American Headache Society (AHS): Annual Meeting

WASHINGTON – Women with a high burden of episodic migraine don’t appear to have any related cognitive impairment.

A small prospective study has found that women with as many as 10 migraines per month scored well within the normal range on tests of learning and memory, efficiency and attention, and processing speed, Jill Jesurum, Ph.D., reported in a poster at the annual meeting of the American Headache Society.

"This is very good news for women with migraine," said Dr. Jesurum, scientific director of the Swedish Heart and Vascular Institute at the Swedish Medical Center, Seattle. "I see migraine patients in my own clinic, and many are very worried because they feel they have some type of cognitive problems from their migraines."

Photo credit: ©fred goldstein/Fotolia.com.

She presented a subanalysis of the CAMP (Comorbidities Associated With Migraine and Patent Foramen Ovale) study. The ongoing study aims to assess cognitive impairment and other comorbidities in at least 40 patients with migraine aura and a large patent foramen ovale, compared with migraineurs who do not have the heart defect.

Dr. Jesurum’s substudy comprised 28 women with a high migraine burden. The subjects’ mean age was 35 years. They had experienced migraines for a mean 19 years, with a mean of eight migraines each month. The MIDAS (Migraine Disability Assessment Test) and HIT-6 (Headache Impact Test–6) both showed that these women experienced severe disability with their migraines, with a mean MIDAS score of 40 and a mean HIT-6 score of 64. Depression and anxiety were minimal and moderate, according to mean test scores.

The women underwent a battery of cognitive testing during a headache-free period; they had no headache symptoms and no alcohol or opioid use during the 24 hours before the testing. The analysis controlled for antiepileptic agents as well as the use of NSAIDs and anticoagulant or antiplatelet drugs. A neuropsychologist who was blinded to the headache ratings administered and scored the tests.

"What we found was very encouraging," Dr. Jesurum said in an interview. "These women with a very high migraine burden were functioning at a high cognitive level during their headache-free periods. All of them scored within 1 standard deviation in all of the tests."

A subanalysis of the data showed no significant relationships between cognitive function scores and monthly migraine frequency. However, Dr. Jesurum noted, "When we looked at migraine burden and disability as measured by the HIT-6 and the MIDAS, we did see many significant inverse relationships between migraine burden, disability and cognitive function. The higher the migraine burden and the higher the disability, the lower the cognitive functions were, but that relationship was not significant when [we looked] at monthly migraine frequency."

This may reflect the perceived intensity of migraines, she said. "One woman might have two migraines a month, but if they totally wreck her life and she can’t work or take care of her children, that may negatively impact her cognitive function. On the other hand, another may have 5 or even 10 migraines a month, but if she’s able to treat them adequately and go about her daily life, they may not affect her cognitive function."

Because the study was so small did not have a comparator, it must be regarded as exploratory, Dr. Jesurum noted. Also, the women were generally very well educated, with 54% having at least a bachelor’s degree.

"The results may not be generalizable to other areas or populations with a different educational level, but it still is a very encouraging initial observation," she said.

The research was supported by grants from Coherex Medical, the John L. Locke Jr. Charitable Trust, NMT Medical, and the National Headache Foundation. Neither Dr. Jesurum not her coinvestigators had any relevant financial disclosures.

WASHINGTON – Women with a high burden of episodic migraine don’t appear to have any related cognitive impairment.

A small prospective study has found that women with as many as 10 migraines per month scored well within the normal range on tests of learning and memory, efficiency and attention, and processing speed, Jill Jesurum, Ph.D., reported in a poster at the annual meeting of the American Headache Society.

"This is very good news for women with migraine," said Dr. Jesurum, scientific director of the Swedish Heart and Vascular Institute at the Swedish Medical Center, Seattle. "I see migraine patients in my own clinic, and many are very worried because they feel they have some type of cognitive problems from their migraines."

Photo credit: ©fred goldstein/Fotolia.com.

She presented a subanalysis of the CAMP (Comorbidities Associated With Migraine and Patent Foramen Ovale) study. The ongoing study aims to assess cognitive impairment and other comorbidities in at least 40 patients with migraine aura and a large patent foramen ovale, compared with migraineurs who do not have the heart defect.

Dr. Jesurum’s substudy comprised 28 women with a high migraine burden. The subjects’ mean age was 35 years. They had experienced migraines for a mean 19 years, with a mean of eight migraines each month. The MIDAS (Migraine Disability Assessment Test) and HIT-6 (Headache Impact Test–6) both showed that these women experienced severe disability with their migraines, with a mean MIDAS score of 40 and a mean HIT-6 score of 64. Depression and anxiety were minimal and moderate, according to mean test scores.

