Publications by authors named "Rigmor Højland Jensen"

55 Publications

Spontaneous intracranial hypotension presenting with progressive cognitive decline.

BMJ Case Rep 2021 Jul 21;14(7). Epub 2021 Jul 21.

Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, DK, Glostrup, Denmark

A 63-year-old woman presented with headache, progressive somnolence, neurocognitive decline and urinary incontinence through a year. Medical history was unremarkable except for hypertension and hypercholesterolaemia. Neurological examination was normal. Brain MRI showed findings typical for spontaneous intracranial hypotension (subdural fluid collection, pachymeningeal enhancement, brain sagging) and pituitary tumour. The patient's complaints improved dramatically but temporarily after treatment with each of repeated targeted as well as non-targeted blood patches and a trial with continuous intrathecal saline infusion. Extensive work up including repeated MRI-scans, radioisotope cisternographies, CT and T2-weighted MR myelography could not localise the leakage, but showed minor root-cysts at three levels. Finally, lateral decubitus digital subtraction dynamic myelography with subsequent CT myelography identified a tiny dural venous fistula at the fourth thoracic level. After surgical venous ligation, the patient fully recovered. Awareness of spontaneous dural leaks and their heterogeneous clinical picture are important and demands an extensive workup.
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http://dx.doi.org/10.1136/bcr-2020-241285DOI Listing
July 2021

Poor social support and loneliness in chronic headache: Prevalence and effect modifiers.

Cephalalgia 2021 Jun 23:3331024211020392. Epub 2021 Jun 23.

Danish Headache Center, Rigshospitalet‒Glostrup, University of Copenhagen, Glostrup, Denmark.

Objective: To explore the prevalence of poor social support and loneliness among people with chronic headache, and how these might be effect modifiers in the relationships between chronic headache and stress, medication overuse, and self-rated health.

Background: Poor social support and loneliness are consistently linked to worse health outcomes. There are few epidemiologic studies on their effect on headache.

Methods: The Danish Capital Region Health Survey, a cross-sectional survey, was conducted in 2017. Participants were asked about headache, pain medication use, social support, loneliness, perceived stress, and self-rated health. Data were accessed from sociodemographic registers. Logistic regression analyses were performed to test for effect modification.

Results: The response rate was 52.6% (55,185 respondents) and was representative of the target population. People with chronic headache were more likely to report poor social support and loneliness compared to those without chronic headache ( < 0.0001 for both). Odds ratios for the combination of chronic headache and poor social support were very high for stress (odds ratio 8.1), medication overuse (odds ratio 21.9), and poor self-rated health (odds ratio 10.2) compared to those without chronic headache and with good social support. Those who reported both chronic headache and loneliness had a very high odds ratio for stress (odds ratio 14.4), medication overuse (odds ratio 20.1), and poor self-rated health (odds ratio 15.9) compared to those without chronic headache and low loneliness score. When adjusted for sociodemographic factors, poor social support and loneliness were not significant effect modifiers in almost all these associations. Loneliness was a significant effect modifier in the association between chronic headache and medication overuse, but exerted greater effect among those who did not report they were lonely.

Conclusion: Poor social support and loneliness were prevalent among people with chronic headache. The combination of chronic headache and poor social support or loneliness showed higher odds ratios for stress, medication overuse, and poor self-rated health compared to those with good social support and low loneliness scores. The effect of loneliness in the relationship between chronic headache and medication overuse warrants further study.
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http://dx.doi.org/10.1177/03331024211020392DOI Listing
June 2021

Use of coping strategies in the management of medication overuse headache.

Patient Educ Couns 2021 May 25. Epub 2021 May 25.

Research Unit of Health Sciences, University hospital of Southern Denmark, Esbjerg, Finsensgade 35, 6700 Esbjerg, Denmark; Department of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 5000 Odense, Denmark. Electronic address:

Objectives: Use of Motivational Interviewing (MI) in education may improve medication-overuse headache (MOH) patients' ability to cope with pain. In a randomised controlled trial, we evaluated the effect of education focusing on behavioural change among MOH patients.

Methods: Ninety-eight MOH patients were randomized (1:1) to standard treatment and 12-weeks of MI-based education versus standard treatment alone after detoxification. Outcome of interest was changes in coping strategies measured by the Coping Strategy Questionnaire at four- and nine months.

Results: The educational program improved patients' perceived efficacy in the use of their coping strategies to control pain, both at four-and nine months follow-up (mean±SE): ∆:0.84 ± 0.35, 95% CI:0.16;1.52, p = 0.02 and: ∆: 0.90 ± 0.39, 95% CI:0.14;1.66, p = 0.02, respectively. No between-group differences were detected in the other coping subscales. Within the intervention group, the coping strategy subscales Catastrophizing, and Reinterpretation of pain sensation were significantly improved at nine months follow-up (p = 0.003 vs. p = 0.012, respectively). No changes were found in the control group.

Conclusion: MI-based education focused on behavioural changes improved MOH patients' perceived efficacy in the use of their coping strategies to control pain.

Practice Implications: Education based on MI could be valuable for MOH patients with respect to behavioural changes and perceived headache control.
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http://dx.doi.org/10.1016/j.pec.2021.05.035DOI Listing
May 2021

Prevalence of pre-cluster symptoms in episodic cluster headache: Is it possible to predict an upcoming bout?

Cephalalgia 2021 Jun 20;41(7):799-809. Epub 2021 Jan 20.

Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark.

Background: Early symptoms prior to a cluster headache bout have been reported to occur days or weeks before the actual beginning of the cluster headache bouts. This study aimed to describe the prevalence of pre-cluster (premonitory) symptoms and examine the predictability of an upcoming cluster headache bout.

Methods: 100 patients with episodic cluster headache were included in this retrospective cross-sectional study. All patients underwent a semi-structured interview including 25 questions concerning pre-cluster symptoms.

