Dr. Grossi's Blog


Dr. Philip Grossi
Thursday, 24 February 2011


Headaches generally and migraine headaches in particular are a common topic of discussion in the office. I suppose this is related to the fact that migraines are co-morbid with mood disorders in a large percentage of individuals. Some researchers place the co-morbidity at 40%. Last year witnessed some major advances in understanding headache pathophysiology and the formal approval of treatments that were thought to be helpful but were not approved.

illustration to headache blog

Dodick and colleagues published in Headache  the results of two large-scale, randomized, placebo-controlled trials that provided evidence for the efficacy of onabotulinumtoxinA in the prophylaxis of chronic migraine. Chronic migraine is a complication of episodic migraine and is characterized by more that 15 headaches per month with proportional loss of work and concomitant high health care costs. Treatment includes pharmacotherapy and avoidance of aggravating factors. Dodick's analysis of the results of the treated versus the placebo group revealed a statistically significant decrease in the number of headache days as well as the hours of headache and scores on the Headache Impact Test in the onabotulinumtoxinA treated group.  This is the first approved treatment for the prevention of chronic migraine.

Holroyd et.al. studied 232 adults who had at least 3 migraines per 30 days. They first optimized the acute treatment and then assessed the benefits of preventive treatment and behavioral interventions. The primary end point of the study was the number of migraine headaches per 30 days, and the secondary end points were migraine-related quality of life issues. Their results suggest that preventive pharmacotherapy and behavioral interventions were best when combined.

Cohen et al. studied individuals with cluster headaches. Cluster headaches (they occur in clusters and thus the name) are one-sided attacks of intense pain that are usually accompanied by tearing, drooping eyelid, injection of the conjunctiva and running nose on the same side as the attack.  While subcutaneous sumatriptan has been the acute treatment, its use is limited to individuals without cardiovascular disease. Cohen reported on 76 patients who experienced 298 attacks and were treated with high-flow oxygen or high-flow room air.  The primary end point was adequate relief at the fifteen-minute marker.  They found that the relief rate with oxygen was 78% versus 20% for room air.  This study provides evidence for the effectiveness of high-flow oxygen for the acute treatment for cluster headache.