The women underwent a battery of cognitive testing during a headache-free period; they had no headache symptoms and no alcohol or opioid use during the 24 hours before the testing. The analysis controlled for antiepileptic agents as well as the use of NSAIDs and anticoagulant or antiplatelet drugs. A neuropsychologist who was blinded to the headache ratings administered and scored the tests.

"What we found was very encouraging," Dr. Jesurum said in an interview. "These women with a very high migraine burden were functioning at a high cognitive level during their headache-free periods. All of them scored within 1 standard deviation in all of the tests."

A subanalysis of the data showed no significant relationships between cognitive function scores and monthly migraine frequency. However, Dr. Jesurum noted, "When we looked at migraine burden and disability as measured by the HIT-6 and the MIDAS, we did see many significant inverse relationships between migraine burden, disability and cognitive function. The higher the migraine burden and the higher the disability, the lower the cognitive functions were, but that relationship was not significant when [we looked] at monthly migraine frequency."

This may reflect the perceived intensity of migraines, she said. "One woman might have two migraines a month, but if they totally wreck her life and she can’t work or take care of her children, that may negatively impact her cognitive function. On the other hand, another may have 5 or even 10 migraines a month, but if she’s able to treat them adequately and go about her daily life, they may not affect her cognitive function."

Because the study was so small did not have a comparator, it must be regarded as exploratory, Dr. Jesurum noted. Also, the women were generally very well educated, with 54% having at least a bachelor’s degree.

"The results may not be generalizable to other areas or populations with a different educational level, but it still is a very encouraging initial observation," she said.

The research was supported by grants from Coherex Medical, the John L. Locke Jr. Charitable Trust, NMT Medical, and the National Headache Foundation. Neither Dr. Jesurum not her coinvestigators had any relevant financial disclosures.

WASHINGTON – Women with a high burden of episodic migraine don’t appear to have any related cognitive impairment.

A small prospective study has found that women with as many as 10 migraines per month scored well within the normal range on tests of learning and memory, efficiency and attention, and processing speed, Jill Jesurum, Ph.D., reported in a poster at the annual meeting of the American Headache Society.

"This is very good news for women with migraine," said Dr. Jesurum, scientific director of the Swedish Heart and Vascular Institute at the Swedish Medical Center, Seattle. "I see migraine patients in my own clinic, and many are very worried because they feel they have some type of cognitive problems from their migraines."

Photo credit: ©fred goldstein/Fotolia.com.

She presented a subanalysis of the CAMP (Comorbidities Associated With Migraine and Patent Foramen Ovale) study. The ongoing study aims to assess cognitive impairment and other comorbidities in at least 40 patients with migraine aura and a large patent foramen ovale, compared with migraineurs who do not have the heart defect.

Dr. Jesurum’s substudy comprised 28 women with a high migraine burden. The subjects’ mean age was 35 years. They had experienced migraines for a mean 19 years, with a mean of eight migraines each month. The MIDAS (Migraine Disability Assessment Test) and HIT-6 (Headache Impact Test–6) both showed that these women experienced severe disability with their migraines, with a mean MIDAS score of 40 and a mean HIT-6 score of 64. Depression and anxiety were minimal and moderate, according to mean test scores.

The women underwent a battery of cognitive testing during a headache-free period; they had no headache symptoms and no alcohol or opioid use during the 24 hours before the testing. The analysis controlled for antiepileptic agents as well as the use of NSAIDs and anticoagulant or antiplatelet drugs. A neuropsychologist who was blinded to the headache ratings administered and scored the tests.

"What we found was very encouraging," Dr. Jesurum said in an interview. "These women with a very high migraine burden were functioning at a high cognitive level during their headache-free periods. All of them scored within 1 standard deviation in all of the tests."

A subanalysis of the data showed no significant relationships between cognitive function scores and monthly migraine frequency. However, Dr. Jesurum noted, "When we looked at migraine burden and disability as measured by the HIT-6 and the MIDAS, we did see many significant inverse relationships between migraine burden, disability and cognitive function. The higher the migraine burden and the higher the disability, the lower the cognitive functions were, but that relationship was not significant when [we looked] at monthly migraine frequency."

This may reflect the perceived intensity of migraines, she said. "One woman might have two migraines a month, but if they totally wreck her life and she can’t work or take care of her children, that may negatively impact her cognitive function. On the other hand, another may have 5 or even 10 migraines a month, but if she’s able to treat them adequately and go about her daily life, they may not affect her cognitive function."

