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1.  GPs’ experiences with brief intervention for medication-overuse headache: a qualitative study in general practice 
The British Journal of General Practice  2014;64(626):e525-e531.
Background
Medication-overuse headache (MOH) is common in the general population, and most patients are managed in primary health care. Brief Intervention (BI) has been used as a motivational technique for patients with drug and alcohol overuse, and may a have role in the treatment of MOH.
Aim
To explore GPs’ experiences using BI in the management of patients with MOH.
Design and setting
Qualitative study in Norwegian general practice.
Method
Data were collected through four focus group interviews with 22 GPs who participated in an intervention study on BI for MOH. Systematic text condensation was used to analyse transcripts from the focus group interviews.
Results
The GPs experienced challenges when trying to convince patients that the medication they used to treat and prevent headache could cause headache, but labelling MOH as a diagnosis opened up a space for change. GPs were able to use BI within the scope of a regular consultation, and they thought that the structured approach had a potential to change patients’ views about their condition and medication use. Being diagnosed with medication overuse could bring about feelings of guilt in patients, and GPs emphasised that a good alliance with the patient was necessary for successful change using BI to manage MOH.
Conclusion
GPs experience BI as a feasible strategy to treat MOH, and the technique relies on a good alliance between the doctor and patient. When using BI, GPs must be prepared to counter patients’ misconceptions about medication used for headache.
doi:10.3399/bjgp14X681313
PMCID: PMC4141608  PMID: 25179065
headache disorder, secondary; analgesic/adverse effects; primary care, qualitative study
2.  Medication-overuse headache: a review 
Journal of Pain Research  2014;7:367-378.
Medication-overuse headache (MOH) is a worldwide health problem with a prevalence of 1%–2%. It is a severe form of headache where the patients often have a long history of headache and of unsuccessful treatments. MOH is characterized by chronic headache and overuse of different headache medications. Through the years, withdrawal of the overused medication has been recognized as the treatment of choice. However, currently, there is no clear consensus regarding the optimal strategy for management of MOH. Treatment approaches are based on expert opinion rather than scientific evidence. This review focuses on aspects of epidemiology, diagnosis, pathogenesis, prevention, and treatment of MOH. We suggest that information and education about the risk of MOH is important since the condition is preventable. Most patients experience reduction of headache days and intensity after successful treatment. The first step in the treatment of MOH should be carried out in primary care and focus primarily on withdrawal, leaving prophylactic medication to those who do not manage primary detoxification. For most patients, a general practitioner can perform the follow-up after detoxification. More complicated cases should be referred to neurologists and headache clinics. Patients suffering with MOH have much to gain by an earlier treatment-focused approach, since the condition is both preventable and treatable.
doi:10.2147/JPR.S46071
PMCID: PMC4079825  PMID: 25061336
medication-overuse headache; migraine; chronic headache; dependence
3.  Medication-overuse headache: epidemiology, diagnosis and treatment 
Medication-overuse headache (MOH) is one of the most common chronic headache disorders and a public health problem with a worldwide prevalence of 1–2%. It is a condition characterized by chronic headache and overuse of different headache medications, and withdrawal of the overused medication is recognised as the treatment of choice. However, the strategy for achieving withdrawal is, at present, based on expert opinion rather than scientific evidence, partly due to the lack of randomised controlled studies. This narrative review investigates different aspects of epidemiology, diagnosis, risk factors and pathogenesis as well as management for MOH. We suggest that the first step in the treatment of MOH should be carried out in general practice and should focus primarily on detoxification. For most patients, both prevention and follow up after detoxification can also be performed in general practice, thus freeing resources for referral of more complicated cases to headache clinics and neurologists. These suffering patients have much to gain by an earlier treatment-focused approach lower down on the treatment ladder.
doi:10.1177/2042098614522683
PMCID: PMC4110872  PMID: 25083264
chronic headache; dependence; drug safety; medication overuse; migraine
4.  Feasibility of a brief intervention for medication-overuse headache in primary care – a pilot study 
BMC Research Notes  2014;7:165.
Background
Medication-overuse headache (MOH) is a common problem in primary care. Brief intervention (BI) has successfully been used for detoxification from overuse of alcohol and drugs. The aim of this pilot study was to develop and test methodology, acceptability and logistics for a BI for MOH in primary care.
Findings
Observational feasibility study of an intervention in a Norwegian general practice population.