Results: Pre-cluster symptoms were reported by 86% of patients with a mean of 6.8 days (interquartile range 3-14) preceding the bout. An ability to predict an upcoming bout was reported by 57% with a mean 4.6 days (interquartile range 2-7) before the bout. Occurrence of shadow attacks was associated with increased predictability (odds ratio: 3.06, confidence interval: 1.19-7.88, -value = 0.020). In remission periods, 58% of patients reported mild cluster headache symptoms and 53% reported occurrence of single shadow attacks.

Conclusions: The majority of episodic cluster headache patients experienced pre-cluster symptoms, and more than half could predict an upcoming bout, suggesting the significant potential of early intervention. Furthermore, the experience of mild cluster headache symptoms and infrequent shadow attacks in remission periods is common and suggest an underlying pathophysiology extending beyond the cluster headache bouts.
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http://dx.doi.org/10.1177/0333102421989255DOI Listing
June 2021

Real-life treatment of cluster headache in a tertiary headache center - results from the Danish Cluster Headache Survey.

Cephalalgia 2021 Apr 17;41(5):525-534. Epub 2020 Nov 17.

Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark.

Background: Pharmacological treatment of cluster headache constitutes the core of clinical management, but evidence is sparse. We aimed to generate insight in the existing treatment and identify associations between clinical features and treatment response.

Methods: Patients aged 18-65 diagnosed with cluster headache according to the ICHD-2 completed a questionnaire followed by a structured interview. Multiple logistic regression was used to identify associations.

Results: The population consisted of 400 patients with an episodic: chronic ratio of 1.7:1. Episodic patients were more likely to respond to triptans (odds ratio = 1.77, confidence interval: 1.08-2.91,  = 0.023) and oxygen (odds ratio = 1.64, confidence interval: 1.05-2.57,  = 0.031) than chronic. Oxygen response was less likely if pain intensity was very severe (odds ratio = 0.53, confidence interval: 0.33-2.57,  = 0.006) and the risk of a poor response increased with disease duration (odds ratio = 0.79, confidence interval: 0.65-0.96,  = 0.016). Among current users of sumatriptan injection and oxygen, the proportion achieving 100% relief was higher with sumatriptan injection ( > 0.001) than with oxygen. No associations were identified regarding verapamil. Only 57% of current users of preventive medication responded at a 50% level.

Conclusion: Episodic cluster headache is more responsive to acute therapy than chronic. Further, sumatriptan injection was more effective than oxygen and the responder-rate was limited with verapamil. More effective acute and preventive therapies are needed for cluster headache patients.
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http://dx.doi.org/10.1177/0333102420970455DOI Listing
April 2021

Neurofilament light chain as biomarker in idiopathic intracranial hypertension.

Cephalalgia 2020 10 29;40(12):1346-1354. Epub 2020 Jul 29.

Danish Headache Center, Neurological Clinic, Rigshospitalet-Glostrup, Glostrup, Denmark.

Background: Damage of the optic nerve is the major complication of idiopathic intracranial hypertension. A biomarker indicative for optic nerve damage would help identifying high-risk patients requiring surgical procedures. Here, we studied the potential of cerebrospinal fluid neurofilament to predict idiopathic intracranial hypertension-induced optic nerve damage.

Methods: In two centers, serum and cerebrospinal fluid of 61 patients with clinically suspected idiopathic intracranial hypertension were prospectively collected. Neurofilament concentrations were measured and related to ophthalmological assessment.

Results: The average cerebrospinal fluid neurofilament concentration in patients with moderate and severe papilledema was increased compared to patients with minor and no papilledema (1755 ± 3507 pg/ml vs. 244 ± 102 pg/ml;  < 0.001). Cerebrospinal fluid neurofilament concentrations correlated with the maximal lumbar puncture opening pressure (r = 0.67,  < 0.001). In patients fulfilling the Friedman criteria for idiopathic intracranial hypertension with or without papilledema (n = 35), development of bilateral visual field defects and bilateral atrophy of the optic nerve were associated with increased average age-adjusted cerebrospinal fluid neurofilament concentrations. At last follow-up (n = 30), 8/13 of patients with increased, but only 3/17 with normal, cerebrospinal fluid neurofilament had developed bilateral visual field defects and/or bilateral optic nerve atrophy resulting in a sensitivity of 72.7% and a specificity of 73.7% of cerebrospinal fluid neurofilament to detect permanent optic nerve damage.

Conclusions: Cerebrospinal fluid neurofilament is a putative biomarker for optical nerve damage in idiopathic intracranial hypertension.
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http://dx.doi.org/10.1177/0333102420944866DOI Listing
October 2020

Comparison of 3 Treatment Strategies for Medication Overuse Headache: A Randomized Clinical Trial.

JAMA Neurol 2020 09;77(9):1069-1078

Danish Headache Center, Rigshospitalet, Glostrup, Denmark.

Importance: Medication overuse headache (MOH) is a disabling, globally prevalent disorder representing a well-known and debated clinical problem. Evidence for the most effective treatment strategy is needed.

Objective: To compare 3 treatment strategies for MOH.

Design, Setting, And Participants: This open-label, randomized clinical trial with 6 months of follow-up was conducted in the tertiary sector at the Danish Headache Center, Glostrup, from October 25, 2016, to June 28, 2019. Of 483 patients with MOH referred during the inclusion period, 195 met the criteria consisting of migraine and/or tension-type headache, 18 years or older, eligibility for outpatient treatment, no severe physical or psychiatric disorder, no other addiction, and not pregnant or breastfeeding. Of these, 75 refused participation and 120 were included. Data were analyzed from July 3 to September 6, 2019.

Interventions: Random assignment (1:1:1 allocation) to 1 of the 3 outpatient treatments consisting of (1) withdrawal plus preventive treatment, (2) preventive treatment without withdrawal, or (3) withdrawal with optional preventive treatment 2 months after withdrawal.

Main Outcomes And Measures: The primary outcome was change in headache days per month after 6 months. Predefined secondary outcomes were change in monthly migraine days, use of short-term medication, pain intensity, number of responders, patients with remission to episodic headache, and cured MOH.