Because the study was so small did not have a comparator, it must be regarded as exploratory, Dr. Jesurum noted. Also, the women were generally very well educated, with 54% having at least a bachelor’s degree.

"The results may not be generalizable to other areas or populations with a different educational level, but it still is a very encouraging initial observation," she said.

The research was supported by grants from Coherex Medical, the John L. Locke Jr. Charitable Trust, NMT Medical, and the National Headache Foundation. Neither Dr. Jesurum not her coinvestigators had any relevant financial disclosures.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Lankenau Headache Center in Wynnewood, Pa.*

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

* Correction, 7/22/2011: An earlier version of this article included an incorrect affiliation for Dr. Elliott Schulman. He is with the Lankenau Headache Center in Wynnewood, Pa.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

WASHINGTON – Between 20% and 40% of headache patients have endured some kind of maltreatment during their early lives, several epidemiologic studies have concluded.

Yet no study has ever pinpointed exactly which individuals exposed to a particular type of abuse will develop a certain type of headache – or whether they will get headaches at all, Dr. Gretchen Tietjen said at the annual meeting of the American Headache Society.

Photo credit: Nick Piegari/Elsevier Global Medical News

Nor has any study ever conclusively proven the benefit of screening headache patients for childhood abuse, or even helping those patients cope with their history.

Many studies have attempted to show a benefit of screening and treatment, but these generally "come up empty-handed" said Dr. Tietjen, director of the headache treatment and research program at the University of Toledo (Ohio) Medical Center. "It’s very difficult to identify the downstream evidence of morbidity and mortality, and there is even some concern that we could actually cause harm by [recalling events] that are going to be very difficult for a patient to deal with. The risk/benefit ratio for this has never been clearly elucidated."

Multiple animal studies, and now some clinical ones, have found that chronic early life stress induces a host of physical changes that compromise the body’s ability to cope with stress later on. These changes can manifest not only as headache, but as fibromyalgia, irritable bowel syndrome, interstitial cystitis, and chronic fatigue. Anxiety and depression can emerge as well. And some research even suggests that early stress can lead to a lifelong elevation in inflammatory response, setting the stage for a host of other disorders.

The Adverse Childhood Experiences (ACE) study confirmed a strong association between childhood stress and adult headache. ACE included more than 17,000 adults and examined the relationship between frequent headaches and eight early stressors: emotional, physical, or sexual abuse; domestic violence; parental separation or divorce; and living with an adult who was mentally ill, a substance abuser, or engaged in criminal activity (Headache 2010;50:1473-81).

The study found a dose-response relationship between adverse events in childhood and the frequency of adult headaches, said Dr. Tietjen, who was a primary investigator on ACE. With a possible score of 0-8, subjects who reported having five or more early adverse experiences were more than twice as likely to also report adult headache.

Then again, "not everyone who has a stressful childhood or is abused as a child will develop headaches," Dr. Tietjen said in an interview.

The who’s and why’s are still elusive, said Dr. Linda Carpenter, a psychiatrist and researcher at Brown University, Providence, R.I. The end result emerges from a complex and still somewhat mysterious brew of innate temperament, stress type and duration, and environmental mediators. Animal data not only support a neurobiologic link, but an epigenetic link as well. Chronic stress has the ability to change DNA expression, permanently altering the way a body responds to stress. And those changes may even become part of a new generation’s genetic makeup.

Some research also suggests that a new environment can reverse the physical changes of chronic stress. Rats separated from their mothers as babies develop elevated stress responses as they mature. But after living in an enriched environment – a cage with interconnecting burrows and toys to play with – their corticosterone levels during a stress test returned to normal (J. Neurosci. 2002;22:7840-3).

Individual perceptions can moderate or enhance the downstream effects of early maltreatment, said Dr. Elliott Schulman, an ACE coauthor. What one person perceives as a stressful, abusive situation may not trigger the same response in another. The reaction of adults aware of the early situation can also color the final picture, said Dr. Schulman, a neurologist at the Jefferson Headache Center, Philadelphia.

He described a patient with refractory headache who recalled girlhood vacations during which a relative "repeatedly groped her." She reported this to her parents, who assured her that "groping" was not sexual abuse. "If the person believes it was abusive, then it was, for that person," said Dr. Schulman, who routinely addresses abuse during his patient intake. Before the initial visit, each patient receives a registration packet that includes a personal history questionnaire. At the very end of the questionnaire, after the social and marital history, it asks: "Have you been abused?"

