Clinical Review

The proliferation of terms to describe heavy menstrual bleeding sometimes seems never-ending. From “menometrorrhagia” to “uterine hemorrhage,” these terms pop up quickly and confuse discussion of one of the most widespread problems in gynecology.

Enter the International Federation of Gynecology and Obstetrics (FIGO), which decided to tackle the inconsistent terminology and lack of classification of causes of abnormal uterine bleeding (AUB) with an eye toward standardizing research, facilitating discussion, and informing management decisions.

In this article, I focus on three aspects of this effort:

• FIGO’s revamping of terminology and classification
• comparisons of outcomes of hysterectomy versus endometrial ablation and the levonorgestrel-releasing intrauterine system
• guidelines on management of AUB related to ovulatory disorders and endometrial hemostatic dysfunction.

FIGO revamps nomenclature for abnormal uterine bleeding

Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012;207(4):259–265.

As early as 2004, FIGO began a process to standardize the nomenclature for defining both normal and abnormal uterine bleeding in reproductive-aged women who are not pregnant.¹ This process was a response to a lack of consistency and continuity in the design and interpretation of basic science and clinical investigation related to the problem of AUB. Inconsistent definitions of AUB, such as “menorrhagia,” “metrorrhagia,” and “dysfunctional uterine bleeding,” along with the absence of standard categorization of the causes of AUB, have led to confusion and difficulties in comparing clinical trials and in finding significant, relevant, and even meaningful correlations among investigations of AUB. Applying information from asynchronous and often incomplete investigations to evidence-based clinical practice then becomes a challenge for the gynecologist.

Munro and colleagues summarize the process by which FIGO developed both a nomenclature system and a classification system of the causes of AUB, which were formally adopted by FIGO in 2010 and endorsed in 2012 by the American College of Obstetricians and Gynecologists (ACOG).^1-6 The arduous process led to:

• a refined definition of chronic AUB
• a new category called acute AUB
• a method for describing the clinical dimensions of menstruation and the menstrual cycle according to the following parameters:
• regularity of onset
• frequency of onset
• duration of menstrual flow
• heaviness, or volume, of menstrual flow.

Wherever appropriate, the definitions of normal for these parameters were based on statistics from large population studies that used medians and 5th and 95th percentiles.

The term “heavy menstrual bleeding” (HMB) is used to describe a woman’s perception of increased menstrual volume, regardless of regularity, frequency, or duration. AUB is the overarching term to describe any departure from normal menstruation, as defined by the parameters listed above. A group of misleading terms commonly used to describe AUB were eliminated from the FIGO nomenclature system, including “dysfunctional uterine bleeding,” “menorrhagia,” “hypermenorrhea,” “menometrorrhagia,” “polymenorrhagia,” and “metrorrhagia.”

The causes of AUB are classified in nine categories that are arranged according to the acronym PALM-COEIN:

• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia
• Coagulopathy
• Ovulatory disorders
• Endometrial dysfunction
• Iatrogenic
• Not otherwise classified.

Leiomyoma are subclassified as submucous or other, with tertiary subcategorization for intramural, subserosal, and transmural lesions

In general, the components of the PALM group are discrete (structural) entities that are measurable visually via imaging or histopathology, or both, while the COEI (of the COEIN group) includes women for whom the AUB is unrelated to structural abnormalities.

The classification system provides the infrastructure for a thorough investigative process and a means to characterize AUB for an individual who may have one or more potential causes or contributors. Such a comprehensive assessment allows the basic scientist to identify pure populations for tissue and molecular studies, the clinical scientist to identify potential confounders when defining populations for clinical investigation, and the clinician, educator, and trainee to consider the multidimensional nature of AUB where asymptomatic “red herrings” may coexist with otherwise invisible disorders of menstrual function.

The FIGO Menstrual Disorders Working Group anticipates that widespread, international acceptance of the recommended terms, definitions, and classification for AUB will lead to improved and more meaningful communication in clinical trials and published research and will enhance communication between health-care providers and patients, leading to better management of AUB.

 

How hysterectomy for AUB compares with less invasive treatment options

Matteson KA, Abed H, Wheeler TL II, et al; Society of Gynecologic Surgeons Systematic Review Group. A systematic review comparing hysterectomy with less invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol. 2012;19(1):13–28.

To create reliable treatment recommendations for AUB, as defined by the FIGO classification system just described, in women with ovulatory disorders, endometrial hemostatic dysfunction, and concomitant leiomyoma, the Systematic Review Group (SRG) of the Society of Gynecologic Surgeons performed a systematic review of treatments. The analysis was intended to compare hysterectomy with less invasive treatment modalities. The SRG reviewed randomized, controlled trials of AUB treatment that compared hysterectomy with:

• endometrial ablation by resectoscopic loop, rollerball, or thermal balloon
• the LNG-IUS
• medical therapy.

This comprehensive review of literature published between 1950 and January 14, 2011 led the SRG to create seven categories of clinical outcomes:

• bleeding control
• quality of life
• pain
• sexual health
• patient satisfaction
• need for additional treatment
• adverse events.

Of the initial 5,503 titles identified, only 18 articles, representing nine clinical trials, contained data of adequate quality to meet criteria for review. Seven of the trials compared hysterectomy with ablation, one compared hysterectomy with the LNG-IUS, and one compared hysterectomy with medical therapy. As FIGO has pointed out, the lack of homogeneity of terminology used to describe AUB and classification of its causes prevented clinically applicable comparative analyses of treatment outcomes.

Here are some of the SRG’s findings:

• Control of bleeding. Only data regarding amenorrhea were sufficient for comparative analysis. The SRG was able to conclude only that there was moderate strength of evidence supporting the statement that bleeding is better controlled following hysterectomy than following ablation.
• Quality of life. Overall, studies that evaluated quality of life showed improvement after ablation and hysterectomy. The strength of evidence demonstrating no difference between hysterectomy and ablation in postoperative quality of life was moderate.
• Pain, general health, vitality, and social function. Three studies found statistically significant differences in validated dimensions of the SF-36 questionnaire favoring hysterectomy for pain, general health, vitality, and social function. Two of these three studies evaluated minimally invasive hysterectomy by the laparoscopic supracervical or vaginal approach. The strength of evidence on pain beyond the postoperative time period was low and favored hysterectomy over ablation.
• Sexual health. The strength of evidence related to sexual health was low and revealed no differences between hysterectomy and ablation.
• Patient satisfaction. Overall, the quality of evidence was very low, showing no difference between hysterectomy and ablation.
• Need for additional treatment. The quality of evidence was moderate and favored hysterectomy over ablation.
• Adverse events. Evidence of moderate quality favored ablation and the LNG-IUS over hysterectomy, and low-quality evidence favored medical therapy over hysterectomy (TABLES 1, 2).

TABLE 1

What the data reveal about hysterectomy versus ablation

Parameter	Strength of evidence (comparison)
	Hysterectomy	Ablation
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Low (F)	—
Sexual health	Low (S)	Low (S)
Patient satisfaction	Very low (S)	Very low (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

TABLE 2

What the data reveal about hysterectomy versus the levonorgestrel-releasing intrauterine system (LNG-IUS)

Parameter	Strength of evidence (comparison)
	Hysterectomy	LNG-IUS
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Moderate (S)	Moderate (S)
Sexual health	Moderate (S)	Moderate (S)
Patient satisfaction	Moderate (S)	Moderate (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

The SRG concluded that there are tradeoffs between treatment effectiveness and the risk of serious adverse events between hysterectomy, ablation, and the LNG-IUS. It recommended that clinicians be educated about the relative advantages and disadvantages of each option so that they can discuss them with patients.

The SRG developed clinical practice guidelines for the treatment of ovulatory disorders and endometrial hemostatic dysfunction associated with AUB (see below).

Group issues guidelines for treatment of AUB related to ovulatory disorders, endometrial hemostatic dysfunction

Wheeler TL II, Murphy M, Rogers RG, et al; Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. 2012;19(1):81–87.

The SRG used the results of the systematic review just summarized to formulate clinical guidelines for the treatment of AUB related to ovulatory disorders and endometrial hemostatic dysfunction. Recommendations were assigned a grade for their strength on the basis of the quality of supporting evidence, the size of the net medical benefit, and other considerations, including values and preferences applied in judgments. The strength of the clinical recommendation is either “strong” or “weak” and indicates the degree to which one can be confident that adherence to the recommendation will do more good than harm. All of the clinical recommendations described below received a grade of “weak.”

 

One primary suggestion from the study group is patient counseling that must first determine the type of AUB and the degree of burden or distress for the patient, as well as the presence of any additional cycle-related symptoms. Consideration should be given to variables that may modify the inherent risks or benefits of each intervention for the particular patient, as well as her values and preferences regarding treatment harms, benefits, and potential outcomes. Counseling should assess the patient’s need for contraception, desire for future childbearing, and proximity to menopause, as well as any cultural preferences for management.

Based on the clinical evidence related to hysterectomy versus endometrial ablation, the SRG made the following recommendations:

• If the patient desires amenorrhea and less pain and wants to avoid additional therapy, hysterectomy is preferred
• If the patient wants to avoid adverse events and seeks a shorter hospital stay, endometrial ablation is preferred
• If the patient’s main desire is for improvement in overall quality of life or sexual health, either intervention is appropriate, depending on patient preferences.

There were no data available in the systematic review concerning newer technologies for nonhysteroscopic endometrial ablation versus hysterectomy.

Based on the clinical evidence related to hysterectomy versus the LNG-IUS, the SRG made the following recommendations:

• If the patient desires amenorrhea or seeks to avoid additional therapy, hysterectomy is preferred
• If the patient’s main preference is to avoid adverse events, the LNG-IUS is preferred
• If her preference is for improved quality of life or sexual health, either treatment can be offered.

Based on the clinical evidence related to hysterectomy versus systemic medication, the SRG made the following recommendations:

• If the patient wants to become amenorrheic or hopes to avoid further intervention, hysterectomy is recommended
• If she wants to avoid adverse events, medications are recommended
• If her main preference is overall improvement in quality of life, less pain, or improvement in sexual health, either hysterectomy or medication is appropriate.

Note that no standard therapy was given; medical agents included combined oral contraceptive pills, cyclic or continuous progestin, conjugated estrogen with or without progestin, and prostaglandin synthetase inhibitors, usually with hormonal therapy. There are no randomized, controlled trials of other medications such as nonsteroidal anti-inflammatory drugs or tranexamic acid versus hysterectomy.

The SRG cited three main difficulties in the development of clinical guidelines:

• a lack of well-developed randomized, controlled trials of alternative management versus hysterectomy, as well as inconsistent measurement and reporting among the few trials that exist
• a lack of uniformity in AUB diagnoses among the randomized, controlled trials evaluated
• inconsistent use of terminology related to AUB within the trials.

All of these challenges were addressed by the FIGO nomenclature and AUB classification recommendations. Adherence to the FIGO guidelines for future clinical research would eliminate the difficulties faced by this study group and lead to higher-quality clinical evidence that could form the basis of solid clinical recommendations for the treatment of AUB related to ovulatory disorders or endometrial hemostatic dysfunction.

ACKNOWLEDGMENT. Thank you to Dr. Malcolm Munro and Dr. Anita Lee Sloan for their thoughtful reviews of this manuscript.

We want to hear from you! Tell us what you think.

The proliferation of terms to describe heavy menstrual bleeding sometimes seems never-ending. From “menometrorrhagia” to “uterine hemorrhage,” these terms pop up quickly and confuse discussion of one of the most widespread problems in gynecology.

Enter the International Federation of Gynecology and Obstetrics (FIGO), which decided to tackle the inconsistent terminology and lack of classification of causes of abnormal uterine bleeding (AUB) with an eye toward standardizing research, facilitating discussion, and informing management decisions.

In this article, I focus on three aspects of this effort:

• FIGO’s revamping of terminology and classification
• comparisons of outcomes of hysterectomy versus endometrial ablation and the levonorgestrel-releasing intrauterine system
• guidelines on management of AUB related to ovulatory disorders and endometrial hemostatic dysfunction.

FIGO revamps nomenclature for abnormal uterine bleeding

Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012;207(4):259–265.

As early as 2004, FIGO began a process to standardize the nomenclature for defining both normal and abnormal uterine bleeding in reproductive-aged women who are not pregnant.¹ This process was a response to a lack of consistency and continuity in the design and interpretation of basic science and clinical investigation related to the problem of AUB. Inconsistent definitions of AUB, such as “menorrhagia,” “metrorrhagia,” and “dysfunctional uterine bleeding,” along with the absence of standard categorization of the causes of AUB, have led to confusion and difficulties in comparing clinical trials and in finding significant, relevant, and even meaningful correlations among investigations of AUB. Applying information from asynchronous and often incomplete investigations to evidence-based clinical practice then becomes a challenge for the gynecologist.

Munro and colleagues summarize the process by which FIGO developed both a nomenclature system and a classification system of the causes of AUB, which were formally adopted by FIGO in 2010 and endorsed in 2012 by the American College of Obstetricians and Gynecologists (ACOG).^1-6 The arduous process led to:

• a refined definition of chronic AUB
• a new category called acute AUB
• a method for describing the clinical dimensions of menstruation and the menstrual cycle according to the following parameters:
• regularity of onset
• frequency of onset
• duration of menstrual flow
• heaviness, or volume, of menstrual flow.

Wherever appropriate, the definitions of normal for these parameters were based on statistics from large population studies that used medians and 5th and 95th percentiles.

The term “heavy menstrual bleeding” (HMB) is used to describe a woman’s perception of increased menstrual volume, regardless of regularity, frequency, or duration. AUB is the overarching term to describe any departure from normal menstruation, as defined by the parameters listed above. A group of misleading terms commonly used to describe AUB were eliminated from the FIGO nomenclature system, including “dysfunctional uterine bleeding,” “menorrhagia,” “hypermenorrhea,” “menometrorrhagia,” “polymenorrhagia,” and “metrorrhagia.”

The causes of AUB are classified in nine categories that are arranged according to the acronym PALM-COEIN:

• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia
• Coagulopathy
• Ovulatory disorders
• Endometrial dysfunction
• Iatrogenic
• Not otherwise classified.

Leiomyoma are subclassified as submucous or other, with tertiary subcategorization for intramural, subserosal, and transmural lesions

In general, the components of the PALM group are discrete (structural) entities that are measurable visually via imaging or histopathology, or both, while the COEI (of the COEIN group) includes women for whom the AUB is unrelated to structural abnormalities.

The classification system provides the infrastructure for a thorough investigative process and a means to characterize AUB for an individual who may have one or more potential causes or contributors. Such a comprehensive assessment allows the basic scientist to identify pure populations for tissue and molecular studies, the clinical scientist to identify potential confounders when defining populations for clinical investigation, and the clinician, educator, and trainee to consider the multidimensional nature of AUB where asymptomatic “red herrings” may coexist with otherwise invisible disorders of menstrual function.

The FIGO Menstrual Disorders Working Group anticipates that widespread, international acceptance of the recommended terms, definitions, and classification for AUB will lead to improved and more meaningful communication in clinical trials and published research and will enhance communication between health-care providers and patients, leading to better management of AUB.

 

How hysterectomy for AUB compares with less invasive treatment options

Matteson KA, Abed H, Wheeler TL II, et al; Society of Gynecologic Surgeons Systematic Review Group. A systematic review comparing hysterectomy with less invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol. 2012;19(1):13–28.

To create reliable treatment recommendations for AUB, as defined by the FIGO classification system just described, in women with ovulatory disorders, endometrial hemostatic dysfunction, and concomitant leiomyoma, the Systematic Review Group (SRG) of the Society of Gynecologic Surgeons performed a systematic review of treatments. The analysis was intended to compare hysterectomy with less invasive treatment modalities. The SRG reviewed randomized, controlled trials of AUB treatment that compared hysterectomy with:

• endometrial ablation by resectoscopic loop, rollerball, or thermal balloon
• the LNG-IUS
• medical therapy.

This comprehensive review of literature published between 1950 and January 14, 2011 led the SRG to create seven categories of clinical outcomes:

• bleeding control
• quality of life
• pain
• sexual health
• patient satisfaction
• need for additional treatment
• adverse events.

Of the initial 5,503 titles identified, only 18 articles, representing nine clinical trials, contained data of adequate quality to meet criteria for review. Seven of the trials compared hysterectomy with ablation, one compared hysterectomy with the LNG-IUS, and one compared hysterectomy with medical therapy. As FIGO has pointed out, the lack of homogeneity of terminology used to describe AUB and classification of its causes prevented clinically applicable comparative analyses of treatment outcomes.

Here are some of the SRG’s findings:

• Control of bleeding. Only data regarding amenorrhea were sufficient for comparative analysis. The SRG was able to conclude only that there was moderate strength of evidence supporting the statement that bleeding is better controlled following hysterectomy than following ablation.
• Quality of life. Overall, studies that evaluated quality of life showed improvement after ablation and hysterectomy. The strength of evidence demonstrating no difference between hysterectomy and ablation in postoperative quality of life was moderate.
• Pain, general health, vitality, and social function. Three studies found statistically significant differences in validated dimensions of the SF-36 questionnaire favoring hysterectomy for pain, general health, vitality, and social function. Two of these three studies evaluated minimally invasive hysterectomy by the laparoscopic supracervical or vaginal approach. The strength of evidence on pain beyond the postoperative time period was low and favored hysterectomy over ablation.
• Sexual health. The strength of evidence related to sexual health was low and revealed no differences between hysterectomy and ablation.
• Patient satisfaction. Overall, the quality of evidence was very low, showing no difference between hysterectomy and ablation.
• Need for additional treatment. The quality of evidence was moderate and favored hysterectomy over ablation.
• Adverse events. Evidence of moderate quality favored ablation and the LNG-IUS over hysterectomy, and low-quality evidence favored medical therapy over hysterectomy (TABLES 1, 2).

TABLE 1

What the data reveal about hysterectomy versus ablation

Parameter	Strength of evidence (comparison)
	Hysterectomy	Ablation
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Low (F)	—
Sexual health	Low (S)	Low (S)
Patient satisfaction	Very low (S)	Very low (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

TABLE 2

What the data reveal about hysterectomy versus the levonorgestrel-releasing intrauterine system (LNG-IUS)

Parameter	Strength of evidence (comparison)
	Hysterectomy	LNG-IUS
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Moderate (S)	Moderate (S)
Sexual health	Moderate (S)	Moderate (S)
Patient satisfaction	Moderate (S)	Moderate (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

The SRG concluded that there are tradeoffs between treatment effectiveness and the risk of serious adverse events between hysterectomy, ablation, and the LNG-IUS. It recommended that clinicians be educated about the relative advantages and disadvantages of each option so that they can discuss them with patients.

The SRG developed clinical practice guidelines for the treatment of ovulatory disorders and endometrial hemostatic dysfunction associated with AUB (see below).

Group issues guidelines for treatment of AUB related to ovulatory disorders, endometrial hemostatic dysfunction

Wheeler TL II, Murphy M, Rogers RG, et al; Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. 2012;19(1):81–87.

The SRG used the results of the systematic review just summarized to formulate clinical guidelines for the treatment of AUB related to ovulatory disorders and endometrial hemostatic dysfunction. Recommendations were assigned a grade for their strength on the basis of the quality of supporting evidence, the size of the net medical benefit, and other considerations, including values and preferences applied in judgments. The strength of the clinical recommendation is either “strong” or “weak” and indicates the degree to which one can be confident that adherence to the recommendation will do more good than harm. All of the clinical recommendations described below received a grade of “weak.”

