Headache Management

Migraine-Specific Quality-of-Life Questionnaire

The MQoLQ is a questionnaire that assesses the short-term decrements in QOL associated with acute migraine headache attacks. This questionnaire evaluates QOL impairment in the 24 h period following the onset of a migraine headache. The questionnaire is self-administered and is completed quickly and easily. The MQoLQ consists of 15 items with five domains: (1) work functioning, (2) social functioning, (3) energy/vitality, (4) migraine headache symptoms, and (5) feelings and concerns. There are three items within each domain. The response option for each of the items is on a seven point scale, with one indicating maximum impairment of QOL and seven indicating no impairment. Each domain has a maximum score of 21 and a minimum score of three. The scores were compared between migraine-free and migraine periods. The construct validity of the questionnaire was established by showing that there are significant relationships between subjects’ 24 h MQoLQ scores and other indices of clinical migraine headache such as headache severity, limitation of activity, number of associated migraine symptoms, global change in migraine symptoms, and migraine duration. The ability of the MQoLQ to capture within-subject change in QOL was evaluated by comparing QOL scores during a “migraine-free” period with MQoLQ scores 24 h after migraine onset. The MQoLQ should be applicable to all adults suffering from episodic migraine headaches. It was designed primarily for use in clinical trials to assess migraine management and to be responsive to subject changes in QOL in the 24 h following the onset of a migraine headache. The MQoLQ assesses subjective wellbeing and daily ability to function, in addition to measuring the typical associated symptoms of migraine, such as nausea, photophobia/phonophobia, and head pain. The 24 h MQoLQ should not be used to measure global QOL between headache episodes.

Quality-of-Life Questionnaire (MSQ Version 2.1)

The MSQ is a disease-specific QOL instrument with three hypothesized scales; it has been developed, tested, and revised. The MSQ (version 2.1) was structured similarly to older versions of the MSQ (versions 1.0 and 2.0). The revised 14 item MSQ (version 2.1) consists of seven items in the role-restrictive dimension that measure the degree to which performance of normal activities is limited by migraines, four items in the role-preventive dimension that measure the degree to which performance of normal activities is interrupted by migraines, and three items in the emotional function dimension that measure the emotional effects of migraine. The MSQ dimensions had low to modest correlations with the two component scores of the SF-36 and were modestly to moderately correlated with migraine symptoms. The validation was structured in three separate analyses applied to 267 subjects. The MSQ provides clinicians, researchers, and those who fund health care a measurement tool to assess health-related QOL. The questionnaire was designed to be completed quickly and easily in a self-administered form. This study suggested that the mean MSQ (version 2.1) scores six to 12 points higher (indicating better QOL).

Migraine-Specific Quality-of-Life Scale

The MSQOL is used to assess a migraine patient’s QOL over a long period (average of three weeks). It is a valid and reliable self-administered measure and a useful tool in clinical migraine research. The information that MSQOL provides can add important information about migraine’s impact on QOL and the potential benefits of therapeutic interventions. This questionnaire has 25 items, with each question having four answers. The general format and scoring are one, very much; two, quite a lot; three, a little; and four, not at all. The total score is then transferred to a scale of zero to 100, with a higher number representing a better QOL. For the MSQOL, Cronbach’s alpha was 0.92, suggesting that the items are tapping into a single concept. The MSQOL can provide valuable information on a migraineur’s QOL and be a useful adjuvant measure when assessing long-term treatment outcomes.

Headache Impact Test

The HIT is a tool that measures headache’s impact on a person’s ability to function on the job, at home, and in social situations. The HIT was developed by the psychometricians who developed the SF-36 health assessment. HIT was designed for greater accessibility (on the Internet at www.headachetest.com and www.amlhealthy.com and as a paper-based form known as HIT-6). HIT-6 is a practical test that consists of six questions. A patient can complete the test in less than 2 min. HIT-6 assesses disability over a four week period. The range of scores is 36 to 78. Higher scores signify the greater impact of disability. A score of 60 or higher indicates a severe impact (the headache stops family, work, school, or social activities), a score between 56 and 59 indicates a substantial impact, a score between 50 and 55 signifies some impact, and a score below 49 denotes no impact. The availability of this test on the Internet, with feedback provided, makes it a useful tool to help headache sufferers understand the burden of their migraines and seek appropriate management.

