Angst J (1994) The Zurich Study: XXIII. Epidemiology of hedche syndromes in the Zurich cohort study of young dults. Eur Arch Psychitry Clin Neurosci 244: Isler H, Clifford Rose F (2000) The history of hedche. In: Olesen J, Tfelt-Hnsen P, Welch KMA (eds) The hedches, 2nd edn. Lippincott Willims & Wilkins, Phildelphi, pp Isler H (1983) Ds Zeitmuster ls Leitsymptom der Migräne. In: Seitz D, Vogel P (eds) Hämoblstosen, zentrle Motorik, itrogene Schäden, Myositiden. Springer, Berlin, pp Isler H (1986) Frequency nd time course of premonitory phenomen. In: Amery W, Wuquier A (eds) The prelude to the migrine ttck. Billiere Tindll, London, pp Hedche Clssifiction Committee of the Interntionl Hedche Society (1988) Clssifiction nd dignostic criteri for hedche disorders, crnil neurlgi, nd fcil pin. Cephllgi 8[Suppl 7]: Rsmussen BK, Jensen R, Schroll M, Olesen J (1991) Epidemiology of hedche in generl popultion prevlence study. J Clin Epidemiol 44:

7 Göbel H (1997) Kopfschmerz vom Spnnungstyp. In: Göbel H (ed.) Die Kopfschmerzen. Springer, Berlin, p Göbel H (1997) Epidemiologie von Kopfschmerzen. In: Göbel H (ed) Die Kopfschmerzen. Springer, Berlin, p Bundesmt für Sttistik (2000) Bevölkerung: Zivilstnd, Heirten und Scheidungen [WWW document]. URL er01/dufr01.htm 10. Tfelt-Hnsen P, Block G, Dhlöf C, Diener H-C, Ferrri MD, Godsby PJ et l (2000) Guidelines for controlled trils of drugs in migrine, 2nd edn. Cephllgi 20: Isler H, Merikngs KR, Angst J (1991) Tretment ptterns of migrine in the community. Cephllgi [Suppl 11]:110