The patient can check yes or no and, if the answer is yes, he or she can select the type – physical, emotional, or sexual. "This is akin to every other assessment we do," he said. "We ask if patients are smoking, exercising, sleeping well, having unprotected sex, using drugs. We incorporate all this into a routine history. And now that I have incorporated this question as well, I have found out patients want you to ask. If you do, they will tell you."

The next question is what to do when the answer is yes.

"Often, I find that I am the first person who has ever asked, the first person the patient has ever told, and it can be a very emotional time," Dr. Schulman said. He added that he tries to ascertain the current situation. "If the abuse is ongoing, I get an abuse advocate involved and try to help the patient get to a safe place."

If the abuse is in the past, the discussion centers on the possibility that counseling could not only help the patient come to terms with the experience emotionally, but improve headache outcomes as well.

Dr. Tietjen said she also addresses the issue in a questionnaire about life stress. If the response is positive, "I explain that this might have changed their response to stress, and although I can’t change what happened, there are ways to deal with it. We discuss the idea that cognitive-behavioral therapy can be really helpful, rather than adding another pill."

Dr. Carpenter said she takes a different tack. "I don’t engage in conversations about it," she said. "I try to educate the patient about it if there is a history of early life stress by saying, ‘You are biologically programmed to be prone to the effects of stress the rest of your life.’ "

Stress management is key for these patients. "I tell them to become an antistress expert so that any new stress that enters their life doesn’t refuel the entire system," she said. Having this knowledge is very useful for people and helps them leverage multiple modalities of stress management – yoga, exercise, diet – so they can manage their stress and improve their outcomes. "These are very real things people can do to get better, and by doing them, they learn to be less aroused by stressful events."

Dr. Tietjen did not report having any conflicts. Dr. Carpenter reported receiving numerous research grants from pharmaceutical companies, as well as being a member of several speakers bureaus and advisory boards for pharmaceutical companies. Dr. Schulman said he had no disclosures.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Almost half of patients with episodic migraine report having at least one unmet medical need, according to the findings of more than 20,000 people participating in a population-based survey.

The findings suggest that despite the expanding armamentarium of acute migraine-specific therapies, patient satisfaction with treatment is at best low to moderate for many, Dawn Buse, Ph.D., said at the annual meeting of the American Headache Society.

"You all know this is nothing new. You keep working to meet your patients’ needs while considering side effects, cost, effectiveness, and speed of onset." But despite all these efforts, some patients report unsatisfactory results.

Dr. Buse, director of behavioral medicine at the Montefiore Headache Center, New York, and her colleagues examined data from the AMPP (American Migraine Prevalence and Prevention) study (Headache 2008 Sept. 2 [doi:10.1111/j.1526-4610.2008.01217.x]). This population-based survey began in 2004, when a general-population headache screening netted 162,756 respondents, 36,000 of whom reported having severe headache.

The study that was presented at the meeting examined data from the 2009 sample of 11,792 who had been followed since 2005, including 5,600 who met the International Classification of Headache Disorders definition of episodic migraine. A control group comprised 8,315 who were free of severe headache or migraine in the original 2004 survey.

Dr. Buse and her coinvestigators identified five domains of possible unmet treatment needs, and resurveyed the migraine population for their response. The domains included the following:

• Dissatisfaction with current acute treatment (assessed by the 3-item summary from the Patient Perception of Migraine Questionnaire).

• Moderate or severe headache-related disability (defined by a score of at least 11 on the Migraine Disability Assessment Test).

• Excessive use of opioids or barbiturates (that is, using the drugs at least 4 days per month or meeting the DSM-IV criteria for dependence).

• Excessive use of the emergency department or urgent care clinic for headache (that is, at least two visits in the preceding year).

• History of cardiovascular events that might preclude triptan therapy (including heart attack, stroke, angina, claudication, stent placement, or coronary artery bypass graft).

The samples were not significantly different in demographics; most (81%) were women. The mean age in the control group was 51 years vs. 52 years in the two groups with unmet needs. The mean body mass index also differed slightly. Among the control group, the mean BMI was 29 kg/m², compared with 30 in the group with one unmet need and 32 in the group with two or more unmet needs.

Headache days per month also varied between the groups. Those with no unmet needs reported a mean of 2 days per month with headache, compared with 3 days per month for the group with one unmet need, and 5 days per month for those with two or more needs.

Overall, 41% of those with episodic migraine reported having at least one unmet need; 26% reported one and 14% reported two or more.

