Page 128 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

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Chapter 7
patients with a current psychopathology of anxiety and/or depression. Within migraine patients, all three dimensions were independently associated with higher attack frequency and cutaneous allodynia. These findings imply that not only depression, but also anxiety might be an important risk factor for migraine chronification, and concurrent treatment is warranted. Furthermore, this tripartite model of affective disorders is relevant to biological research on chronification pathophysiology.
Chapter 3 describes in a retrospective, controlled follow-up study that support by a specialised headache nurse increases success rates for withdrawal therapy in patients with chronic headache (both migraine and tension type headache) with medication overuse. Withdrawal therapy itself results into a reduction of headache days, especially if the underlying primary headache disorder is migraine alone, as opposed to tension-type headache or a combination of both types. In regard to participants who succeeded to withdraw, the reduction in headache days was independent of the support by a headache nurse. Hence support by a headache nurse is effective to enhance treatment adherence and success of withdrawal, but does not affect the underlying headache type or other ‘intrinsic’ factors and thus the number of headache days. Therefore, in prospective behavioural studies, outcome measurements based on success of withdrawal therapy, coping and grip on pain strategies seem appropriate instead of headache-specific measures.
Chapter 4 enters into the discussion on treatment with Botulinum toxin A (BTA) in chronic migraine, and the initiation of preventatives before withdrawal of acute headache medication. Botulinum toxin A is widely used as treatment of chronic migraine. Efficacy in studies, however, was only modest and likely influenced by unblinding due to Botox-induced removal of forehead wrinkles. Moreover, 65% of study participants were overusing acute headache medication and might have benefitted from withdrawal. In a double blind, placebo-controlled randomised clinical trial in chronic migraine patients with medication overuse, we assessed whether add-on therapy with BTA enhances efficacy of acute withdrawal. At the start of a 12-week withdrawal period, participants were randomised to receive BTA (155 units; 31 injection sites) or placebo (saline). To prevent unblinding, placebo-treated participants received a low dose of BTA in the forehead region (17.5 units; 7 injection sites) next to saline (24 injection sites).