Measurement of Headache Pain 249them from their offending medications and to start them on
an appropriate prophylactic course. Some of the patients
received behavioral treatment in addition to detoxi“cation.
At the “rst planned follow-up, both groups revealed similar
levels of improvement. However, at the three-year follow-up,
patients receiving the combined treatment showed greater
improvement on two of three measures collected prospec-
tively and lower rates of relapse. Additional discussion of
abuse and abuse-proneness may be found in Saper and
Sheftell (2000).
Treating patients who have cluster headache chie”y by
nonpharmacological treatments has met with limited success
(Blanchard, Andrasik, Jurish, & Teders, 1982). Nonpharma-
cological approaches may still be of value to some cluster
sufferers, however, in helping them cope more effectively
with the at times overwhelming distress that may result from
having to endure repeated, intense attacks of these types of
headache. Similarly, patients whose headaches occur follow-
ing trauma typically experience a multitude of problems that
make treatment particularly dif“cult (Andrasik & Wincze,
1994; Ramadan & Keidel, 2000). A coordinated, interdisci-
plinary approach, similar to that found in place at most com-
prehensive pain centers, is typically required (Duckro, Tait,
Margolis, & Silvermintz, 1985; Medina, 1992). Inpatient
headache specialty units have sprouted across the country to
handle complicated cases; headaches that are prolonged, un-
relenting, and intractable; are caused or exacerbated by sub-
stances; are accompanied by signi“cant medical disease; or
require complicated copharmacy (Freitag, 1992). Intensive
multidisciplinary headache treatment programs (day and
inpatient), modeled after those in place at chronic pain cen-
ters, have shown great value with patients who are particu-
larly dif“cult to treat (e.g., Saper, Lake, Madden, & Kreeger,
1999).
Despite their best efforts to identify, characterize, and de-
“ne all forms of headache, some headache types have not
been addressed adequately by the IHS. The “rst of these is
daily or near daily headache, which is widespread, particu-
larly in pain specialty clinics. Studies have shown that a size-
able number of people presenting with chronic daily headache
cannot be classi“ed according to the IHS criteria (Silberstein,
Lipton, Solomon, & Mathew, 1994). The diagnostic chal-
lenge is distinguishing between a migraineous headache that
has been •transformedŽ to a continuous presentation (“rst dis-
cussed by Mathew, Reuveni, & Perez, 1987), from a chronic
form of tension-type headache, that is due in part to medica-
tion rebound, and other rare forms of short-duration daily pain
(Guitera, Muñoz, Castillo, & Pascual, 1999). This distinction
(migraine versus other) is especially important when pursuing
pharmacological treatment.
Although a sizeable number of females experience all or a
portion of their migraine symptoms during a menstrual cycle,
little attention has been given to the study of such headaches
(MacGregor, 1997; Massiou & Bousser, 2000). Indeed, the
IHS did not list menstrual migraine as a diagnostic entity,
leaving those who have investigated this topic to develop
their own criteria. Early investigations suggested that head-
aches linked to the menstrual cycle were not as responsive to
behavioral treatment as were those migraines that occurred at
other times. More recent research has begun to question this
notion (Holroyd & Lipchik, 1997). Clearly, further study of
this headache type is warranted.MEASUREMENT OF HEADACHE PAINHeadache DiaryPain is a private event and no method yet exists that can reli-
ably objectify any headache parameters. By default, subjec-
tive diary-based ratings have come to be regarded as the
•gold standard.Ž In early research on headache (Budzynski,
Stoyva, Adler, & Mullaney, 1973), patients were asked to rate
pain intensity on an hour-by-hour, day-by-day basis on
recording grids reproduced on pocket-sized cards. Medica-
tion consumption was monitored as well. Because change in
headache could occur along varied dimensions, several dif-
ferent indices were examined: frequency, duration, severity
(peak or mean level), and Headache Index/Activity, a com-
posite or derived measure that incorporated all dimensions
(calculated by summing all intensity values during which a
headache was present). This latter measure was believed to
re”ect the total burden or suf fering of patients.
In behavioral treatment studies, the composite diary mea-
sure has been utilized most consistently. However, commit-
tees recently charged by the IHS to develop guidelines for
conducting and evaluating pharmacological agents have
recommended that composite measures no longer be used
(International Headache Society, 1999a, 1999b). This index
is seen as weighting severity and duration in an arbitrary
manner, which renders it of little value when conducting
comparisons across subjects. Further, the clinical meaning of
changes is noted to be unclear. Rather, these committees rec-
ommend that the following serve as the primary diary-based
measures of headache pain:1.Number of days with headache in a four-week period (see
Blanchard, Hillhouse, Appelbaum, & Jaccard, 1987, for a
contrasting opinion about the desired length of the mea-
surement interval).