The unmet need that was most commonly reported was headache-related disability of moderate to severe intensity (19%). Some 15% claimed dissatisfaction with their current therapy. Opioid or barbiturate use or dependence was seen in 13% of respondents. In all, 10% reported cardiovascular disease that could preclude triptan use, although 26% of these used the drugs despite these risks. Finally, 2% reported frequent headache-related visits to the ED or urgent care center.

"When we looked at the three most frequently reported areas, we saw an interesting overlap," Dr. Buse said. "Of the 19% who met the criteria for moderate to severe headache-related disability, 10% met that area only. But 4% of them also reported opioid overuse, 3% also reported dissatisfaction with their medications, and 2% endorsed all three of these areas."

The investigators then contrasted psychological comorbidities between the group with unmet needs and the 60% who reported no unmet needs. Anxiety and depression correlated significantly with the number of unmet needs.

Among the control group, 5% met criteria for anxiety and 10% for depression. Among the group with one unmet need, the rates were 11% for anxiety and 22% for depression. Among the group with at least two unmet needs, the rates were 21% for anxiety and 41% for depression.

In an interview, Dr. Buse said the relationship between headache and psychiatric disorders is not well-understood, but appears to be bidirectional. Anxiety increases the likelihood and the severity of headache, whereas headaches increase the risk of anxiety. The brain neurotransmitters that are involved in depression may also predispose a person to headache, but years of headache pain also increase the risk of becoming depressed, she said.

The AMPP study is funded by the American Headache Society through grants from Ortho-McNeil Neurologics and Merck Sharp & Dohme Corp., a subsidiary of Merck.

Dr. Buse has received research support from Allergan Pharmaceuticals, Iroko Pharmaceuticals, MAP Pharmaceuticals, and Merck.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.

WASHINGTON – Returning soldiers with posttraumatic headache seemed to have a poorer treatment outcome than did those with idiopathic migraine, regardless of the concurrent presence of posttraumatic stress disorder, according to the findings of a retrospective study.

"This may suggest that there is some fundamental difference in the pain mechanism between the two headache groups," according to Dr. Jacqueline Rosenthal of the Madigan Army Medical Center, Tacoma, Wash. "One theory is that those with migraine may be more susceptible to stress as a central contributor to their headache," she said at the annual meeting of the American Headache Society.

Dr. Rosenthal and her colleagues retrospectively analyzed 441 solders, mean age 30 years, who presented to the center’s neurology clinic with headache. In addition to headache diagnosis, all of the patients underwent screening for PTSD, defined as a score of at least 50 on the PTSD Symptom Checklist.

All of those with posttraumatic headache had a history of head trauma within 7 days preceding the onset of the headache. In the migraine group, there were patients with head trauma, but the injury did not precipitate the headache, Dr. Rosenthal explained. Individual physicians determined the course of patient treatment, but those with PTSD also received behavioral therapy.

Dr. Rosenthal and her colleagues examined headache frequency at baseline and after 3 months of treatment in four subgroups: migraineurs with and without PTSD, and posttraumatic headache patients with or without PTSD.

Of the total, 171 (39%) had a diagnosis of idiopathic migraine; 270 (61%) were diagnosed with posttraumatic headache. One-third of the entire cohort, (145) also met the criteria for PTSD. Of these, significantly more had posttraumatic headache than migraine (72% vs. 28%).

Patients with migraine and PTSD had significantly more headache days per month than did those with migraine but no PTSD (21 vs. 14 days per month). But PTSD did not affect headache frequency in patients with posttraumatic headache (17 days per month with PTSD vs. 16 days without PTSD).

Chronic daily headache was significantly more common in migraineurs with PTSD than in those without (68% vs. 44%). But PTSD had no significant association with chronic daily headache in the posttraumatic headache group (58% with PTSD vs. 52% without).

Although outcomes were significantly worse in posttraumatic headache patients than in migraineurs, PTSD did not exert any significant effect in either group, Dr. Rosenthal said. Headache frequency declined by 16% in both groups with posttraumatic headache. Among those with migraine, headache frequency declined by 28% among those with PTSD and by 35% in those without the disorder, but that difference did not meet statistical significance.

A discussant pointed out that soldiers with posttraumatic headache might have experienced more serious or frequent blast injuries, which could account for the poorer outcomes. Dr. Rosenthal said the study did not account for any characteristics of the blast injuries incurred, but agreed that these could have an effect on treatment outcome.

Dr. Rosenthal did not report having any conflicts of interest. She indicated that the study conclusions did not necessarily reflect the views of the United States Army.