 

One primary suggestion from the study group is patient counseling that must first determine the type of AUB and the degree of burden or distress for the patient, as well as the presence of any additional cycle-related symptoms. Consideration should be given to variables that may modify the inherent risks or benefits of each intervention for the particular patient, as well as her values and preferences regarding treatment harms, benefits, and potential outcomes. Counseling should assess the patient’s need for contraception, desire for future childbearing, and proximity to menopause, as well as any cultural preferences for management.

Based on the clinical evidence related to hysterectomy versus endometrial ablation, the SRG made the following recommendations:

• If the patient desires amenorrhea and less pain and wants to avoid additional therapy, hysterectomy is preferred
• If the patient wants to avoid adverse events and seeks a shorter hospital stay, endometrial ablation is preferred
• If the patient’s main desire is for improvement in overall quality of life or sexual health, either intervention is appropriate, depending on patient preferences.

There were no data available in the systematic review concerning newer technologies for nonhysteroscopic endometrial ablation versus hysterectomy.

Based on the clinical evidence related to hysterectomy versus the LNG-IUS, the SRG made the following recommendations:

• If the patient desires amenorrhea or seeks to avoid additional therapy, hysterectomy is preferred
• If the patient’s main preference is to avoid adverse events, the LNG-IUS is preferred
• If her preference is for improved quality of life or sexual health, either treatment can be offered.

Based on the clinical evidence related to hysterectomy versus systemic medication, the SRG made the following recommendations:

• If the patient wants to become amenorrheic or hopes to avoid further intervention, hysterectomy is recommended
• If she wants to avoid adverse events, medications are recommended
• If her main preference is overall improvement in quality of life, less pain, or improvement in sexual health, either hysterectomy or medication is appropriate.

Note that no standard therapy was given; medical agents included combined oral contraceptive pills, cyclic or continuous progestin, conjugated estrogen with or without progestin, and prostaglandin synthetase inhibitors, usually with hormonal therapy. There are no randomized, controlled trials of other medications such as nonsteroidal anti-inflammatory drugs or tranexamic acid versus hysterectomy.

The SRG cited three main difficulties in the development of clinical guidelines:

• a lack of well-developed randomized, controlled trials of alternative management versus hysterectomy, as well as inconsistent measurement and reporting among the few trials that exist
• a lack of uniformity in AUB diagnoses among the randomized, controlled trials evaluated
• inconsistent use of terminology related to AUB within the trials.

All of these challenges were addressed by the FIGO nomenclature and AUB classification recommendations. Adherence to the FIGO guidelines for future clinical research would eliminate the difficulties faced by this study group and lead to higher-quality clinical evidence that could form the basis of solid clinical recommendations for the treatment of AUB related to ovulatory disorders or endometrial hemostatic dysfunction.

ACKNOWLEDGMENT. Thank you to Dr. Malcolm Munro and Dr. Anita Lee Sloan for their thoughtful reviews of this manuscript.

We want to hear from you! Tell us what you think.

The proliferation of terms to describe heavy menstrual bleeding sometimes seems never-ending. From “menometrorrhagia” to “uterine hemorrhage,” these terms pop up quickly and confuse discussion of one of the most widespread problems in gynecology.

Enter the International Federation of Gynecology and Obstetrics (FIGO), which decided to tackle the inconsistent terminology and lack of classification of causes of abnormal uterine bleeding (AUB) with an eye toward standardizing research, facilitating discussion, and informing management decisions.

In this article, I focus on three aspects of this effort:

• FIGO’s revamping of terminology and classification
• comparisons of outcomes of hysterectomy versus endometrial ablation and the levonorgestrel-releasing intrauterine system
• guidelines on management of AUB related to ovulatory disorders and endometrial hemostatic dysfunction.

FIGO revamps nomenclature for abnormal uterine bleeding

Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012;207(4):259–265.

As early as 2004, FIGO began a process to standardize the nomenclature for defining both normal and abnormal uterine bleeding in reproductive-aged women who are not pregnant.¹ This process was a response to a lack of consistency and continuity in the design and interpretation of basic science and clinical investigation related to the problem of AUB. Inconsistent definitions of AUB, such as “menorrhagia,” “metrorrhagia,” and “dysfunctional uterine bleeding,” along with the absence of standard categorization of the causes of AUB, have led to confusion and difficulties in comparing clinical trials and in finding significant, relevant, and even meaningful correlations among investigations of AUB. Applying information from asynchronous and often incomplete investigations to evidence-based clinical practice then becomes a challenge for the gynecologist.

Munro and colleagues summarize the process by which FIGO developed both a nomenclature system and a classification system of the causes of AUB, which were formally adopted by FIGO in 2010 and endorsed in 2012 by the American College of Obstetricians and Gynecologists (ACOG).^1-6 The arduous process led to:

• a refined definition of chronic AUB
• a new category called acute AUB
• a method for describing the clinical dimensions of menstruation and the menstrual cycle according to the following parameters:
• regularity of onset
• frequency of onset
• duration of menstrual flow
• heaviness, or volume, of menstrual flow.

Wherever appropriate, the definitions of normal for these parameters were based on statistics from large population studies that used medians and 5th and 95th percentiles.

The term “heavy menstrual bleeding” (HMB) is used to describe a woman’s perception of increased menstrual volume, regardless of regularity, frequency, or duration. AUB is the overarching term to describe any departure from normal menstruation, as defined by the parameters listed above. A group of misleading terms commonly used to describe AUB were eliminated from the FIGO nomenclature system, including “dysfunctional uterine bleeding,” “menorrhagia,” “hypermenorrhea,” “menometrorrhagia,” “polymenorrhagia,” and “metrorrhagia.”

The causes of AUB are classified in nine categories that are arranged according to the acronym PALM-COEIN:

• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia
• Coagulopathy
• Ovulatory disorders
• Endometrial dysfunction
• Iatrogenic
• Not otherwise classified.

Leiomyoma are subclassified as submucous or other, with tertiary subcategorization for intramural, subserosal, and transmural lesions

In general, the components of the PALM group are discrete (structural) entities that are measurable visually via imaging or histopathology, or both, while the COEI (of the COEIN group) includes women for whom the AUB is unrelated to structural abnormalities.

The classification system provides the infrastructure for a thorough investigative process and a means to characterize AUB for an individual who may have one or more potential causes or contributors. Such a comprehensive assessment allows the basic scientist to identify pure populations for tissue and molecular studies, the clinical scientist to identify potential confounders when defining populations for clinical investigation, and the clinician, educator, and trainee to consider the multidimensional nature of AUB where asymptomatic “red herrings” may coexist with otherwise invisible disorders of menstrual function.

The FIGO Menstrual Disorders Working Group anticipates that widespread, international acceptance of the recommended terms, definitions, and classification for AUB will lead to improved and more meaningful communication in clinical trials and published research and will enhance communication between health-care providers and patients, leading to better management of AUB.

 

How hysterectomy for AUB compares with less invasive treatment options

Matteson KA, Abed H, Wheeler TL II, et al; Society of Gynecologic Surgeons Systematic Review Group. A systematic review comparing hysterectomy with less invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol. 2012;19(1):13–28.

To create reliable treatment recommendations for AUB, as defined by the FIGO classification system just described, in women with ovulatory disorders, endometrial hemostatic dysfunction, and concomitant leiomyoma, the Systematic Review Group (SRG) of the Society of Gynecologic Surgeons performed a systematic review of treatments. The analysis was intended to compare hysterectomy with less invasive treatment modalities. The SRG reviewed randomized, controlled trials of AUB treatment that compared hysterectomy with:

• endometrial ablation by resectoscopic loop, rollerball, or thermal balloon
• the LNG-IUS
• medical therapy.

This comprehensive review of literature published between 1950 and January 14, 2011 led the SRG to create seven categories of clinical outcomes:

• bleeding control
• quality of life
• pain
• sexual health
• patient satisfaction
• need for additional treatment
• adverse events.

Of the initial 5,503 titles identified, only 18 articles, representing nine clinical trials, contained data of adequate quality to meet criteria for review. Seven of the trials compared hysterectomy with ablation, one compared hysterectomy with the LNG-IUS, and one compared hysterectomy with medical therapy. As FIGO has pointed out, the lack of homogeneity of terminology used to describe AUB and classification of its causes prevented clinically applicable comparative analyses of treatment outcomes.

Here are some of the SRG’s findings:

• Control of bleeding. Only data regarding amenorrhea were sufficient for comparative analysis. The SRG was able to conclude only that there was moderate strength of evidence supporting the statement that bleeding is better controlled following hysterectomy than following ablation.
• Quality of life. Overall, studies that evaluated quality of life showed improvement after ablation and hysterectomy. The strength of evidence demonstrating no difference between hysterectomy and ablation in postoperative quality of life was moderate.
• Pain, general health, vitality, and social function. Three studies found statistically significant differences in validated dimensions of the SF-36 questionnaire favoring hysterectomy for pain, general health, vitality, and social function. Two of these three studies evaluated minimally invasive hysterectomy by the laparoscopic supracervical or vaginal approach. The strength of evidence on pain beyond the postoperative time period was low and favored hysterectomy over ablation.
• Sexual health. The strength of evidence related to sexual health was low and revealed no differences between hysterectomy and ablation.
• Patient satisfaction. Overall, the quality of evidence was very low, showing no difference between hysterectomy and ablation.
• Need for additional treatment. The quality of evidence was moderate and favored hysterectomy over ablation.
• Adverse events. Evidence of moderate quality favored ablation and the LNG-IUS over hysterectomy, and low-quality evidence favored medical therapy over hysterectomy (TABLES 1, 2).

TABLE 1

What the data reveal about hysterectomy versus ablation

Parameter	Strength of evidence (comparison)
	Hysterectomy	Ablation
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Low (F)	—
Sexual health	Low (S)	Low (S)
Patient satisfaction	Very low (S)	Very low (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

TABLE 2

What the data reveal about hysterectomy versus the levonorgestrel-releasing intrauterine system (LNG-IUS)

Parameter	Strength of evidence (comparison)
	Hysterectomy	LNG-IUS
Bleeding control	Moderate (F)	—
Quality of life	Moderate (S)	Moderate (S)
Lower pain	Moderate (S)	Moderate (S)
Sexual health	Moderate (S)	Moderate (S)
Patient satisfaction	Moderate (S)	Moderate (S)
Need for additional treatment	Moderate (F)	—
Adverse events	—	Moderate (F)
F=Evidence favors comparator; S=no difference between comparators

The SRG concluded that there are tradeoffs between treatment effectiveness and the risk of serious adverse events between hysterectomy, ablation, and the LNG-IUS. It recommended that clinicians be educated about the relative advantages and disadvantages of each option so that they can discuss them with patients.

The SRG developed clinical practice guidelines for the treatment of ovulatory disorders and endometrial hemostatic dysfunction associated with AUB (see below).

Group issues guidelines for treatment of AUB related to ovulatory disorders, endometrial hemostatic dysfunction

Wheeler TL II, Murphy M, Rogers RG, et al; Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. 2012;19(1):81–87.

The SRG used the results of the systematic review just summarized to formulate clinical guidelines for the treatment of AUB related to ovulatory disorders and endometrial hemostatic dysfunction. Recommendations were assigned a grade for their strength on the basis of the quality of supporting evidence, the size of the net medical benefit, and other considerations, including values and preferences applied in judgments. The strength of the clinical recommendation is either “strong” or “weak” and indicates the degree to which one can be confident that adherence to the recommendation will do more good than harm. All of the clinical recommendations described below received a grade of “weak.”

 

One primary suggestion from the study group is patient counseling that must first determine the type of AUB and the degree of burden or distress for the patient, as well as the presence of any additional cycle-related symptoms. Consideration should be given to variables that may modify the inherent risks or benefits of each intervention for the particular patient, as well as her values and preferences regarding treatment harms, benefits, and potential outcomes. Counseling should assess the patient’s need for contraception, desire for future childbearing, and proximity to menopause, as well as any cultural preferences for management.

Based on the clinical evidence related to hysterectomy versus endometrial ablation, the SRG made the following recommendations:

• If the patient desires amenorrhea and less pain and wants to avoid additional therapy, hysterectomy is preferred
• If the patient wants to avoid adverse events and seeks a shorter hospital stay, endometrial ablation is preferred
• If the patient’s main desire is for improvement in overall quality of life or sexual health, either intervention is appropriate, depending on patient preferences.

There were no data available in the systematic review concerning newer technologies for nonhysteroscopic endometrial ablation versus hysterectomy.

Based on the clinical evidence related to hysterectomy versus the LNG-IUS, the SRG made the following recommendations:

• If the patient desires amenorrhea or seeks to avoid additional therapy, hysterectomy is preferred
• If the patient’s main preference is to avoid adverse events, the LNG-IUS is preferred
• If her preference is for improved quality of life or sexual health, either treatment can be offered.

Based on the clinical evidence related to hysterectomy versus systemic medication, the SRG made the following recommendations:

• If the patient wants to become amenorrheic or hopes to avoid further intervention, hysterectomy is recommended
• If she wants to avoid adverse events, medications are recommended
• If her main preference is overall improvement in quality of life, less pain, or improvement in sexual health, either hysterectomy or medication is appropriate.

Note that no standard therapy was given; medical agents included combined oral contraceptive pills, cyclic or continuous progestin, conjugated estrogen with or without progestin, and prostaglandin synthetase inhibitors, usually with hormonal therapy. There are no randomized, controlled trials of other medications such as nonsteroidal anti-inflammatory drugs or tranexamic acid versus hysterectomy.

The SRG cited three main difficulties in the development of clinical guidelines:

• a lack of well-developed randomized, controlled trials of alternative management versus hysterectomy, as well as inconsistent measurement and reporting among the few trials that exist
• a lack of uniformity in AUB diagnoses among the randomized, controlled trials evaluated
• inconsistent use of terminology related to AUB within the trials.

All of these challenges were addressed by the FIGO nomenclature and AUB classification recommendations. Adherence to the FIGO guidelines for future clinical research would eliminate the difficulties faced by this study group and lead to higher-quality clinical evidence that could form the basis of solid clinical recommendations for the treatment of AUB related to ovulatory disorders or endometrial hemostatic dysfunction.

ACKNOWLEDGMENT. Thank you to Dr. Malcolm Munro and Dr. Anita Lee Sloan for their thoughtful reviews of this manuscript.

We want to hear from you! Tell us what you think.

As health-care professionals, we are well trained in the importance of taking a detailed, targeted history and incorporating appropriate assessments to determine a treatment plan, which often includes prescriptions, a medical procedure, or a referral. Our extensive training allows us to make and implement expert decisions.

At the same time, I’ve found that the most valued aspect of our job is the relationships we develop with our patients. We know details that probably no one else knows about them. This is likely most true for us clinicians whose practices address women’s sexual health. A deep level of trust develops over time.

As part of that relationship of trust, we have unique opportunities to influence not only a woman’s health but also her overall quality of life. What I found over the years is that many women don’t necessarily need any prescription or referral or procedure. What they do often need is guidance, direction, and encouragement.

Some of my greatest achievements in delivering health care have not happened in a delivery room or because of a medication I prescribed. Instead, they have occurred in the office where, for example, I see a woman who took my recommendations 1 year ago to change her diet and begin exercising. Now, 30 lb lighter, she feels like a new person. This is one example of a knowledgeable physician applying “extensive training and expert decisions” to incorporate low-tech treatments with great success.

So what does this have to do with vibrators in a doctor’s office? Well, without many FDA-approved medications to treat sexual dysfunction, we are left with over-the-counter possibilities and such “low-tech” options as counseling and guidance.

Sexual dysfunction is common among our patients

According to the National Health and Social Life Survey, 43% of women are affected by some aspect of sexual dysfunction, and 22% associate that dysfunction with personal distress. The distress was highest for women aged 45 to 64. Additional correlates included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence.¹ Sexual complaints among women diagnosed with cancer can be as high as 90%.²

Does this describe anyone in your practice? We can agree that women’s sexual issues are common, whether we acknowledge that in our practice by querying women on their sexual health or not (and many of us are not).

We’re not talking to our patients about their sexual health enough. In a 2012 survey of more than 1,000 ObGyns about whether they talk with their patients about sex,³ investigators found that:

• 63% routinely ask whether their patient is sexually active
• 40% routinely ask if the patient is having any problems regarding sex
• 29% ask about sexual satisfaction
• 28% ask about sexual orientation or identity
• 14% ask about sexual pleasure.

Whatever the reason, talking about sexual health is easier for some people than for others, and that goes for both clinicians and patients.

What are our treatment options if sexual dysfunction is identified?

Unfortunately, the therapeutic armamentarium for women’s sexual health is limited—perhaps a contributor to many clinicians’ reluctance to broach the topic. Pharmacologically, we have no FDA-approved treatments for female sexual dysfunction except localized estrogen treatment for vulvovaginal atrophy and the Eros device for arousal and orgasmic disorders.

There are off-label options of testosterone, buproprion, or sildenafil citrate, but many practitioners and patients are reluctant to consider these options specifically because they are off label.

Over-the-counter. These options are available for women, and can be helpful. For patients with discomfort due to vaginal dryness, it is important to educate them on the benefits of vaginal moisturizers and lubricants. Many women don’t know about these options, and far fewer understand the difference between these products (ie, water-based vs hybrid vs silicone lubricants).

Patients are more likely to comply with treatment when products are available in the office

Here in my small Midwestern city, there are 15 moisturizers or lubricants on the shelf at Rite-Aid; 38 at Walgreens. My patients are unlikely to sort through the options, and many tell me they use “whatever my husband bought for me.” I’ve had a menopausal patient report using K-Y Intense. For an atrophic postmenopausal vagina, that product is very uncomfortable. She was now downright scared to try additional options.

This is the patient to whom I explain lubricant options by placing on her hand dabs of water-based, hybrid, and silicone products. I let her note the differences in feel and consistency, allowing her to determine which is most acceptable to her. My office offers a small selection of each of those products so she can leave the appointment with the selection of her choice—no label reading or comparison shopping in the aisle of Walgreens as her neighbor walks by; no accidental purchase of products that increase rather than relieve her discomfort.

 

Among US women aged 45 to 64, 30% have urinary incontinence, one of the conditions that correlate with an increased incidence of sexual distress.⁴ Incontinence treatments may include behavioral modification, medication, a referral to physical therapy, perhaps surgery, and Kegel exercises.

Physical therapists are masterful in their ability to successfully treat urinary incontinence, but the limitations of time, cost, and insurance coverage are a deterrent to successful follow-through. When performed correctly, Kegel exercises may result in a cure for stress urinary incontinence in 50% to 70% of women.⁵ Exercise tools can help women isolate the pelvic floor muscles and perform Kegel exercises correctly, but I don’t find them at Rite-Aid or Walgreens. In my office, I can describe how these tools can assist women in doing their exercises, can show them what the tools look like and how they are used, and have them available for purchase.

When vaginal dilators are indicated for vaginismus or postradiation changes to the vagina, I show the patient the dilators and how to use them, and I have them available for purchase.

Now, what about those vibrators?

An Internet-based survey of more than 2,000 women aged 18 to 60 indicated that 52% have used a vibrator.⁶ In my own (unpublished) survey of more than 100 women, 43% indicated they had used a sex toy or device (about equally in partnered and solo sex). About half of women have experience with a vibrator—which means half do not. That’s in spite of the fact that vibrator use correlates with more sexual satisfaction. It may help with a decrease in latency and increase the intensity of the orgasmic response. I commonly hear women say, “Orgasm takes so much longer and comes and goes so quickly it’s hardly worth it.” Those are the women who may benefit from introducing a vibrator.