Six general practitioners (GPs) were recruited. A screening questionnaire for MOH was sent to all 18–50 year old patients on these GPs` list. GPs were taught BI, which was applied to MOH patients as follows: Severity of dependence scale (SDS) scores were collected and individual feedback was given of the relationship between the SDS, medication overuse and headache. Finally, advice to reduce medication was given. Patients were invited to a headache interview three months after the BI. Main outcomes were feedback from GPs/patients about the feasibility and logistics of the study design, screening/recruitment process, BI and headache interviews. Efficacy and patient-related outcomes were not focused. The patients reported a high degree of acceptability of the methodology. The GPs reported the BI to be feasible to implement within a busy practice and to represent a new and improved instrument for communication with MOH patients. The BI requires further testing in a randomised controlled trial (RCT) in order to provide evidence of efficacy.
Conclusion
This feasibility study will be used to improve the BI for MOH and the design of a cluster-RCT.
Trial registration
ClinicalTrials.gov: NCT01078012 (Initially registered as controlled efficacy trial but changed to observational study).
doi:10.1186/1756-0500-7-165
PMCID: PMC3994567  PMID: 24646429
Chronic headache; Medication-overuse headache; Migraine; Brief intervention; General practice; Severity of dependence scale; Feasibility study; Pilot study
5.  Contraceptive-induced amenorrhoea leads to reduced migraine frequency in women with menstrual migraine without aura 
Background
Menstrual migraine without aura (MM) affects approximately 20% of female migraineurs in the general population. The aim of the present study was to investigate the influence of contraception on the attacks of migraine without aura (MO) in women with MM.
Findings
141 women from the general population with a history of MM according to the International Classification of Headache Disorders II (ICHD II) were interviewed by a headache specialist. Of 49 women with a history of MM currently using hormonal contraception, 23 reported amenorrhoea. Significantly more women with amenorrhoea reported no MO- days during the preceding month compared to women without amenorrhoea (OR 16.1; 95% confidence interval (CI) 1.8-140.4; P = 0.003). A reduction of MO-frequency was more often reported in women with than without amenorrhoea (OR 3.5; 95% CI 1.1-11.4; P = 0.04).
Conclusion
Amenorrhoea leads to a reduction of MO-frequency in women with MM using hormonal contraceptives. Future prospective studies on MM should focus on contraceptive methods that achieve amenorrhoea.
doi:10.1186/1129-2377-15-30
PMCID: PMC4038831  PMID: 24884461
Menstrual migraine without aura; Migraine; Amenorrhoea; Contraception; Hormones; Estrogen; Progestin; Prostaglandins; Ovulation
6.  Pericranial tenderness in chronic tension-type headache: the Akershus population-based study of chronic headache 
Background
Most knowledge on chronic tension-type headache (CTTH) is based on data from selected clinic populations, while data from the general population is sparse. Since pericranial tenderness is found to be the most prominent finding in CTTH, we wanted to explore the relationship between CTTH and pericranial muscle tenderness in a population-based sample.
Methods
An age- and gender-stratified random sample of 30,000 persons aged 30-44 years from the general population received a mailed questionnaire. Those with a self-reported chronic headache were interviewed and examined by neurological residents. The questionnaire response rate was 71% and the interview participation rate was 74%. The International Classification of Headache Disorders II was used. Pericranial muscle tenderness was assessed by a total tenderness score (TTS) involving 8 pairs of muscles and tendon insertions. Cross-sectional data from the Danish general population using the same scoring system were used for comparison.
Results
The tenderness scores were significantly higher in women than men in all muscle groups. The TTS was significantly higher in those with co-occurrence of migraine compared with those without; 19.3 vs. 16.8, p = 0.02. Those with bilateral CTTH had a significantly higher TTS than those with unilateral CTTH. The TTS decreased significantly with age. People with CTTH had a significantly higher TTS compared to the general population.
Conclusions
People with CTTH have increased pericranial tenderness. Elevated tenderness scores are associated with co-occurrence of migraine, bilateral headache and low age.
Whether the increased muscle tenderness is primary or secondary to the headache should be addressed by future studies.
doi:10.1186/1129-2377-15-58
PMCID: PMC4165634  PMID: 25193401
Epidemiology; Population-based; Chronic tension-type headache; Pericranial tenderness
7.  Management of secondary chronic headache in the general population: the Akershus study of chronic headache 
Background
The prevalence of secondary chronic headache in our population is 0.5%. Data is sparse on these types of headache and information about utilisation of health care and medication is missing. Our aim was to evaluate utility of health service services and medication use in secondary chronic headache in the general population.
