Ottar Sjaastad

One aim of the Vågå study of headache epidemiology was to depict the total panorama of headaches in a small-sized, Norwegian community at the end of the 20th century. In the present part of the study, a search was made for the rare, global headaches. Various, relatively unknown headache categories were observed, such as hydrogen sulphide intoxication ( n = 2) after exposure to H₂S ambient air concentrations of ≥100 p.p.m. In Vågå, nitroglycerine headache (‘dynamite headache’) proved to be a relatively frequent disorder ( n = 13). This represents approximately 0.7% of the study group. A main reason for this, in all probability unusually high frequency is that there previously have been soapstone mines within the precincts of the parish. Another relatively frequently occurring headache followed exposure to wind ( n = 7; 0.38%). Ice-cream headache was rare ( n = 3; 0.16%), when only the general question was asked: ‘other headaches?’. Approximately 7 years later, an ad hoc procedure was adopted: 50 parishioners who did not answer positively concerning ice-cream headache on the first examination were asked specific questions concerning ice-cream headache. Four had had such an experience, i.e. prevalence of 8%, which is 50 times higher than the original result, but still a rather low prevalence when compared with the mean prevalence from other studies: 39%. This demonstrates that the result as regards prevalence, even for a headache such as ice-cream headache, to a large degree depends upon the interview technique used.

A search has been made for the neck-tongue syndrome. It started out with a systematic inquiry during the Vågå study of headache epidemiology during the years 1995-97. Two cases were detected relatively early during the study. This led to a scrutiny of such cases also in our hospital headache practice. The origin - and the basis of the study, nevertheless, was the Vågå study. In the Vågå study, where 1838 18-65-year-old parishioners were examined, there were four neck-tongue syndrome cases (N-TS), i.e. a prevalence of approximately 0.22%. N-TS may be more frequent than hitherto surmised. A variant was observed in one case; a young male: instead of numbness, a ‘spasm’ seemed to occur in the tongue. None of the four had at any time consulted their physician for their complaints. In our regular headache practice, two new cases were detected. In one of them and in one of the Vågå cases, there was a combination with ipsilateral cervicogenic headache (CEH). In N-TS, there may be both ipsilateral headache and upper extremity sensory phenomena, a constellation reminiscent of CEH. The possible pathogenetic relationship between N-TS and CEH is therefore discussed in some detail.

In whiplash studies, there may be interpretation difficulties: are post–whiplash findings, when present, a consequence of the whiplash trauma, or did they exist prior to trauma? In the Vågå headache epidemiology study (1995–1997), there was a headache history and detailed physical/neurological findings from the face/head/neck in 1838 18–65–year-old parishioners. In September 2001, four years after the Vågå study, a search through the Health Centre files divulged six cases with whiplash trauma in the intervening period. These parishioners could thus be their own controls. Two females did not develop new complaints. In the four parishioners with apparently new, subjective complaints, i. e., headache, neck pain, and a feeling of stiffness in the neck, there were corresponding findings as regards various parameters: shoulder area skin–roll test, changes in two, possible changes in two; range of motion, neck, changes in two, borderline changes in one; “features indicative of cervical abnormality” (“CF”), changes in all four; the mean, post–whiplash stage value was: 3.6+, against 1.6+ prior to accident (Vågå: only 0.93%, “CF” exceeding 3+). In the two without new complaints, the mean “CF” value was 1.0+. The number of cases is small, but the similarity of the symptoms—and signs—following whiplash injury may suggest an element of organic origin in the whiplash syndrome.

Jabs (stabs) usually last ≤3 s and are located in the skull area, mostly anteriorly. In many cases, there are only a few jabs during lifetime. With this definition, jabs are frequent, thus at 35.2% in the Vågå study of headache epidemiology. Long-lasting jabs (?), i.e. paroxysms lasting 10-120 s, were present in six out of 1779 parishioners. These pain paroxysms seemed mainly to be side-locked, but could not be provoked. Possibly, these long-lasting jabs after all mainly are regular jabs. To include the ≤2-minute-long paroxysms among the jabs will necessitate a rather drastic change of criteria. This group of jabs may, nevertheless, be heterogeneous. In two parishioners, the paroxysms were associated with a migraine-like pain. The paroxysms occasionally became most intense (2-10 times the basal pain), and then, and only then, were they combined with stark, visual phenomena: wave-like movements ('undulation'), anopsia, but also: immense dizziness, nausea/vomiting. The nature of the side-locked basal pain, although migraine-like, remains unsolved.

In a recent, hospital-based report, we described a small series of 5 patients with unilateral, more or less chronic, severe forehead pain, that could be transitorily abated by anaesthetic blockade of the supraorbital nerve and more permanently abated by ‘liberation’ operation directed towards the nerve exit area at the supraorbital notch. However, epidemiological data on supraorbital neuralgia are lacking. Among 1838 18-65-year-old inhabitants in Vågå (88.6% of the eligible ones), there were 10 who presented the following clinical picture: (1) Unilateral forehead/ocular pain, not diagnosed or diagnosable as any other, particular, unilateral headache; (2) Steadfast unilaterality; (3) Increased tenderness upon pressure over the exit site of the supraorbital nerve (incisura frontalis) on that side —in those who were in an active phase; (4) Foregoing trauma in the forehead/supraorbital rim area, ipsilaterally. In approximately half the cases, there was a moderate, ipsilateral sensory loss. A striking finding was the occurrence of jabs in the symptomatic area, and in synchrony with the neuralgia pain. These 10 inhabitants correspond to a prevalence of 0.5% (or 0.65% if two nontrauma cases are included).