A 52-year-old postmenopausal woman presented to me with inability to orgasm, estimating 5 years had passed since she’d last experienced one. She had a diagnosis of multiple sclerosis and was taking a selective serotonin reuptake inhibitor. She had tried a vibrator in the past, without success. As a physician, I knew that she needed a more powerful motor for more intense stimulation. I was able to let her feel the difference and obtain the appropriate vibrator. Imagine her appreciation when she returned after achieving success.

The suggestion that a woman introduce a vibrator into her sexual life is nuanced. It is important that we as providers explore and understand our patients’ concerns, beliefs, and attitudes toward this option. Women may lack information or have misinformation that can be addressed in a sensitive, professional way in the privacy and safety of an office visit.

Once a woman understands the benefits a vibrator may offer, how does she proceed? I live in a community that does not have a “sex shop,” and I don’t feel comfortable referring patients to one that is 30 miles away.

Google offers 23,000,000 results for “vibrators.” Amazon provides 400 pages of products. Adam and Eve, a leading online “sex toys” shop, offers 524 vibrators. To get to the options, a patient would need to navigate some distasteful images, guess at quality and safety, and wouldn’t find much relevant health information.

Three years ago I attended an Adult Novelty Expo. I can attest to the variety of products on the market, most of which I would never consider advising a patient to use. Some can give off an awful “toxic smell,” which I would prefer my patients not have in contact with their genitals. Some are extremely complex—one vibrator introduced at the expo boasted 42 different functions with 8 control buttons. A small, curated selection of safe, well-designed, and effective vibrators is welcomed in my office.

Providing vibrators for purchase in the office can bypass confusion

Part of what patients value is that they can evaluate and purchase these products with privacy, confidentiality, and convenience in a clinician’s office. These purchases result from a safe, nonjudgmental, informed discussion with their provider, in the context of a relationship that has been developed over time.

Feedback from happy customers/ patients. Knowing there is controversy about health-care providers selling products, I’m upfront in asking for feedback from patients and online customers. These are some of their comments:

• “I trust you completely. You have a history of taking a personal interest in my health.”
• “I am personally grateful for the store and have passed it on to my friends, because where else are we going to go for these things? … It seems like another way you are keeping your patients’ health and well-being in the forefront of your practice. You have created a safe place for us to reconnect with an important part of ourselves.”
• “Anyone who comes back to a professional after the first ‘I’ll give him a shot’ visit does so because she trusts that person. If she didn’t, she wouldn’t be there. One of the things she trusts is your judgment.”
• “If you, in your professional opinion and personal experience, honestly believe a lotion, device, or book to be beneficial, there is nothing wrong with saying so (and one can make the case that you are shirking your duties to your readers and patients if you do NOT mention these things).”

 

Their comments reinforce my earlier point that the trust we develop with our patients is very valuable and must not be compromised.

Opportunity for revenue

I’ve focused on issues of comprehensive, practical service to patients because that is my primary motivation for offering products through my practice. That said, there are, of course, opportunities for revenue through retail in or in conjunction with your practice. (See “How to expand your services,” above.) That revenue can offset other cost pressures or contribute to overall profitability. Or, you could decide to provide products at cost as a service. Either way, you need to be thorough in investigating the financial implications and overhead requirements.

In addition to locating and testing products, there will be time invested in setting up accounts, managing cash flow and inventory and conducting the transactions. You may find, as I have, that depending on scale and resources available, it’s most effective for a practice to work with a distribution or retail partner.

For me, selling products makes sense

I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. But I’ve seen repeatedly and first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.

When my patients can walk out with products they’re ready to use—rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. My patients, especially those who’ve revived their sexuality when they’d nearly given up, tell me it’s an invaluable part of my practice.

We want to hear from you! Tell us what you think.

As health-care professionals, we are well trained in the importance of taking a detailed, targeted history and incorporating appropriate assessments to determine a treatment plan, which often includes prescriptions, a medical procedure, or a referral. Our extensive training allows us to make and implement expert decisions.

At the same time, I’ve found that the most valued aspect of our job is the relationships we develop with our patients. We know details that probably no one else knows about them. This is likely most true for us clinicians whose practices address women’s sexual health. A deep level of trust develops over time.

As part of that relationship of trust, we have unique opportunities to influence not only a woman’s health but also her overall quality of life. What I found over the years is that many women don’t necessarily need any prescription or referral or procedure. What they do often need is guidance, direction, and encouragement.

Some of my greatest achievements in delivering health care have not happened in a delivery room or because of a medication I prescribed. Instead, they have occurred in the office where, for example, I see a woman who took my recommendations 1 year ago to change her diet and begin exercising. Now, 30 lb lighter, she feels like a new person. This is one example of a knowledgeable physician applying “extensive training and expert decisions” to incorporate low-tech treatments with great success.

So what does this have to do with vibrators in a doctor’s office? Well, without many FDA-approved medications to treat sexual dysfunction, we are left with over-the-counter possibilities and such “low-tech” options as counseling and guidance.

Sexual dysfunction is common among our patients

According to the National Health and Social Life Survey, 43% of women are affected by some aspect of sexual dysfunction, and 22% associate that dysfunction with personal distress. The distress was highest for women aged 45 to 64. Additional correlates included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence.¹ Sexual complaints among women diagnosed with cancer can be as high as 90%.²

Does this describe anyone in your practice? We can agree that women’s sexual issues are common, whether we acknowledge that in our practice by querying women on their sexual health or not (and many of us are not).

We’re not talking to our patients about their sexual health enough. In a 2012 survey of more than 1,000 ObGyns about whether they talk with their patients about sex,³ investigators found that:

• 63% routinely ask whether their patient is sexually active
• 40% routinely ask if the patient is having any problems regarding sex
• 29% ask about sexual satisfaction
• 28% ask about sexual orientation or identity
• 14% ask about sexual pleasure.

Whatever the reason, talking about sexual health is easier for some people than for others, and that goes for both clinicians and patients.

What are our treatment options if sexual dysfunction is identified?

Unfortunately, the therapeutic armamentarium for women’s sexual health is limited—perhaps a contributor to many clinicians’ reluctance to broach the topic. Pharmacologically, we have no FDA-approved treatments for female sexual dysfunction except localized estrogen treatment for vulvovaginal atrophy and the Eros device for arousal and orgasmic disorders.

There are off-label options of testosterone, buproprion, or sildenafil citrate, but many practitioners and patients are reluctant to consider these options specifically because they are off label.

Over-the-counter. These options are available for women, and can be helpful. For patients with discomfort due to vaginal dryness, it is important to educate them on the benefits of vaginal moisturizers and lubricants. Many women don’t know about these options, and far fewer understand the difference between these products (ie, water-based vs hybrid vs silicone lubricants).

Patients are more likely to comply with treatment when products are available in the office

Here in my small Midwestern city, there are 15 moisturizers or lubricants on the shelf at Rite-Aid; 38 at Walgreens. My patients are unlikely to sort through the options, and many tell me they use “whatever my husband bought for me.” I’ve had a menopausal patient report using K-Y Intense. For an atrophic postmenopausal vagina, that product is very uncomfortable. She was now downright scared to try additional options.

This is the patient to whom I explain lubricant options by placing on her hand dabs of water-based, hybrid, and silicone products. I let her note the differences in feel and consistency, allowing her to determine which is most acceptable to her. My office offers a small selection of each of those products so she can leave the appointment with the selection of her choice—no label reading or comparison shopping in the aisle of Walgreens as her neighbor walks by; no accidental purchase of products that increase rather than relieve her discomfort.

 

Among US women aged 45 to 64, 30% have urinary incontinence, one of the conditions that correlate with an increased incidence of sexual distress.⁴ Incontinence treatments may include behavioral modification, medication, a referral to physical therapy, perhaps surgery, and Kegel exercises.

Physical therapists are masterful in their ability to successfully treat urinary incontinence, but the limitations of time, cost, and insurance coverage are a deterrent to successful follow-through. When performed correctly, Kegel exercises may result in a cure for stress urinary incontinence in 50% to 70% of women.⁵ Exercise tools can help women isolate the pelvic floor muscles and perform Kegel exercises correctly, but I don’t find them at Rite-Aid or Walgreens. In my office, I can describe how these tools can assist women in doing their exercises, can show them what the tools look like and how they are used, and have them available for purchase.

When vaginal dilators are indicated for vaginismus or postradiation changes to the vagina, I show the patient the dilators and how to use them, and I have them available for purchase.

Now, what about those vibrators?

An Internet-based survey of more than 2,000 women aged 18 to 60 indicated that 52% have used a vibrator.⁶ In my own (unpublished) survey of more than 100 women, 43% indicated they had used a sex toy or device (about equally in partnered and solo sex). About half of women have experience with a vibrator—which means half do not. That’s in spite of the fact that vibrator use correlates with more sexual satisfaction. It may help with a decrease in latency and increase the intensity of the orgasmic response. I commonly hear women say, “Orgasm takes so much longer and comes and goes so quickly it’s hardly worth it.” Those are the women who may benefit from introducing a vibrator.

A 52-year-old postmenopausal woman presented to me with inability to orgasm, estimating 5 years had passed since she’d last experienced one. She had a diagnosis of multiple sclerosis and was taking a selective serotonin reuptake inhibitor. She had tried a vibrator in the past, without success. As a physician, I knew that she needed a more powerful motor for more intense stimulation. I was able to let her feel the difference and obtain the appropriate vibrator. Imagine her appreciation when she returned after achieving success.

The suggestion that a woman introduce a vibrator into her sexual life is nuanced. It is important that we as providers explore and understand our patients’ concerns, beliefs, and attitudes toward this option. Women may lack information or have misinformation that can be addressed in a sensitive, professional way in the privacy and safety of an office visit.

Once a woman understands the benefits a vibrator may offer, how does she proceed? I live in a community that does not have a “sex shop,” and I don’t feel comfortable referring patients to one that is 30 miles away.

Google offers 23,000,000 results for “vibrators.” Amazon provides 400 pages of products. Adam and Eve, a leading online “sex toys” shop, offers 524 vibrators. To get to the options, a patient would need to navigate some distasteful images, guess at quality and safety, and wouldn’t find much relevant health information.

Three years ago I attended an Adult Novelty Expo. I can attest to the variety of products on the market, most of which I would never consider advising a patient to use. Some can give off an awful “toxic smell,” which I would prefer my patients not have in contact with their genitals. Some are extremely complex—one vibrator introduced at the expo boasted 42 different functions with 8 control buttons. A small, curated selection of safe, well-designed, and effective vibrators is welcomed in my office.

Providing vibrators for purchase in the office can bypass confusion

Part of what patients value is that they can evaluate and purchase these products with privacy, confidentiality, and convenience in a clinician’s office. These purchases result from a safe, nonjudgmental, informed discussion with their provider, in the context of a relationship that has been developed over time.

Feedback from happy customers/ patients. Knowing there is controversy about health-care providers selling products, I’m upfront in asking for feedback from patients and online customers. These are some of their comments:

• “I trust you completely. You have a history of taking a personal interest in my health.”
• “I am personally grateful for the store and have passed it on to my friends, because where else are we going to go for these things? … It seems like another way you are keeping your patients’ health and well-being in the forefront of your practice. You have created a safe place for us to reconnect with an important part of ourselves.”
• “Anyone who comes back to a professional after the first ‘I’ll give him a shot’ visit does so because she trusts that person. If she didn’t, she wouldn’t be there. One of the things she trusts is your judgment.”
• “If you, in your professional opinion and personal experience, honestly believe a lotion, device, or book to be beneficial, there is nothing wrong with saying so (and one can make the case that you are shirking your duties to your readers and patients if you do NOT mention these things).”

 

Their comments reinforce my earlier point that the trust we develop with our patients is very valuable and must not be compromised.

Opportunity for revenue

I’ve focused on issues of comprehensive, practical service to patients because that is my primary motivation for offering products through my practice. That said, there are, of course, opportunities for revenue through retail in or in conjunction with your practice. (See “How to expand your services,” above.) That revenue can offset other cost pressures or contribute to overall profitability. Or, you could decide to provide products at cost as a service. Either way, you need to be thorough in investigating the financial implications and overhead requirements.

In addition to locating and testing products, there will be time invested in setting up accounts, managing cash flow and inventory and conducting the transactions. You may find, as I have, that depending on scale and resources available, it’s most effective for a practice to work with a distribution or retail partner.

For me, selling products makes sense

I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. But I’ve seen repeatedly and first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.

When my patients can walk out with products they’re ready to use—rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. My patients, especially those who’ve revived their sexuality when they’d nearly given up, tell me it’s an invaluable part of my practice.

We want to hear from you! Tell us what you think.

As health-care professionals, we are well trained in the importance of taking a detailed, targeted history and incorporating appropriate assessments to determine a treatment plan, which often includes prescriptions, a medical procedure, or a referral. Our extensive training allows us to make and implement expert decisions.

At the same time, I’ve found that the most valued aspect of our job is the relationships we develop with our patients. We know details that probably no one else knows about them. This is likely most true for us clinicians whose practices address women’s sexual health. A deep level of trust develops over time.

As part of that relationship of trust, we have unique opportunities to influence not only a woman’s health but also her overall quality of life. What I found over the years is that many women don’t necessarily need any prescription or referral or procedure. What they do often need is guidance, direction, and encouragement.

Some of my greatest achievements in delivering health care have not happened in a delivery room or because of a medication I prescribed. Instead, they have occurred in the office where, for example, I see a woman who took my recommendations 1 year ago to change her diet and begin exercising. Now, 30 lb lighter, she feels like a new person. This is one example of a knowledgeable physician applying “extensive training and expert decisions” to incorporate low-tech treatments with great success.

So what does this have to do with vibrators in a doctor’s office? Well, without many FDA-approved medications to treat sexual dysfunction, we are left with over-the-counter possibilities and such “low-tech” options as counseling and guidance.

Sexual dysfunction is common among our patients

According to the National Health and Social Life Survey, 43% of women are affected by some aspect of sexual dysfunction, and 22% associate that dysfunction with personal distress. The distress was highest for women aged 45 to 64. Additional correlates included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence.¹ Sexual complaints among women diagnosed with cancer can be as high as 90%.²

Does this describe anyone in your practice? We can agree that women’s sexual issues are common, whether we acknowledge that in our practice by querying women on their sexual health or not (and many of us are not).

We’re not talking to our patients about their sexual health enough. In a 2012 survey of more than 1,000 ObGyns about whether they talk with their patients about sex,³ investigators found that:

• 63% routinely ask whether their patient is sexually active
• 40% routinely ask if the patient is having any problems regarding sex
• 29% ask about sexual satisfaction
• 28% ask about sexual orientation or identity
• 14% ask about sexual pleasure.

Whatever the reason, talking about sexual health is easier for some people than for others, and that goes for both clinicians and patients.

What are our treatment options if sexual dysfunction is identified?

Unfortunately, the therapeutic armamentarium for women’s sexual health is limited—perhaps a contributor to many clinicians’ reluctance to broach the topic. Pharmacologically, we have no FDA-approved treatments for female sexual dysfunction except localized estrogen treatment for vulvovaginal atrophy and the Eros device for arousal and orgasmic disorders.

There are off-label options of testosterone, buproprion, or sildenafil citrate, but many practitioners and patients are reluctant to consider these options specifically because they are off label.

Over-the-counter. These options are available for women, and can be helpful. For patients with discomfort due to vaginal dryness, it is important to educate them on the benefits of vaginal moisturizers and lubricants. Many women don’t know about these options, and far fewer understand the difference between these products (ie, water-based vs hybrid vs silicone lubricants).

Patients are more likely to comply with treatment when products are available in the office

Here in my small Midwestern city, there are 15 moisturizers or lubricants on the shelf at Rite-Aid; 38 at Walgreens. My patients are unlikely to sort through the options, and many tell me they use “whatever my husband bought for me.” I’ve had a menopausal patient report using K-Y Intense. For an atrophic postmenopausal vagina, that product is very uncomfortable. She was now downright scared to try additional options.

This is the patient to whom I explain lubricant options by placing on her hand dabs of water-based, hybrid, and silicone products. I let her note the differences in feel and consistency, allowing her to determine which is most acceptable to her. My office offers a small selection of each of those products so she can leave the appointment with the selection of her choice—no label reading or comparison shopping in the aisle of Walgreens as her neighbor walks by; no accidental purchase of products that increase rather than relieve her discomfort.

 

Among US women aged 45 to 64, 30% have urinary incontinence, one of the conditions that correlate with an increased incidence of sexual distress.⁴ Incontinence treatments may include behavioral modification, medication, a referral to physical therapy, perhaps surgery, and Kegel exercises.

Physical therapists are masterful in their ability to successfully treat urinary incontinence, but the limitations of time, cost, and insurance coverage are a deterrent to successful follow-through. When performed correctly, Kegel exercises may result in a cure for stress urinary incontinence in 50% to 70% of women.⁵ Exercise tools can help women isolate the pelvic floor muscles and perform Kegel exercises correctly, but I don’t find them at Rite-Aid or Walgreens. In my office, I can describe how these tools can assist women in doing their exercises, can show them what the tools look like and how they are used, and have them available for purchase.

When vaginal dilators are indicated for vaginismus or postradiation changes to the vagina, I show the patient the dilators and how to use them, and I have them available for purchase.

Now, what about those vibrators?

An Internet-based survey of more than 2,000 women aged 18 to 60 indicated that 52% have used a vibrator.⁶ In my own (unpublished) survey of more than 100 women, 43% indicated they had used a sex toy or device (about equally in partnered and solo sex). About half of women have experience with a vibrator—which means half do not. That’s in spite of the fact that vibrator use correlates with more sexual satisfaction. It may help with a decrease in latency and increase the intensity of the orgasmic response. I commonly hear women say, “Orgasm takes so much longer and comes and goes so quickly it’s hardly worth it.” Those are the women who may benefit from introducing a vibrator.

A 52-year-old postmenopausal woman presented to me with inability to orgasm, estimating 5 years had passed since she’d last experienced one. She had a diagnosis of multiple sclerosis and was taking a selective serotonin reuptake inhibitor. She had tried a vibrator in the past, without success. As a physician, I knew that she needed a more powerful motor for more intense stimulation. I was able to let her feel the difference and obtain the appropriate vibrator. Imagine her appreciation when she returned after achieving success.

The suggestion that a woman introduce a vibrator into her sexual life is nuanced. It is important that we as providers explore and understand our patients’ concerns, beliefs, and attitudes toward this option. Women may lack information or have misinformation that can be addressed in a sensitive, professional way in the privacy and safety of an office visit.

Once a woman understands the benefits a vibrator may offer, how does she proceed? I live in a community that does not have a “sex shop,” and I don’t feel comfortable referring patients to one that is 30 miles away.

Google offers 23,000,000 results for “vibrators.” Amazon provides 400 pages of products. Adam and Eve, a leading online “sex toys” shop, offers 524 vibrators. To get to the options, a patient would need to navigate some distasteful images, guess at quality and safety, and wouldn’t find much relevant health information.

Three years ago I attended an Adult Novelty Expo. I can attest to the variety of products on the market, most of which I would never consider advising a patient to use. Some can give off an awful “toxic smell,” which I would prefer my patients not have in contact with their genitals. Some are extremely complex—one vibrator introduced at the expo boasted 42 different functions with 8 control buttons. A small, curated selection of safe, well-designed, and effective vibrators is welcomed in my office.