Results: Of 120 patients, 102 (mean [SD] age, 43.9 [11.8] years; 81 women [79.4%]) completed the 6-month follow-up. Headache days per month were reduced by 12.3 (95% CI, 9.3-15.3) in the withdrawal plus preventive group, by 9.9 (95% CI, 7.2-12.6) in the preventive group, and by 8.5 (95% CI, 5.6-11.5) in the withdrawal group (P = .20). No difference was found in reduction of migraine days per month, use of short-term medication, or headache intensity. In the withdrawal plus preventive group, 23 of 31 patients (74.2%) reverted to episodic headache, compared with 21 of 35 (60.0%) in the preventive group and 15 of 36 (41.7%) in the withdrawal group (P = .03). Moreover, 30 of 31 patients (96.8%) in the withdrawal plus preventive group were cured of MOH, compared with 26 of 35 (74.3%) in the preventive group and 32 of 36 (88.9%) in the withdrawal group (P = .03). These findings corresponded to a 30% (relative risk, 1.3; 95% CI, 1.1-1.6) increased chance of MOH cure in the withdrawal plus preventive group compared with the preventive group (P = .03).

Conclusion And Relevance: All 3 treatment strategies were effective, but based on these findings, withdrawal therapy combined with preventive medication from the start of withdrawal is recommended as treatment for MOH.

Trial Registration: ClinicalTrials.gov Identifier: NCT02993289.
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http://dx.doi.org/10.1001/jamaneurol.2020.1179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251504PMC
September 2020

Low frequency activation of the sphenopalatine ganglion does not induce migraine-like attacks in migraine patients.

Cephalalgia 2020 08 22;40(9):966-977. Epub 2020 Apr 22.

Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark.

Introduction: Cephalic autonomic symptoms occur in 27‒73% of migraine patients during attacks. The role of parasympathetic activation in migraine attack initiation remains elusive. Low frequency stimulation of the sphenopalatine ganglion increases parasympathetic outflow. In this study, we hypothesized that low frequency stimulation of the sphenopalatine ganglion would provoke migraine-like attacks in migraine patients.

Methods: In a double-blind randomized sham-controlled crossover study, 12 migraine patients with a sphenopalatine ganglion neurostimulator received low frequency or sham stimulation for 30 min on two separate days. We recorded headache characteristics, cephalic autonomic symptoms, ipsilateral mechanical perception and pain thresholds, mean blood flow velocity in the middle cerebral artery (V) and diameter of the superficial temporal artery during and after stimulation.

Results: Five patients (42%) reported a migraine-like attack after low frequency stimulation compared to six patients (50%) after sham ( = 1.000). We found a significant increase in mechanical detection thresholds during low frequency stimulation compared to baseline ( = 0.007). Occurrence of cephalic autonomic symptoms and changes in mechanical perception thresholds, V and diameter of the superficial temporal artery showed no difference between low frequency stimulation compared to sham ( = 0.533).

Conclusion: Low frequency stimulation of the sphenopalatine ganglion did not induce migraine-like attacks or autonomic symptoms in migraine patients. These data suggest that increased parasympathetic outflow by the sphenopalatine ganglion neurostimulator does not initiate migraine-like attacks. ClinicalTrials.gov registration number NCT02510742.
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http://dx.doi.org/10.1177/0333102420921156DOI Listing
August 2020

Persistent post-traumatic headache attributed to mild traumatic brain injury: Deep phenotyping and treatment patterns.

Cephalalgia 2020 05 26;40(6):554-564. Epub 2020 Feb 26.

Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.

Objective: To investigate clinical characteristics and treatment patterns in persistent post-traumatic headache attributed to mild traumatic brain injury.

Methods: A total of 100 individuals with persistent post-traumatic headache attributed to mild traumatic brain injury were enrolled between July 2018 and June 2019. Deep phenotyping was performed using a semi-structured interview while allodynia was assessed using the 12-item Allodynia Symptom Checklist.

Results: In 100 subjects with persistent post-traumatic headache, the mean headache frequency was 25.4 ± 7.1 days per month. The most common headache phenotype was chronic migraine-like headache (n = 61) followed by combined episodic migraine-like and tension-type-like headache (n = 29) while nine subjects reported "pure" chronic tension-type-like headache. The most frequent trigger factors were stress, lack of sleep, and bright lights. A history of preventive medication use was reported by 63 subjects, of which 79% reported failure of at least one preventive drug, while 19% reported failure of at least four preventive drugs. Cutaneous allodynia was absent in 54% of the subjects, mild in 23%, moderate in 17%, and severe in 6%.

Conclusions: The headache profile of individuals with persistent post-traumatic headache most often resembled a chronic migraine-like phenotype or a combined episodic migraine-like and tension-type-like headache phenotype. Migraine-specific preventive medications were largely reported to be ineffective. Therefore, there is a pressing need for pathophysiological insights and disease-specific therapies.
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http://dx.doi.org/10.1177/0333102420909865DOI Listing
May 2020

Monitoring chronic headache and medication-overuse headache prevalence in Denmark.

Cephalalgia 2020 01 15;40(1):6-18. Epub 2019 Sep 15.

Danish Headache Center, Rigshospitalet Glostrup, Glostrup, Denmark.

Objectives: To study chronic headache and medication-overuse headache (MOH) prevalence; to identify groups with high prevalence of these conditions; and to identify the most frequently used pain medications among respondents with chronic headache.

Background: Chronic headache and MOH prevalence in Denmark were last estimated in 2010.

Methods: In this cross-sectional study, 104,950 individuals aged ≥16 years were randomly sampled for the 2017 Danish Capital Region Health Survey. Responses to questions about headache and use of acute pain medications were linked to demographic registries. MOH was defined as headache ≥15 days/month plus self-report of use of pain medications ≥10 or 15 days/month, in the last three months. Weighted prevalence proportions were calculated.