Headache Impact Questionnaire

The HimQ measures pain and limitations in activity over a three month period. This instrument was the precursor to the MIDAS instrument (see disability scales). The HimQ score is derived from four frequency-based questions (i.e. number of headaches, missed days of work, missed days of chores, or missed days of non-work-related activity) and four summary measures of the average experience across headaches (i.e. average pain intensity and average reduced effectiveness when having a headache at work, during household chores, and in non-work-related activity). ^, This scale was validated after assessing the pain and limitations in activity in a population-based sample of 132 migraine headache sufferers enrolled in a 90 day daily-diary study who completed the HimQ at the end of the study. Previous studies of the validity of retrospective pain and disability reporting were mixed. ^, Study participants completed the HimQ in person and then completed daily diaries for 90 days. The HimQ was developed to identify headache sufferers who have the greatest need for medical care. Self-administered questionnaires can adequately capture information to rate pain severity.

Headache Needs Assessment Survey

The HANA questionnaire was designed to assess two dimensions (frequency and bothersomeness) of migraine’s impact. Seven issues related to living with migraine were used as ratings of frequency and bothersomeness. Validation studies were performed in a Web-based survey, a clinical trial responsiveness population, and a retest reliability population. Headache characteristics (e.g. frequency, severity, and treatment), demographic information, and the HDI were used for external validation. The HANA can be used in medical practice groups (e.g. headache centers, managed care groups) as a screening tool to detect potential problems. Scores from the scale are compared before and after treatment to determine the headache’s impact. Primary care physicians could use the HANA to screen patients with a migraine for further evaluation. Once identified, those with severe migraines may be candidates for further evaluation and immediate treatment. The HANA has several advantages in that it can (1) select who should be treated, (2) increase productivity by adequately treating headaches, and (3) identify the need for aggressive treatment without the usual slow advancement through stepped-care algorithms. This brief, self-applied questionnaire may be a useful screening tool to evaluate migraine’s impact. The two-dimensional approach to patient-reported QOL allows individuals to weigh the impact of both frequency and bothersomeness of chronic migraine (CM) on multiple aspects of daily life.

Henry Ford Hospital Disability Inventory

The HDI is useful in assessing the impact of headaches and its treatment on daily living. It is a paper-and-pencil instrument that probes the functional and emotional effects of headaches on everyday life. The HDI is a 25 item headache disability inventory, with each item requiring a “yes” (four points), “sometimes” (two points), or “no” (zero points) response. Therefore a maximum score of 100 points reflects severe self-perceived headache disability. The scale is easy to complete and simple to score and interpret. The HDI has high internal consistency, reliability, and good content validity; the long-term (two month) test-retest stability of the HDI was robust. ^, The test-retest reliability for the beta-HDI was acceptable for the total score and functional and emotional subscale scores. Scales of this nature help investigators understand headache’s impact on everyday life. Therefore the HDI can be used to (1) assess the impact of headache on the patient’s daily living, (2) monitor the effect of therapeutic intervention, and (3) plan for a global approach to coping with headache with the patient’s involvement.

Migraine Disability Assessment Questionnaire

The MIDAS questionnaire ( Fig. 38.1 ) was developed to measure headache-related disability and improve doctor–patient communication about the functional consequences of migraines. The questionnaire was based on five disability questions that focus on lost time in three domains: schoolwork or work for pay; household work or chores; and family, social, and leisure activities. This scale can be used by physicians, nurses, pharmacists, and alternative practitioners. It is easy to complete and takes only a few minutes. The MIDAS questionnaire has demonstrated reliability, as reported in two separate population-based studies, one in the United States and one in the United Kingdom, and validity by using a three month daily-diary study as the “gold standard.” Scores on the MIDAS are highly correlated with physician judgments about the severity of illness and the need for treatment. This instrument is scored as follows: a score of 5–10 indicates little or no disability, 10–20 indicates moderate disability, and higher than 20 indicates severe disability. The MIDAS questionnaire is an important part of a package of educational, investigative, and therapeutic measures and could play a major role in improving the care of patients with migraines and other types of headaches. ^, A randomized, placebo-controlled trial showed that the MIDAS grade provides a basis for selecting initial treatment in stratified care.