Providing vibrators for purchase in the office can bypass confusion

Part of what patients value is that they can evaluate and purchase these products with privacy, confidentiality, and convenience in a clinician’s office. These purchases result from a safe, nonjudgmental, informed discussion with their provider, in the context of a relationship that has been developed over time.

Feedback from happy customers/ patients. Knowing there is controversy about health-care providers selling products, I’m upfront in asking for feedback from patients and online customers. These are some of their comments:

• “I trust you completely. You have a history of taking a personal interest in my health.”
• “I am personally grateful for the store and have passed it on to my friends, because where else are we going to go for these things? … It seems like another way you are keeping your patients’ health and well-being in the forefront of your practice. You have created a safe place for us to reconnect with an important part of ourselves.”
• “Anyone who comes back to a professional after the first ‘I’ll give him a shot’ visit does so because she trusts that person. If she didn’t, she wouldn’t be there. One of the things she trusts is your judgment.”
• “If you, in your professional opinion and personal experience, honestly believe a lotion, device, or book to be beneficial, there is nothing wrong with saying so (and one can make the case that you are shirking your duties to your readers and patients if you do NOT mention these things).”

 

Their comments reinforce my earlier point that the trust we develop with our patients is very valuable and must not be compromised.

Opportunity for revenue

I’ve focused on issues of comprehensive, practical service to patients because that is my primary motivation for offering products through my practice. That said, there are, of course, opportunities for revenue through retail in or in conjunction with your practice. (See “How to expand your services,” above.) That revenue can offset other cost pressures or contribute to overall profitability. Or, you could decide to provide products at cost as a service. Either way, you need to be thorough in investigating the financial implications and overhead requirements.

In addition to locating and testing products, there will be time invested in setting up accounts, managing cash flow and inventory and conducting the transactions. You may find, as I have, that depending on scale and resources available, it’s most effective for a practice to work with a distribution or retail partner.

For me, selling products makes sense

I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. But I’ve seen repeatedly and first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.

When my patients can walk out with products they’re ready to use—rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. My patients, especially those who’ve revived their sexuality when they’d nearly given up, tell me it’s an invaluable part of my practice.

We want to hear from you! Tell us what you think.

Millions of Americans currently lack access to dental care and oral health preventive services because of financial and/or geographic obstacles.^1,2 Although community water fluoridation has benefited many Americans during the past 50 years, difficulties in obtaining dental care is a persistent public health challenge.² Primary care providers (PCPs) can help improve health population-wide by educating patients in good dental hygiene and offering preventive oral health services to patients who would otherwise go without them.

The chief components of preventive dental care include daily brushing with fluoride toothpaste, flossing, routine dental check-ups and professional dental cleanings provided by a licensed dentist and staff, and use of dental sealants and topical fluoride. During the primary care appointment, a routine intraoral exam, including inspection of both hard and soft oral tissues for leukoplakia, gross decay, stained dental structures, and other pathologic changes, is essential. Primary care patients who use any form of tobacco should undergo inspection of the intraoral surfaces of the lips and assessment for adenopathy of the surrounding lymph nodes.

Counseling, including recommending routine preventive dental services (and, for some patients, allaying their fears of seeing a dentist^2,3), and positive reinforcement of good oral hygiene practices should be addressed during every primary care encounter. Identifying patients without access to professional dental care is important, as the PCP may be their only source of oral health education, including referrals to local dental clinics.

Application of topical fluoride is an important means of improving dental health, and a cost-effective procedure for both patients and providers4 (see “Fluoride Use,”^2,3,5-16). By following published guidelines for use of topical fluoride varnish, PCPs can reduce decay and mineralize enamel, thereby protecting the patient against enamel erosion.^6,11,17 This service can and should be offered in primary care offices to patients who lack access to routine dental care and are likely to benefit from this effective weapon against tooth decay.

As part of the National Interprofessional Initiative on Oral Health, a comprehensive continuing education curriculum for PCPs called “Smiles for Life”^18,19 offers topics in eight focus areas, ranging from systemic conditions that affect oral health to concerns found in specific patient populations. The course is easily accessed online (www.niioh.org/smiles-life-curriculum) and provides valuable continuing education credits at no charge.

BEA, AGE 3

Bea lives with her mother and four older brothers and sisters. She is enrolled in Medicaid, but her mother has been unable to locate dental services for any of her children. With every call to a dental office within a 30-minute commute from their home, Bea’s mother has been told, “We don’t accept Medicaid.”

Under her state’s Medicaid plan, Bea has been seen for her primary health care needs since she was a newborn. She was bottle-fed from birth; her mother reports she has stopped taking the bottle to bed within the past few months. While conducting her three-year well-child exam, you note gross decay (see Figure 1).

Dental Services for Children

Nationwide, Medicaid is required to provide coverage for dental services for enrolled children, as well as those who qualify for the CHIP (Children’s Health Insurance Program).²⁰ However, there is no mandate for privately owned dental practices to accept Medicaid payments.

Lack of dental care is the greatest unmet health care need in American children.²¹ In children without health insurance, access to dental care is most challenging, and those enrolled in Medicaid are the second least likely to receive services. As a result of these and other factors, one-third of US children ages 3 to 5 have dental caries in their primary teeth, and one in every four US children is estimated to have untreated decay^2,21-23 (see Figure 2). African-American and Hispanic children experience greater disparities in dental care than do those of other ethnicities.²¹

Dental decay is the most common chronic illness of childhood (five times as common as asthma), with higher incidence in low-income and minority preschool children.^1,24,25 Tooth decay affects growth patterns and nutrition, with associated pain and infection interfering with school attendance.

 

The small number of dentists who treat children and are willing to accept Medicaid reimbursement is a significant concern. In most dental programs, dedicated pedodontic training is optional. The mismatch of number of qualified dentists to the growing population of such patients is projected to worsen in the coming years.²³

Potential solutions to correct this mismatch of dental services accessible to the underserved have included^26-31:

• Addition of paraprofessional dental therapists (persons who have received two years’ training in a specific academic program) to the health care team, in public health clinics, schools, and other settings
•  Interprofessional dental education (ie, cross-training physicians, NPs, PAs, and RNs in preventive dental services)
• An increasingly diverse array of competent providers who are trained, authorized, and compensated to provide evidence-based care
• Removing licensure restrictions for non–US-trained dentists
• Financial incentives for dentists to practice in dental Health Professional Shortage Areas
• Improved education of parents regarding the benefits of routine dental services.

The Institute of Medicine (IOM)²⁶ has challenged state legislatures to mandate a one-year dental residency to be completed among underserved populations before dental licensure is granted. This challenge reflects the IOM’s acknowledgement that dental services, essential to patients’ well-being, are grossly lacking in the US.

Dental Care Education for Parents

Healthy baby teeth help children eat well and speak clearly. Decayed and abscessed teeth cause the same degree of pain and suffering in young children as they do in adults. Thus, regardless of ethnicity or socioeconomic status, all parents should be routinely encouraged to oversee daily dental hygiene practices for their children; it is important for PCPs to explain to parents their expectations in this regard.

Dental care for children should begin as soon as the first tooth erupts. New teeth should be cleaned daily with a soft cloth and inspected by parents for any discolorations. From age 2 years until children are able to clean all dental surfaces adequately (age 7 or 8), parents should brush their children’s teeth at least once daily with a toothbrush, after applying a thin film of fluoride toothpaste. Children should undergo their first professional dental check-up at about age 1 year.^19,26 

Parents must be made aware of other factors that can impair their children’s dental health. For example, the foods most likely to promote dental decay contain highly fermentable carbohydrates, are highly processed and sticky, and cause oral pH levels to fall below 5.5 (at which point demineralization may occur).³² Examples include presweetened cereals, dried fruits, cookies, and potato chips. Cheese, peanuts, meat, and eggs are less cariogenic.

Other important teaching points are “don’ts”: putting a baby to bed with a bottle that contains anything but a sugar-free liquid; using spill-proof spouted cups filled with juice or other sugary drinks all day; serving a large proportion of cariogenic foods.

BREANNE, AGE 22

Breanne attends a community college, where she is studying business. She reports to the college health clinic, complaining of an intermittent sharp pain in one of her lower molars over the past four days, occurring when she eats or drinks anything cold.

Before she turned 21, Breanne received routine dental services under her parents’ insurance. Now a full-time student no longer covered by her parents’ plan, she has no income with which to purchase dental coverage. Years ago, Breanne received dental sealants on all of her molars in a school-based program, and she routinely brushes daily (see Figure 3). She says she “usually remembers to floss.”

Because of her pain, Breanne is medicated with an anti-inflammatory agent. She is referred to a nearby dental clinic for further evaluation.

 

 

Dental Concerns in Young Adults

Up to one-third of Americans, including college-age students, lack access to oral health services.³³ Use of annual dental services, including school-based care, significantly reduces young adults’ risk for tooth loss.³⁴ From early adulthood on, poor dental health is associated with cardiovascular and respiratory disease, cerebral ischemia, diabetes, difficulty with chewing and oral pain, and poor self-image.²⁴

PCPs should emphasize the importance of preventive services as they examine the oral structure during routine health care encounters. Adding the question, “When did you last have a dental exam?” can launch an effective discussion about the importance of good dental health.

Tooth surfaces with pits and fissures are the most vulnerable to decay. Dental sealants can protect these vulnerable areas, reducing decay by 60% to 82%.^2,32,35 Sealants are the most effective preventive measure for reducing cavity formation; they are not harmful to fillings and can actually reduce the progression of decay when applied over small existing carious lesions.³⁵ Currently, however, only 30% and 38% of children and adolescents, respectively, have undergone application of sealants.³⁶ Thus, it is vital for PCPs to recommend dental sealants to all their patients.^35,37,38

Young adults should also be questioned about their exercise patterns. While daily exercise is of benefit to good health, young adults who engage in too-frequent, overly vigorous exercise have been found vulnerable to dental erosion.³⁹ This irreversible condition can result from the rapid breathing, sweat-induced dehydration, and decreased salivary flow associated with strenuous exercise. Reduced salivary flow disrupts the protection against erosive acids afforded by bathing of teeth with saliva, leading to a fivefold greater risk for developing erosions. Patients should be encouraged to hydrate before exercise to reduce these risks.³⁹

Dental Health Notes for Young Women

For female patients of childbearing age like Breanne, dental health is important not only for the patient, but for her future children as well. Poor maternal dental health has been associated with preterm births and low birth weights.^40-43 Women who have health insurance, who are in good general health, and who regularly visit a primary care medical provider are also the most likely to see a dental care provider during pregnancy.⁴⁰

Pregnancy is associated with a risk for poor dental care in any population.^42,44 During pregnancy, Medicaid-enrolled women are 30% less likely to see a dentist than women with private health insurance, and women with no health insurance are 70% less likely to see a dentist.⁴⁴ Among pregnant women who experience a dental problem, less than half will schedule a dental appointment. Postponing dental care till after delivery incurs additional risk, as the new mother will be busy with her child and may have lost her health care coverage in the interim.

Dental concerns commonly encountered during pregnancy are listed in Table 3.^41,42 There is also evidence that maternal transmission of mutans streptococci can lead to early childhood caries,^42,45 further highlighting the importance of dental care during pregnancy (eg, use of chlorhexidine rinses in pregnant women with dental caries⁴²). The association between periodontal disease and preterm delivery and lower birth weights^40-43 makes it critical to reduce maternal periodontal inflammation through timely dental referrals.

SAUL, AGE 42

Saul, a lifelong resident of Mississippi, has worked in construction since age 18. He has never had health or dental insurance and thus he rarely seeks preventive services. As he recalls, he has had “two fillings in my jaw teeth since I was a kid,” but otherwise has had no dental care. He brushes daily to avoid having to see a dentist. He is presenting today as a new patient only because he has a rash.

 

 

Benefits of Fluoride Use During Middle Age

Dental care needs peak between ages 55 and 64, with the majority of care prompted by dental decay⁴⁶ (see Figure 4). A discussion about dental health should be raised when the PCP completes the review of systems or while discussing other preventive services. The option of fluoride varnish should not be overlooked in a patient of any age, particularly one with a recognizable deficiency of preventive dental services. Explaining the benefits of topical fluoride varnish (see “Fluoride Use”) and offering an opportunity to receive it in the office may persuade a patient like Saul to take advantage of this proven anticarious procedure.

Of note, topical fluoride varnish is not harmful to existing dental fillings; rather, some restorative dental material is produced and continuously released with fluoride to protect the surrounding enamel surfaces.⁴⁷ Fluoride varnish also reduces the progression of decay that is already present.¹¹ Extending exposure to fluoride with varnish allows more effective penetration of the enamel; fluoride that remains in the saliva increases the protection further.^48,49

Patients who undergo this safe procedure should be reminded to continue brushing daily with fluoridated toothpaste and drinking fluoridated water (if it is available).⁵⁰

GILL, AGE 77

Gill grew up in Grant County, New Mexico, in an area not far from Silver City; there, fluoride supplementation in the local water did not begin until Gill was about 40. His family never stressed oral hygiene, and his remaining teeth show gross plaque and decay.

He sees you routinely for his chronic illnesses, and today he has presented for his annual physical. Gill has Medicare without supplemental insurance.

Dental Care in the Medicare Years

Medicare does not cover preventive dental services unless hospitalization is required; in that case, it is covered under Medicare Part A.⁵¹ Publicly supported dental services are primarily offered for children, leaving Medicare recipients responsible for the costs of dental care. As a last resort, some patients will seek dental care at a hospital emergency department (ED). Most often prompted to visit the ED for relief of pain triggered by dental fractures or abscesses, patients usually leave with pain medications and antibiotics only; their general dental health needs remain unmet.⁵²

 

The most common dental concerns among elderly patients include edentulism (toothlessness, which is reported in one in four Medicare beneficiaries¹), xerostomia (dry mouth), periodontal disease, ill-fitting or worn prosthetics, and progressive decay affecting fractured teeth¹ (see Figure 5). As many elderly patients endure a combination of these uncomfortable, possibly painful, conditions, it is important for the PCP to inquire about them during the physical exam and the review of symptoms. At each step, a window of opportunity opens to make appropriate recommendations.

Consider, for example, the patient who cannot easily perform daily oral hygiene because of diabetic neuropathy, severe arthritis, previous cerebral vascular accidents with motor deficits, or declining cognitive function.²⁴ For these patients, referrals for occupational therapy evaluation and recommendations for oral hygiene devices can be made, along with instructions to schedule dental cleanings.

Significant Comorbidities

It is important for PCPs to recognize the association between certain diseases and poor oral health. With the progression of age, the risk increases for type 2 diabetes. Among older diabetic patients with periodontitis (and the systemic inflammation associated with it), the difficulty of maintaining glycemic control increases as well.⁵³ Conversely, diabetic patients who are immunocompromised are at elevated risk for periodontitis. In more than 20 years of formal data collection, periodontists have identified and confirmed an anecdotal relationship between diabetes and severe periodontal disease.²⁶

Elderly patients with poor dental health are also at increased risk for chronic kidney disease. Periodontal disease alone increases the risk for nephropathy 1.5-fold to twofold.⁵⁴Finally, patients’ risk for oral cancer increases with age. Known risk factors for oral cancers include smoking, use of chewing tobacco, alcohol consumption, chronic friction, and exposure to ultraviolet radiation.⁵⁵ Survival rates for oral cancers are poor, reemphasizing the need for a thorough oral exam during primary care visits.

Other Challenges for Older Patients

Members of ethnic minority groups and lower-income populations, men, patients with cognitive impairment, and persons who never completed high school are the most likely to avoid, discontinue, or lack access to dental services.⁵⁶ Loss of dental coverage on retirement is associated with a significant decline in elderly patients’ use of dental services. Though now living on a fraction of their preretirement income, millions of retirees are required to pay out-of-pocket for dental services.⁵⁷

Topical fluoride varnish alone cannot alleviate this multimillion dollar concern, but using it to reinforce retirees’ remaining enamel and prevent caries can help reduce their dental care expenditures. However, until federal and state policymakers act to cover preventive services,^2,58 PCPs have little to offer elderly patients beyond oral hygiene education and in-office application of topical fluoride.

Strategies to Reinforce Dental Health

In practices where electronic medical records are in use, a recommendation for dental services should be printed as a patient reminder. Printed recommendations and referrals from PCPs do improve patient compliance.⁵⁹ In addition to the printed office summary, older patients can be handed a summary of oral health suggestions from the National Institute on Aging, NIH⁵⁹ (www.nia.nih.gov/health/publication/taking-care-your-teeth-and-mouth).

CONCLUSION

For most Americans with dental health insurance, access to services, and a willingness to practice good oral hygiene, dental care quality is above average. However, health care disparities and a lack of dental coverage prevent millions of Americans from routinely seeking dental services—making it essential for PCPs to promote oral hygiene and offer professional dental referrals with patients of all ages. Topical fluoride varnish, which can reduce the risk for decay as well as progression of existing decay, is an important preventive service that is within the scope of primary care practice.

Millions of Americans currently lack access to dental care and oral health preventive services because of financial and/or geographic obstacles.^1,2 Although community water fluoridation has benefited many Americans during the past 50 years, difficulties in obtaining dental care is a persistent public health challenge.² Primary care providers (PCPs) can help improve health population-wide by educating patients in good dental hygiene and offering preventive oral health services to patients who would otherwise go without them.

The chief components of preventive dental care include daily brushing with fluoride toothpaste, flossing, routine dental check-ups and professional dental cleanings provided by a licensed dentist and staff, and use of dental sealants and topical fluoride. During the primary care appointment, a routine intraoral exam, including inspection of both hard and soft oral tissues for leukoplakia, gross decay, stained dental structures, and other pathologic changes, is essential. Primary care patients who use any form of tobacco should undergo inspection of the intraoral surfaces of the lips and assessment for adenopathy of the surrounding lymph nodes.

Counseling, including recommending routine preventive dental services (and, for some patients, allaying their fears of seeing a dentist^2,3), and positive reinforcement of good oral hygiene practices should be addressed during every primary care encounter. Identifying patients without access to professional dental care is important, as the PCP may be their only source of oral health education, including referrals to local dental clinics.

Application of topical fluoride is an important means of improving dental health, and a cost-effective procedure for both patients and providers4 (see “Fluoride Use,”^2,3,5-16). By following published guidelines for use of topical fluoride varnish, PCPs can reduce decay and mineralize enamel, thereby protecting the patient against enamel erosion.^6,11,17 This service can and should be offered in primary care offices to patients who lack access to routine dental care and are likely to benefit from this effective weapon against tooth decay.

As part of the National Interprofessional Initiative on Oral Health, a comprehensive continuing education curriculum for PCPs called “Smiles for Life”^18,19 offers topics in eight focus areas, ranging from systemic conditions that affect oral health to concerns found in specific patient populations. The course is easily accessed online (www.niioh.org/smiles-life-curriculum) and provides valuable continuing education credits at no charge.

BEA, AGE 3

Bea lives with her mother and four older brothers and sisters. She is enrolled in Medicaid, but her mother has been unable to locate dental services for any of her children. With every call to a dental office within a 30-minute commute from their home, Bea’s mother has been told, “We don’t accept Medicaid.”

Under her state’s Medicaid plan, Bea has been seen for her primary health care needs since she was a newborn. She was bottle-fed from birth; her mother reports she has stopped taking the bottle to bed within the past few months. While conducting her three-year well-child exam, you note gross decay (see Figure 1).