Results: Among 55,185 respondents, chronic headache prevalence was 3.0% (95% CI: 2.3-3.2) and MOH prevalence was 2.0% (95% CI: 1.8-2.1). Both conditions were more common among females and the middle-aged. Respondents on social welfare or receiving early retirement pensions had the highest prevalences. Among those with chronic headache, 44.7% overused over-the-counter analgesics for headache; paracetamol 41.5%; a combination of different pain relievers 25.3%; ibuprofen 21.9%; opioids 17.0%; combination preparations 14.3%; and triptans 9.1%.

Conclusions: The highest prevalence of chronic headache and MOH was seen among people with low socioeconomic position. Overuse of paracetamol was most common. Reported opioid use was higher than expected. Groups with high prevalence of MOH should be the focus of public health interventions on rational use of OTC and prescription pain medications.
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http://dx.doi.org/10.1177/0333102419876909DOI Listing
January 2020

Complete withdrawal is the most feasible treatment for medication-overuse headache: A randomized controlled open-label trial.

Eur J Pain 2019 07 15;23(6):1162-1170. Epub 2019 Mar 15.

Danish Headache Center, Rigshospitalet Glostrup, Copenhagen, Denmark.

Background: Complete stop of acute medication and/or migraine medication for treatment of medication-overuse headache (MOH) has previously been reported more effective in reducing headache days and migraine days per month compared with restricted intake of acute medication. However, it is unknown whether complete stop or restricted intake is the most feasible treatment for patients.

Objectives: To investigate whether feasibility of withdrawal in MOH is different between complete stop of acute medication and restricted intake, and whether reductions in headache-related medication dependence, anxiety and depression differ between the treatments.

Methods: Medication-overuse headache patients were included in a prospective, open-label, outpatient study and randomized to two months of withdrawal with either no analgesics or acute migraine medication (programme A) or acute medication restricted to 2 days/week (programme B). After 6 and 12 months, patients graded feasibility of withdrawal. Dependence was measured by Severity of Dependence Scale (SDS), while anxiety and depression were measured by Hospital Anxiety and Depression Scale (HADS).

Results: We included 72 MOH patients with primary migraine and/or tension-type headache. Forty-nine completed withdrawal and the SDS questionnaire at 12-month follow-up, and the feasibility of withdrawal was significantly higher in programme A compared to programme B (p < 0.001). At 12 months, the dependence was reduced by 44% in programme A compared to 26% in programme B (p = 0.053), while the anxiety score was reduced by 32% and 11%, respectively (p = 0.048).

Conclusions: Withdrawal with complete stop of acute medication was more feasible and most effective in reducing headache-related anxiety compared with restricted intake.

Significance: A complete stop of all analgesics is the most effective treatment for MOH regarding reduction in headache days but has often been regarded as too challenging for patients. However, in this study, complete stop appears to be more feasible compared with restricted intake of analgesics seen from the patients' perspective.
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http://dx.doi.org/10.1002/ejp.1383DOI Listing
July 2019

Predictive role of presenting symptoms and clinical findings in idiopathic intracranial hypertension.

J Neurol Sci 2019 Apr 6;399:89-93. Epub 2019 Feb 6.

Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Denmark.

Background: The aim of the study was to evaluate the presenting symptoms and signs of idiopathic intracranial hypertension (IIH) in a large cohort of patients and to estimate their possible role in establishing the diagnosis of IIH.

Methods: This prospective cohort study in two tertiary centers, the Danish Headache Center in Rigshospitalet-Glostrup and the Neurology Clinic of the Clinical Center of Serbia, included 286 patients referred by attending specialists for possible IIH evaluation. Patients were divided into two groups: one with confirmed IIH diagnosis and one with rejected IIH diagnosis.

Results: The diagnosis of IIH was confirmed in 219 (76.6%) patients. It was more often confirmed if the patient was referred by an ophthalmologist than if the referral was from a neurologist (83.6% vs. 69.8%, p = .029) and in patients with higher body mass index (BMI) (p = .032). Transient visual obscurations (p = .006), double vision (p = .033), neck pain (p = .025), and tinnitus (p = .013) were presenting symptoms more frequently reported by patients with IIH diagnosis. In the same group of patients, papilledema (p < .001) and sixth nerve palsy (p = .010) were noted significantly more often. Papilledema was extracted by multivariate analysis as an independent predictor of IIH diagnosis (p < .001).

Conclusion: Although studies investigating IIH report an abundance of presenting symptoms, our results indicate that these symptoms are not diagnostic for IIH. Papilledema is the most reliable clinical sign predicting the correct IIH diagnosis in patients with suspected IIH.
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http://dx.doi.org/10.1016/j.jns.2019.02.006DOI Listing
April 2019

Complete withdrawal is the most effective approach to reduce disability in patients with medication-overuse headache: A randomized controlled open-label trial.

Cephalalgia 2019 06 7;39(7):863-872. Epub 2019 Feb 7.

Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark.

Background: Medication-overuse headache leads to high disability and decreased quality of life, and the best approach for withdrawal has been debated.

Aim: To compare change in disability and quality of life between two withdrawal programs.

Methods: We randomized medication-overuse headache patients to program A (two months without acute analgesics or migraine medications) or program B (two months with acute medications restricted to two days/week) in a prospective, outpatient study. At 6 and 12 months, we measured disability and headache burden by the Headache Under-Response to Treatment index (HURT). We estimated quality of life by EUROHIS-QOL 8-item at 2-, 6-, and 12-month follow-up. Primary endpoint was disability change at 12 months.

Results: We included 72 medication-overuse headache patients with primary migraine and/or tension-type headache. Fifty nine completed withdrawal and 54 completed 12-month follow-up. At 12-month follow-up, 41 patients completed HURT and 38 completed EUROHIS-QOL 8-item. Disability reduction was 25% in program-A and 7% in program-B ( p = 0.027). Headache-burden reduction was 33% in program-A and 3% in program-B ( p = 0.005). Quality of life was increased by 8% in both programs without significant difference between the programs ( p = 0.30). At 2-month follow-up, quality of life increased significantly more in program-A than program-B ( p = 0.006).

Conclusion: Both withdrawal programs reduced disability and increased quality of life. Withdrawal without acute medication was the most effective in reducing disability in medication-overuse headache patients.