Methods
An age and gender stratified cross-sectional epidemiological survey included 30,000 persons 30–44 years old. Diagnoses were interview-based. The International Classification of Headache Disorders 2nd ed. was applied along with supplementary definitions for chronic rhinosinusitis and cervicogenic headache. Secondary chronic headache exclusively due to medication overuse was excluded.
Results
One hundred and thirteen participants had secondary chronic headache. Thirty % had never consulted a physician, 70% had consulted their GP, 35% had consulted a neurologist and 5% had been hospitalised due to their secondary chronic headache. Co-occurrence of migraine or medication overuse increased the physician contact. Acute headache medication was taken by 84% and 11% used prophylactic medication. Complementary and alternative medicine was used by 73% with the higher frequency among those with than without physician contact.
Conclusion
The pattern of health care utilisation indicates that there is room for improving management of secondary chronic headache.
doi:10.1186/1129-2377-14-5
PMCID: PMC3606965  PMID: 23565808
Secondary chronic headache; Chronic migraine; Medication-overuse headache; Health care utilisation; General population
8.  Study protocol: Brief intervention for medication overuse headache - A double-blinded cluster randomised parallel controlled trial in primary care 
BMC Neurology  2012;12:70.
Background
Chronic headache (headache ≥ 15 days/month for at least 3 months) affects 2–5% of the general population. Medication overuse contributes to the problem. Medication-overuse headache (MOH) can be identified by using the Severity of Dependence Scale (SDS). A “brief intervention” scheme (BI) has previously been used for detoxification from drug and alcohol overuse in other settings. Short, unstructured, individualised simple information may also be enough to detoxify a large portion of those with MOH. We have adapted the structured (BI) scheme to be used for MOH in primary care.
Methods/Design
A double-blinded cluster randomised parallel controlled trial (RCT) of BI vs. business as usual. Intervention will be performed in primary care by GPs trained in BI. Patients with MOH will be identified through a simple screening questionnaire sent to patients on the GPs lists. The BI method involves an approach for identifying patients with high likelihood of MOH using simple questions about headache frequency and the SDS score. Feedback is given to the individual patient on his/her score and consequences this might have regarding the individual risk of medication overuse contributing to their headache. Finally, advice is given regarding measures to be taken, how the patient should proceed and the possible gains for the patient. The participating patients complete a headache diary and receive a clinical interview and neurological examination by a GP experienced in headache diagnostics three months after the intervention. Primary outcomes are number of headache days and number of medication days per month at 3 months. Secondary outcomes include proportions with 25 and 50% improvement at 3 months and maintenance of improvement and quality of life after 12 months.
Discussion
There is a need for evidence-based and cost-effective strategies for treatment of MOH but so far no consensus has been reached regarding an optimal medication withdrawal method. To our knowledge this is the first RCT of structured non-pharmacological MOH treatment in primary care. Results may hold the potential of offering an instrument for treating MOH patients in the general population by GPs.
Trial registration
ClinicalTrials.gov identifier: NCT01314768
doi:10.1186/1471-2377-12-70
PMCID: PMC3488483  PMID: 22883540
Medication-overuse headache; Chronic headache; Chronic tension-type headache; Migraine; Brief intervention; General practice; Primary care; Cluster randomised controlled trial
9.  Management of primary chronic headache in the general population: the Akershus study of chronic headache 
The Journal of Headache and Pain  2011;13(2):113-120.
Primary chronic headaches cause more disability and necessitate high utilisation of health care. Our knowledge is based on selected populations, while information from the general population is largely lacking. An age and gender-stratified cross-sectional epidemiological survey included 30,000 persons aged 30–44 years. Respondents with self-reported chronic headache were interviewed by physicians. The International Classification of Headache Disorders was used. Of all primary chronic headache sufferers, 80% had consulted their general practitioner (GP), of these 19% had also consulted a neurologist and 4% had been hospitalised. Co-occurrence of migraine increased the probability of contact with a physician. A high Severity of Dependence Scale score increased the probability for contact with a physician. Complementary and alternative medicine (CAM) was used by 62%, most often physiotherapy, acupuncture and chiropractic. Contact with a physician increased the probability of use of CAM. Acute headache medications were taken by 87%, while only 3% used prophylactic medication. GPs manage the majority of those with primary chronic headache, 1/5 never consults a physician for their headache, while approximately 1/5 is referred to a neurologist or hospitalised. Acute headache medication was frequently overused, while prophylactic medication was rarely used. Thus, avoidance of acute headache medication overuse and increased use of prophylactic medication may improve the management of primary chronic headaches in the future.
doi:10.1007/s10194-011-0391-8
PMCID: PMC3274574  PMID: 21993986
Primary chronic headache; Chronic migraine; Medication-overuse headache; Health care utilisation; General population
10.  Management of primary chronic headache in the general population: the Akershus study of chronic headache 
The Journal of Headache and Pain  2011;13(2):113-120.