Dental Services for Children

Nationwide, Medicaid is required to provide coverage for dental services for enrolled children, as well as those who qualify for the CHIP (Children’s Health Insurance Program).²⁰ However, there is no mandate for privately owned dental practices to accept Medicaid payments.

Lack of dental care is the greatest unmet health care need in American children.²¹ In children without health insurance, access to dental care is most challenging, and those enrolled in Medicaid are the second least likely to receive services. As a result of these and other factors, one-third of US children ages 3 to 5 have dental caries in their primary teeth, and one in every four US children is estimated to have untreated decay^2,21-23 (see Figure 2). African-American and Hispanic children experience greater disparities in dental care than do those of other ethnicities.²¹

Dental decay is the most common chronic illness of childhood (five times as common as asthma), with higher incidence in low-income and minority preschool children.^1,24,25 Tooth decay affects growth patterns and nutrition, with associated pain and infection interfering with school attendance.

 

The small number of dentists who treat children and are willing to accept Medicaid reimbursement is a significant concern. In most dental programs, dedicated pedodontic training is optional. The mismatch of number of qualified dentists to the growing population of such patients is projected to worsen in the coming years.²³

Potential solutions to correct this mismatch of dental services accessible to the underserved have included^26-31:

• Addition of paraprofessional dental therapists (persons who have received two years’ training in a specific academic program) to the health care team, in public health clinics, schools, and other settings
•  Interprofessional dental education (ie, cross-training physicians, NPs, PAs, and RNs in preventive dental services)
• An increasingly diverse array of competent providers who are trained, authorized, and compensated to provide evidence-based care
• Removing licensure restrictions for non–US-trained dentists
• Financial incentives for dentists to practice in dental Health Professional Shortage Areas
• Improved education of parents regarding the benefits of routine dental services.

The Institute of Medicine (IOM)²⁶ has challenged state legislatures to mandate a one-year dental residency to be completed among underserved populations before dental licensure is granted. This challenge reflects the IOM’s acknowledgement that dental services, essential to patients’ well-being, are grossly lacking in the US.

Dental Care Education for Parents

Healthy baby teeth help children eat well and speak clearly. Decayed and abscessed teeth cause the same degree of pain and suffering in young children as they do in adults. Thus, regardless of ethnicity or socioeconomic status, all parents should be routinely encouraged to oversee daily dental hygiene practices for their children; it is important for PCPs to explain to parents their expectations in this regard.

Dental care for children should begin as soon as the first tooth erupts. New teeth should be cleaned daily with a soft cloth and inspected by parents for any discolorations. From age 2 years until children are able to clean all dental surfaces adequately (age 7 or 8), parents should brush their children’s teeth at least once daily with a toothbrush, after applying a thin film of fluoride toothpaste. Children should undergo their first professional dental check-up at about age 1 year.^19,26 

Parents must be made aware of other factors that can impair their children’s dental health. For example, the foods most likely to promote dental decay contain highly fermentable carbohydrates, are highly processed and sticky, and cause oral pH levels to fall below 5.5 (at which point demineralization may occur).³² Examples include presweetened cereals, dried fruits, cookies, and potato chips. Cheese, peanuts, meat, and eggs are less cariogenic.

Other important teaching points are “don’ts”: putting a baby to bed with a bottle that contains anything but a sugar-free liquid; using spill-proof spouted cups filled with juice or other sugary drinks all day; serving a large proportion of cariogenic foods.

BREANNE, AGE 22

Breanne attends a community college, where she is studying business. She reports to the college health clinic, complaining of an intermittent sharp pain in one of her lower molars over the past four days, occurring when she eats or drinks anything cold.

Before she turned 21, Breanne received routine dental services under her parents’ insurance. Now a full-time student no longer covered by her parents’ plan, she has no income with which to purchase dental coverage. Years ago, Breanne received dental sealants on all of her molars in a school-based program, and she routinely brushes daily (see Figure 3). She says she “usually remembers to floss.”

Because of her pain, Breanne is medicated with an anti-inflammatory agent. She is referred to a nearby dental clinic for further evaluation.

 

 

Dental Concerns in Young Adults

Up to one-third of Americans, including college-age students, lack access to oral health services.³³ Use of annual dental services, including school-based care, significantly reduces young adults’ risk for tooth loss.³⁴ From early adulthood on, poor dental health is associated with cardiovascular and respiratory disease, cerebral ischemia, diabetes, difficulty with chewing and oral pain, and poor self-image.²⁴

PCPs should emphasize the importance of preventive services as they examine the oral structure during routine health care encounters. Adding the question, “When did you last have a dental exam?” can launch an effective discussion about the importance of good dental health.

Tooth surfaces with pits and fissures are the most vulnerable to decay. Dental sealants can protect these vulnerable areas, reducing decay by 60% to 82%.^2,32,35 Sealants are the most effective preventive measure for reducing cavity formation; they are not harmful to fillings and can actually reduce the progression of decay when applied over small existing carious lesions.³⁵ Currently, however, only 30% and 38% of children and adolescents, respectively, have undergone application of sealants.³⁶ Thus, it is vital for PCPs to recommend dental sealants to all their patients.^35,37,38

Young adults should also be questioned about their exercise patterns. While daily exercise is of benefit to good health, young adults who engage in too-frequent, overly vigorous exercise have been found vulnerable to dental erosion.³⁹ This irreversible condition can result from the rapid breathing, sweat-induced dehydration, and decreased salivary flow associated with strenuous exercise. Reduced salivary flow disrupts the protection against erosive acids afforded by bathing of teeth with saliva, leading to a fivefold greater risk for developing erosions. Patients should be encouraged to hydrate before exercise to reduce these risks.³⁹

Dental Health Notes for Young Women

For female patients of childbearing age like Breanne, dental health is important not only for the patient, but for her future children as well. Poor maternal dental health has been associated with preterm births and low birth weights.^40-43 Women who have health insurance, who are in good general health, and who regularly visit a primary care medical provider are also the most likely to see a dental care provider during pregnancy.⁴⁰

Pregnancy is associated with a risk for poor dental care in any population.^42,44 During pregnancy, Medicaid-enrolled women are 30% less likely to see a dentist than women with private health insurance, and women with no health insurance are 70% less likely to see a dentist.⁴⁴ Among pregnant women who experience a dental problem, less than half will schedule a dental appointment. Postponing dental care till after delivery incurs additional risk, as the new mother will be busy with her child and may have lost her health care coverage in the interim.

Dental concerns commonly encountered during pregnancy are listed in Table 3.^41,42 There is also evidence that maternal transmission of mutans streptococci can lead to early childhood caries,^42,45 further highlighting the importance of dental care during pregnancy (eg, use of chlorhexidine rinses in pregnant women with dental caries⁴²). The association between periodontal disease and preterm delivery and lower birth weights^40-43 makes it critical to reduce maternal periodontal inflammation through timely dental referrals.

SAUL, AGE 42

Saul, a lifelong resident of Mississippi, has worked in construction since age 18. He has never had health or dental insurance and thus he rarely seeks preventive services. As he recalls, he has had “two fillings in my jaw teeth since I was a kid,” but otherwise has had no dental care. He brushes daily to avoid having to see a dentist. He is presenting today as a new patient only because he has a rash.

 

 

Benefits of Fluoride Use During Middle Age

Dental care needs peak between ages 55 and 64, with the majority of care prompted by dental decay⁴⁶ (see Figure 4). A discussion about dental health should be raised when the PCP completes the review of systems or while discussing other preventive services. The option of fluoride varnish should not be overlooked in a patient of any age, particularly one with a recognizable deficiency of preventive dental services. Explaining the benefits of topical fluoride varnish (see “Fluoride Use”) and offering an opportunity to receive it in the office may persuade a patient like Saul to take advantage of this proven anticarious procedure.

Of note, topical fluoride varnish is not harmful to existing dental fillings; rather, some restorative dental material is produced and continuously released with fluoride to protect the surrounding enamel surfaces.⁴⁷ Fluoride varnish also reduces the progression of decay that is already present.¹¹ Extending exposure to fluoride with varnish allows more effective penetration of the enamel; fluoride that remains in the saliva increases the protection further.^48,49

Patients who undergo this safe procedure should be reminded to continue brushing daily with fluoridated toothpaste and drinking fluoridated water (if it is available).⁵⁰

GILL, AGE 77

Gill grew up in Grant County, New Mexico, in an area not far from Silver City; there, fluoride supplementation in the local water did not begin until Gill was about 40. His family never stressed oral hygiene, and his remaining teeth show gross plaque and decay.

He sees you routinely for his chronic illnesses, and today he has presented for his annual physical. Gill has Medicare without supplemental insurance.

Dental Care in the Medicare Years

Medicare does not cover preventive dental services unless hospitalization is required; in that case, it is covered under Medicare Part A.⁵¹ Publicly supported dental services are primarily offered for children, leaving Medicare recipients responsible for the costs of dental care. As a last resort, some patients will seek dental care at a hospital emergency department (ED). Most often prompted to visit the ED for relief of pain triggered by dental fractures or abscesses, patients usually leave with pain medications and antibiotics only; their general dental health needs remain unmet.⁵²

 

The most common dental concerns among elderly patients include edentulism (toothlessness, which is reported in one in four Medicare beneficiaries¹), xerostomia (dry mouth), periodontal disease, ill-fitting or worn prosthetics, and progressive decay affecting fractured teeth¹ (see Figure 5). As many elderly patients endure a combination of these uncomfortable, possibly painful, conditions, it is important for the PCP to inquire about them during the physical exam and the review of symptoms. At each step, a window of opportunity opens to make appropriate recommendations.

Consider, for example, the patient who cannot easily perform daily oral hygiene because of diabetic neuropathy, severe arthritis, previous cerebral vascular accidents with motor deficits, or declining cognitive function.²⁴ For these patients, referrals for occupational therapy evaluation and recommendations for oral hygiene devices can be made, along with instructions to schedule dental cleanings.

Significant Comorbidities

It is important for PCPs to recognize the association between certain diseases and poor oral health. With the progression of age, the risk increases for type 2 diabetes. Among older diabetic patients with periodontitis (and the systemic inflammation associated with it), the difficulty of maintaining glycemic control increases as well.⁵³ Conversely, diabetic patients who are immunocompromised are at elevated risk for periodontitis. In more than 20 years of formal data collection, periodontists have identified and confirmed an anecdotal relationship between diabetes and severe periodontal disease.²⁶

Elderly patients with poor dental health are also at increased risk for chronic kidney disease. Periodontal disease alone increases the risk for nephropathy 1.5-fold to twofold.⁵⁴Finally, patients’ risk for oral cancer increases with age. Known risk factors for oral cancers include smoking, use of chewing tobacco, alcohol consumption, chronic friction, and exposure to ultraviolet radiation.⁵⁵ Survival rates for oral cancers are poor, reemphasizing the need for a thorough oral exam during primary care visits.

Other Challenges for Older Patients

Members of ethnic minority groups and lower-income populations, men, patients with cognitive impairment, and persons who never completed high school are the most likely to avoid, discontinue, or lack access to dental services.⁵⁶ Loss of dental coverage on retirement is associated with a significant decline in elderly patients’ use of dental services. Though now living on a fraction of their preretirement income, millions of retirees are required to pay out-of-pocket for dental services.⁵⁷

Topical fluoride varnish alone cannot alleviate this multimillion dollar concern, but using it to reinforce retirees’ remaining enamel and prevent caries can help reduce their dental care expenditures. However, until federal and state policymakers act to cover preventive services,^2,58 PCPs have little to offer elderly patients beyond oral hygiene education and in-office application of topical fluoride.

Strategies to Reinforce Dental Health

In practices where electronic medical records are in use, a recommendation for dental services should be printed as a patient reminder. Printed recommendations and referrals from PCPs do improve patient compliance.⁵⁹ In addition to the printed office summary, older patients can be handed a summary of oral health suggestions from the National Institute on Aging, NIH⁵⁹ (www.nia.nih.gov/health/publication/taking-care-your-teeth-and-mouth).

CONCLUSION

For most Americans with dental health insurance, access to services, and a willingness to practice good oral hygiene, dental care quality is above average. However, health care disparities and a lack of dental coverage prevent millions of Americans from routinely seeking dental services—making it essential for PCPs to promote oral hygiene and offer professional dental referrals with patients of all ages. Topical fluoride varnish, which can reduce the risk for decay as well as progression of existing decay, is an important preventive service that is within the scope of primary care practice.

Millions of Americans currently lack access to dental care and oral health preventive services because of financial and/or geographic obstacles.^1,2 Although community water fluoridation has benefited many Americans during the past 50 years, difficulties in obtaining dental care is a persistent public health challenge.² Primary care providers (PCPs) can help improve health population-wide by educating patients in good dental hygiene and offering preventive oral health services to patients who would otherwise go without them.

The chief components of preventive dental care include daily brushing with fluoride toothpaste, flossing, routine dental check-ups and professional dental cleanings provided by a licensed dentist and staff, and use of dental sealants and topical fluoride. During the primary care appointment, a routine intraoral exam, including inspection of both hard and soft oral tissues for leukoplakia, gross decay, stained dental structures, and other pathologic changes, is essential. Primary care patients who use any form of tobacco should undergo inspection of the intraoral surfaces of the lips and assessment for adenopathy of the surrounding lymph nodes.

Counseling, including recommending routine preventive dental services (and, for some patients, allaying their fears of seeing a dentist^2,3), and positive reinforcement of good oral hygiene practices should be addressed during every primary care encounter. Identifying patients without access to professional dental care is important, as the PCP may be their only source of oral health education, including referrals to local dental clinics.

Application of topical fluoride is an important means of improving dental health, and a cost-effective procedure for both patients and providers4 (see “Fluoride Use,”^2,3,5-16). By following published guidelines for use of topical fluoride varnish, PCPs can reduce decay and mineralize enamel, thereby protecting the patient against enamel erosion.^6,11,17 This service can and should be offered in primary care offices to patients who lack access to routine dental care and are likely to benefit from this effective weapon against tooth decay.

As part of the National Interprofessional Initiative on Oral Health, a comprehensive continuing education curriculum for PCPs called “Smiles for Life”^18,19 offers topics in eight focus areas, ranging from systemic conditions that affect oral health to concerns found in specific patient populations. The course is easily accessed online (www.niioh.org/smiles-life-curriculum) and provides valuable continuing education credits at no charge.

BEA, AGE 3

Bea lives with her mother and four older brothers and sisters. She is enrolled in Medicaid, but her mother has been unable to locate dental services for any of her children. With every call to a dental office within a 30-minute commute from their home, Bea’s mother has been told, “We don’t accept Medicaid.”

Under her state’s Medicaid plan, Bea has been seen for her primary health care needs since she was a newborn. She was bottle-fed from birth; her mother reports she has stopped taking the bottle to bed within the past few months. While conducting her three-year well-child exam, you note gross decay (see Figure 1).

Dental Services for Children

Nationwide, Medicaid is required to provide coverage for dental services for enrolled children, as well as those who qualify for the CHIP (Children’s Health Insurance Program).²⁰ However, there is no mandate for privately owned dental practices to accept Medicaid payments.

Lack of dental care is the greatest unmet health care need in American children.²¹ In children without health insurance, access to dental care is most challenging, and those enrolled in Medicaid are the second least likely to receive services. As a result of these and other factors, one-third of US children ages 3 to 5 have dental caries in their primary teeth, and one in every four US children is estimated to have untreated decay^2,21-23 (see Figure 2). African-American and Hispanic children experience greater disparities in dental care than do those of other ethnicities.²¹

Dental decay is the most common chronic illness of childhood (five times as common as asthma), with higher incidence in low-income and minority preschool children.^1,24,25 Tooth decay affects growth patterns and nutrition, with associated pain and infection interfering with school attendance.

 

The small number of dentists who treat children and are willing to accept Medicaid reimbursement is a significant concern. In most dental programs, dedicated pedodontic training is optional. The mismatch of number of qualified dentists to the growing population of such patients is projected to worsen in the coming years.²³

Potential solutions to correct this mismatch of dental services accessible to the underserved have included^26-31:

• Addition of paraprofessional dental therapists (persons who have received two years’ training in a specific academic program) to the health care team, in public health clinics, schools, and other settings
•  Interprofessional dental education (ie, cross-training physicians, NPs, PAs, and RNs in preventive dental services)
• An increasingly diverse array of competent providers who are trained, authorized, and compensated to provide evidence-based care
• Removing licensure restrictions for non–US-trained dentists
• Financial incentives for dentists to practice in dental Health Professional Shortage Areas
• Improved education of parents regarding the benefits of routine dental services.

The Institute of Medicine (IOM)²⁶ has challenged state legislatures to mandate a one-year dental residency to be completed among underserved populations before dental licensure is granted. This challenge reflects the IOM’s acknowledgement that dental services, essential to patients’ well-being, are grossly lacking in the US.

Dental Care Education for Parents

Healthy baby teeth help children eat well and speak clearly. Decayed and abscessed teeth cause the same degree of pain and suffering in young children as they do in adults. Thus, regardless of ethnicity or socioeconomic status, all parents should be routinely encouraged to oversee daily dental hygiene practices for their children; it is important for PCPs to explain to parents their expectations in this regard.

Dental care for children should begin as soon as the first tooth erupts. New teeth should be cleaned daily with a soft cloth and inspected by parents for any discolorations. From age 2 years until children are able to clean all dental surfaces adequately (age 7 or 8), parents should brush their children’s teeth at least once daily with a toothbrush, after applying a thin film of fluoride toothpaste. Children should undergo their first professional dental check-up at about age 1 year.^19,26 

Parents must be made aware of other factors that can impair their children’s dental health. For example, the foods most likely to promote dental decay contain highly fermentable carbohydrates, are highly processed and sticky, and cause oral pH levels to fall below 5.5 (at which point demineralization may occur).³² Examples include presweetened cereals, dried fruits, cookies, and potato chips. Cheese, peanuts, meat, and eggs are less cariogenic.

Other important teaching points are “don’ts”: putting a baby to bed with a bottle that contains anything but a sugar-free liquid; using spill-proof spouted cups filled with juice or other sugary drinks all day; serving a large proportion of cariogenic foods.

BREANNE, AGE 22

Breanne attends a community college, where she is studying business. She reports to the college health clinic, complaining of an intermittent sharp pain in one of her lower molars over the past four days, occurring when she eats or drinks anything cold.

Before she turned 21, Breanne received routine dental services under her parents’ insurance. Now a full-time student no longer covered by her parents’ plan, she has no income with which to purchase dental coverage. Years ago, Breanne received dental sealants on all of her molars in a school-based program, and she routinely brushes daily (see Figure 3). She says she “usually remembers to floss.”

Because of her pain, Breanne is medicated with an anti-inflammatory agent. She is referred to a nearby dental clinic for further evaluation.

 

 

Dental Concerns in Young Adults

Up to one-third of Americans, including college-age students, lack access to oral health services.³³ Use of annual dental services, including school-based care, significantly reduces young adults’ risk for tooth loss.³⁴ From early adulthood on, poor dental health is associated with cardiovascular and respiratory disease, cerebral ischemia, diabetes, difficulty with chewing and oral pain, and poor self-image.²⁴

PCPs should emphasize the importance of preventive services as they examine the oral structure during routine health care encounters. Adding the question, “When did you last have a dental exam?” can launch an effective discussion about the importance of good dental health.