Trial Registration: Clinicaltrials.gov (NCT02903329).
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http://dx.doi.org/10.1177/0333102419828994DOI Listing
June 2019

Sleep in cluster headache revisited: Results from a controlled actigraphic study.

Cephalalgia 2019 05 23;39(6):742-749. Epub 2018 Nov 23.

1 Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Denmark.

Background And Aim: Cluster headache attacks exhibit a nocturnal predilection, but little is known of long-term sleep and circadian rhythm. The aim was to compare actigraphy measures, firstly in episodic cluster headache patients in bout and in remission and, secondly, to compare each disease phase with controls.

Methods: Episodic cluster headache patients (ICHD III-beta), from the Danish Headache Center and healthy, age- and sex-matched controls participated. Sleep and activity were measured using actigraphy continuously for 2 weeks, along with sleep diaries and, for patients, also attack registration.

Results: Patients in bout (n = 17, 2.3 attacks/day) spent more time in bed (8.4 vs. 7.7 hours, p = 0.021) and slept more (7.2 vs. 6.6 hours, p = 0.036) than controls (n = 15). In remission (n = 11), there were no differences compared with controls. Neither were there differences between patients in the two disease phases. In five patients, attacks/awakenings occurred at the same hour several nights in a row.

Conclusion: Actigraphy offers the possibility of a continuous and long study period in a natural (non-hospital) environment. The study indicates that sleep does not differ between the bout and remission phase of episodic cluster headache. The repeated attacks/awakenings substantiate that circadian or homeostatic mechanisms are involved in the pathophysiology. The protocol was made available at ClinicalTrials.gov (NCT02853487).
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http://dx.doi.org/10.1177/0333102418815506DOI Listing
May 2019

Cluster headache beyond the pain phase: A prospective study of 500 attacks.

Neurology 2018 08 27;91(9):e822-e831. Epub 2018 Jul 27.

From the Danish Headache Center, Department of Neurology (A.S., N.L., R.B., A.H., R.J., M.B.), Rigshospitalet-Glostrup, University of Copenhagen; and Department of Clinical Physiology and Nuclear Medicine (M.B.), Center for Functional and Diagnostic Imaging, Hvidovre Hospital, Copenhagen, Denmark.

Objective: To describe the nature, prevalence, and duration of symptoms in the preictal, ictal, and postictal phases of cluster headache (CH) attacks.

Methods: Fifty-seven patients with episodic or chronic CH participated in this prospective, observational study. In a questionnaire concerning 33 CH and migraine-related symptoms, patients reported the clinical features of up to 10 CH attacks/patient. The questionnaire was divided into 3 sections: a preictal phase, ictal phase, and postictal phase. For each phase, patients documented whether the given symptom was present, and if possible estimated the duration of the symptom.

Results: In total, 500 CH attack descriptions were obtained. In the preictal phase, general symptoms (most frequently concentration difficulties, restlessness, and mood changes) occurred 20 minutes prior to 46.0% of attacks. Local painful and autonomic symptoms were observed 10 minutes prior to 54.6% and 35% of attacks, respectively. Postictally, pain and autonomic symptoms resolved over 20 minutes, leaving patients with fatigue (36.2%), decreased energy (39.0%), and concentration difficulties (27.6%), lasting a median of 60 minutes.

Conclusions: Preictal and postictal symptoms are very frequent in CH, demonstrating that CH attacks are not composed of a pain phase alone. Since the origin of CH attacks is unresolved, studies of preictal and postictal symptoms could contribute to the understanding of CH pathophysiology and, potentially, early, abortive treatment strategies.
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http://dx.doi.org/10.1212/01.wnl.0000542491.92981.03DOI Listing
August 2018

Economic benefits of treating medication-overuse headache - results from the multicenter COMOESTAS project.

Cephalalgia 2019 02 8;39(2):274-285. Epub 2018 Jul 8.

7 Headache Science Centre, C. Mondino National Neurological Institute, Pavia, Italy.

Background: Medication-overuse headache is a costly disease for individuals and society.

Objective: To estimate the impact of medication-overuse headache treatment on direct and indirect headache-related health care costs.

Methods: This prospective longitudinal study was part of the COMOESTAS project (COntinuous MOnitoring of Medication Overuse Headache in Europe and Latin America: development and STAndardization of an Alert and decision support System). Patients with medication-overuse headache were included from four European and two Latin American headache centers. Costs of acute medication, costs of health care services, and measurements of productivity were calculated at baseline and at 6-month follow-up Treatment consisted of overused drug withdrawal with optional preventive medication.

Results: A total of 475 patients (71%) completed treatment and were followed up for 6 months. Direct health care costs were on average reduced significantly by 52% ( p < 0.001) for the total study population. Significant reductions were seen in both number of consumed tablets (-71%, p < 0.001) and number of visits to physicians (-43%, p < 0.001). Fifty percent of patients reduced their number of consumed tablets ≥ 80%. Headache-related productivity loss, calculated either as absence from work or ≥ 50% reduction of productivity during the workday, were reduced by 21% and 34%, respectively ( p < 0.001).

Conclusion: Standardized treatment of medication-overuse headache in six countries significantly reduced direct health care costs and increased productivity. This emphasizes the importance of increasing awareness of the value of treating medication-overuse headache.

Trial Registration: The trial was registered at ClinicalTrials.gov (no. NCT02435056).
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http://dx.doi.org/10.1177/0333102418786265DOI Listing
February 2019

Psychological, clinical, and therapeutic predictors of the outcome of detoxification in a large clinical population of medication-overuse headache: A six-month follow-up of the COMOESTAS Project.

Cephalalgia 2019 01 27;39(1):135-147. Epub 2018 Jun 27.

1 Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy.

Aim: To identify factors that may be predictors of the outcome of a detoxification treatment in medication-overuse headache.

Methods: Consecutive patients entering a detoxification program in six centres in Europe and Latin America were evaluated and followed up for 6 months. We evaluated anxious and depressive symptomatology (though patients with severe psychiatric comorbidity were excluded), quality of life, headache-related disability, headache characteristics, and prophylaxis upon discharge.