Primary chronic headaches cause more disability and necessitate high utilisation of health care. Our knowledge is based on selected populations, while information from the general population is largely lacking. An age and gender-stratified cross-sectional epidemiological survey included 30,000 persons aged 30–44 years. Respondents with self-reported chronic headache were interviewed by physicians. The International Classification of Headache Disorders was used. Of all primary chronic headache sufferers, 80% had consulted their general practitioner (GP), of these 19% had also consulted a neurologist and 4% had been hospitalised. Co-occurrence of migraine increased the probability of contact with a physician. A high Severity of Dependence Scale score increased the probability for contact with a physician. Complementary and alternative medicine (CAM) was used by 62%, most often physiotherapy, acupuncture and chiropractic. Contact with a physician increased the probability of use of CAM. Acute headache medications were taken by 87%, while only 3% used prophylactic medication. GPs manage the majority of those with primary chronic headache, 1/5 never consults a physician for their headache, while approximately 1/5 is referred to a neurologist or hospitalised. Acute headache medication was frequently overused, while prophylactic medication was rarely used. Thus, avoidance of acute headache medication overuse and increased use of prophylactic medication may improve the management of primary chronic headaches in the future.
doi:10.1007/s10194-011-0391-8
PMCID: PMC3274574  PMID: 21993986
Primary chronic headache; Chronic migraine; Medication-overuse headache; Health care utilisation; General population
11.  Self-reported menstrual migraine in the general population 
A number of women with migraine experience increased incidence of attacks during the perimenstrual period. The Appendix of the International Classification of Headache Disorders (ICHD II) describes two types of migraine without aura related to menstruation: pure menstrual migraine (PMM) and menstrually related migraine (MRM). The phrase “menstrual migraine” is often used to cover both PMM and MRM. Although menstrual migraine is well recognized, further scientific evidence is needed before these definitions can be formally included in the ICHD III. The aim of the present study was to investigate the prevalence of PMM and MRM in the general population in Norway. The survey included 15,000 women, 30–44 years old, residing in the eastern part of Norway. They received a postal questionnaire containing six questions about migraine, headache frequency and the relation of migraine and menstruation. The study included 11,123 women. The questionnaire response rate was 77%. The prevalence of self-reported migraine was 34.8%. Of the migraineurs, 21% reported migraine related to menstruation in at least two of three menstrual cycles, of which 7.7% were considered to have PMM and 13.2% MRM. This corresponds to the prevalence of PMM and MRM in the general population of 2.7 and 4.6%, respectively. Thus, self-reported menstrual migraine among women aged 30–44 years appears to be common in the general population in Norway.
doi:10.1007/s10194-010-0197-0
PMCID: PMC3452281  PMID: 20186561
Menstrual migraine; Prevalence; Epidemiology; General population
12.  Continuous levodopa for advanced Parkinson’s disease 
Parkinson’s disease is characterized by the progression of the disease from the early stages where it still has little functional consequence for afflicted patients, to an advanced stage disease with large consequences in terms of function, quality of life and individual and societal costs. Motor fluctuations and symptoms of levodopa overdosage may occur in parallel with increasing Parkinsonian symptoms. This leads to a narrower therapeutic window which causes problems with traditional oral medication. Various ways of optimizing oral treatment should be tried but often have limited effects. In addition to the previous alternatives of neurosurgery (especially deep brain stimulation of the subthalamic nuclei) and continuous apomorphine treatment there is now also the alternative of continuous enteral levodopa administration via a trans-abdominal tube. The effect of the treatment may be tested individually via naso-duodenal administration before a decision is made whether to continue with permanent treatment. In the present article, the challenges to treatment of Parkinson’s disease in these phases are described as well as the various treatment alternatives available. Focus is mainly on the clinical studies of continuous levodopa infusion therapies, especially enteral administration of levodopa/carbidopa gel. The place of enteral levodopa/carbidopa gel treatment among the other treatment methods is also discussed.
PMCID: PMC2654791  PMID: 19300565
Parkinson’s disease; levodopa; carbidopa; levodopa/carbidopa gel

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