Hangover headache has been focused upon in connection with the Vågå study of headache epidemiology, with 714 cases among 1122 dalesmen (64%). Most frequently the headache was global in location. It was more frequently located in the anterior (frontotemporal) than occipital area. A unilateral headache was present in only 3% of the dalesmen, many of whom were migraineurs. Headache seemed to be more intense in males than females. Headache usually seemed to be of a lower intensity than the pain of migraine, but higher than, or similar to, that of tension-type headache. The headache appeared late in the night/early morning hours, i. e., several hours after discontinuation of drinking. In most cases, headache stopped in the late morning hours, or at high noon, but it could even last until somewhat late in the afternoon; it rarely, if ever, exceeded 12 hours duration. Red wine seemed mostly to provoke headache the same evening (with traits similar to those of the spontaneously occurring headache attacks). Criteria for hangover headache are proposed.

As part of the Vågå study of headache epidemiology, the symptomatology of hangover headache has been studied in 1122 parishioners in the age group 18–65 years; male/female ratio 1.14. The following criteria for hangover headache were adhered to: (1) intoxication by alcohol, (2) headache, and (3) onset of headache >3 hours after discontinuation of drinking. As demonstrated elsewhere, headache was present in 64% of the cases. Throbbing was present in 85% of those affected, nausea in 60% and vomiting in 25%, with significant male preponderance for all three. Photo- and phonophobia were more rarely present. Not only does hangover headache seem to be more frequent in males—as previously demonstrated; it also seems to be more severe in males. Ninety per cent of the hangover headache victims felt that the gastro-intestinal symptoms originated in the gastro-intestinal tract and were not secondary to the headache.

In Vågå, Norway, with 3907 inhabitants, there were 2075 18–65-year-old dalesmen available for the headache epidemiology study. A total of 1838 dalesmen (88.6%) were personally examined. However, due to uncertainty whether hangover headache could be incorporated, this part of the study was started at no. 500. Of the remaining 1338 dalesmen, 1122, i. e., 83.9%, were questioned about hangover headache. The parochial “drinking culture” could probably best be characterised as binge drinking and not as a constant, daily consumption. Inclusion criteria were: intoxication by alcohol; headache; and the headache manifesting itself more than three hours after the end of drinking. In the whole series, 714 dalesmen had experienced hangover headache (“delayed alcohol-induced headache”) during their lifetime (64%). This may be the best way to express hangover headache prevalence. Among those who had been “exposed to proper amounts of alcohol”, the prevalence was considerably higher: 88%. With the existing drinking pattern, hangover headache clearly dominated in males (M/F ratio: 1.50 vs. 0.72 in those without hangover headache (p<0.0005)). Consistency tests showed high Kappa values.

In connection with the Vågå study of headache epidemiology, a search was made for caffeine-withdrawal headache in 1741 parishioners. Female to male ratio 1.05; mean age 44.2 years (range 18-65 years). A face-to-face interview technique was used. The mean consumption of coffee was 4.7 cups a day. Males on an average consumed more coffee (5.1 ± 3.3 cups/day) than females (4.4 ± 3.1 cups/day). Neither in those with a high consumption of coffee: ≥10 cups a day ( n = 134), nor in those with a considerable variation in consumption: ≥10 cups/day ( n = 31) did there seem to be a definite increase in headache resembling caffeine-withdrawal headache, for instance during weekends. In seven parishioners, however, there did seem to be such a headache, and in two of them, the evidence was rather convincing. This headache generally seemed to be mild and global and occurred mainly in the morning hours on weekends. There was no nausea, no throbbing quality of the pain, and no reported use of analgesics. Coffee seemed to abate the headache. This frequency (0.4%) should, clearly, be regarded as a minimum figure. Caffeine-withdrawal headache at the grassroots level may be a rather rare, generally vague, symptom-poor headache.

In the Vågå study of headache epidemiology, the “skinroll test” was carried out at the top (“arch”) of the shoulder girdle. For this purpose, a skin caliper (Servier, Leiden) was used. A total of 1796 parishioners aged 18–65 years (51% women) was examined. A repeat test was also carried out. The skin-roll test consists of two components: measurement of skin-fold thickness and assessment of the pain level. The average arch skinfold thickness on the right side, was 15.0 (SD=5.9 mm; range, 3–60) and was significantly lower in men (mean, 13.8 mm) than in women (16.1 mm). Among the subjects without headache (n=246), the average skin-fold thickness was 14.3 (SD=5.7 mm). Immediately repeating the test revealed a measurement error >3 mm in 1.1% of cases. Asymmetry in the shoulder arch area exceeded the measurement error in 6.1% of the cases. The skin-fold thickness at an anterior site in the shoulder area was always less than that at the shoulder arch.