Tooth surfaces with pits and fissures are the most vulnerable to decay. Dental sealants can protect these vulnerable areas, reducing decay by 60% to 82%.^2,32,35 Sealants are the most effective preventive measure for reducing cavity formation; they are not harmful to fillings and can actually reduce the progression of decay when applied over small existing carious lesions.³⁵ Currently, however, only 30% and 38% of children and adolescents, respectively, have undergone application of sealants.³⁶ Thus, it is vital for PCPs to recommend dental sealants to all their patients.^35,37,38

Young adults should also be questioned about their exercise patterns. While daily exercise is of benefit to good health, young adults who engage in too-frequent, overly vigorous exercise have been found vulnerable to dental erosion.³⁹ This irreversible condition can result from the rapid breathing, sweat-induced dehydration, and decreased salivary flow associated with strenuous exercise. Reduced salivary flow disrupts the protection against erosive acids afforded by bathing of teeth with saliva, leading to a fivefold greater risk for developing erosions. Patients should be encouraged to hydrate before exercise to reduce these risks.³⁹

Dental Health Notes for Young Women

For female patients of childbearing age like Breanne, dental health is important not only for the patient, but for her future children as well. Poor maternal dental health has been associated with preterm births and low birth weights.^40-43 Women who have health insurance, who are in good general health, and who regularly visit a primary care medical provider are also the most likely to see a dental care provider during pregnancy.⁴⁰

Pregnancy is associated with a risk for poor dental care in any population.^42,44 During pregnancy, Medicaid-enrolled women are 30% less likely to see a dentist than women with private health insurance, and women with no health insurance are 70% less likely to see a dentist.⁴⁴ Among pregnant women who experience a dental problem, less than half will schedule a dental appointment. Postponing dental care till after delivery incurs additional risk, as the new mother will be busy with her child and may have lost her health care coverage in the interim.

Dental concerns commonly encountered during pregnancy are listed in Table 3.^41,42 There is also evidence that maternal transmission of mutans streptococci can lead to early childhood caries,^42,45 further highlighting the importance of dental care during pregnancy (eg, use of chlorhexidine rinses in pregnant women with dental caries⁴²). The association between periodontal disease and preterm delivery and lower birth weights^40-43 makes it critical to reduce maternal periodontal inflammation through timely dental referrals.

SAUL, AGE 42

Saul, a lifelong resident of Mississippi, has worked in construction since age 18. He has never had health or dental insurance and thus he rarely seeks preventive services. As he recalls, he has had “two fillings in my jaw teeth since I was a kid,” but otherwise has had no dental care. He brushes daily to avoid having to see a dentist. He is presenting today as a new patient only because he has a rash.

 

 

Benefits of Fluoride Use During Middle Age

Dental care needs peak between ages 55 and 64, with the majority of care prompted by dental decay⁴⁶ (see Figure 4). A discussion about dental health should be raised when the PCP completes the review of systems or while discussing other preventive services. The option of fluoride varnish should not be overlooked in a patient of any age, particularly one with a recognizable deficiency of preventive dental services. Explaining the benefits of topical fluoride varnish (see “Fluoride Use”) and offering an opportunity to receive it in the office may persuade a patient like Saul to take advantage of this proven anticarious procedure.

Of note, topical fluoride varnish is not harmful to existing dental fillings; rather, some restorative dental material is produced and continuously released with fluoride to protect the surrounding enamel surfaces.⁴⁷ Fluoride varnish also reduces the progression of decay that is already present.¹¹ Extending exposure to fluoride with varnish allows more effective penetration of the enamel; fluoride that remains in the saliva increases the protection further.^48,49

Patients who undergo this safe procedure should be reminded to continue brushing daily with fluoridated toothpaste and drinking fluoridated water (if it is available).⁵⁰

GILL, AGE 77

Gill grew up in Grant County, New Mexico, in an area not far from Silver City; there, fluoride supplementation in the local water did not begin until Gill was about 40. His family never stressed oral hygiene, and his remaining teeth show gross plaque and decay.

He sees you routinely for his chronic illnesses, and today he has presented for his annual physical. Gill has Medicare without supplemental insurance.

Dental Care in the Medicare Years

Medicare does not cover preventive dental services unless hospitalization is required; in that case, it is covered under Medicare Part A.⁵¹ Publicly supported dental services are primarily offered for children, leaving Medicare recipients responsible for the costs of dental care. As a last resort, some patients will seek dental care at a hospital emergency department (ED). Most often prompted to visit the ED for relief of pain triggered by dental fractures or abscesses, patients usually leave with pain medications and antibiotics only; their general dental health needs remain unmet.⁵²

 

The most common dental concerns among elderly patients include edentulism (toothlessness, which is reported in one in four Medicare beneficiaries¹), xerostomia (dry mouth), periodontal disease, ill-fitting or worn prosthetics, and progressive decay affecting fractured teeth¹ (see Figure 5). As many elderly patients endure a combination of these uncomfortable, possibly painful, conditions, it is important for the PCP to inquire about them during the physical exam and the review of symptoms. At each step, a window of opportunity opens to make appropriate recommendations.

Consider, for example, the patient who cannot easily perform daily oral hygiene because of diabetic neuropathy, severe arthritis, previous cerebral vascular accidents with motor deficits, or declining cognitive function.²⁴ For these patients, referrals for occupational therapy evaluation and recommendations for oral hygiene devices can be made, along with instructions to schedule dental cleanings.

Significant Comorbidities

It is important for PCPs to recognize the association between certain diseases and poor oral health. With the progression of age, the risk increases for type 2 diabetes. Among older diabetic patients with periodontitis (and the systemic inflammation associated with it), the difficulty of maintaining glycemic control increases as well.⁵³ Conversely, diabetic patients who are immunocompromised are at elevated risk for periodontitis. In more than 20 years of formal data collection, periodontists have identified and confirmed an anecdotal relationship between diabetes and severe periodontal disease.²⁶

Elderly patients with poor dental health are also at increased risk for chronic kidney disease. Periodontal disease alone increases the risk for nephropathy 1.5-fold to twofold.⁵⁴Finally, patients’ risk for oral cancer increases with age. Known risk factors for oral cancers include smoking, use of chewing tobacco, alcohol consumption, chronic friction, and exposure to ultraviolet radiation.⁵⁵ Survival rates for oral cancers are poor, reemphasizing the need for a thorough oral exam during primary care visits.

Other Challenges for Older Patients

Members of ethnic minority groups and lower-income populations, men, patients with cognitive impairment, and persons who never completed high school are the most likely to avoid, discontinue, or lack access to dental services.⁵⁶ Loss of dental coverage on retirement is associated with a significant decline in elderly patients’ use of dental services. Though now living on a fraction of their preretirement income, millions of retirees are required to pay out-of-pocket for dental services.⁵⁷

Topical fluoride varnish alone cannot alleviate this multimillion dollar concern, but using it to reinforce retirees’ remaining enamel and prevent caries can help reduce their dental care expenditures. However, until federal and state policymakers act to cover preventive services,^2,58 PCPs have little to offer elderly patients beyond oral hygiene education and in-office application of topical fluoride.

Strategies to Reinforce Dental Health

In practices where electronic medical records are in use, a recommendation for dental services should be printed as a patient reminder. Printed recommendations and referrals from PCPs do improve patient compliance.⁵⁹ In addition to the printed office summary, older patients can be handed a summary of oral health suggestions from the National Institute on Aging, NIH⁵⁹ (www.nia.nih.gov/health/publication/taking-care-your-teeth-and-mouth).

CONCLUSION

For most Americans with dental health insurance, access to services, and a willingness to practice good oral hygiene, dental care quality is above average. However, health care disparities and a lack of dental coverage prevent millions of Americans from routinely seeking dental services—making it essential for PCPs to promote oral hygiene and offer professional dental referrals with patients of all ages. Topical fluoride varnish, which can reduce the risk for decay as well as progression of existing decay, is an important preventive service that is within the scope of primary care practice.

CASE Eric K, age 25, is in your office, seeking help for chronic headache—which he’s had nearly every day for the past 9 months. He says that the headaches vary in quality and intensity. Sometimes the pain is in the right temporal area; has a throbbing, pulsating quality; and is accompanied by nausea and photophobia. These headaches are incapacitating, with an intensity of 10 on a scale of one to 10. When they occur, the patient reports, all he can do is take migraine medication and lie down in a darkened room for several hours, until the pain goes away. He cannot identify any triggers.

He also gets headaches that are not incapacitating, but occur almost daily, the patient says, describing a dull bilateral pressure that usually begins in the afternoon and worsens until he takes headache medication. He denies any fever, chills, weight loss, visual changes, or tinnitus. His medical history is significant only for obesity, but a system review is positive for depression and insomnia. Physical examination reveals normal vital signs; normal head, eyes, ears, nose, and throat (HEENT); and normal fundoscopic and neurological exams.

Patients like Mr. K can be challenging for primary care physicians, but referral to a neurologist is indicated only in the most intractable cases. For the vast majority of patients with frequent headaches, family physicians can perform the diagnostic work-up and oversee treatment. This review will help with both.

What kind of headache?

While most headaches are sporadic in nature, the prevalence of “chronic daily headache” ranges from 3% to 5% worldwide.^1-3

Chronic daily headache is not a diagnosis, however, nor is it an indication that a patient has a headache every day. According to the International Classification of Headache Disorders (ICHD-II), chronic daily headache encompasses several distinct primary headache disorders that have a frequency of ≥15 times per month for at least 3 months. These disorders are also classified by duration, as long (>4 hours) or short.⁴

The text and tables that follow focus on the diagnosis and treatment of the 4 primary headache disorders of long duration—chronic migraine (CM), chronic tension-type headache (CTTH), hemicrania continua (HC), and new daily persistent headache (NDPH) (TABLE 1).^4,5 Although medication overuse headache (MOH) is not a primary headache, it is included in this review because it often contributes to and complicates treatment of primary headache disorders. What’s more, most chronic daily headache syndromes are inextricably linked to medication overuse.^6,7

Which individuals are at risk?
Risk factors for chronic headache include female sex, older age, obesity, heavy caffeine consumption, tobacco use, low educational level, overuse of abortive headache medications, and a history of head and neck trauma.⁸ Episodic migraine (EM)—that is, migraines that occur ≤14 times a month—is also a risk factor for chronic headache.

ICHD-II classifies EM as a progressive disease that transforms to CM at a rate of 3% per year.⁹ Transformation of EM to CM has been found to occur after as few as 5 days of barbiturates or 8 days of opiates per month.¹⁰

Patients with EM should be warned about the potential for migraines to become chronic and have their acute headache medications replaced with a prophylactic drug if the frequency approaches 2 per week.

TABLE 1
Diagnosing and treating chronic headache^4,5

Type of headache	ICHD-II diagnostic criteria	First-line treatment
Chronic migraine	Headache fulfilling criteria for migraine without aura ≥8 days/month Headache occurs ≥15 d/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: TCAs SNRIs Anticonvulsants Beta-blockers Botulinum toxin A Limit acute medication; avoid triggers; initiate lifestyle modification
Chronic tension-type headache	Headache fulfilling criteria for tension-type headache Occurs ≥15 days/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: Amitriptyline Venlafaxine Mirtazapine Limit acute medication; avoid triggers; initiate lifestyle modification
Medication overuse headache	Headache occurs ≥15 days/mo Single abortive medication use ≥10 days/mo or combination therapy ≥15 days/mo for ≥3 mo Headache developed or worsened during medication overuse	Discontinue overused acute meds; provide headache education; bridge with NSAIDs, prednisone, or botulinum toxin A; begin prophylactic medication
Hemicrania continua	Headache for ≥3 mo All of the following characteristics: Unilateral pain without side shift Daily and continuous, without pain-free periods Moderate intensity, but with exacerbations of severe pain At least one of the following on the same side as the pain: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhea Ptosis and/or miosis Complete response to therapeutic doses of indomethacin	Indomethacin
New daily persistent headache	Headache for ≥3 mo Characteristics of tension-type headache (but migrainous features are common) Unrelenting from onset or within 3 days of onset No medication overuse	Rule out secondary causes; treat according to migrainous or tension features of headache
ICHD-II, International Classification of Headache Disorders; NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants.

 

Pinpointing the type of headache

An accurate diagnosis requires a thorough headache history and a HEENT and neurological examination. The history should include questions about the characteristics of the headache, including the location, intensity, frequency, timing, associated symptoms, previous headache diagnoses, and triggers, and address comorbidities, medication use, caffeine intake, and family history.⁸ In the absence of red flags—age >50 years, history of headache or systemic illness, sudden onset, or papilledema, among other findings that may indicate more serious conditions (TABLE 2)⁷—advanced imaging and further work-up are not needed.

TABLE 2
Beyond headache: Red flags warrant additional testing⁷

Red flag	Condition(s) to rule out
Age of onset >50 y	Giant cell arteritis, mass lesion, stroke
No prior history of headache OR change in characteristic from prior headaches	Cancer, aneurysm, stroke, cerebral sinus thrombosis, infection
“Thunderclap” headache	Ruptured aneurysm
Signs or symptoms of systemic illness (eg, fever, chills, weight loss)	Meningitis, encephalitis, cancer
History of systemic illness, such as cancer, autoimmune disease, or HIV	Brain metastasis, mass lesion, autoimmune meningitis, thrombosis
Headache brought on by change in head position or Valsalva maneuver	Spontaneous CSF leak or Chiari malformation
Occipital location of headache (in children)	Brain tumor
Neurological symptoms	Mass lesion, encephalitis
Papilledema	Idiopathic intracranial hypertension, cerebral sinus thrombosis
CSF, cerebrospinal fluid; HIV, human immunodeficiency virus.

Migraine or tension headache?
Chronic migraine. To be classified as CM, the headache must have occurred ≥15 days a month for 3 months or more and have features of migraine, such as unilateral location, pulsating quality, and moderate to severe intensity. Migraines are aggravated by physical activity and associated with nausea and/or vomiting, photophobia, and phonophobia, and may or may not be preceded by aura. Common triggers include stress, menstruation, alcohol, skipped meals, dehydration, and chocolate. Migraines typically respond to ergots and triptans.^4,5

Partial treatment. Patients with CM often take medication early in the course of a headache. This sometimes results in a partially treated migraine that develops into a headache with tension-type features, such as a bilateral location, a pressing quality, and mild-to-moderate intensity, as well as a possible transformation to MOH. This is most likely to occur in patients who have migraines without an aura.

To avoid partial treatment, medications for acute migraine should be taken within 30 minutes of an attack, in a dose that’s sufficient to relieve the pain within 2 hours, with no need for a second dose—a protocol known as “one and done.” Efficacy of a triptan can be improved by adding a nonsteroidal anti-inflammatory drug (NSAID).¹⁰

A definitive diagnosis of CM is only possible in the absence of medication overuse.^4,5 A patient who is overusing abortive headache medication and whose headache meets the criteria for CM should be given a diagnosis of probable CM instead.

Chronic tension-type headache. In addition to traits common to tension headaches, CTTH may be associated with mild nausea, photophobia, or phonophobia (but typically only one such feature at a time). There may also be tenderness to palpation of the pericranial muscles. Unlike migraine, CTTH is not affected by physical activity.

Here, too, overuse of headache medication is often a factor and should be stopped, if possible, before a definitive diagnosis of CTTH can be made.

Headache with overlapping features. It is possible for a patient to have chronic headache with features of both migraine and tension headache. Advise patients whose headaches have varying characteristics to keep a headache journal to determine which features are more prominent. Patients with smart phones can download a free app, such as iHeadache or My Headache Log Pro, to be used for this purpose.^11,12

When to suspect medication overuse headache
MOH is sometimes referred to as a rebound headache or drug-induced headache. Headaches associated with medication overuse have variable intensity. Patients with MOH often awaken from sleep with a headache, and neck pain is highly prevalent.¹⁰

Quantifying overuse. According to ICHD-II, overuse is defined as using a single abortive headache medication ≥10 times a month or using 2 or more such drugs ≥15 times a month.⁵

Triptans have the potential to cause MOH more quickly and in lower doses compared with other acute headache medications. However, analgesics—especially combination products such as butalbital/acetaminophen/caffeine (Fioricet)—are most frequently associated with the development of MOH.^13,14 NSAIDs have less potential to cause MOH and are sometimes given as bridge therapy for patients who are discontinuing their acute headache medication.

 

Less common primary headache disorders
Hemicrania continua, a rare cause of chronic daily headache, is unilateral, without shifting sides, and the intensity is moderate to severe—and unrelenting. HC is associated with autonomic features such as lacrimation, ptosis, and nasal congestion.

New daily persistent headache is characterized by an out-of-the-blue onset of a headache that becomes unremitting soon after it develops. To receive a diagnosis of NDPH, the patient must have a headache that started suddenly and has continued for 3 months or more.

Most patients diagnosed with NDPH are able to recall, to the day, when the headache started. More than 50% report a precipitating event, such as a viral illness, a stressful experience, or surgery.¹⁵ ICHD-II defines NDPH as having the characteristics of a tension headache. Notably, however, migrainous features are also common, and neurologists often diagnose NDPH with either migrainous or tension-type features.¹⁶

The sudden onset of NDPH is a red flag and, like other red flags, always warrants further work-up. Magnetic resonance imaging with gadolinium is preferred to computed tomography. Magnetic resonance venography or lumbar puncture may also be considered.^15,16

Review comorbidities, rule out secondary causes
Patients who suffer from frequent headaches have a high prevalence of depression, anxiety,^17,18 sleep disorders,¹⁹ obesity,²⁰ irritable bowel disease, fibromyalgia,²¹ temporomandibular joint disorder,²² and chronic fatigue syndrome. Treatment of these disorders may increase the efficacy of headache treatment. Conversely, overuse of headache medications can make comorbidities harder to treat.

Treating chronic headache: Which drugs are best?
A multimodal approach combining pharmacologic and nonpharmacologic therapies is usually required for patients with chronic headache. The particular therapy and prognosis depend on the type of headache a patient has and the presence of comorbidities (TABLE 3).^6,7,23,24

TABLE 3
Consider comorbidities in prophylaxis selection^6,7,23,24

Comorbidity	What to choose	What to avoid
Depression	Venlafaxine	—
Bipolar disorder	Valproic acid	Venlafaxine, amitriptyline, mirtazapine
Insomnia (CM)	Amitriptyline	—
Insomnia (CTTH)	Mirtazapine	—
Obesity	Topiramate	Amitriptyline
Hypertension	Metoprolol, propranolol	—
Cardiac conduction abnormalities	—	Amitriptyline
Fibromyalgia	Amitriptyline, tizanidine	—
CM, chronic migraine; CTTH, chronic tension-type headache.

Choice for migraine prophylaxis? Here’s what the evidence tells us

Although most studies of the benefits of prophylaxis have involved patients with episodic or frequent migraine rather than CM, extrapolation of the findings to patients with CM is not unreasonable. And, although dozens of pharmacologic and complementary therapies have been studied for migraine prophylaxis and certain classes of drugs have been identified as effective, there are very few head-to-head trials comparing agents.

The American Academy of Neurology and the American Headache Society published a summary of the evidence in 2012.²³ Key findings: The types of medication with the most evidence to support their use as first-line agents for CM are antidepressants, anticonvulsants, and beta-blockers.

Antidepressants, especially tricyclics (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have been found to be effective. Chief among them are amitriptyline, a TCA, which is inexpensive and may be beneficial for patients with coexisting insomnia due to its sedating effect, and venlafaxine, an SNRI, which may help treat comorbid depression.²³ Amitriptyline is associated with weight gain and can prolong the QT interval at higher doses. There is insufficient or conflicting evidence of the value of selective serotonin reuptake inhibitors for migraine prophylaxis.