Results: Of the 492 patients who completed the six-month follow up, 407 ceased overuse following the detoxification (non overusers), another 23 ceased overuse following detoxification but relapsed during the follow-up. In the 407 non-overusers, headache acquired an episodic pattern in 287 subjects (responders). At the multivariate analyses, lower depression scores (odds ratio = 0.891; p = 0.001) predicted ceasing overuse. The primary headache diagnosis - migraine with respect to tension-type headache (odds ratio = 0.224; p = 0.001) or migraine plus tension-type headache (odds ratio = 0.467; p = 0.002) - and the preventive treatment with flunarizine (compared to no such treatment) (odds ratio = 0.891; p = 0.001) predicted being a responder. A longer duration of chronic headache (odds ratio = 1.053; p = 0.032) predicted relapse into overuse. Quality of life and disability were not associated with any of the outcomes.

Conclusions: Though exploratory in nature, these findings point to specific factors that are associated with a positive outcome of medication-overuse headache management, while identifying others that may be associated with a negative outcome. Evaluation of the presence/absence of these factors may help to optimize the management of this challenging groups of chronic headache sufferers.
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http://dx.doi.org/10.1177/0333102418783317DOI Listing
January 2019

The burden of headache, also for the adolecents?

Scand J Pain 2018 Jul 1;2(3):146-147. Epub 2018 Jul 1.

The Danish Headache Centre, Department of Neurology, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark.

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http://dx.doi.org/10.1016/j.sjpain.2011.06.001DOI Listing
July 2018

Migraine co-existing tension-type headache and neck pain: Validation of questionnaires.

Scand J Pain 2015 Jul 1;8(1):10-16. Epub 2015 Jul 1.

Department of Health Sciences, Lund University, P.O. Box 157, 221 00 Lund, Sweden.

Aabstract Background and aim Migraine often includes co-existing tension-type headache (TTH) and neck pain (NP). Multiple headache questionnaires assessing headache impact have beendescribed previously; however, none of the existing questionnaires have been designed to cover migraine with co-existing TTH and NP. Therefore a new questionnaire was developed to measure these co-morbidities. The aim was to determine face and content validity of the newly developed questionnaire, "Impact of Migraine, Tension-Type Headache and Neck Pain" (impact M-TTH-NP) and to determine face and content validity of the International Physical Activity Questionnaire (IPAQ short form), Migraine-Specific Quality of Life Questionnaire (MSQ v. 2.1), WHO-Five Well-Being Index (WHO-5), Major Depression Inventory (MDI) and Neck Disability Index (NDI) not yet validated in this target population. Material and methods The new multi-dimensional questionnaire "Impact M-TTH-NP" cover pain, triggers, psychosocial, socioeconomic and work related aspects, based on a four-week recall period. The items are rated on an 11-point numeric rating scale with the end points 0 = no impact and 10 = most imaginable impact. Face validity was assessed by migraine patients with co-existing TTH and NP. They were recruited between September 2012 and March 2013 from a tertiary referral headache centre. Nine women with a mean age of 38 years participated in group interviews. The questionnaires were reviewed for relevance and meaningfulness. Content validity was assessed by 13 headache experts. They had worked with headache diseases for an average of 9 (range, 2-38) years. Experts were recruited between August 2012 and October 2012. Nine medical doctors, two physical therapists, one headache nurse and one psychologist (eight women and five men, mean age of 42 years) participated. The experts rated each item of the questionnaires using a four-point Likert scale with the end points 1 = not relevant and 4 = highly relevant. The quantitative measurement of content validity was calculated by the item-level content validity index (I-CVI) and the scale-level content validity average method (S-CVI/Ave). The average deviation (AD) index was used as a measure of interrater agreement. Results Impact M-TTH-NP showed acceptable face validity. Of 78 items twelve were revised and one was added based on group interviews and expert review. Seventy-two items (92%) obtained I-CVI≥0.78 (range 0.78-1.00) indicating excellent content validity, 71 items (91%) obtained acceptable AD index. Nine items did not meet either the limit for excellent I-CVI and/or acceptable AD index. The overall S-CVI/Ave was 0.92 indicating an excellent content validity. In addition, four of the five additional questionnaires showed acceptable face validity (MSQ, WHO-5, MDI and NDI) and three showed excellent content validity (WHO-5, MDI and NDI) for patients suffering from migraine and co-existing TTH and NP. Conclusions and implications The impact M-TTH-NP questionnaire showed acceptable face validity and excellent content validity and may be useful when evaluating treatment effect in this target group. The new impact M-TTH-NP questionnaire in combination with the additional questionnaires that together assess pain, triggers, psychosocial and socioeconomic aspects may provide a deeper understanding of the complexity of migraine with co-existing TTH and NP.
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http://dx.doi.org/10.1016/j.sjpain.2015.03.001DOI Listing
July 2015

Idiopathic intracranial hypertension: consensus guidelines on management.

J Neurol Neurosurg Psychiatry 2018 10 14;89(10):1088-1100. Epub 2018 Jun 14.

Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.

The aim was to capture interdisciplinary expertise from a large group of clinicians, reflecting practice from across the UK and further, to inform subsequent development of a national consensus guidance for optimal management of idiopathic intracranial hypertension (IIH).

Methods: Between September 2015 and October 2017, a specialist interest group including neurology, neurosurgery, neuroradiology, ophthalmology, nursing, primary care doctors and patient representatives met. An initial UK survey of attitudes and practice in IIH was sent to a wide group of physicians and surgeons who investigate and manage IIH regularly. A comprehensive systematic literature review was performed to assemble the foundations of the statements. An international panel along with four national professional bodies, namely the Association of British Neurologists, British Association for the Study of Headache, the Society of British Neurological Surgeons and the Royal College of Ophthalmologists critically reviewed the statements.

Results: Over 20 questions were constructed: one based on the diagnostic principles for optimal investigation of papilloedema and 21 for the management of IIH. Three main principles were identified: (1) to treat the underlying disease; (2) to protect the vision; and (3) to minimise the headache morbidity. Statements presented provide insight to uncertainties in IIH where research opportunities exist.

