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Monday, November 11, 2013

Clinic speak: headache in MS

Headache in MS: is it a bigger problem than expected? 
#MSBlog #MSResearch #ClinicSpeak

"In this study more than half of MSers reported headache. Wow! This is a much higher self-reported prevalence of headache than I would have expected from my own clinical experience. What is your experience?"

"In the introduction the investigators suggest that headache may be due to inflammation, in particular B cell follicles, in the meninges (membranes covering the brain) of MSers. Why? Interestingly, the actual brain substance is devoid of pain fibres or pain receptors. The pain sensitive structures in the brain that cause headache or the blood vessels (arteries, veins and venous sinuses), meninges (membranous coverings of the brain), cranial nerves, paranasal air sinuses, skull and scalp. These investigators suggest that inflammation in the meninges and around blood vessels is causing headaches in MSers. However, they provide no evidence that this is the case. If this was the case then treatment with anti-inflammatory agents to reduce inflammation should reduce headaches. This data may be available in trial databases, but as it hasn't been collected systematically it won't be very useful."

"The MS inflammation-headache hypothesis may be a subject to study in more detail using questionnaires given pre and post DMTs and using MRI and CSF analysis to quantify inflammation and to see if it correlates with headache. if this was  the case then headaches could be another sign of MS disease activity. In other words if you develop headache, or your headaches get worse, this may indicate that your MS is active."

"Migraine in MSers is very common as I have previously commented on. I usually treat migraine in MSers as I would treat it in people without MS. You have to maintain a headache diary to ascertain how frequent and disabling the headaches are. Don't rely on your memories to provide you with the information; you will simply forget and over- or under-report your headache frequency and severity. The treatment strategy for migraine is based on three principles; prophylaxis, abortive and symptomatic treatments. Prophylactic treatments for migraine include drugs such as propanolol (beta-blockers), anti-convulsants (topiramate, valproic acid), anti-depressants (amitriptyline) and calcium channel blockers that reduce the frequency or prevent migraine. Abortive therapies are taken at the onset of the headache to stop the migraine getting worse; licensed abortive therapies are essentially the class of drugs called triptans. Finally, there are symptomatic treatments that are given to treat the pain, nausea and vomiting that are common in migraine sufferers. One of the problem in acute migraine is that migraine also affects the function of the gut with delayed gastric emptying; therefore oral tablets may not work or their effects are unpredictable. If oral drugs don't work we have to use other routes of administration; i.e. intranasal, sublingual (under the tongue), rectal suppositories or even subcutaneous or intramuscular injections. In addition to medication there are large number of lifestyle interventions that have been shown to reduce the frequency and severity of migraines, one of these includes exercise. More recently botox injections and greater occipital nerve block have been shown to work in some people with chronic migraine. If you have severe intermittent headaches that have not been diagnosed or treated you should speak to your neurologist. Migraine, and other headaches, are another unpleasant MS co-morbidity that may need treating to improve your quality of life. This is why MS needs an holistic approach."

Background: Recent studies on MS pathology mention the involvement of "tertiary B cell follicles" in MS pathogenesis. This inflammatory process, which occurs with interindividually great variance, might be a link between MS pathology and headaches.

Aim: The aim of this study was to detect the prevalence of headaches and of subtypes of headaches (migraine, cluster, tension-type headache [TTH]) in an unselected MS collective and to compile possibly influencing factors. 

Methods: Unselected MSers (n = 180) with and without headache were examined by a semi-structured interview using a questionnaire about headache, depression and the health status. Additionally clinical MS data (expanded disability state score [EDSS], MS course, medication, disease duration) were gathered. 

Results: N = 98 MSers (55.4%) reported headaches in the previous 4 weeks. They subsequently grouped MSers with headache according to the IHS criteria and detected 16 (16.3%) MSers suffering from migraine (migraine with aura: 2 [2%]; migraine without aura: 14 [14.3%]), 23 (23.5%) suffering from TTH and none with a cluster headache. Thus, headaches of 59 (60.2%) MSers remained unclassified. When comparing MSers with and without headaches significant differences in age, gender, MS course, physical functioning, pain and social functioning occurred. MSers with headaches were significantly younger of age (p = 0.001), female (p = 0.001) and reported more often of a clinically isolated syndrome (CIS) and relapsing/remitting MS (RRMS) instead of secondary chronic progressive MS (SCP). EDSS was significantly lower in MSers suffering from headaches compared to the MSers without headaches (p = 0.001). 

Conclusion: In conclusion headache in MSers is a relevant symptom, especially in early stages of the MS disease. Especially unclassified headache seems to represent an important symptom in MS course and requires increased attention.

"To try and replicate this studies findings I would appreciate it if you could complete this short survey. Thank you."

Click here to see the study AND to view the source of this article


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