Anticonvulsants that have been studied most extensively for migraine are topiramate and sodium valproate. Both have level A ratings for established efficacy.²³ Topiramate has also been shown to be noninferior to amitriptyline in reducing migraine frequency and is associated with weight loss, rather than weight gain.²⁵ (Topiramate and valproic acid should be avoided in women who are hoping to become pregnant.) Gabapentin has conflicting evidence and is not recommended for migraine.²³

Beta-blockers that appear to be most effective as prophylaxis for CM are propranolol, metoprolol, and timolol.^23,26 Any of these would be the obvious choice for a patient with comorbid hypertension. Beta-blockers can take several months to have an effect on migraines, however. Their use as CM prophylaxis may be limited by their adverse effect profile, which includes erectile dysfunction, bradycardia, and hypotension, although the lower dosage needed for migraine prophylaxis may be a mitigating factor. Calcium channel blockers are commonly prescribed for migraine, but there is little evidence to support their use for CM.²³

Other medications that are likely effective for migraine prophylaxis include naproxen²⁴ and tizanidine²⁷ (a muscle relaxant). Complementary and alternative treatments that appear to be effective include magnesium, feverfew, butterbur, and riboflavin, although the benefits may not be noticeable for several months.²⁴

Botulinum toxin A is the only medication approved by the US Food and Drug Administration for prevention of CM. It is generally considered to be a second-line agent because of its high cost and the need for training and expertise to administer it. Botulinum toxin A is not effective as prophylaxis for EM.²⁸

 

Treating other headache syndromes

Chronic tension-type headache. Treatment of CTTH applies similar principles to those of CM, and amitriptyline and venlafaxine—as well as mirtazapine, a sedating SNRI—have evidence to support their use for this type of headache.²⁹ Overall, however, CTTH therapies have not been studied as extensively as those for migraine. There is conflicting evidence of the value of anticonvulsants for prophylaxis of CTTH, and botulinum toxin A has been shown to be no better than placebo.³⁰

Medication overuse headache. Prophylactic medications are not effective in patients who are overusing acute headache medications, and patients with MOH should be instructed to stop the offending drugs. Withdrawal of triptans, simple analgesics, and ergots—either cold turkey or with a slow wean over 4 to 6 weeks—is fairly safe and can be done in an outpatient setting. Concomitant use of prednisone, long-acting NSAIDs, or botulinum toxin A can be used as “bridge therapy” to relieve acute pain. Start the patient on a prophylactic medication based on the best estimate of his or her baseline headache and comorbidities.^31,32 For patients who have been overusing opiates or barbiturates, most experts recommend inpatient treatment to manage withdrawal symptoms and prevent complications.¹⁰

Most patients with MOH will improve with drug withdrawal, but some will be left with the same disabling headaches that caused them to overuse medication in the first place. For such patients, weekly office visits during the withdrawal period may be helpful. After completion of the bridge therapy, they will likely require abortive headache treatment, but its use must be limited to no more than twice a week. Referral to a specialty headache clinic may be appropriate for such patients.

Hemicrania continua. The treatment for HC is indomethacin. A 2- to 5-day course typically results in complete recovery.

New daily persistent headache. For patients with NDPH, the first step is ruling out secondary causes. Once that has been done, most experts recommend trying to characterize the headache as having features of either migraine or tension and treating accordingly with preventive therapy. If acute headache medication is still needed, limit the quantity you prescribe and stress the importance of taking it no more than twice a week.

CASE Mr. K receives a diagnosis of MOH and probable CM. You explain the way MOH develops and how his medication use has contributed to the escalation of his headaches, and ask him to stop all the headache medications he has been using and to keep a headache journal. You prescribe meloxicam as a short-term bridge therapy and low-dose venlafaxine, which is increased to 150 mg/d over the next 4 weeks; recommend riboflavin 400 mg/d; and refer Mr. K to a neurologist for botulinum toxin A.

You ask him to return in 4 weeks and explain that because he has successfully stopped the overuse of acute headache medications, he can begin taking them again—provided he limits their use to no more than twice a week.

Nonpharmacologic measures can help, too
Lifestyle modification can play an important role in the treatment of chronic daily headache. Advise patients of the importance of proper sleep hygiene, regular exercise, stress reduction, and a healthy diet, as well as avoiding known triggers and minimizing intake of caffeine. Tell patients that biofeedback, cognitive behavioral therapy, and physical therapy may play a role in conjunction with pharmacotherapy, especially for CTTH,^26,29,33 but that hypnosis, acupuncture, chiropractic manipulation, transcutaneous electrical nerve stimulation, and hyperbaric oxygen have too little evidence to recommend for or against their use.^26,34

In discussing treatment for chronic headache and the goals of therapy with a patient with chronic headache, it is important to be frank. Explain that while a complete cure is not always possible, a decrease in both the frequency and severity of headaches and an improvement in the quality of life and the patient’s ability to function are realistic goals.

CASE At the 3-month follow-up, Mr. K reports that his headaches are down to less than twice a week, and that he is undergoing cognitive behavioral therapy for depression. For acute headache pain, he takes sumatriptan 100 mg with ibuprofen 800 mg, and is careful not to do so more than twice a week.

CASE Eric K, age 25, is in your office, seeking help for chronic headache—which he’s had nearly every day for the past 9 months. He says that the headaches vary in quality and intensity. Sometimes the pain is in the right temporal area; has a throbbing, pulsating quality; and is accompanied by nausea and photophobia. These headaches are incapacitating, with an intensity of 10 on a scale of one to 10. When they occur, the patient reports, all he can do is take migraine medication and lie down in a darkened room for several hours, until the pain goes away. He cannot identify any triggers.

He also gets headaches that are not incapacitating, but occur almost daily, the patient says, describing a dull bilateral pressure that usually begins in the afternoon and worsens until he takes headache medication. He denies any fever, chills, weight loss, visual changes, or tinnitus. His medical history is significant only for obesity, but a system review is positive for depression and insomnia. Physical examination reveals normal vital signs; normal head, eyes, ears, nose, and throat (HEENT); and normal fundoscopic and neurological exams.

Patients like Mr. K can be challenging for primary care physicians, but referral to a neurologist is indicated only in the most intractable cases. For the vast majority of patients with frequent headaches, family physicians can perform the diagnostic work-up and oversee treatment. This review will help with both.

What kind of headache?

While most headaches are sporadic in nature, the prevalence of “chronic daily headache” ranges from 3% to 5% worldwide.^1-3

Chronic daily headache is not a diagnosis, however, nor is it an indication that a patient has a headache every day. According to the International Classification of Headache Disorders (ICHD-II), chronic daily headache encompasses several distinct primary headache disorders that have a frequency of ≥15 times per month for at least 3 months. These disorders are also classified by duration, as long (>4 hours) or short.⁴

The text and tables that follow focus on the diagnosis and treatment of the 4 primary headache disorders of long duration—chronic migraine (CM), chronic tension-type headache (CTTH), hemicrania continua (HC), and new daily persistent headache (NDPH) (TABLE 1).^4,5 Although medication overuse headache (MOH) is not a primary headache, it is included in this review because it often contributes to and complicates treatment of primary headache disorders. What’s more, most chronic daily headache syndromes are inextricably linked to medication overuse.^6,7

Which individuals are at risk?
Risk factors for chronic headache include female sex, older age, obesity, heavy caffeine consumption, tobacco use, low educational level, overuse of abortive headache medications, and a history of head and neck trauma.⁸ Episodic migraine (EM)—that is, migraines that occur ≤14 times a month—is also a risk factor for chronic headache.

ICHD-II classifies EM as a progressive disease that transforms to CM at a rate of 3% per year.⁹ Transformation of EM to CM has been found to occur after as few as 5 days of barbiturates or 8 days of opiates per month.¹⁰

Patients with EM should be warned about the potential for migraines to become chronic and have their acute headache medications replaced with a prophylactic drug if the frequency approaches 2 per week.

TABLE 1
Diagnosing and treating chronic headache^4,5

Type of headache	ICHD-II diagnostic criteria	First-line treatment
Chronic migraine	Headache fulfilling criteria for migraine without aura ≥8 days/month Headache occurs ≥15 d/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: TCAs SNRIs Anticonvulsants Beta-blockers Botulinum toxin A Limit acute medication; avoid triggers; initiate lifestyle modification
Chronic tension-type headache	Headache fulfilling criteria for tension-type headache Occurs ≥15 days/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: Amitriptyline Venlafaxine Mirtazapine Limit acute medication; avoid triggers; initiate lifestyle modification
Medication overuse headache	Headache occurs ≥15 days/mo Single abortive medication use ≥10 days/mo or combination therapy ≥15 days/mo for ≥3 mo Headache developed or worsened during medication overuse	Discontinue overused acute meds; provide headache education; bridge with NSAIDs, prednisone, or botulinum toxin A; begin prophylactic medication
Hemicrania continua	Headache for ≥3 mo All of the following characteristics: Unilateral pain without side shift Daily and continuous, without pain-free periods Moderate intensity, but with exacerbations of severe pain At least one of the following on the same side as the pain: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhea Ptosis and/or miosis Complete response to therapeutic doses of indomethacin	Indomethacin
New daily persistent headache	Headache for ≥3 mo Characteristics of tension-type headache (but migrainous features are common) Unrelenting from onset or within 3 days of onset No medication overuse	Rule out secondary causes; treat according to migrainous or tension features of headache
ICHD-II, International Classification of Headache Disorders; NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants.

 

Pinpointing the type of headache

An accurate diagnosis requires a thorough headache history and a HEENT and neurological examination. The history should include questions about the characteristics of the headache, including the location, intensity, frequency, timing, associated symptoms, previous headache diagnoses, and triggers, and address comorbidities, medication use, caffeine intake, and family history.⁸ In the absence of red flags—age >50 years, history of headache or systemic illness, sudden onset, or papilledema, among other findings that may indicate more serious conditions (TABLE 2)⁷—advanced imaging and further work-up are not needed.

TABLE 2
Beyond headache: Red flags warrant additional testing⁷

Red flag	Condition(s) to rule out
Age of onset >50 y	Giant cell arteritis, mass lesion, stroke
No prior history of headache OR change in characteristic from prior headaches	Cancer, aneurysm, stroke, cerebral sinus thrombosis, infection
“Thunderclap” headache	Ruptured aneurysm
Signs or symptoms of systemic illness (eg, fever, chills, weight loss)	Meningitis, encephalitis, cancer
History of systemic illness, such as cancer, autoimmune disease, or HIV	Brain metastasis, mass lesion, autoimmune meningitis, thrombosis
Headache brought on by change in head position or Valsalva maneuver	Spontaneous CSF leak or Chiari malformation
Occipital location of headache (in children)	Brain tumor
Neurological symptoms	Mass lesion, encephalitis
Papilledema	Idiopathic intracranial hypertension, cerebral sinus thrombosis
CSF, cerebrospinal fluid; HIV, human immunodeficiency virus.

Migraine or tension headache?
Chronic migraine. To be classified as CM, the headache must have occurred ≥15 days a month for 3 months or more and have features of migraine, such as unilateral location, pulsating quality, and moderate to severe intensity. Migraines are aggravated by physical activity and associated with nausea and/or vomiting, photophobia, and phonophobia, and may or may not be preceded by aura. Common triggers include stress, menstruation, alcohol, skipped meals, dehydration, and chocolate. Migraines typically respond to ergots and triptans.^4,5

Partial treatment. Patients with CM often take medication early in the course of a headache. This sometimes results in a partially treated migraine that develops into a headache with tension-type features, such as a bilateral location, a pressing quality, and mild-to-moderate intensity, as well as a possible transformation to MOH. This is most likely to occur in patients who have migraines without an aura.

To avoid partial treatment, medications for acute migraine should be taken within 30 minutes of an attack, in a dose that’s sufficient to relieve the pain within 2 hours, with no need for a second dose—a protocol known as “one and done.” Efficacy of a triptan can be improved by adding a nonsteroidal anti-inflammatory drug (NSAID).¹⁰

A definitive diagnosis of CM is only possible in the absence of medication overuse.^4,5 A patient who is overusing abortive headache medication and whose headache meets the criteria for CM should be given a diagnosis of probable CM instead.

Chronic tension-type headache. In addition to traits common to tension headaches, CTTH may be associated with mild nausea, photophobia, or phonophobia (but typically only one such feature at a time). There may also be tenderness to palpation of the pericranial muscles. Unlike migraine, CTTH is not affected by physical activity.

Here, too, overuse of headache medication is often a factor and should be stopped, if possible, before a definitive diagnosis of CTTH can be made.

Headache with overlapping features. It is possible for a patient to have chronic headache with features of both migraine and tension headache. Advise patients whose headaches have varying characteristics to keep a headache journal to determine which features are more prominent. Patients with smart phones can download a free app, such as iHeadache or My Headache Log Pro, to be used for this purpose.^11,12

When to suspect medication overuse headache
MOH is sometimes referred to as a rebound headache or drug-induced headache. Headaches associated with medication overuse have variable intensity. Patients with MOH often awaken from sleep with a headache, and neck pain is highly prevalent.¹⁰

Quantifying overuse. According to ICHD-II, overuse is defined as using a single abortive headache medication ≥10 times a month or using 2 or more such drugs ≥15 times a month.⁵

Triptans have the potential to cause MOH more quickly and in lower doses compared with other acute headache medications. However, analgesics—especially combination products such as butalbital/acetaminophen/caffeine (Fioricet)—are most frequently associated with the development of MOH.^13,14 NSAIDs have less potential to cause MOH and are sometimes given as bridge therapy for patients who are discontinuing their acute headache medication.

 

Less common primary headache disorders
Hemicrania continua, a rare cause of chronic daily headache, is unilateral, without shifting sides, and the intensity is moderate to severe—and unrelenting. HC is associated with autonomic features such as lacrimation, ptosis, and nasal congestion.

New daily persistent headache is characterized by an out-of-the-blue onset of a headache that becomes unremitting soon after it develops. To receive a diagnosis of NDPH, the patient must have a headache that started suddenly and has continued for 3 months or more.

Most patients diagnosed with NDPH are able to recall, to the day, when the headache started. More than 50% report a precipitating event, such as a viral illness, a stressful experience, or surgery.¹⁵ ICHD-II defines NDPH as having the characteristics of a tension headache. Notably, however, migrainous features are also common, and neurologists often diagnose NDPH with either migrainous or tension-type features.¹⁶

The sudden onset of NDPH is a red flag and, like other red flags, always warrants further work-up. Magnetic resonance imaging with gadolinium is preferred to computed tomography. Magnetic resonance venography or lumbar puncture may also be considered.^15,16

Review comorbidities, rule out secondary causes
Patients who suffer from frequent headaches have a high prevalence of depression, anxiety,^17,18 sleep disorders,¹⁹ obesity,²⁰ irritable bowel disease, fibromyalgia,²¹ temporomandibular joint disorder,²² and chronic fatigue syndrome. Treatment of these disorders may increase the efficacy of headache treatment. Conversely, overuse of headache medications can make comorbidities harder to treat.

Treating chronic headache: Which drugs are best?
A multimodal approach combining pharmacologic and nonpharmacologic therapies is usually required for patients with chronic headache. The particular therapy and prognosis depend on the type of headache a patient has and the presence of comorbidities (TABLE 3).^6,7,23,24

TABLE 3
Consider comorbidities in prophylaxis selection^6,7,23,24

Comorbidity	What to choose	What to avoid
Depression	Venlafaxine	—
Bipolar disorder	Valproic acid	Venlafaxine, amitriptyline, mirtazapine
Insomnia (CM)	Amitriptyline	—
Insomnia (CTTH)	Mirtazapine	—
Obesity	Topiramate	Amitriptyline
Hypertension	Metoprolol, propranolol	—
Cardiac conduction abnormalities	—	Amitriptyline
Fibromyalgia	Amitriptyline, tizanidine	—
CM, chronic migraine; CTTH, chronic tension-type headache.

Choice for migraine prophylaxis? Here’s what the evidence tells us

Although most studies of the benefits of prophylaxis have involved patients with episodic or frequent migraine rather than CM, extrapolation of the findings to patients with CM is not unreasonable. And, although dozens of pharmacologic and complementary therapies have been studied for migraine prophylaxis and certain classes of drugs have been identified as effective, there are very few head-to-head trials comparing agents.

The American Academy of Neurology and the American Headache Society published a summary of the evidence in 2012.²³ Key findings: The types of medication with the most evidence to support their use as first-line agents for CM are antidepressants, anticonvulsants, and beta-blockers.

Antidepressants, especially tricyclics (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have been found to be effective. Chief among them are amitriptyline, a TCA, which is inexpensive and may be beneficial for patients with coexisting insomnia due to its sedating effect, and venlafaxine, an SNRI, which may help treat comorbid depression.²³ Amitriptyline is associated with weight gain and can prolong the QT interval at higher doses. There is insufficient or conflicting evidence of the value of selective serotonin reuptake inhibitors for migraine prophylaxis.

Anticonvulsants that have been studied most extensively for migraine are topiramate and sodium valproate. Both have level A ratings for established efficacy.²³ Topiramate has also been shown to be noninferior to amitriptyline in reducing migraine frequency and is associated with weight loss, rather than weight gain.²⁵ (Topiramate and valproic acid should be avoided in women who are hoping to become pregnant.) Gabapentin has conflicting evidence and is not recommended for migraine.²³

Beta-blockers that appear to be most effective as prophylaxis for CM are propranolol, metoprolol, and timolol.^23,26 Any of these would be the obvious choice for a patient with comorbid hypertension. Beta-blockers can take several months to have an effect on migraines, however. Their use as CM prophylaxis may be limited by their adverse effect profile, which includes erectile dysfunction, bradycardia, and hypotension, although the lower dosage needed for migraine prophylaxis may be a mitigating factor. Calcium channel blockers are commonly prescribed for migraine, but there is little evidence to support their use for CM.²³

Other medications that are likely effective for migraine prophylaxis include naproxen²⁴ and tizanidine²⁷ (a muscle relaxant). Complementary and alternative treatments that appear to be effective include magnesium, feverfew, butterbur, and riboflavin, although the benefits may not be noticeable for several months.²⁴

Botulinum toxin A is the only medication approved by the US Food and Drug Administration for prevention of CM. It is generally considered to be a second-line agent because of its high cost and the need for training and expertise to administer it. Botulinum toxin A is not effective as prophylaxis for EM.²⁸

 

Treating other headache syndromes

Chronic tension-type headache. Treatment of CTTH applies similar principles to those of CM, and amitriptyline and venlafaxine—as well as mirtazapine, a sedating SNRI—have evidence to support their use for this type of headache.²⁹ Overall, however, CTTH therapies have not been studied as extensively as those for migraine. There is conflicting evidence of the value of anticonvulsants for prophylaxis of CTTH, and botulinum toxin A has been shown to be no better than placebo.³⁰

Medication overuse headache. Prophylactic medications are not effective in patients who are overusing acute headache medications, and patients with MOH should be instructed to stop the offending drugs. Withdrawal of triptans, simple analgesics, and ergots—either cold turkey or with a slow wean over 4 to 6 weeks—is fairly safe and can be done in an outpatient setting. Concomitant use of prednisone, long-acting NSAIDs, or botulinum toxin A can be used as “bridge therapy” to relieve acute pain. Start the patient on a prophylactic medication based on the best estimate of his or her baseline headache and comorbidities.^31,32 For patients who have been overusing opiates or barbiturates, most experts recommend inpatient treatment to manage withdrawal symptoms and prevent complications.¹⁰

Most patients with MOH will improve with drug withdrawal, but some will be left with the same disabling headaches that caused them to overuse medication in the first place. For such patients, weekly office visits during the withdrawal period may be helpful. After completion of the bridge therapy, they will likely require abortive headache treatment, but its use must be limited to no more than twice a week. Referral to a specialty headache clinic may be appropriate for such patients.

