Practitioners are familiar with the category of patients who have headaches every day or almost every day. Moreover, it is these patients who seek help not only from neurologists, but also to doctors of other specialties in connection with a variety of somatic complaints and disorders in the emotional sphere. The futile search for organic causes of this chronic suffering, on the one hand, and the failure of pharmacological treatment, on the other, sometimes have a disappointing impression not only on the patient, but also on the doctor. Therefore, chronic daily headache (CEHD) is a major diagnostic and therapeutic problem.
Being inherently chronic, it is this form of headache that reduces the quality of life of patients to the greatest extent. HEHD is the most common cause of long-term disability, maladjustment in professional activity and everyday life. With this form of headache, depression is represented to the greatest extent with all the accompanying disorders.
Epidemiological data also show how important it is to study this phenomenon. The prevalence of CHEHD in the population is approximately 2 – 4%. At the same time, women suffer much more often (about 5 – 6 times).
Criteria and classification of HEGB
It should be recognized that the question of identifying these headaches is often difficult. Among the variety of complaints in such patients, it is extremely difficult to distinguish the primary form of headache. Interestingly, approximately 43% of all headache patients are not classified according to the current International Headache Association criteria (IHS, 1988). Apparently, the majority of these patients are patients with CHEHD. The problem is that this classification offers criteria based on the profile of attacks and those clinical manifestations that the patient has at the time of the visit to the doctor, without analyzing the anamnestic information about the development of the disease, which is in fact a factor determining the primary headache. underlying HEGB.
HEHD is a heterogeneous group of diseases that includes various forms of headaches that occur daily or almost every day for a long period of time. The main criterion for chronic daily headache is the time factor – the presence of headaches at least 6 days a week, at least 4 hours a day, at least 15 days a week, at least 6 months. a year.
The nosographic analysis of CHEHD is not completely clear. In terms of the main clinical manifestations and even in accordance with the formal criteria of the IHS, CHEHD is closest to chronic tension headaches. And a false impression of their identity can be created.
The main part of CHEHD is made up of two forms of primary headaches: in 78% of cases it is a transformed migraine, in 15.3% – chronic tension headache, and only slightly more than 6% falls on other forms: 1) “drug-induced” headaches (so-called “Abusal”); 2) migraine with interparoxysmal headache; 3) “new persistent headache”; 4) “hemicrania continua” – a rare form of persistent headache of strictly hemicranial localization, with some “migraine features”; 5) post-traumatic headache; 6) cervicogenic headache.
This list is not fully defined. But an important common factor of these primary forms of headaches is the possibility of their clinical transformation, i.e. being initially different in terms of the main clinical manifestations over time and under the influence of various factors, in some patients they can transform into chronic daily headaches. Therefore, for the diagnosis of CHEHD, the most important is a retrospective analysis of anamnestic data with the study of both the clinical features of the initial forms of headaches and the search for possible causes and factors contributing to the transformation of these headaches into CHEHD.
Clinical features of HEGB
The study of the clinical features of CHEHD indicates that they are very nonspecific. The nature of the headache in this form, as a rule, is monotonous (50%) and much less often this pain is “pulsating” (29%) or squeezing (13%) in the form of “helmet” and “hoop”.
The topography of pain is characteristic – it is almost always diffuse and bilateral, which is the main feature of CEHD. It is only possible to single out individual zones of predominance of pain (frontal, occipital, bitemporal). It is noteworthy that this pain in intensity in most cases is moderate (55%), in some situations it can increase.
The accompanying symptoms are diverse: photophobia (42%), phonophobia (37%), osmophobia (27%), nausea (24%), or a combination of these symptoms.
The factors that exacerbate these headaches are: physical fatigue, emotional stress, head movements, insufficient sleep, irregular diet, alcohol, and changes in the weather. Thus, this headache can be provoked and aggravated by a wide variety of factors, which actually distinguishes it from chronic tension headache, which is not aggravated by daily activities. Rest and sleep are factors that reduce HEHB.
One more feature should be noted – CHEHD among all forms of headaches is the leader in the representation of “comorbid” disorders: various autonomic and emotional-affective disorders, somatic complaints in the cardiovascular, respiratory and gastrointestinal systems and, most importantly, the almost obligatory presence of depressive disorders , often occurring in “masked” forms. The analysis of these comorbid disorders is extremely important for this category of patients, since it is these manifestations in the mental and somatic spheres that make the diagnosis so difficult, and most importantly, the choice of adequate treatment for these patients.
