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Dextroamphetamine for chronic tension-type headache
- David C Haas (12 January 2008)
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Headache from an Ophthalmologist's perspective
- Mohammad T Masoud (13 January 2008)
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Manual Therapists and Headache
- Richard J N Gribble (14 January 2008)
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Tension-Type Headache
- Arianne P Verhagen, Marjolein Y Berger and Jan Passchier (22 January 2008)
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Is dipyrone an option for episodic tension type headache?
- Cesar Augusto Guevara-Cuellar (4 February 2008)
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David C Haas, Retired professor of neurology, SUNY Upstate Medical University, Syracuse, NY, USA 7549 Hunt Lane, Fayetteville, NY, 13066 USA
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In their clinical review of tension-type hedache, Loder and Rizzoli did not include dextroamphetamine as a potentially effective preventive for chronic tension-type headache in some patients, as shown by our n of 1 trials using a randomized, double-blinded, controlled, multiple-crossover design (Headache 2004;44:1029-1037). In a group of 8 patients ostensibly improved on dextroamphetamine before the trial (Trial 1), 5 had considerably lower mean daily headache grades on dextroamphetamine than on (equi-stimulatory) caffeine--the control drug. Moreover, P values indicated real amphetamine effects. In a group of 8 subjects who had never taken amphetamine (Trial 2), 3 had markedly lower headache grades on amphetamine with P values supporting or strongly supporting real amphetamine effects. Caffeine failed to produce a significant differential effect in any subject. All but two of the 16 subjects had previously taken amitriptyline. None had obtained adequate headache relief. Trivial adverse effects occurred in a minority of subjects and as often with caffeine as with amphetamine. No craving for amphetamine occurred. These results should now encourage investigators to study the effect of dextroamphetamine in chronic tension-type headache patients unrelieved by amitriptyline. Individual patient's responses can generally be determined by relatively brief n of 1 trials as described in our paper. Subjects whose trials indicate a real beneficial dextroamphetamine effect could receive this drug afterwards. If our data is valid, some of these patients will even be essentially free from headache while taking dextroamphetamine. David C Haas, MD dc_haas@yahoo.com Competing interests: None declared |
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Mohammad T Masoud, Senior House Officer, Ophthalmology Cheltenham General Hospital, GL53 7AG. tahir_dr@hotmail.com
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Dear Editor, I read the article by Loder and Rizzoli on tension-type headache with interest [1]. There are some important aspects of headaches which need mention. As described by the authors, some forms of headaches are accompanied by pain involving the neck. Giant cell arteritis (GCA) is an important differential diagnosis that must be kept in mind by clinicians assessing such patients. Any delays in the diagnosis may result in the involvement of eyes causing significant visual loss. A detailed history, examination of temporal arteries, fundus check, an urgent ESR and occasionally temporal artery biopsy is required to make the diagnosis. Delay in the diagnosis of GCA is the second most common cause of GP ophthalmic cases claims settled by the MDU [2]. The authors have also mentioned the examination protocol that should be followed by clinicians in the assessment of patients with tension-type headaches. Ideally this must include eye examination to check for reduced visual acuity, ptosis, ophthalmoplegia, diplopia, conjunctival redness, pupillary abnormality and swollen optic discs. Conditions like refractive errors, conjunctivitis, uveitis, angle-closure glaucoma, cranial neuropathies and cavernous sinus lesions can present with periocular pain and headaches [3,4]. References: 1 Loder E, rizzoli P. Tension-type headache. BMJ 2008; 336: 88-92 2 Claims trends. MDU journal Volume 23, Issue 2, Dec 2007 3 Tomsak RL. Ophthalmologic aspects of headache. Med Clin North Am. 1991 May;75(3):693-706. 4 Rosenblatt MA, Sakol PJ. Ocular and periocular pain. Otolaryngol Clin North Am. 1989 Dec;22(6):1173-203 Competing interests: None declared |
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Richard J N Gribble, Musculoskeletal Physician/Osteopath London College of Osteopathic Medicine, 10 Boston Place London NW1 6QH
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Loder & Rizzoli mention palpation of pericranial muscles as being valuable in the physical examination. Manual therapists also assess segmental motion in the cervical spine in addition to the soft tissue changes to diagnose somatic dysfunctional areas . The motion restriction helps to determine the appropriate manual treatment. Any cervical level, but particularly occipito-atlantal and upper cervical dysfunctions can cause tension-type headache. A patient not responding to usual treatments may benefit from assessment and appropriate treatment from a manual therapist. Competing interests: None declared |
