BOSTON—Quantitative analysis of headache diaries may help with the diagnosis and treatment of chronic headache, reported Herbert G. Markley, MD, at the 50th Annual Scientific Meeting of the American Headache Society.
Documenting Headache Patterns
Dr. Markley and colleagues designed an International Headache Society–compliant 0- to 10-point daily headache diary to document headache patterns and help confirm diagnosis. The diary was then used to calculate a monthly pain intensity score, which assisted in the judgment of effects of new medications or procedures. “If the monthly pain intensity scores are plotted on a monthly graph, this can document the long-term course of the headache pattern by showing periods of exacerbation and improvement, relating these to seasons or addition of certain medications,” said Dr. Markley, Director of the New England Regional Headache Center in Worcester, Massachusetts.
A daily 0- to 4-point disability scale was also used to assess effects of procedures, he said. This added the capability to prospectively record disability on a monthly or long-term basis, instead of retrospectively using impact scales, such as the Migraine Disability Assessment Scale or the Headache Impact Test–6.
Quantitative Scoring
Daily headache frequency was graphed a month at a time, and the following scores were derived from headache logs: total monthly number of headache-free days; total monthly headache score; total monthly disability score; mean disability score; monthly sum of individual doses of rescue medication; and days per month that rescue medication is used, by drug. On the headache logs, patients also scored headache frequency (number of attacks per day), neck pain, or pain in other head regions.
“Patients who try to remember all the details of their days in bed, the number of days they took a triptan, and so forth, can never present such information to the practitioner,” Dr. Markley told Neurology Reviews. However, quantitative scoring allows for comparison of month-to-month changes in headache patterns.
Graphs of episodic migraine showed a large number of headache-free days—usually with a headache score of less than 50. Graphs of chronic migraine showed a “sawtooth” pattern of semiperiodic exacerbations and remissions. “In typical chronic migraine which has transformed from episodic migraine, there are an almost invariable four to eight headache peaks per month,” Dr. Markley said. The three chronic migraine phenotypes—frequent, daily, and continuous—as well as refractory chronic daily headache are easily identified on the headache diary graphs with increasingly fewer drops in headache peaks. Graphs can also indicate discontinuation and overuse of treatment, as well as periods of remission.
“Real-Time” Data
Treating patients with consistent use of a quantitative diary instrument gives clinicians a better way to assess headache disorders, “closer to the ideal of having ‘real-time’ numerical data as used by internists when they measure blood pressure at every visit or by cardiologists when they measure ejection fraction, and so forth,” commented Dr. Markley.
“Calculated monthly headache scores may aid choice of therapy, convince patients that chosen medications are effective, or indicate lack of efficacy and a need to change therapy,” Dr. Markley concluded. Therefore, “quantitative analysis of headache diaries is a valuable and important tool for the management of headache patients in a headache specialty practice and should be considered a part of the armamentarium of all certified practitioners.”
—Marguerite Spellman