In the general structure of CHEGB, as already mentioned, transformed migraine (TM) or a chronic form of migraine is most represented. In the modern international classification, this form of migraine is undeservedly absent, although there is a chronic tension headache and a chronic cluster headache. Obviously, with this form, distinct clinical features can be distinguished: previous history of migraine, family history of migraine, “migraine” symptoms (vegetative, accompaniment, phono-, photophobia, symptoms of aura are possible), dynamics of pain during periods of menstruation and pregnancy, excessive use of analgesics or anti-migraine drugs, response to anti-migraine therapy, the presence of affective disorders.
Long-term clinical observations of these patients suggest the possibility of identifying criteria for the diagnosis of TM (S. Silberstein): 1) the presence of migraine cephalalgias in the anamnesis, meeting the criteria 1.1 – 1.6 IHS (1988); 2) daily or almost daily headaches for more than 1 month; 3) the duration of the headache is at least 4 hours per day (in the absence of therapy); 4) a history of the transformation period of headache (an increase in frequency with a simultaneous decrease in its intensity and the severity of “migraine” properties) for about 3 months. Knowledge and use of these criteria is extremely important in practical terms, since it significantly affects the choice of optimal treatment methods. At the same time, clinical observations of patients with CHEHD from these positions can reduce the percentage of unclassified headaches from 43 to 25%.
No less important in the problem of TM is the analysis of the factors leading to the evolution of primary migraine into such a variant of HEHD. There are two possible types of TM: with and without the drug abuse factor. Moreover, the first option is found incomparably more often. Therefore, you should pay attention to the following signs: habitual use of analgesics (more than 1000 mg of aspirin) more than 5 days a week; use of combinations of analgesics containing caffeine, barbiturates (more than 3 tablets a day) more than 3 days a week; use of narcotic analgesics (more than 1 tablet per day); using ergotamine (more than 1 mg) more than 2 days a week. The presence of even one of the listed signs allows the fact of drug abuse, and it is clear that in such cases, the choice of patient management tactics should not be to increase the dose of drugs used to enhance the analgesic effect, but to completely cancel the drug used or replace it with drugs of a different class.
For the clinical transformation of chronic migraine, it is fundamentally important to analyze the evolutionary pattern, which clinically looks as follows: characteristic migraine attacks gradually increase in frequency, interictal headaches resembling tension headaches appear, and at the same time the intensity of individual migraine cephalgias and the brightness of their vegetative accompaniment decrease. At the end of the transformation period, the painless intervals practically disappear, only periodically there are intense headaches that have some features of migraine cephalgias.
In this case, unilateral headaches become bilateral, paroxysmal headaches turn into chronic ones, the intensity of pain, accompanying and autonomic symptoms decreases.
The nature of the transformation of this headache is quite the same. Only 20% can experience “acute” sudden transformation (after trauma, colds, surgery, somatic diseases or as a result of traumatic life events). Much more often there is a gradual transformation, which, as a rule, is associated with two circumstances: the presence of drug abuse (“abusal” factor) and mental factors, among which depressive disorders are of leading importance.
Mention should be made of the existence of another clinical variant of the combination of paroxysmal and permanent headaches – migraine with interparoxysmal headache. Apparently, at the clinical level, it is a variant of TM with more vivid clinical manifestations at the migraine pole of this phenomenon, since along with constant non-intense headache in this form, patients periodically experience attacks of cephalgia, which are obviously “migraine” in nature.
The second most frequent form of CHEHD is chronic tension headache (CHHD), for the diagnosis of which the corresponding IHS criteria have been developed (1988): 1) headache with a frequency of at least 180 days a year; 2) family history of CHHD; 3) the absence of “migraine” features of the headache; 4) the absence of focal neurological signs; 5) excessive use of analgesics; 6) lack of response to anti-migraine therapy; 7) the presence of emotional disorders.