Conclusions: In collaboration with many different specialists, professions and patient representatives, we have developed guidance statements for the investigation and management of adult IIH.
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http://dx.doi.org/10.1136/jnnp-2017-317440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166610PMC
October 2018

The Melanopsin-Mediated Pupillary Light Response Is Not Changed in Patients with Newly Diagnosed Idiopathic Intracranial Hypertension.

Neuroophthalmology 2018 Apr 18;42(2):65-72. Epub 2017 Aug 18.

Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark.

Previously, it has been reported that melanopsin-mediated pupillary light response (PLR), measured with pupillometry, is reduced in patients with idiopathic intracranial hypertension (IIH), indicating the clinical utility of the tool in the diagnosis of IIH. In the current study, the authors aimed to measure the PLR in 13 treatment-naive patients with new-onset IIH and 13 healthy controls. In contrast to the previous report, which was based on patients with longstanding IIH ( = 13), the authors found no significant difference in the melanopsin-mediated PLR ( = 0.48).
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http://dx.doi.org/10.1080/01658107.2017.1344251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858859PMC
April 2018

Intracranial Pressure: A Comparison of the Noninvasive HeadSense Monitor versus Lumbar Pressure Measurement.

World Neurosurg 2018 Apr 2;112:e576-e580. Epub 2018 Feb 2.

Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark. Electronic address:

Objective: To compare a new method of noninvasive intracranial pressure (nICP) measurement with conventional lumbar puncture (LP) opening pressure.

Methods: In a prospective multicenter study, patients undergoing LP for diagnostic purposes underwent intracranial pressure measurements with HeadSense, a noninvasive transcranial acoustic device, and indirectly with LP. Noninvasive measurements were conducted with the head in a 30° tilt and in supine position before and after LP. The primary endpoint was the correlation between nICP measurement in supine position before LP and the LP opening pressure.

Results: There was no correlation between supine nICPs before LP and the LP opening pressures (r = -0.211, P = 0.358). The 30° head-tilt nICPs correlated with the supine nICPs before LP (r = 0.830, P < 0.01). There was no correlation between supine nICPs before and after LP (r = 0.056, P = 0.831) or between 30° head-tilt nICPs and LP opening pressures (r = -0.038, P = 0.861).

Conclusions: There was no correlation between nICPs and LP opening pressures. Further development is warranted before transcranial acoustic HeadSense can become a clinical tool for investigating patients with neurologic conditions.
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http://dx.doi.org/10.1016/j.wneu.2018.01.089DOI Listing
April 2018

Sphenopalatine ganglion stimulation for cluster headache, results from a large, open-label European registry.

J Headache Pain 2018 Jan 18;19(1). Epub 2018 Jan 18.

Department of Systems Neuroscience, Universitäts-Klinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.

Background: Cluster headache (CH) is a disabling primary headache disorder characterized by severe periorbital pain. A subset of patients does not respond to established pharmacological therapy. This study examines outcomes of a cohort of mainly chronic CH patients treated with sphenopalatine ganglion (SPG) stimulation.

Methods: Patients were followed in an open-label prospective study for 12 months. Ninety-seven CH patients (88 chronic, 9 episodic) underwent trans-oral insertion of a microstimulator targeting the SPG. Patients recorded stimulation effect prospectively for individual attacks. Frequency, use of preventive and acute medications, headache impact (HIT-6) and quality of life measures (SF-36v2) were monitored at clinic visits. Per protocol, frequency responders experienced ≥ 50% reduction in attack frequency and acute responders treated ≥ 50% of attacks. HIT-6 responders experienced an improvement ≥ 2.3 units and SF-36 responders ≥ 4 units vs. baseline.

Results: Eighty-five patients (78 chronic, 7 episodic) remained implanted and were evaluated for effectiveness at 12 months. In total, 68% of all patients were responders, 55% of chronic patients were frequency responders and 32% of all patients were acute responders. 67% of patients using acute treatments were able to reduce the use of these by 52% and 74% of chronic patients were able to stop, reduce or remain off all preventive medications. 59% of all patients were HIT-6 responders, 67% were SF-36 responders.

Conclusions: This open-label registry corroborates that SPG stimulation is an effective therapy for CH patients providing therapeutic benefits and improvements in use of medication as well as headache impact and quality of life.
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http://dx.doi.org/10.1186/s10194-017-0828-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773459PMC
January 2018

The effects of aerobic exercise for persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled, clinical trial.

Cephalalgia 2018 10 15;38(12):1805-1816. Epub 2018 Jan 15.

2 Danish Headache Centre, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark.

Aim To evaluate aerobic exercise in migraine and co-existing tension-type headache and neck pain. Methods Consecutively recruited persons with migraine and co-existing tension-type headache and neck pain were randomized into an exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 minutes, three times/week. Controls continued usual daily activities. Pain frequency, intensity, and duration; physical fitness, level of physical activity, well-being and ability to engage in daily activities were assessed at baseline, after treatment and at follow-up. Results Fifty-two persons completed the study. Significant between-group improvements for the exercise group were found for physical fitness, level of physical activity, migraine burden and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Within the exercise group, significant reduction was found for migraine frequency, pain intensity and duration, neck pain intensity, and burden of migraine; an increase in physical fitness and well-being. Conclusions Exercise significantly reduced the burden of migraine and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Exercise also reduced migraine frequency, pain intensity and duration, although this was not significant compared to controls. These results emphasize the importance of regular aerobic exercise for reduction of migraine burden.
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http://dx.doi.org/10.1177/0333102417752119DOI Listing
October 2018

Kvinder kan også få Hortons hovedpine.

Ugeskr Laeger 2017 10;179(44)

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October 2017

Board Walk - October 2016.

Cephalalgia 2016 Oct;36(11):1096-1097

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http://dx.doi.org/10.1177/0333102416663828DOI Listing
October 2016

Cranial parasympathetic activation induces autonomic symptoms but no cluster headache attacks.