Hemicrania continua. The treatment for HC is indomethacin. A 2- to 5-day course typically results in complete recovery.

New daily persistent headache. For patients with NDPH, the first step is ruling out secondary causes. Once that has been done, most experts recommend trying to characterize the headache as having features of either migraine or tension and treating accordingly with preventive therapy. If acute headache medication is still needed, limit the quantity you prescribe and stress the importance of taking it no more than twice a week.

CASE Mr. K receives a diagnosis of MOH and probable CM. You explain the way MOH develops and how his medication use has contributed to the escalation of his headaches, and ask him to stop all the headache medications he has been using and to keep a headache journal. You prescribe meloxicam as a short-term bridge therapy and low-dose venlafaxine, which is increased to 150 mg/d over the next 4 weeks; recommend riboflavin 400 mg/d; and refer Mr. K to a neurologist for botulinum toxin A.

You ask him to return in 4 weeks and explain that because he has successfully stopped the overuse of acute headache medications, he can begin taking them again—provided he limits their use to no more than twice a week.

Nonpharmacologic measures can help, too
Lifestyle modification can play an important role in the treatment of chronic daily headache. Advise patients of the importance of proper sleep hygiene, regular exercise, stress reduction, and a healthy diet, as well as avoiding known triggers and minimizing intake of caffeine. Tell patients that biofeedback, cognitive behavioral therapy, and physical therapy may play a role in conjunction with pharmacotherapy, especially for CTTH,^26,29,33 but that hypnosis, acupuncture, chiropractic manipulation, transcutaneous electrical nerve stimulation, and hyperbaric oxygen have too little evidence to recommend for or against their use.^26,34

In discussing treatment for chronic headache and the goals of therapy with a patient with chronic headache, it is important to be frank. Explain that while a complete cure is not always possible, a decrease in both the frequency and severity of headaches and an improvement in the quality of life and the patient’s ability to function are realistic goals.

CASE At the 3-month follow-up, Mr. K reports that his headaches are down to less than twice a week, and that he is undergoing cognitive behavioral therapy for depression. For acute headache pain, he takes sumatriptan 100 mg with ibuprofen 800 mg, and is careful not to do so more than twice a week.

CASE Eric K, age 25, is in your office, seeking help for chronic headache—which he’s had nearly every day for the past 9 months. He says that the headaches vary in quality and intensity. Sometimes the pain is in the right temporal area; has a throbbing, pulsating quality; and is accompanied by nausea and photophobia. These headaches are incapacitating, with an intensity of 10 on a scale of one to 10. When they occur, the patient reports, all he can do is take migraine medication and lie down in a darkened room for several hours, until the pain goes away. He cannot identify any triggers.

He also gets headaches that are not incapacitating, but occur almost daily, the patient says, describing a dull bilateral pressure that usually begins in the afternoon and worsens until he takes headache medication. He denies any fever, chills, weight loss, visual changes, or tinnitus. His medical history is significant only for obesity, but a system review is positive for depression and insomnia. Physical examination reveals normal vital signs; normal head, eyes, ears, nose, and throat (HEENT); and normal fundoscopic and neurological exams.

Patients like Mr. K can be challenging for primary care physicians, but referral to a neurologist is indicated only in the most intractable cases. For the vast majority of patients with frequent headaches, family physicians can perform the diagnostic work-up and oversee treatment. This review will help with both.

What kind of headache?

While most headaches are sporadic in nature, the prevalence of “chronic daily headache” ranges from 3% to 5% worldwide.^1-3

Chronic daily headache is not a diagnosis, however, nor is it an indication that a patient has a headache every day. According to the International Classification of Headache Disorders (ICHD-II), chronic daily headache encompasses several distinct primary headache disorders that have a frequency of ≥15 times per month for at least 3 months. These disorders are also classified by duration, as long (>4 hours) or short.⁴

The text and tables that follow focus on the diagnosis and treatment of the 4 primary headache disorders of long duration—chronic migraine (CM), chronic tension-type headache (CTTH), hemicrania continua (HC), and new daily persistent headache (NDPH) (TABLE 1).^4,5 Although medication overuse headache (MOH) is not a primary headache, it is included in this review because it often contributes to and complicates treatment of primary headache disorders. What’s more, most chronic daily headache syndromes are inextricably linked to medication overuse.^6,7

Which individuals are at risk?
Risk factors for chronic headache include female sex, older age, obesity, heavy caffeine consumption, tobacco use, low educational level, overuse of abortive headache medications, and a history of head and neck trauma.⁸ Episodic migraine (EM)—that is, migraines that occur ≤14 times a month—is also a risk factor for chronic headache.

ICHD-II classifies EM as a progressive disease that transforms to CM at a rate of 3% per year.⁹ Transformation of EM to CM has been found to occur after as few as 5 days of barbiturates or 8 days of opiates per month.¹⁰

Patients with EM should be warned about the potential for migraines to become chronic and have their acute headache medications replaced with a prophylactic drug if the frequency approaches 2 per week.

TABLE 1
Diagnosing and treating chronic headache^4,5

Type of headache	ICHD-II diagnostic criteria	First-line treatment
Chronic migraine	Headache fulfilling criteria for migraine without aura ≥8 days/month Headache occurs ≥15 d/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: TCAs SNRIs Anticonvulsants Beta-blockers Botulinum toxin A Limit acute medication; avoid triggers; initiate lifestyle modification
Chronic tension-type headache	Headache fulfilling criteria for tension-type headache Occurs ≥15 days/mo for ≥3 mo No overuse of medication No secondary headache	Prophylactic therapy: Amitriptyline Venlafaxine Mirtazapine Limit acute medication; avoid triggers; initiate lifestyle modification
Medication overuse headache	Headache occurs ≥15 days/mo Single abortive medication use ≥10 days/mo or combination therapy ≥15 days/mo for ≥3 mo Headache developed or worsened during medication overuse	Discontinue overused acute meds; provide headache education; bridge with NSAIDs, prednisone, or botulinum toxin A; begin prophylactic medication
Hemicrania continua	Headache for ≥3 mo All of the following characteristics: Unilateral pain without side shift Daily and continuous, without pain-free periods Moderate intensity, but with exacerbations of severe pain At least one of the following on the same side as the pain: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhea Ptosis and/or miosis Complete response to therapeutic doses of indomethacin	Indomethacin
New daily persistent headache	Headache for ≥3 mo Characteristics of tension-type headache (but migrainous features are common) Unrelenting from onset or within 3 days of onset No medication overuse	Rule out secondary causes; treat according to migrainous or tension features of headache
ICHD-II, International Classification of Headache Disorders; NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants.

 

Pinpointing the type of headache

An accurate diagnosis requires a thorough headache history and a HEENT and neurological examination. The history should include questions about the characteristics of the headache, including the location, intensity, frequency, timing, associated symptoms, previous headache diagnoses, and triggers, and address comorbidities, medication use, caffeine intake, and family history.⁸ In the absence of red flags—age >50 years, history of headache or systemic illness, sudden onset, or papilledema, among other findings that may indicate more serious conditions (TABLE 2)⁷—advanced imaging and further work-up are not needed.

TABLE 2
Beyond headache: Red flags warrant additional testing⁷

Red flag	Condition(s) to rule out
Age of onset >50 y	Giant cell arteritis, mass lesion, stroke
No prior history of headache OR change in characteristic from prior headaches	Cancer, aneurysm, stroke, cerebral sinus thrombosis, infection
“Thunderclap” headache	Ruptured aneurysm
Signs or symptoms of systemic illness (eg, fever, chills, weight loss)	Meningitis, encephalitis, cancer
History of systemic illness, such as cancer, autoimmune disease, or HIV	Brain metastasis, mass lesion, autoimmune meningitis, thrombosis
Headache brought on by change in head position or Valsalva maneuver	Spontaneous CSF leak or Chiari malformation
Occipital location of headache (in children)	Brain tumor
Neurological symptoms	Mass lesion, encephalitis
Papilledema	Idiopathic intracranial hypertension, cerebral sinus thrombosis
CSF, cerebrospinal fluid; HIV, human immunodeficiency virus.

Migraine or tension headache?
Chronic migraine. To be classified as CM, the headache must have occurred ≥15 days a month for 3 months or more and have features of migraine, such as unilateral location, pulsating quality, and moderate to severe intensity. Migraines are aggravated by physical activity and associated with nausea and/or vomiting, photophobia, and phonophobia, and may or may not be preceded by aura. Common triggers include stress, menstruation, alcohol, skipped meals, dehydration, and chocolate. Migraines typically respond to ergots and triptans.^4,5

Partial treatment. Patients with CM often take medication early in the course of a headache. This sometimes results in a partially treated migraine that develops into a headache with tension-type features, such as a bilateral location, a pressing quality, and mild-to-moderate intensity, as well as a possible transformation to MOH. This is most likely to occur in patients who have migraines without an aura.

To avoid partial treatment, medications for acute migraine should be taken within 30 minutes of an attack, in a dose that’s sufficient to relieve the pain within 2 hours, with no need for a second dose—a protocol known as “one and done.” Efficacy of a triptan can be improved by adding a nonsteroidal anti-inflammatory drug (NSAID).¹⁰

A definitive diagnosis of CM is only possible in the absence of medication overuse.^4,5 A patient who is overusing abortive headache medication and whose headache meets the criteria for CM should be given a diagnosis of probable CM instead.

Chronic tension-type headache. In addition to traits common to tension headaches, CTTH may be associated with mild nausea, photophobia, or phonophobia (but typically only one such feature at a time). There may also be tenderness to palpation of the pericranial muscles. Unlike migraine, CTTH is not affected by physical activity.

Here, too, overuse of headache medication is often a factor and should be stopped, if possible, before a definitive diagnosis of CTTH can be made.

Headache with overlapping features. It is possible for a patient to have chronic headache with features of both migraine and tension headache. Advise patients whose headaches have varying characteristics to keep a headache journal to determine which features are more prominent. Patients with smart phones can download a free app, such as iHeadache or My Headache Log Pro, to be used for this purpose.^11,12

When to suspect medication overuse headache
MOH is sometimes referred to as a rebound headache or drug-induced headache. Headaches associated with medication overuse have variable intensity. Patients with MOH often awaken from sleep with a headache, and neck pain is highly prevalent.¹⁰

Quantifying overuse. According to ICHD-II, overuse is defined as using a single abortive headache medication ≥10 times a month or using 2 or more such drugs ≥15 times a month.⁵

Triptans have the potential to cause MOH more quickly and in lower doses compared with other acute headache medications. However, analgesics—especially combination products such as butalbital/acetaminophen/caffeine (Fioricet)—are most frequently associated with the development of MOH.^13,14 NSAIDs have less potential to cause MOH and are sometimes given as bridge therapy for patients who are discontinuing their acute headache medication.

 

Less common primary headache disorders
Hemicrania continua, a rare cause of chronic daily headache, is unilateral, without shifting sides, and the intensity is moderate to severe—and unrelenting. HC is associated with autonomic features such as lacrimation, ptosis, and nasal congestion.

New daily persistent headache is characterized by an out-of-the-blue onset of a headache that becomes unremitting soon after it develops. To receive a diagnosis of NDPH, the patient must have a headache that started suddenly and has continued for 3 months or more.

Most patients diagnosed with NDPH are able to recall, to the day, when the headache started. More than 50% report a precipitating event, such as a viral illness, a stressful experience, or surgery.¹⁵ ICHD-II defines NDPH as having the characteristics of a tension headache. Notably, however, migrainous features are also common, and neurologists often diagnose NDPH with either migrainous or tension-type features.¹⁶

The sudden onset of NDPH is a red flag and, like other red flags, always warrants further work-up. Magnetic resonance imaging with gadolinium is preferred to computed tomography. Magnetic resonance venography or lumbar puncture may also be considered.^15,16

Review comorbidities, rule out secondary causes
Patients who suffer from frequent headaches have a high prevalence of depression, anxiety,^17,18 sleep disorders,¹⁹ obesity,²⁰ irritable bowel disease, fibromyalgia,²¹ temporomandibular joint disorder,²² and chronic fatigue syndrome. Treatment of these disorders may increase the efficacy of headache treatment. Conversely, overuse of headache medications can make comorbidities harder to treat.

Treating chronic headache: Which drugs are best?
A multimodal approach combining pharmacologic and nonpharmacologic therapies is usually required for patients with chronic headache. The particular therapy and prognosis depend on the type of headache a patient has and the presence of comorbidities (TABLE 3).^6,7,23,24

TABLE 3
Consider comorbidities in prophylaxis selection^6,7,23,24

Comorbidity	What to choose	What to avoid
Depression	Venlafaxine	—
Bipolar disorder	Valproic acid	Venlafaxine, amitriptyline, mirtazapine
Insomnia (CM)	Amitriptyline	—
Insomnia (CTTH)	Mirtazapine	—
Obesity	Topiramate	Amitriptyline
Hypertension	Metoprolol, propranolol	—
Cardiac conduction abnormalities	—	Amitriptyline
Fibromyalgia	Amitriptyline, tizanidine	—
CM, chronic migraine; CTTH, chronic tension-type headache.

Choice for migraine prophylaxis? Here’s what the evidence tells us

Although most studies of the benefits of prophylaxis have involved patients with episodic or frequent migraine rather than CM, extrapolation of the findings to patients with CM is not unreasonable. And, although dozens of pharmacologic and complementary therapies have been studied for migraine prophylaxis and certain classes of drugs have been identified as effective, there are very few head-to-head trials comparing agents.

The American Academy of Neurology and the American Headache Society published a summary of the evidence in 2012.²³ Key findings: The types of medication with the most evidence to support their use as first-line agents for CM are antidepressants, anticonvulsants, and beta-blockers.

Antidepressants, especially tricyclics (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have been found to be effective. Chief among them are amitriptyline, a TCA, which is inexpensive and may be beneficial for patients with coexisting insomnia due to its sedating effect, and venlafaxine, an SNRI, which may help treat comorbid depression.²³ Amitriptyline is associated with weight gain and can prolong the QT interval at higher doses. There is insufficient or conflicting evidence of the value of selective serotonin reuptake inhibitors for migraine prophylaxis.

Anticonvulsants that have been studied most extensively for migraine are topiramate and sodium valproate. Both have level A ratings for established efficacy.²³ Topiramate has also been shown to be noninferior to amitriptyline in reducing migraine frequency and is associated with weight loss, rather than weight gain.²⁵ (Topiramate and valproic acid should be avoided in women who are hoping to become pregnant.) Gabapentin has conflicting evidence and is not recommended for migraine.²³

Beta-blockers that appear to be most effective as prophylaxis for CM are propranolol, metoprolol, and timolol.^23,26 Any of these would be the obvious choice for a patient with comorbid hypertension. Beta-blockers can take several months to have an effect on migraines, however. Their use as CM prophylaxis may be limited by their adverse effect profile, which includes erectile dysfunction, bradycardia, and hypotension, although the lower dosage needed for migraine prophylaxis may be a mitigating factor. Calcium channel blockers are commonly prescribed for migraine, but there is little evidence to support their use for CM.²³

Other medications that are likely effective for migraine prophylaxis include naproxen²⁴ and tizanidine²⁷ (a muscle relaxant). Complementary and alternative treatments that appear to be effective include magnesium, feverfew, butterbur, and riboflavin, although the benefits may not be noticeable for several months.²⁴

Botulinum toxin A is the only medication approved by the US Food and Drug Administration for prevention of CM. It is generally considered to be a second-line agent because of its high cost and the need for training and expertise to administer it. Botulinum toxin A is not effective as prophylaxis for EM.²⁸

 

Treating other headache syndromes

Chronic tension-type headache. Treatment of CTTH applies similar principles to those of CM, and amitriptyline and venlafaxine—as well as mirtazapine, a sedating SNRI—have evidence to support their use for this type of headache.²⁹ Overall, however, CTTH therapies have not been studied as extensively as those for migraine. There is conflicting evidence of the value of anticonvulsants for prophylaxis of CTTH, and botulinum toxin A has been shown to be no better than placebo.³⁰

Medication overuse headache. Prophylactic medications are not effective in patients who are overusing acute headache medications, and patients with MOH should be instructed to stop the offending drugs. Withdrawal of triptans, simple analgesics, and ergots—either cold turkey or with a slow wean over 4 to 6 weeks—is fairly safe and can be done in an outpatient setting. Concomitant use of prednisone, long-acting NSAIDs, or botulinum toxin A can be used as “bridge therapy” to relieve acute pain. Start the patient on a prophylactic medication based on the best estimate of his or her baseline headache and comorbidities.^31,32 For patients who have been overusing opiates or barbiturates, most experts recommend inpatient treatment to manage withdrawal symptoms and prevent complications.¹⁰

Most patients with MOH will improve with drug withdrawal, but some will be left with the same disabling headaches that caused them to overuse medication in the first place. For such patients, weekly office visits during the withdrawal period may be helpful. After completion of the bridge therapy, they will likely require abortive headache treatment, but its use must be limited to no more than twice a week. Referral to a specialty headache clinic may be appropriate for such patients.

Hemicrania continua. The treatment for HC is indomethacin. A 2- to 5-day course typically results in complete recovery.

New daily persistent headache. For patients with NDPH, the first step is ruling out secondary causes. Once that has been done, most experts recommend trying to characterize the headache as having features of either migraine or tension and treating accordingly with preventive therapy. If acute headache medication is still needed, limit the quantity you prescribe and stress the importance of taking it no more than twice a week.

CASE Mr. K receives a diagnosis of MOH and probable CM. You explain the way MOH develops and how his medication use has contributed to the escalation of his headaches, and ask him to stop all the headache medications he has been using and to keep a headache journal. You prescribe meloxicam as a short-term bridge therapy and low-dose venlafaxine, which is increased to 150 mg/d over the next 4 weeks; recommend riboflavin 400 mg/d; and refer Mr. K to a neurologist for botulinum toxin A.

You ask him to return in 4 weeks and explain that because he has successfully stopped the overuse of acute headache medications, he can begin taking them again—provided he limits their use to no more than twice a week.

Nonpharmacologic measures can help, too
Lifestyle modification can play an important role in the treatment of chronic daily headache. Advise patients of the importance of proper sleep hygiene, regular exercise, stress reduction, and a healthy diet, as well as avoiding known triggers and minimizing intake of caffeine. Tell patients that biofeedback, cognitive behavioral therapy, and physical therapy may play a role in conjunction with pharmacotherapy, especially for CTTH,^26,29,33 but that hypnosis, acupuncture, chiropractic manipulation, transcutaneous electrical nerve stimulation, and hyperbaric oxygen have too little evidence to recommend for or against their use.^26,34

In discussing treatment for chronic headache and the goals of therapy with a patient with chronic headache, it is important to be frank. Explain that while a complete cure is not always possible, a decrease in both the frequency and severity of headaches and an improvement in the quality of life and the patient’s ability to function are realistic goals.

CASE At the 3-month follow-up, Mr. K reports that his headaches are down to less than twice a week, and that he is undergoing cognitive behavioral therapy for depression. For acute headache pain, he takes sumatriptan 100 mg with ibuprofen 800 mg, and is careful not to do so more than twice a week.