Page 138 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

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Chapter 7
by a headache nurse,47 but a proportion of only 35% with chronic migraine suggest a population at lower risk. Therefore, when considering secondary or tertiary preventive strategies by a headache nurse, a selection of patients could be made on presence of known risk factors, to select those in need.
Some secondary and even primary prevention strategies can be considered for a broader population in order to prevent medication overuse. A multicenter trial suggests a role for electronic monitoring. Patients using an electronic headache diary with an alert system and communication option had a lower rate of medication overuse compared to patients using paper a headache diary.48
As primary prevention, a national awareness campaign including online videos, publications at news websites, distribution of information brochures, and education of general practitioners was implemented in Denmark for a period of 4 months.49 Two independent surveys on awareness on existence of medication overuse headache before and after the campaign suggested some effect (30.8% versus 38.2% of respondents were aware of medication overuse headache), but it did not result in better knowledge on a safe pain killer dosage, and the survey did not include data on the prevalence of medication overuse headache. Hence, the (cost-)effectiveness of such a campaign is uncertain.
Together with medication overuse, depression is indicated in a large systematic review as one of the most important (modifiable) risk factors for migraine progression, both in magnitude as in level of evidence.34 Chapter 2 suggests anxiety as a risk factor as well, which is a largely unexplored area. Some preliminary data support this finding, but this data was not included in the systematic review, as it is only available via conference abstracts, and was not peer reviewed.34 A population study with a long follow-up period (11 years) did identify comorbid depression and/or anxiety as a risk factor for medication overuse headache, but did neither differentiate between migraine and non- migraine headache as underlying diagnosis, nor separate depression and anxiety as a risk factor.50 A recent population study replicated the stronger association between migraine and anxiety as compared migraine and depression, but a potential association with migraine attack frequency was not examined.51 Screening for and concurrent therapy of psychiatric comorbidity is advised, based on the known increased risk for chronification, and the burden of psychiatric comorbidity. Nevertheless, the risk reduction of migraine chronification upon