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Headache - A way of life?
Headaches are one of life’s most common medical afflictions. Studies have shown that up to 90% of the general population suffer from headaches at some point in life but this implies that 10% of our population have never, ever had a headache in their life. Here in Singapore, a recent large-scale epidemiological study found that the overall lifetime prevalence of headache here was 82.7%, which did not vary between racial groups. Of these, migraines afflicts up to 9.3% of people, 39.9% suffer from episodic tension type headache and 2.4% from chronic tension type headache.
Headaches could not be classified in 31.2% of the respondents. The modal age of headache onset in all races was in the second decade and was similar in all races. Headache morbidity was independent of age, sex, income level, marital status, shift duties, and educational level, and correlated only with race and a positive family history of severe headache. Non-Chinese compared with Chinese were more likely to suffer from severe headaches, seek medical attention and to require medical leave for their symptoms. Non-Chinese also had more migrainous headaches than Chinese did.
The study also found that elevated blood pressure, poor visual acuity, and decreased hours of sleep did not correlate with increased frequency, intensity, or duration of headaches. Individuals who performed shift work had more frequent, although not more intense or long-lasting, headaches. High or low income had no effect on headache prevalence or severity. In another early study done on NUS undergraduates, 10.9% had migraine without aura, 29.8% had tension-type headaches, 1.1% had migraine with aura, and in 56.3% the headache could not be classified. The lifetime prevalence of headache in this population was 98.1%.
In 2000, the Ministry of Health in Singapore published a clinical practice guideline on the diagnosis and management of headache. The guideline recommends that physicians should always make an accurate diagnosis of the type of headache and its cause. The guideline also recommends that physicians use the International Headache Society diagnostic criteria for headache disorders to aid in their diagnosis. The guidelines publish a list of medications with level I and II clinical evidence for the prophylaxis and abortive treatment of both tension type headache and migraines.
In general, tricyclic antidepressants and SSRIs such as amitriptyline and fluoxetine are effective as a prophylaxis in both tension type headache and migraines. Anti-epileptic medications e.g. topiramate and sodium valproate are effective for migraine prophylaxis as are beta-blockers e.g. propranalol and calcium channel blockers e.g. verapamil and flunarizine. Abortively, simple analgesics e.g. acetaminophen and acetylsalicylic acid are effective for both tension type headaches and migraines; as are NSAIDs e.g. ibuprofen and naproxen sodium. Migraine specific abortive medications e.g. ergotamines and triptans are very effective at terminating acute migraine attacks. Detailed pharmacological guidelines for the treatment of migraines have been published by the US Headache Consortium, a multi-disciplinary grouping of medical professionals and these guidelines are available on the website of the American Headache Society (AHS).
These guidelines also list out the evidence behind various non-pharmacological methods of migraine treatment. They found evidence of efficacy for the use of thermal and EMG biofeedback, cognitive-behavioral therapy (CBT), relaxation and behavioral training. Evidence-based recommendations were not possible for the use of hypnosis, TENS, acupuncture, chiropractic manipulation, occlusal adjustments or hyperbaric oxygen.
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