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• Are headache therapists anxiolytic or anxiogenic?
  Vinod K Gupta
  Published on: 13 April 2016
• Brain imaging in patients with chronic daily headache
  Sudhir Kumar
  Published on: 13 April 2016

• Published on: 13 April 2016

  Are headache therapists anxiolytic or anxiogenic?

  • Vinod K Gupta, Physician

  Dear Editor,

  The most critical influence on the psychiatric morbidity of patients with chronic daily headache (CDH) is the underlying pathophysiological and therapeutic belief of the therapist / general practitioner. While a diagnosis of migraine appears less sinister to lay persons, CDH might seem more formidable. CDH certainly appears more formidable than its more benign but unfashionable older hyphenated version,...

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  Dear Editor,

  The most critical influence on the psychiatric morbidity of patients with chronic daily headache (CDH) is the underlying pathophysiological and therapeutic belief of the therapist / general practitioner. While a diagnosis of migraine appears less sinister to lay persons, CDH might seem more formidable. CDH certainly appears more formidable than its more benign but unfashionable older hyphenated version, tension-type headache (TTH). TTH is a much less alarming diagnosis that is readily understood and accepted (and probably volunteered as an explanation) by most patients but acronyms have gripped medicine and its practitioners. Nevertheless, by removing the term “tension” from CDH, we are no wiser about the origin of the disorder. It is not generally appreciated that the overly elaborate 1988 headache classification of the International Headache Society and its newer version of 2004 is purely phenomenological and not based on any fundamental pathophysiological differences.[1] To believe that each of the several divisions and subdivisions of migraine and TTH / CDH represents a distinct pathophysiological entity is a classic form of irrational scepticism that demands complete suspension of clinical disbelief.

  Primary headache research is a long chain of loosely-connected assumptions held together by serendipity.[2,3] The basis for the notion that migraine is the direct outcome of brain / brainstem aberration is completely nebulous but is central to the rationale for advising (by the therapist) and expecting or demanding (by the patient) advanced neuroimaging for management of primary headaches, including CDH. Transmission of the therapist’s belief, howsoever nuanced, to the patient is inevitable. If both beta-blockers and antidepressants can prevent migraine as well as CDH, the presumed pathophysiological difference(s) between the two are very likely to be inconsequential.

  Currently, few headache therapists can make sense of the science and the myths that surround primary headaches. There is little reason to maintain, as Dr. Sudhir Kumar suggests, that “informing” patients could help in the decision making process for patients with CDH (or migraine). The ethical façade of informing patients about issues that we ourselves are not yet comfortable with merely (? hopefully) lessens legal liability whenever a secondary cause for headache subsequently becomes apparent. While anxiety-provoking therapists might recommend neuroimaging to all their headache patients, astute therapists might evolve their own algorithms when not to offer neuroimaging. The longer the history of CDH, the lesser is the likelihood for positive “embarrassing” neuroimaging findings. In atypical daily headache of recent onset with failure to respond to therapy within 4 weeks, neuroimaging is a sensible option.[4] We should be thankful for the occasional patient who defies such commonsense thinking and compels us to maintain a higher index of suspicion at all times in order to recommend neuroimaging earlier.

  To cut down on associated psychiatric morbidity in CDH, early institution of established therapies is important. Not unexpectedly, the placebo effect of negative neuroimaging is short-lasting. Ideally, cost considerations and Government funding policies must not colour scientific perspective. In the far-less-than-ideal world that we all live in, let us work to minimize the impact of such non-scientific guidelines.

  References

  1. Gupta VK. Classification of primary headaches: pathophysiology versus nosology? BMJ 2004. Available at: http://bmj.bmjjournals.com/cgi/eletters/328/7432/119.

  2. Gupta VK. Sleep remits and precipitates migraine: role of the monoaminergic-vasopressin system. J Neurol Neurosurg Psychiatry (10 November 2005). Available at: http://jnnp.bmjjournals.com/cgi/eletters/76/10/1467.

  3. Gupta V. Migraine, cortical excitability and evoked potentials: a clinico-pharmacological perspective. Brain. 2005;128:E36.

  4. Gupta VK. MRI imaging in primary headaches. Radiology (In press).

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Brain imaging in patients with chronic daily headache

  • Sudhir Kumar, Consultant Neurologist

  Dear Editor,

  I read with interest the recent article regarding the role of neuroimaging in patients with chronic daily headache (CDH). Though Howard et al. conclude that patients with CDH could be managed without a brain imaging;[1] I would be hesitant to avoid a brain scan in several such patients.

  Firstly, there are no randomized controlled trials on the usefulness or otherwise of neuroimaging in patien...

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  Dear Editor,

  I read with interest the recent article regarding the role of neuroimaging in patients with chronic daily headache (CDH). Though Howard et al. conclude that patients with CDH could be managed without a brain imaging;[1] I would be hesitant to avoid a brain scan in several such patients.

  Firstly, there are no randomized controlled trials on the usefulness or otherwise of neuroimaging in patients with headache. In large series with headache, 2-4% of the scans are abnormal;[2] and the figure is even higher in some retrospective case series.[3] These figures could be important from a public point of view and for the Governmental agencies responsible for funding scans, but have no meaning from an individual patient’s perspective. For example, if a patient is denied neuroimaging and a treatable pathology such as hydatid cyst of the brain diagnosed at a later date, it could be embarrassing for the treating physician.[4] A recent publication highlighted that cerebral venous thrombosis could also present with headache alone, and the diagnosis could be missed without MR venogram.[5]

  Secondly, there are legal implications of missing an abnormality by not offering scans.

  Therefore, a safer protocol would be to counsel the patient regarding the option of neuroimaging, the likelihood of getting an abnormal CT/MR finding and its implication on the treatment, besides the cost of scanning. Informed patients could help in the decision-making process.

  References

  1. Howard L, Wessely S, Leese M, et al. Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry. 2005;76:1558-64.

  2. Goadsby PJ. To scan or not to scan in headache? BMJ. 2004;329:469- 70.

  3. Valenca MM, Valenca LP, Menezes TL. Computed tomography scan of the head in patients with migraine or tension-type headache. Arq Neuropsiquiatr. 2002;60:542-7.

  4. Kumar S. A patient’s opinion is often valuable. J Postgrad Med 2004; 50:216.

  5. Cumurciuc R, Crassard I, Sarov M, Valade D, Bousser MG. Headache as the only sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry. 2005; 76:1084-7.

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  Conflict of Interest:
  None declared.

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