Cephalalgia 2018 07 30;38(8):1418-1428. Epub 2017 Oct 30.

1 Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.

Background Low frequency (LF) stimulation of the sphenopalatine ganglion (SPG) may increase parasympathetic outflow and provoke cluster headache (CH) attacks in CH patients implanted with an SPG neurostimulator. Methods In a double-blind randomized sham-controlled crossover study, 20 CH patients received LF or sham stimulation for 30 min on two separate days. We recorded headache characteristics, cephalic autonomic symptoms (CAS), plasma levels of parasympathetic markers such as pituitary adenylate cyclase-activating polypeptide-38 (PACAP38) and vasoactive intestinal peptide (VIP), and mechanical detection and pain thresholds as a marker of sensory modulation. Results In the immediate phase (0-60 min), 16 (80%) patients experienced CAS after LF stimulation, while nine patients (45%) reported CAS after sham ( p = 0.046). We found no difference in induction of cluster-like attacks between LF stimulation (n = 7) and sham stimulation (n = 5) ( p = 0.724). There was no difference in mechanical detection and pain thresholds, and in PACAP and VIP plasma concentrations between LF and sham stimulation ( p ≥ 0.162). Conclusion LF stimulation of the SPG induced autonomic symptoms, but no CH attacks. These data suggest that increased parasympathetic outflow is not sufficient to induce CH attacks in patients. Study protocol ClinicalTrials.gov registration number NCT02510729.
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http://dx.doi.org/10.1177/0333102417738250DOI Listing
July 2018

Complete detoxification is the most effective treatment of medication-overuse headache: A randomized controlled open-label trial.

Cephalalgia 2018 02 19;38(2):225-236. Epub 2017 Oct 19.

Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Denmark.

Background There is lack of evidence on how to detoxify medication-overuse headache. Aim To compare the effect of complete stop of acute medication with restricted intake. Methods Medication-overuse headache patients were included in a prospective, outpatient study and randomized to two months' detoxification with either a) no analgesics or acute migraine-medication (program A), or b) acute medication restricted to two days/week (program B). Detoxification was followed by preventives if indicated. Patients were followed up at 2, 6 and 12 months. Percentage reduction in headache days/month after 6 months was the primary outcome. Results We included 72 medication-overuse headache patients with a primary migraine and/or tension-type headache diagnosis. Fifty-nine completed detoxification, 58 (81%) were followed up at month 6 and 53 (74%) at month 12. At month 6, program A reduced headache days/month by 46% (95% CI 34-58) compared with 22% (95% CI 11-34) in program-B ( p = 0.005), and 70% in program A versus 42% in program B were reverted to episodic headache ( p = 0.04). Migraine-days/month were reduced by 7.2 in program A ( p < 0.001) and 3.6 in program B ( p = 0.002) after 6 months. Conclusion Both detoxification programs were very effective. Detoxification without analgesics or acute migraine-medication was the most effective program. Trial registration Clinicaltrials.gov (NCT02903329).
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http://dx.doi.org/10.1177/0333102417737779DOI Listing
February 2018

National awareness campaign to prevent medication-overuse headache in Denmark.

Cephalalgia 2018 06 10;38(7):1316-1325. Epub 2017 Oct 10.

1 Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Copenhagen, Denmark.

Background Medication-overuse headache is prevalent, but in principle preventable. Objective To describe the Danish national awareness campaign for medication-overuse headache. Methods The Danish Headache Center, the Association of Danish Pharmacies, and headache patient organizations implemented a four-month medication-overuse headache awareness campaign in 2016. Target groups were the general public, general practitioners, and pharmacists. Key messages were: Overuse of pain-medication can worsen headaches; pain-medication should be used rationally; and medication-overuse headache is treatable. A range of communication technologies was used. A survey on the public's awareness of medication-overuse headache was conducted. Results The Danish adult population is 4.2 million. Online videos were viewed 297,000 times in three weeks. All 400 pharmacies received campaign materials. Over 28,000 leaflets were distributed. Two radio interviews were conducted. A television broadcast about headache reached an audience of 520,000. Forty articles were published in print media. Information was accessible at 32 reputable websites and five online news agencies. Three scientific papers were published. Information was available at an annual conference of general practitioners, including a headache lecture. The survey showed an increase in percentage of the public who knew about medication-overuse headache (from 31% to 38%). Conclusion A concerted campaign to prevent medication-overuse headache can be implemented through involvement of key stakeholders.
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http://dx.doi.org/10.1177/0333102417736898DOI Listing
June 2018

Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain.

J Headache Pain 2017 Dec 18;18(1):46. Epub 2017 Apr 18.

Department of Health Sciences, Lund University, P.O. Box 157, 221 00, Lund, Sweden.

Background: The prevalence of migraine with co-existing tension-type headache and neck pain is high in the general population. However, there is very little literature on the characteristics of these combined conditions. The aim of this study was to investigate a) the prevalence of migraine with co-existing tension-type headache and neck pain in a clinic-based sample, b) the level of physical activity, psychological well-being, perceived stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain compared to healthy controls, c) the perceived ability of persons with migraine and co-existing tension-type headache and neck pain to perform physical activity, and d) which among the three conditions (migraine, tension-type headache or neck pain) is rated as the most burdensome condition.

Methods: The study was conducted at a tertiary referral specialised headache centre where questionnaires on physical activity, psychological well-being, perceived stress and self-rated health were completed by 148 persons with migraine and 100 healthy controls matched by sex and average age. Semi-structured interviews were conducted to assess characteristics of migraine, tension-type headache and neck pain.

Results: Out of 148 persons with migraine, 100 (67%) suffered from co-existing tension-type headache and neck pain. Only 11% suffered from migraine only. Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress and poorer self-rated health compared to healthy controls. They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.

Conclusions: Migraine with co-existing tension-type headache and neck pain was highly prevalent in a clinic-based sample. Persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity, and to improve psychological well-being, perceived stress and self-rated health.
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http://dx.doi.org/10.1186/s10194-017-0753-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395520PMC
December 2017
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