1058
13. 14.
15.
16.
17.
18.
19.
behalf of the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials. Assessing disease activity in rheumatoid arthritis: the EULAR handbook of standard methods. Zurich: European League Against Rheumatism; 1993. Fries JF, