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1.  The differential diagnosis of chronic daily headaches: an algorithm-based approach 
The Journal of Headache and Pain  2007;8(5):263-272.
Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for “red flags” that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is ≥4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.
doi:10.1007/s10194-007-0418-3
PMCID: PMC2793374  PMID: 17955166
Chronic daily headache; Differential diagnosis; Strategy
2.  Chronic paroxysmal hemicrania in paediatric age: report of two cases 
The Journal of Headache and Pain  2011;12(2):263-267.
Chronic paroxysmal hemicrania (CPH) is a rare primary headache syndrome, which is classified along with hemicrania continua and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) as trigeminal autonomic cephalalgia (TACs). CPH is characterised by short-lasting (2–30 min), severe and multiple (more than 5/day) pain attacks. Headache is unilateral, and fronto-orbital-temporal pain is combined with cranial autonomic symptoms. According to the International Classification of Headache Disorders, 2nd edition, the attacks are absolutely responsive to indomethacin. CPH has been only rarely and incompletely described in the developmental age. Here, we describe two cases concerning a 7-year-old boy and a 11-year-old boy with short-lasting, recurrent headache combined with cranial autonomic features. Pain was described as excruciating, and was non-responsive to most traditional analgesic drugs. The clinical features of our children’s headache and the positive response to indomethacin led us to propose the diagnosis of CPH. Therefore, our children can be included amongst the very few cases of this trigeminal autonomic cephalgia described in the paediatric age.
doi:10.1007/s10194-011-0315-7
PMCID: PMC3072501  PMID: 21340658
Chronic paroxysmal hemicrania; Trigeminal autonomic cephalgias; Children; Indomethacin
3.  Chronic paroxysmal hemicrania in paediatric age: report of two cases 
The Journal of Headache and Pain  2011;12(2):263-267.
Chronic paroxysmal hemicrania (CPH) is a rare primary headache syndrome, which is classified along with hemicrania continua and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) as trigeminal autonomic cephalalgia (TACs). CPH is characterised by short-lasting (2–30 min), severe and multiple (more than 5/day) pain attacks. Headache is unilateral, and fronto-orbital-temporal pain is combined with cranial autonomic symptoms. According to the International Classification of Headache Disorders, 2nd edition, the attacks are absolutely responsive to indomethacin. CPH has been only rarely and incompletely described in the developmental age. Here, we describe two cases concerning a 7-year-old boy and a 11-year-old boy with short-lasting, recurrent headache combined with cranial autonomic features. Pain was described as excruciating, and was non-responsive to most traditional analgesic drugs. The clinical features of our children’s headache and the positive response to indomethacin led us to propose the diagnosis of CPH. Therefore, our children can be included amongst the very few cases of this trigeminal autonomic cephalgia described in the paediatric age.
doi:10.1007/s10194-011-0315-7
PMCID: PMC3072501  PMID: 21340658
Chronic paroxysmal hemicrania; Trigeminal autonomic cephalgias; Children; Indomethacin
4.  Chronic headaches: from research to clinical practice 
The Journal of Headache and Pain  2005;6(4):175-178.
Chronic daily headache (CDH) is a heterogeneous group of headaches that includes primary and secondary varieties. Primary CDH is a frequent entity that probably affects 4–5% of the population. It can be subdivided into headaches of short duration (<4 h/attack) like chronic cluster headache, and disorders of long duration (>4 h/attack). Primary CDH of long duration includes transformed migraine, chronic tension–type headache, and new daily persistent headache and hemicrania continua. Analgesics, ergots and triptan overuse are frequent in all types of CDH. We revise recent insights into the epidemiology, pathophysiology, clinical characteristics and prognosis of CDH.
doi:10.1007/s10194-005-0177-y
PMCID: PMC3452019  PMID: 16362656
Chronic migraine; Chronic tension–type headache; New persistent daily headache; Physiopathology; Epidemiology
5.  Osmophobia in primary headaches 
The Journal of Headache and Pain  2005;6(4):213-215.
This study evaluates osmophobia (defined as an unpleasant perception, during a headache attack, of odours that are non–aversive or even pleasurable outside the attacks) in connection with the diagnosis of primary headaches. We recruited 775 patients from our Headache Centre (566 females, 209 males; age 38±12 years), of whom 477 were migraineurs without aura (MO), 92 with aura (MA), 135 had episodic tension–type headache (ETTH), 44 episodic cluster headache (ECH), 2 chronic paroxysmal hemicrania (CPH) and 25 other primary headaches (OPHs: 12 primary stabbing headaches, 2 primary cough headaches, 3 primary exertional headaches, 2 primary headaches associated with sexual activity, 3 hypnic headaches, 2 primary thunderclap headaches and 1 hemicrania continua). Among them, 43% with MO (205/477), 39% with MA (36/92), and 7% with CH (3/44) reported osmophobia during the attacks; none of the 135 ETTH and 25 OPH patients suffered this symptom. We conclude that osmophobia is a very specific marker to discriminate adequately between migraine (MO and MA) and ETTH; moreover, from this limited series it seems to be a good discriminant also for OPHs, and for CH patients not sharing neurovegetative symptoms with migraine. Therefore, osmophobia should be considered a good candidate as a new criterion for the diagnosis of migraine.
doi:10.1007/s10194-005-0188-8
PMCID: PMC3451998  PMID: 16362667
Osmophobia; Migraine; Primary headaches; International Headache Classification
6.  A case of short–lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Discussion of clinical features and differential diagnosis 
The Journal of Headache and Pain  2005;6(6):469-470.
Chronic short–lasting headaches, in which trigeminal autonomic cephalalgias (TACs) are included, are relatively rare syndromes and not always well recognised. We present a case highly suggestive of short–lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and we try to affirm essential points to distinguish the diagnosis from other TACs and chronic short–lasting headaches. We conclude that the qualifying points for differential diagnosis are number and duration of attacks in a day, presence of autonomic features and lack of indomethacin effect.
doi:10.1007/s10194-005-0261-3
PMCID: PMC3452302  PMID: 16388343
SUNCT; TACs
7.  P05.06. Treating Chronic Daily Headache Without Giving Yourself One: A Rational Integrative Algorithm of Care 
Focus Areas: Integrative Approaches to Care, Alleviating Pain
Chronic daily headache (CDH) is a descriptive term that encompasses multiple headache diagnoses and effects. It refers to a group of headache disorders characterized by a headache occurring on 15 or more days per month for more than 3 months. CDH affects 4% of the adult population in the United States, with similar figures around the world. The burden of CDH is extremely high, with considerable financial impact as well as impact on quality of life. The diagnosis and integrative management of CDH require a knowledge of distinct CDH subcategories and familiarity with conventional treatment regimens.
Approximately one third of patients seeking integrative care do so because of pain. Overall, 49.5% of US adults with severe headache, 13.5 million adults, reported using at least one complementary and alternative medicine (CAM) therapy within 12 months. However, integrative therapies offered at various centers around the United States do not offer a uniform approach to pain.
Sometimes the disconnect between plausible, scientific explanations and efficacy of treatment has resulted in the dismissal of integrative care. Even within the integrative medicine community, a tension exists between applying ideal-world evidence-based outcomes and real-world patient-centered care. The complex, personalized interventions required in integrative medicine lack the rigor of standardized protocols. Practitioners often struggle with when and how to use integrative approaches that may lack the scientific rationale clinicians are accustomed to when employing conventional medical options.
This presentation will provide a review of a successful five-pronged, integrative medicine treatment approach for CDH. The presenters are the medical directors of Alliance Institute for Integrative Medicine (AIIM), overseeing 20 000 patient visits each year, the majority of which deal with pain.
doi:10.7453/gahmj.2013.097CP.P05.06
PMCID: PMC3875029
8.  The patients’ perceptions of migraine and chronic daily headache: a qualitative study 
This study aimed to gain insight into the management of migraine and chronic daily headache (CDH) from the patients’ perspective. This article outlines the patients’ perceptions of migraine and chronic daily headache. Thirteen semi–structured interviews were carried out with patients suffering from IHS migraine. Five patients, due to their headache frequency of more than 15 headache days per month, were classed as CDH patients. The data were transcribed verbatim and analysed in accordance with the grounded theory methodology. The main themes were: headaches, impact and headaches related to health issues. The theme ‘headaches’ was sub-divided into ‘their pain and symptoms’, ‘differentiating between their headaches’ and ‘perceptions of headaches as barriers and facilitators to management’. The patients’ perceptions of migraine and CDH were sometimes conflicting and influenced the patients’ management behaviours. The qualitative methodology may help to inform doctors, other healthcare professionals and headache researchers about the patients’ perspective and possibly develop future headache research, care and education.
doi:10.1007/s10194-005-0144-7
PMCID: PMC3451956  PMID: 16362190
Migraine; Chronic daily headache; Patient; Perceptions
9.  Paroxysmal hemicrania responding to topiramate 
Chronic paroxysmal hemicrania (CPH) is a rare primary headache syndrome, which is classified along with cluster headache and short‐lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) as a trigeminal autonomic cephalalgia. CPH is exquisitely responsive to indomethacin so much so that the response is one of the current diagnostic criteria. The case of a patient with CPH, who had marked epigastric symptoms with indomethacin treatment and responded well to topiramate 150 mg daily, is reported. Cessation of topiramate caused return of episodes, and the response has persisted for 2 years. Topiramate may be a treatment option in CPH.
doi:10.1136/jnnp.2006.096651
PMCID: PMC2117807  PMID: 17172571
10.  Paroxysmal hemicrania responding to topiramate 
BMJ Case Reports  2009;2009:bcr06.2009.2007.
Chronic paroxysmal hemicrania (CPH) is a rare primary headache syndrome, which is classified along with cluster headache and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) as a trigeminal autonomic cephalalgia. CPH is exquisitely responsive to indomethacin, so much so that the response is one of the current diagnostic criteria. The case of a patient with CPH, who had marked epigastric symptoms with indomethacin treatment and responded well to topiramate 150 mg daily, is reported. Cessation of topiramate caused return of episodes, and the response has persisted for 2 years. Topiramate may be a treatment option in CPH.
doi:10.1136/bcr.06.2009.2007
PMCID: PMC3027924  PMID: 21734918
11.  Topiramate in the treatment of refractory chronic daily headache. An open trial 
Chronic daily headache (CDH) is a debilitating disorder that becomes a treatment challenge in patients refractory to the treatment. We hereby report our experience with topiramate treatment in patients with refractory CDH. The study design was a prospective, protocol–based follow–up and retrospective analysis of headache diaries. We treated with topiramate at slowly increased moderate increments 11 CDH patients who were refractory to multiple previous treatments. Topiramate treatment was effective in 7 (64%) patients. The treatment resulted in a 66% (median) decrease of the headache days per week and a significant decrease in headache severity, a reduction of the headache hours per day, and weekly analgesic consumption. These effects continued for an average follow–up of 8±4 months. The average effective dose was 100 mg/day. Slowly increasing the drug at moderate increments resulted in high tolerability of topiramate. We found topiramate to be an effective long–standing treatment option for patients with refractory CDH. Slow increments of the dosage contributed to high tolerability of the drug.
doi:10.1007/s10194-005-0155-4
PMCID: PMC3452312  PMID: 16362646
Topiramate; Chronic daily headache; Headache prevention
12.  Different forms of trigeminal autonomic cephalalgias in the same patient: description of a case 
The Journal of Headache and Pain  2010;11(3):281-284.
The trigeminal autonomic cephalalgias (TACs), including cluster headache, paroxysmal hemicrania and SUNCT, are characterized by the cardinal combination of short-lasting unilateral pain and autonomic phenomena affecting the head. Hemicrania continua (HC) shares many clinical characteristics with TACs, including unilateral pain and ipsilateral autonomic features. Nevertheless, HC is separately classified in the revised International Classification of Headache Disorders (ICHD-II). Here, we describe the case of a 45-year-old man presenting an unusual concurrence of different forms of primary headaches associated with autonomic signs, including subsequently ipsilateral cluster headache, SUNCT and HC. This report supports the theory that common mechanisms could be involved in pathophysiology of different primary headache syndromes.
doi:10.1007/s10194-010-0210-7
PMCID: PMC3451915  PMID: 20376519
Hemicrania continua; Cluster headache; SUNCT; TACs
13.  Review of botulinum toxin type A for the prophylactic treatment of chronic daily headache 
Botulinum toxin A is increasingly used in the treatment of idiopathic and symptomatic headache disorders. However, only few controlled trials are available and many trials can hardly be compared to each other because of different endpoints and different trial designs. In particular chronic daily headache, which is defined as an idiopathic headache occurring on more than 15 days per month for at least 3 months and a daily duration of at least 4 hours, is considered as a headache disorder with possible efficacy of botulinum toxin A. For the prophylactic treatment of chronic tension-type headache and chronic migraine, no sufficient positive evidence for a successful treatment can be obtained from randomized, double-blind, and placebo-controlled trials to date. For the treatment of chronic daily headache including medication overuse headache, there is some positive evidence for efficacy in a subgroup of patients. To date, the majority of double-blind and placebo-controlled studies do not suggest that botulinum toxin A is efficacious in the treatment of chronic idiopathic headache disorders. However, it is possible that some subgroups of patients with chronic daily headache will benefit from a long-term treatment with botulinum toxin A.
PMCID: PMC2656318  PMID: 19300611
botulinum toxin A; chronic daily headache; chronic tension-type headache; chronic migraine
14.  Chronic daily headache: old problems, new vistas 
The Journal of Headache and Pain  2000;1(Suppl 1):S5-S10.
In 1988 the problems concerning chronic daily headache (CDH) were neglected by the classification of the International Headache Society (IHS). More than ten years later, this issue is still debated, also in light of the foreseen revised classification. Several terms have been used to define the clinical picture of CDH, and different criteria have been proposed for the diagnosis of these forms. In most cases, CDH appears to evolve from an episodic migraine, but the temporal limits between an episodic and a no-longer episodic form of migraine are questionable. A decreased threshold for headache recurrence in CDH is currently hypothesized, and it may be due to either an impaired control system or a sensitization of the trigeminal neurons, occurring regardless of the original nature of headache. The identification of genetic alterations and neurobiological changes underlying the different forms of CDH may greatly facilitate any nosographic and therapeutical approach to this broad spectrum of disorders.
doi:10.1007/s101940070018
PMCID: PMC3611796
Key words Chronic daily headache; Tension-type headache; Migraine; Drug abuse; Nosography
15.  Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S51-S61.
The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that are characterized by strictly unilateral trigeminal distribution pain occurring in association with ipsilateral cranial autonomic symptoms. This group includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These disorders are very painful, often considered to be some of the most painful conditions known to mankind, and consequently are highly disabling. They are distinguished by the frequency of attacks of pain, the length of the attacks and very characteristic responses to medical therapy, such that the diagnosis can usually be made clinically, which is important because it dictates therapy. The management of TACs can be very rewarding for physicians and highly beneficial to patients.
doi:10.4103/0972-2327.100007
PMCID: PMC3444219  PMID: 23024564
Cluster headache; paroxysmal hemicrania; SUNA; SUNCT; trigeminal autonomic cephalalgias
16.  An unusual form of TAC–TAC sine autonomic phenomena 
The Journal of Headache and Pain  2008;9(5):331-332.
The trigeminal autonomic cephalalgias (TACs) are characterized by the cardinal combination of short-lasting unilateral pain and autonomic phenomena affecting the head, including cluster headache, paroxysmal hemicrania and SUNCT. Infrequently reported have been cases with dissociation of these two cardinal features- usually with autonomic phenomena without pain, rather than the reverse. Herein is described the case of a 56-year-old man presenting with an unusual form of TAC resembling chronic paroxysmal hemicrania but with a lower frequency of occurrence, with temporal features not typical of previously described TACs, and consisting of severe unilateral head pain without any autonomic symptoms or signs, absolutely responsive to indomethacin
doi:10.1007/s10194-008-0060-8
PMCID: PMC3452201  PMID: 18685807
Trigeminal autonomic cephalalgia; Paroxysmal hemicrania; Dissociation; Trigeminal-autonomic reflex
17.  Prevalence of headache in an elderly population: attack frequency, disability, and use of medication 
OBJECTIVES—To assess the 1 year prevalence of tension-type headache (TTH), migraine headache (MH), and chronic daily headache (CDH), as well as of headache in general in a rural elderly population.
METHODS—A door to door two phase survey was carried out on all elderly (⩾65 years) residents in three villages in central Italy. Participants completed a standardised headache questionnaire and underwent a clinical evaluation by a neurologist. Headache diagnosis was made according to the classification of the International Headache Society, with minor modifications for the classification of patients with MH with⩾15 attacks/month.
RESULTS—Eight hundred and thirty three (72.6%) of the 1147 eligible persons completed the study protocol. One year prevalence rates were respectively 44.5% for TTH, 11.0% for MH, 2.2% for symptomatic headaches, and 0.7% for the remaining types of headache. The prevalence of headache in general was 51.0% because 62 residents had both TTH and MH attacks. Prevalence rates of patients with headache were higher in women than men (62.1% and 36.6% respectively) and decreased steadily with age for the 65-74, 75-84, and 85-96 age groups (56.7%, 45.2% and 26.1% respectively). Prevalence rates were 20.4% for patients with moderate to severe attacks, 18.0% for those with ⩾1 attacks a month, and 4.4% for those with CDH. Of the 425 with headache 52 (12.2%) had not taken any drugs for their attacks in the previous year, 195 (45.9%) had taken them regularly, and 178 (41.9%) had taken them only when the headache pain interfered with activities that could not be postponed. Medication overuse was reported by 37.8% of patients with CDH with higher proportions for transformed migraine than for patients with chronic TTH (69.2% and 23.8% respectively, p=0.009)
CONCLUSIONS—A consistent proportion of elderly people have primary headaches and consultation with a specialist is particularly recommended for patients with moderate or severe attacks, or with CDH.


doi:10.1136/jnnp.70.3.377
PMCID: PMC1737286  PMID: 11181862
18.  Temporomandibular disorders in headache patients 
Objective: To identify the frequency of signs and symptoms of temporomandibular disorder (TMD) and its seve-rity in individuals with headache. Study Design: 60 adults divided into three groups of 20 individuals: chronic daily headache (CDH), episodic headache (EH) and a control group without headache (WH). Headache diagnosis was performed according to the criteria of International Headache Society and the signs and symptoms of TMD were achieved by using a clinical exam and an anamnestic questionnaire. The severity of TMD was defined by the temporomandibular index (TMI). Results: The TMD signs and symptoms were always more frequent in individuals with headache, especially report of pain in TMJ area (CDH, n=16; EH, n=12; WH, n=6), pain to palpation on masseter (CDH, n=19; EH, n=16; WH, n=11) which are significantly more frequent in episodic and chronic daily headache. The mean values of temporomandibular and articular index (CDH patients) and muscular index (CDH and EH patients) were statistically higher than in patients of the control group, notably the articular (CDH=0.38; EH=0.25;WH=0.19) and muscular (CDH=0.46; EH=0.51; WH=0.26) indices. Conclusions: These findings allow us to speculate that masticatory and TMJ pain are more common in headache subjects. Besides, it seems that the TMD is more severe in headache patients.
Key words:Temporomandibular dysfunction, headache disorders.
doi:10.4317/medoral.18007
PMCID: PMC3505700  PMID: 22926473
19.  Psychiatric comorbidity in pediatric chronic daily headache 
Objectives
The objectives of this study were to assess comorbid psychiatric diagnoses in youth with chronic daily headache (CDH) and to examine relationships between psychiatric status and CDH symptom severity, as well as headache-related disability.
Methods
Standardized psychiatric interviews (Kiddie Schedule for Affective Disorders and Schizophrenia, KSADS) were conducted with 169 youth ages 10–17 diagnosed with CDH. Participants provided prospective reports of headache frequency with a daily headache diary and completed measures of symptom severity, headache-related disability (PedMIDAS) and quality of life (PedsQL).
Results
Results showed that 29.6% of CDH patients met criteria for at least one current psychiatric diagnosis, and 34.9% met criteria for at least one lifetime psychiatric diagnosis. No significant relationship between psychiatric status and headache frequency, duration, or severity was found. However, children with at least one lifetime psychiatric diagnosis had greater functional disability and poorer quality of life than those without a psychiatric diagnosis.
Discussion
Contrary to research in adults with chronic headaches, most youth with CDH did not appear to be at an elevated risk for comorbid psychiatric diagnosis. However, patients with a comorbid psychiatric diagnosis were found to have higher levels of headache-related disability and poorer quality of life. Implications for treatment are discussed.
doi:10.1177/0333102412460776
PMCID: PMC3692295  PMID: 22990686
Chronic daily headache; pediatric; psychiatric comorbidity; emotional adjustment; headache-related disability; quality of life
20.  Stress and Sleep Duration Predict Headache Severity in Chronic Headache Sufferers 
Pain  2012;153(12):2432-2440.
The objective of this study was to evaluate the time-series relationships between stress, sleep duration, and headache pain among patients with chronic headaches. Sleep and stress have long been recognized as potential triggers of episodic headache (< 15 headache days/month), though prospective evidence is inconsistent and absent in patients diagnosed with chronic headaches (≥ 15 days/month). We reanalyzed data from a 28-day observational study of chronic migraine (n = 33) and chronic tension-type headache (n = 22) sufferers. Patients completed the Daily Stress Inventory and recorded headache and sleep variables using a daily sleep/headache diary. Stress ratings, duration of previous nights' sleep, and headache severity were modeled using a series of linear mixed models with random effects to account for individual differences in observed associations. Models were displayed using contour plots. Two consecutive days of either high stress or low sleep were strongly predictive of headache, whereas two days of low stress or adequate sleep were protective. When patterns of stress or sleep were divergent across days, headache risk was increased only when the earlier day was characterized by high stress or poor sleep. As predicted, headache activity in the combined model was highest when high stress and low sleep occurred concurrently during the prior 2 days denoting an additive effect. Future research is needed to expand on current findings among chronic headache patients and to develop individualized models that account for multiple simultaneous influences of headache trigger factors.
doi:10.1016/j.pain.2012.08.014
PMCID: PMC3626265  PMID: 23073072
Stress; Sleep; Headache; Time-series; Headache trigger factors; Headache precipitants
21.  Association of psychiatric co-morbidity and efficacy of treatment in chronic daily headache in Indian population 
Objective:
To study the prevalence of psychiatric co-morbidity in patients of chronic daily headache (CDH) and compare the efficacy of treatment between various type of headache associated with psychiatric co-morbidity.
Materials and Methods:
Prospective case control cohort study, 92 consecutive patients of CDH meeting eligibility criteria. The diagnosis of various subtypes of CDH was made according to the IHS criteria. Age, sex, educational, marital and socioeconomic status, matched controls were also selected. Patients were evaluated with the Mini International Neuropsychiatric Interview (MINI) scale at the time of enrolment and at 3 months.
Results:
CDH accounted for 28% of all headache patients. The mean age of presentation was 30.2 ± 10.3 years, male: Female ratio of 28:64 and mean duration of 4.56 ± 0.56 years. Chronic migraine (CM) accounted for 59 patients, chronic tension type headache (CTTH) 22 patients, new daily persistent headache (NDPH) 3 patients and miscellaneous 8 patients. Psychiatric co-morbidity was present in 53.3% patients with CDH, and was more common in CM (62.7%) as compared to CTTH (36.4%). Single psychiatric co-morbidity was seen in 26 patients, while 23 patients had multiple co-morbidity. Major depressive episode, anxiety disorder, agoraphobia and dysthymia were significant psychiatric co-morbidities. Patients with CM were treated with topiramate or divalproex sodium ER and CTTH were treated with amitriptyline. 55 patients came for follow up at 3 months, improvement in headache was seen in 29 patients.
Conclusion:
Psychiatric co-morbidity was present in more than 50% patients with CDH and its presence along with a duration of ≥2 years was associated with a poor response to treatment.
doi:10.4103/0976-3147.112736
PMCID: PMC3724287  PMID: 23914085
Chronic daily headache; chronic migraine; chronic tension type headache; psychiatric co-morbidity
22.  Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) secondary to epidermoid cyst in the right cerebellopontine angle successfully treated with surgery 
The Journal of Headache and Pain  2011;12-12(3):385-387.
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare headache syndrome classified among the trigeminal autonomic cephalalgias. It is usually idiopathic, although infrequent secondary forms have been described. Recently, the term short-lasting unilateral headache with cranial autonomic symptoms (SUNA) has been defined by the International Headache Society (ICHD-2) as similar to SUNCT with less prominent absent conjunctival injection and lacrimation. We report a patient with paroxysmal orbito-temporal pains, phenotypically suggesting SUNA, secondary to epidermoid cyst in the cerebellopontine angle which disappeared after tumor resection. Neuroimaging should be considered in all patients with SUNA, notably in those with atypical presentation as our patient who presented on examination trigeminal hypoesthesia and tinnitus. Realization of a brain MRI would rule out injuries that causes this type of syndrome.
doi:10.1007/s10194-011-0326-4
PMCID: PMC3094668  PMID: 21409598
SUNA; Epidermoid cyst; Cerebellopontine angle; Surgery; Treatment
23.  Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) secondary to epidermoid cyst in the right cerebellopontine angle successfully treated with surgery 
The Journal of Headache and Pain  2011;12(3):385-387.
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare headache syndrome classified among the trigeminal autonomic cephalalgias. It is usually idiopathic, although infrequent secondary forms have been described. Recently, the term short-lasting unilateral headache with cranial autonomic symptoms (SUNA) has been defined by the International Headache Society (ICHD-2) as similar to SUNCT with less prominent absent conjunctival injection and lacrimation. We report a patient with paroxysmal orbito-temporal pains, phenotypically suggesting SUNA, secondary to epidermoid cyst in the cerebellopontine angle which disappeared after tumor resection. Neuroimaging should be considered in all patients with SUNA, notably in those with atypical presentation as our patient who presented on examination trigeminal hypoesthesia and tinnitus. Realization of a brain MRI would rule out injuries that causes this type of syndrome.
doi:10.1007/s10194-011-0326-4
PMCID: PMC3094668  PMID: 21409598
SUNA; Epidermoid cyst; Cerebellopontine angle; Surgery; Treatment
24.  Headache prevalence and characteristics among school children as assessed by prospective paper diary recordings 
The Journal of Headache and Pain  2011;13(2):129-136.
In the present school-based study, a convenience sample of 477 students in grades 6–9 and second year in high school from a city and a smaller town recorded daily occurrence and intensity of headaches in a standard paper diary during a 3-week period. Total headache activity (headache sum), number of headache days, intensity level and duration for weekly headaches were estimated. Approximately 85% of the adolescents had experienced headache of any intensity level during the 3-week recording period. On the average, they reported 2.5 headache days per week and a mean intensity level for headache episodes of 1.7. Our estimates for headache of any intensity level (1–5) occurring at least once a week was surprisingly high (73.8%). For the highest intensity level across the whole 3-week period, almost identical proportions of mild and moderate headaches were reported by students (22.3–22.5%), while about twice as many (40.7%) had experienced severe headaches. Girls consistently reported more headaches than boys, in particular of the moderate and severe intensity types. Students in the city also reported more frequent and intense headaches than those in the town. Peak headache activity was observed at noon and in the afternoon and in the days from the middle of the week until weekend. The use of prospective recordings in diaries will further advance our knowledge on the prevalence and characteristics of recurrent headaches among children and adolescents in community samples.
doi:10.1007/s10194-011-0410-9
PMCID: PMC3274578  PMID: 22200765
Epidemiology; Assessment; Diary; Adolescents; School
25.  Headache prevalence and characteristics among school children as assessed by prospective paper diary recordings 
The Journal of Headache and Pain  2011;13(2):129-136.
In the present school-based study, a convenience sample of 477 students in grades 6–9 and second year in high school from a city and a smaller town recorded daily occurrence and intensity of headaches in a standard paper diary during a 3-week period. Total headache activity (headache sum), number of headache days, intensity level and duration for weekly headaches were estimated. Approximately 85% of the adolescents had experienced headache of any intensity level during the 3-week recording period. On the average, they reported 2.5 headache days per week and a mean intensity level for headache episodes of 1.7. Our estimates for headache of any intensity level (1–5) occurring at least once a week was surprisingly high (73.8%). For the highest intensity level across the whole 3-week period, almost identical proportions of mild and moderate headaches were reported by students (22.3–22.5%), while about twice as many (40.7%) had experienced severe headaches. Girls consistently reported more headaches than boys, in particular of the moderate and severe intensity types. Students in the city also reported more frequent and intense headaches than those in the town. Peak headache activity was observed at noon and in the afternoon and in the days from the middle of the week until weekend. The use of prospective recordings in diaries will further advance our knowledge on the prevalence and characteristics of recurrent headaches among children and adolescents in community samples.
doi:10.1007/s10194-011-0410-9
PMCID: PMC3274578  PMID: 22200765
Epidemiology; Assessment; Diary; Adolescents; School

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