Obviously, CGHD is transformed from a primary episodic tension headache that meets the relevant IHS criteria. The evolutionary pattern of CGBN, like TM, is quite the same: episodic tension headache over time can decrease in intensity, while its frequency increases. At the end of the transformation, the painless gaps practically disappear completely. It is noteworthy that acute sudden types of transformation are practically not known for CGBN. The evolution of this headache occurs gradually, and it is especially important to note that this headache is influenced almost exclusively by two factors: “abusal” and mental. Those. For this form of headache, the analysis of mental, especially depressive, disorders and the identification of the drug abuse factor is, as in the case of TM, extremely important in practical terms.
Another variant of HEHD is the recently isolated form of “new persistent headache”, the main feature of which is the chronic daily nature of pain from the very moment of its onset. Perhaps it is only a clinical variant of CEHD, but the nature of the factors and its possible causes still require clarification.
Discussion of the problem of CHEHD is inextricably linked with the factor of improper and unjustified use of drugs, with the so-called abusal factor. Analysis of the characteristics of “drug-induced” headaches is the flip side of the CHEHD problem. The main causes and ways of development of primary headaches, the reasons for the ineffectiveness of the methods of treatment used are becoming clearer, and most importantly, the views on the principles of subsequent therapy are radically changing.
The problem of “medicinal headaches” is extremely urgent, since it is assumed that in about 5 – 10% of all cases, headaches meet the criteria of “abusal”. Their prevalence is the same for all economically developed countries in which over-the-counter forms of analgesic drugs are widely used.
A structural analysis of this syndrome shows that 65% of cases are primary migraine, 27% are tension headaches, and 8% are other forms. These ratios show to some extent their correspondence with HEGB.
The main meaning of “abusal” pain is as follows: regular or frequent use of analgesics, ergotamine-type drugs, aspirin, barbiturates, benzodiazepine drugs and other compounds used to treat migraines and tension headaches can worsen existing and cause additional headaches, which themselves themselves differ from the original cephalgia. Certain patterns are important for these headaches. First, the “abusal” factor is a non-specific phenomenon – apparently, there is no single specific drug exclusively responsible for the development of certain headaches. To a greater extent, the dose and duration of use of the drug, as well as the combination of various drugs, matter. Secondly, the deprivation of a chronically used drug to one degree or another improves the patient’s condition.
To describe this nature of headaches, different terms are used: “analgesic-induced headache”, ergotamine headache, etc. Apparently, these terms are only synonyms, in all cases we are talking about headaches associated with chronic intake of a certain class of medicinal drugs.
The problem of “abusal” headaches began to develop actively in the early 1980s, when it was noticed that patients suffering from frequent migraine cephalgias or tension headaches are prone to abuse analgesics or ergotamine drugs. Before that, the headache caused by chronic intake of phenacetin was well known, which for a long time was considered a specific property of this drug and such pains were called phenacetin. Later, Horton and Graham described ergotamine headaches. In the future, the list of drugs that can cause headaches has expanded significantly. Subsequent studies have shown a positive role for the withdrawal of these drugs and the prescription of antidepressants.
In practice, it can be very difficult to identify the specific drug causing the abusal headache, since about 90% of patients with chronic headaches use more than one drug at a time. In these cases, it is important to analyze the entire history of the development of headache and the experience of using analgesics in each specific patient. As a rule, the “abuse” factor is formed gradually. Initially, the appropriate medication is taken at the earliest sign of headache or to prevent it, chronic medication becomes a lifestyle for these patients. At the same time, the analgesic effect of the drug gradually decreases, which, in turn, leads to an increase in the dose and a combination of various analgesics. And the consequence of such unjustified treatment and uncontrolled use of over-the-counter analgesics is the transformation of the existing headache, its chronicity and the fact that the headache is induced by the drugs used.
These practically important questions served as the basis for identifying a separate form of “abusal headaches”. According to the IHS, it is defined as a headache caused by regular chronic medication use.
The main criteria for the diagnosis of “abusal” headaches are as follows:
1) headache develops after 3 months. after starting daily medication; 2) the minimum required dose of the drug has been established; 3) the headache is chronic (at least 15 days a month); 4) headache worsens immediately after drug withdrawal; 5) the headache disappears within 1 month after discontinuation of the drug.
