SYNOPSIS630 (39%) of 1600 patients seen in a Headache Clinic over a three year period had chronic daily headaches (CDH). In 78% of these CDH patients, the daily headaches evolved out of a prior history of episodic migraine; these patients we designate as having "transformed" or "evolutive" migraine. The other 12% had migraine headaches which were daily from the start.Patients with transformed migraine, in contrast to those with daily headaches from the start, have a significantly higher incidence of positive family history of migraine, menstrual aggravation of migraine, identifiable trigger factors, associated G.I. and neurological symptoms, and early morning awakening with headache.The CDH group in general over-used symptomatic medication and exhibited abnormalities on behavioral scale testing. Withdrawal of daily symptomatic medication, institution of a low tyramine low caffeine diet, initiation of prophylactic anti-migraine therapy, and biofeedback and behavioral therapy, gave worthwhile improvement in 76% of chronic daily headache patients.Factors which promote "evolution" of migraine from intermittent to chronic daily occurrence are not well-defined but may include medication abuse, medication withdrawal, and psychiatric disturbances. (Headache 27:102-106, 1987) The traditional teaching considers migraine as a purely episodic phenomena, and daily headaches are categorized as muscle contraction or tension headache. Clinical observation of Dalsgaard-Neilsen 1 indicated that 73% of patients with migraine get frequent low grade headaches between their attacks. He concluded that headache is not just an episodic phenomena, but a permanent deviation from normal, because their biologic threshold for headache is lower than in the normal population.Discussing the natural history of migraine, Graham 2 observed that in some individuals headache may show an increasing frequency of attack until they become daily in occurrence. In 1982, Mathew et al 3 reported a series of patients who had a clear-cut history of episodic migraine in the past, whose headaches, over the years transformed into a daily or near daily headache. This communication is an extension of that paper with additional observations and a larger number of patients. MATERIALS AND METHODSThe history and clinical features of 630 chronic daily headache patients were analyzed in detail. These 630 patients were selected from a series of 1600 patients seen in a headache clinic population between the years 1982 and 1985. The diagnostic breakdown of the 1600 patients in a headache clinic population is given in Table 1. Chronic daily headaches formed 39% of the patients seen.The diagnostic criteria for migraine is shown in Table 2, where certain points are allocated for individual clinical features of migraine. A minimum of 5 points out of 10 was considered essential to meet the diagnostic criteria for migraine. Chronic daily headaches were divided into three types: Type I: starts as daily or near daily headache with no change in the severity and lacks migrainous ...

SYNOPSIS The three most commonly used modalities in the prophylactic treatment of headache, namely propranolol, amitriptyline and biofeedback training, were compared individually and in combination. Three hundred forty patients with migraine end 375 patients with mixed headache were randomly allotted to 8 therapeutic categories. The total duration of the study was 312 years and the therapeutic groups were evaluated for a period of 7 months including I month of pretreatment observation. Improvement was assessed by percentage of change in the average headache index during the last three months of evaluation from the pretreatment headache index. In the migraine group 273 patients completed the study. Improvement was significantly higher in patients receiving prophylactic treatment compared to control patients who were on abortive Ergotamine treatment. Propranolol plus biofeedback yielded the best results in the migraine group and addition of amitriptyline did not significantly change the percentage of improvement. Propranolol alone (62%) was significantly superior to amitriptyline (42%) (p < 0.01). The differences between propranolol alone and propranolol plus amitriptyline was not statistically significant. In the mixed headache group 281 patients completed the study. The most effective treatment was combination of amitriptyline, propranolol and biofeedback training. Amitriptyline alone was superior to propranolol alone in the treatment of mixed headache (p<0.01). A combination of propranolol and amitriptyline was superior to either of those alone. Biofeedback, though by itself, did not appear to be the treatment of choice, significantly contributed to better results as an adjunct when it is combined with pharmacological agents. Concomitant use of propranolol and amitriptyline did not result in any adverse reactions or clinical incompatibility.

SYNOPSIS Based on clinical features, a group of 31 patients with cluster headache was divided into 1) episodic cluster headache, with months or years of headache free intervals, 2) chronic cluster headache without significant headache free intervals. Chronic type could be subdivided into primary and secondary varieties, secondary being a transformation from episodic cluster headache. A clinical trial of Lithium Carbonate was undertaken. Blood levels of lithium were determined at regular intervals to monitor the therapeutic dosage. Lithium was found to be an effective prophylactic agent in both episodic and chronic cluster headache patients. The percentage of improvement based on headache index was as follows: 55% of patients had more than 90% improvement; 10% of patients showed 60–90% improvement; 15% of patients showed 25–60% improvement; and 20% no improvement. Effectiveness of lithium was evident in less than a week after the initiation of treatment in those who responded. 55% of patients showed mild side effects such as tremor, nausea, diarrhea, abdominal discomfort and lethargy. Only one patient had serious side effects which needed discontinuation of therapy.The beneficial effect of lithium on cluster headaches appear to be independent of its anti‐depressant action. Mechanism of action of lithium in cluster headache is not clear.

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