Commentary: Acute Tension-Type Headaches Are Associated with Impaired Cognitive Function and More Negative Mood

摘要

I found Smith’s article ( 1 ) extremely interesting. The author reported that an acute attack of tension-type headache (TTH) may be “associated with an increase in negative affect, poorer performance on working memory and semantic memory tasks, slower psychomotor performance, and increased distraction from irrelevant stimuli” ( 1 ). Although there are a number of articles dealing with cognition/behavior in headache patients ( 2 – 4 ), there is still a consensus that the two most frequent primary headaches, migraine and TTH ( 5 ), do not significantly affect cognitive functions to a degree that daily activities are seriously affected, particularly when one considers the interictal periods. It is well known that migraine attacks are incapacitating, whereas the TTH attacks are mild or moderate in intensity, not affecting the activities of everyday life. In fact, patients with TTH may suffer severe headache attacks, resulting in impairment of routine activities. In a study carried out in our university ( 6 ), involving 121 female nurses, 536 headache attacks were registered, 117 with features of TTH and 10 of probably TTH, 3 of these 127 attacks (2.4%) were considered severe. Considering that headache attacks are relatively frequent, and the fact that they may impair cognitive function, the physician should consider prophylactic measures to avoid triggering attacks during the performance of important tasks, in particular, those that demand a high level of attention and precision. The interesting results obtained by Smith ( 1 ) need, however, to be confirmed by other works with a larger number of subjects. In addition, the current different treatments that may be used as preventive forms to control the TTH attacks are usually not corroborated by evidence-based medicine. When we are dealing with children suffering from TTH, which are regarded as a prevalent and debilitating condition for both child and his or her family, the parents are often reluctant to accept a prescription with a pharmacological agent ( 7 ). They tend to prefer a non-pharmacological treatment as their first choice ( 7 ). One of the approaches to be tried in children is to stimulate a healthy lifestyle in order to avoid factors that could trigger headaches at both home and school (e.g., a good quality of sleep, adequate water and food ingestion, physical activity, and learning how to cope with psychosocial stressors) ( 7 ). There are various other non-pharmacological strategies that may be adopted to reduce the possibility of a headache attack (Figure 1 ). Acupuncture, manipulation, joint range of motion, massage, cold packs, home exercise programs, advice on posture, muscle stretching techniques, retraining, and razor are some alternatives that might be of use ( 8 ). A recent update of a Cochrane review concluded that acupuncture is effective for treating frequent episodic or chronic TTHs ( 9 ). Figure 1 Pharmacological and non-pharmacological strategies that may be adopted to reduce the possibility of a tension-type headache attack, which may impair cognitive function, representing a major cause of concern, when the individual is engaged in activities that demand an optimization of performance . Since the major concern here is the cognitive impairment during headache attacks, the use of preventive drugs to avoid such crises must bear in mind a possible additional cognitive deficit triggered by the choice of medication. The most widely used drug for treating TTH is amitriptyline, which, although it may attenuate a negative mood, can in fact worsen the cognitive symptomatology ( 10 ). There are a number of other pharmacological agents that have been employed as prophylactic treatment, such as antiepileptic drugs (sodium valproate, topiramate, and gabapentin), benzodiazepines, botulinum toxin, noradrenergic and specific serotonergic antidepressants (mirtazapine), serotonin re-uptake inhibitor antidepressants, and other tricyclic antidepressants ( 11 ); however, memory impairment has been reported with some of them. A recent review ( 12 ) concluded that, in epileptic patients, some antiepileptic drugs, namely phenobarbital, phenytoin, topiramate, and zonisamide, can impair cognitive function. On the other hand, sodium valproate, carbamazepine, gabapentin, and oxcarbazepine do not appear to affect cognition. In addition, phenobarbital, valproate, gabapentin, topiramate, levetiracetam, and zonisamide may produce adverse behavioral side effects, although carbamazepine was considered neutral by the authors ( 12 ). Nevertheless, venlafaxine and SSRIs were no more effective than amitriptyline or placebo in reducing the attack frequency in chronic TTH ( 13 ). Recent evidence suggests that it is indeed possible to protect cognitive functioning by pharmacoterapy, despite the fact that its effectiveness has not been demonstrated to date in children or adolescents. The newly introduced drugs, levetiracetam and lamotrigine, seem to induce positive cognitiv