For the “abuse” factor, approximate doses have been developed and a class of drugs capable of causing these headaches has been determined: ergotamine – at least 2 mg per day; aspirin – at least 50 g per month; combinations of analgesics – at least 100 tablets per month; barbiturates – at least 1 tablet in 1 day or benzodiazepines (diazepam – at least 300 mg in 1 month); narcotic analgesics.
To understand the essence of “abusal” headaches, it is important to note one significant regularity, which is that this phenomenon develops exclusively in people who initially suffer from headaches, and almost never develops in people taking the same drugs for another reason. Thus, long-term use of analgesics and salicylates for the treatment of polyarthritis, long-term prophylactic use of aspirin in patients with stroke or myocardial infarction, the use of ergotamine for the treatment of arterial hypotension – in all these cases, “abusus” headache almost never develops. On the other hand, withdrawal of the drug, which is an “abusus” factor in more than 60% of CHEHD cases, completely relieves the headache, and in about 40%, only those headaches that were observed in patients before the transformation period remain.
The mechanisms for the development of drug dependence are extremely complex. Various factors seem to play a role in “abusal” headaches as a particular variant of this dependence. First of all, these are psychological factors, for which personality traits play a certain role, the formation of a special habit of taking analgesics, often with a preventive purpose, fear of pain. Moreover, many patients have doctors’ recommendations to take, in particular, ergotamine as early as possible to prevent migraine attacks. At the same time, many who suffer from frequent headaches are well aware that an attempt to reduce the dose or eliminate the intake of the drug leads to a sharp increase in headaches. Along with this, the side “psychotropic” effects of analgesics and antimigraine drugs (sedative or stimulant) may also play a role in the formation of this drug dependence. The role of certain biological factors of this phenomenon is also possible, but their nature requires clarification. One of the possible neurophysiological mechanisms of the formation of “abusal” headache is the existence of a factor of chronic suppression of somatic afferentation, in particular in the trigeminal system under the influence of chronic action of analgesics, which can lead to an increase in the central thresholds of pain perception and inhibition of the activity of endogenous opiates. The possible involvement of other factors is being discussed, but this issue still requires further study.
The development of certain views on the essence of “abusal” headaches and determines the main tactics of their treatment. The most important and effective method is the complete abolition of the drug, which is the “abusal” factor. Clinical experience shows that drug and behavioral therapy are unpromising in cases where the patient continues to take symptomatic drugs on a daily basis. At the same time, it is important to identify such a drug, since patients themselves rarely tell doctors about taking OTC drugs. If this drug is identified and the appropriate criteria for abusal headaches are met, the first stage of treatment is withdrawal; complete elimination of this drug.
The cancellation method has some peculiarities. On an outpatient basis, it is possible in the following cases: 1) when it comes to drugs of the ergotamine series, triptans, non-opioid analgesics, non-steroidal anti-inflammatory drugs; 2) when there is a high level of patient motivation to get rid of the headache; and 3) when there is support from friends and family. In such patients, drug withdrawal should be abrupt and sudden.
In some cases, it is necessary to cancel the drug in stationary conditions: 1) in the presence of drug dependence for more than 5 years; 2) when this dependence is caused by tranquilizers, barbiturates, opioid analgesics; 3) in case of ineffectiveness of outpatient treatment; 4) in the presence of high anxiety and depression. Such patients are shown a gradual withdrawal of the drug within 2 to 3 weeks.
Typical withdrawal symptoms occur in the first 2-10 days and include withdrawal headaches, nausea, vomiting, hypotension, tachycardia, sleep disturbances, and anxiety. Seizures and hallucinations occur extremely rarely and exclusively in cases of dependence on barbiturates and tranquilizers contained in analgesic drugs. Therefore, the next stage of treatment is the correction of withdrawal symptoms and relief of headache with drugs of a different class, i.e. not being a “abuse” factor. In accordance with clinical manifestations, it is possible to use non-steroidal anti-inflammatory drugs, acetylsalicylic acid, dihydroergotamine, b-blockers, calcium channel blockers, nootropics (pyritinol, etc.).
Since depressive disorders are of primary importance in the formation of “abusal” headaches, an important and integral stage of treatment is the use of antidepressants (tricyclic and selective serotonin reuptake inhibitors). At the same time, the justification and effectiveness of these drugs for the treatment of “abusal” headaches is proven. The combination of these methods with various non-drug treatments and behavioral therapy is also effective.