Our knowledge of the underlying mechanisms of migraine has improved in recent years, leading to the development of novel target-based approaches for its treatment. However, the non-migraine headache remains an under-researched area, despite being one of the main causes of disability worldwide.1 At a special lecture during the 19th Congress of the International Headache Society (IHC), Prof. Rigmor Jensen discussed the importance of furthering our understanding of the non-migraine headache, focusing on tension-type headache, medication-overuse headache and cluster headache.
“There is so much interest in headache disorder, and we have to go home and raise awareness in our countries”
– Prof. Rigmor Jensen (University of Copenhagen, Denmark)
Tension-type headache (TTH)
Although TTH is highly prevalent in the general population, it is often not recognised or treated appropriately in specialised clinics. Prof. Jensen described how many of her patients consider TTH to be a normal phenomenon and not a serious disorder. However, in its frequent and chronic forms, TTH can have a significant impact on quality of life for patients.1
Prof. Jensen emphasized that although migraine and TTH have some overlapping features, they are separate disorders. Clinicians should be aware that they frequently coexist in patients and both diagnoses should be applied. In terms of TTH management, there are no specific therapies for TTH and its management often involves triptans. One study showed that patients with TTH had deteriorated neck and shoulder muscle function compared to healthy controls;2 therefore, some patients may benefit from posture correction and normalization of muscle function. Prof. Jensen highlighted the need for further research into the underlying mechanisms of the disease in order to develop specific therapies to improve the management of TTH.
Medication-overuse headache (MOH)
Prof. Jensen stated that although MOH is estimated to affect approximately 63 million individuals worldwide, MOH is both a treatable and preventable condition. Discontinuation of the treatment causing MOH has been shown to increase patient productivity and decrease direct healthcare costs.3 Complete withdrawal of the treatment causing MOH is considered both more effective and more feasible than restricting its intake to detoxify patients.4,5
Prof. Jensen highlighted that even short-term use of painkillers may be harmful and she urged clinicians not to overprescribe medication in the management of MOH. In her opinion, optimal care for MOH requires information and education for both patients and clinicians.
Prof. Jensen began her discussion of cluster headaches with an overview of the temporal symptom development of a cluster headache attack. Prof. Jensen suggests that recognition of the symptoms in the pre-ictal phase (i.e. local painful and autonomic symptoms) could help inform early treatment strategies, before the pain phase occurs.6
Although the diagnostic delay for cluster headache has decreased over time,7 it still remains a problem in cluster headache management. A Danish cohort study showed that the diagnostic delay for cluster headaches was approximately 6.2 years for both men and women, with misdiagnosis of cluster headache being more prevalent among women compared with men (61% vs 46%).8
Prof. Jensen concluded her lecture by emphasizing that non-headache disorders pose a significant public health problem. To improve the care of patients with non-migraine headaches, Prof. Jensen believes that the responsibility of raising disease awareness and providing education lies with the clinician.
Stovner LJ, et al. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018;17:954–976.
Madsen BJ, et al. Neck/shoulder function in tension-type headache patients and the effect of strength training. J Pain Res 2018;11:445–445.
Jellestad PL, et al. Economic benefits of treating medication-overuse headache – results from the multicenter COMOESTAS project. Cephalalgia 2019;39:274–285.
Carlsen LN, et al. Complete detoxification is the most effective treatment of medication-overuse headache: A randomized controlled open-label trial. Cephalalgia 2018;38:225–236.
Engelstoft IMS, et al. Complete withdrawal is the most feasible treatment for medication‐overuse headache: A randomized controlled open‐label trial. Eur J Pain 2019;23:1162–1170.
Snoer A, et al. Cluster headache beyond the pain phase: A prospective study of 500 attacks. Neurology 2018;91:e822–e831.
Frederiksen HH, et al. Diagnostic delay of cluster headache: A cohort study from the Danish Cluster Headache Survey. Cephalalgia 2019;333102419863030. [Epub ahead of print].
Lund N, et al. Chronobiology differs between men and women with cluster headache, clinical phenotype does not. Neurology 2017;88:1069–1076.