Epidemiology

The prevalence of migraines is similar and stable in Western countries and the United States. Three large-scale population-based studies have been conducted in the United States, one in 1989, ^, one in 1999, ^, and one in 2004. ^, The first American Migraine Study found that the prevalence of migraine was 17.6% in women and 6% in men. Two follow-up studies, the American Migraine Study II and the American Migraine Prevalence and Prevention Study (AMPPS), provided results identical to the first, indicating that the prevalence of migraine has been stable in the United States, at least over the last 15 years.

Before puberty, the prevalence of migraine is approximately 4% ; after puberty, it increases more rapidly in girls than in boys. It increases until approximately 40 years of age and then declines. Prevalence is lowest in Asian Americans, intermediate in African Americans, and highest in Caucasians. In the United States, the prevalence of migraines decreases as household income increases. ^{, ,}

Migraines decrease the sufferers’ QOL. The World Health Organization (WHO) ranks migraine among the world’s most disabling medical illnesses. Approximately 28 million Americans have severe, disabling migraine headaches. Migraine’s cost to employers is approximately $13 billion per year, and annual medical costs exceed $1 billion. Instruments to quantify migraine disability include the MIDAS and the HIT.

Description of the Migraine Attack

The migraine attack can consist of premonitory, aura, headache, and resolution phases. Premonitory symptoms occur in 20% to 60% of migraineurs, hours to days before the onset of the headache. They may include psychological, neurologic, constitutional, or autonomic features, such as depression, cognitive dysfunction, and bouts of food craving.

Formal Diagnostic Criteria

The IHS subdivides migraine into migraine with aura ( Box 38.2 ) and migraine without aura ( Box 38.3 ). To diagnose migraines without aura, five attacks are needed. No single feature is mandatory, but recurrent episodic attacks must be documented. Migraine persisting for more than three days defines “status migrainosus.” ^, Migraine occurring 15 or more days per month is called CM by the ICHD-3 ( Box 38.4 ).

Migraine with aura is subdivided into typical aura, prolonged aura, hemiplegic migraine, basilar-type migraine, and migraine with acute-onset aura. The IHS classification now allows the association of aura with other headache types. Prolonged aura lasts from 1 h to one week, and persistent aura lasts for more than one week (but resolves); if neuroimaging demonstrates a stroke, a migrainous infarction has occurred.

Migraine Variants

Basilar-type migraine aura is characterized by brainstem symptoms: ataxia, vertigo, tinnitus, diplopia, nausea and vomiting, nystagmus, dysarthria, bilateral paresthesia, or a change in the level of consciousness and cognition. It should be considered when patients have paroxysmal brainstem disturbances. Some have suggested that hemiplegic migraines should be diagnosed if weakness is present.

Ophthalmoplegic migraine is caused by idiopathic inflammatory neuritis. There is an enhancement of the cisternal segment of the oculomotor nerve, followed by resolution over several weeks as the symptoms resolve.

Hemiplegic migraines can be sporadic or familial. Attacks are frequently precipitated by a minor head injury. Familial hemiplegic migraine (FHM) is an autosomal dominant, genetically heterogeneous disorder with variable penetration. FHM includes attacks of migraine without aura, migraine with typical aura, and episodes of prolonged aura, fever, meningismus, and impaired consciousness. Headache may precede the hemiparesis or be absent. The onset of hemiparesis may be abrupt and simulate a stroke. In 20% of unselected FHM families, patients have cerebellar symptoms and signs (nystagmus, progressive ataxia). All have mutations in the CACNA1A gene .