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Arianne P Verhagen, ass prof Erasmus MC University Rotterdam, PO Box 2040, 3000 CA Rotterdam The Netherlands, Marjolein Y Berger and Jan Passchier
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With great interest we read the clinical review of Loder & Rizzoli [1]. Our special interest was directed to the section ‘how should tension-type headache be treated’. The authors recommend the use of analgesics (aspirin) and non-steroidal anti-inflammatory drugs (NSAIDs) based on two randomised clinical trials (RCTs). We regret that the authors did not use our systematic review as reference because this could have made the evidence for their statements much stronger [2]. In our systematic review including 41 papers we clearly conclude that NSAIDs and acetaminophen are both effective for short-term pain relief when compared to placebo in patients with tension-type headaches. No specific type of NSAID appeared to be more effective than others, but ibuprofen showed fewer short-term side effects than other NSAIDs. Contrary, for the combination of analgesics and caffeine we could not find any evidence for or against [2]. More serious, however, are our concerns regarding the recommendations of the authors on preventive strategies. A simple, less than 10 minutes search on PubMed would reveal over 70 RCTs evaluating the effect of preventive medication, relaxation or biofeedback, of which over 30 on prophylactic medication. Yet the authors choose to use six RCTs to base their recommendations on. We strongly believe that the recommendations in this paper concerning preventive medication would be different when more studies were included and appraised. This knowledge comes from a (yet unpublished) systematic review on prophylactic medication in adults with tension-type headache, that we recently performed. The authors recommend amitriptyline as medication with the best evidence, based on 3 RCTs. We found 4 RCTs evaluating amitriptyline compared to placebo and in none of the studies a significant difference could be found. In addition in 11 RCTs amitriptyline was compared to another therapy (medication or other) but in only one study amitriptyline was found to be superior to biofeedback. In all other studies no significant differences between the treatments was found. We firmly believe that publishing clinical reviews in the BMJ serves the busy clinician. We nevertheless regret that the treatment recommendations could be made stronger or would be different when a more rigid systematic review methodology was used. References: 1. Loder E, Rizzoli P. Tension-type headache. BMJ. 2008 Jan 12;336(7635):88-92. 2. AP Verhagen, L Damen, MY Berger, J Passchier, V Merlijn, BW Koes. Is any one analgesic superior for episodic tension-type headache? J Fam Pract2006 Dec;55(12):1064-72 Competing interests: None declared |
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Cesar Augusto Guevara-Cuellar, Professor Assistant University of Valle 25360
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Although the treatment of tensión type headache (TTH) is relatively easy with non steroidal inflammatory analgesic drugs and this condition has a good prognosis, indiscriminate use of these analgesics and the increase of prevalence of TTH has increased medication overuse headache equally(1,2). This resultant problem obliges a more rational approach in use of these medications and a search for other therapeutic alternatives. There is growing evidence that dipyrone is an option in treatment of patients with TTH in an emergency setting. A recent meta-analysis published in Cochrane Database that included 636 adults demonstrated that 0.5g and 1g dipyrone oral and intravenous were significantly better than placebo and acetylsalicylic acid for episodic TTH (3). Other randomised clinical trial showed that dipyrone reduced recurrence and the use of rescue medication in these patients. (4). The main concern with use of dipyrone is the risk of agranulocytosis. However there is evidence that this complication has an incidence of 3.46:1 million and a mortality rate of 0.24:1 million (5) and so is not significantly different from drugs of common use such as penicillin G, carbamazepine, spironolactone , propylthiouracil or ticlopidine. Therefore, use of dipyrone could be an option in treatment of episodic TTH over shorter periods. 1. Obermann M, Katsarava Z. Management of medication-overuse headache. Expert Rev Neurother. 2007; 7:1145-55. 2. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survey. Eur J Epidemiol. 2005;20:243-9. 3. Ramacciotti AS, Soares BG, Atallah AN. Dipyrone for acute primary headaches. Cochrane Database Syst Rev 2007 Apr 18;(2):CD004842. 4. Bigal ME, Bordini CA, Speciali JG. Intravenous dipyrone for the acute treatment of episodic tension-type headache: a randomized, placebo-controlled, double-blind study. Braz J Med Biol Res. 2002 ; 35:1139-45. 5. Ibáñez L, Vidal X, Ballarín E, Laporte JR. Population-based drug-induced agranulocytosis. Arch Intern Med. 2005;165:869-74. Competing interests: None declared |
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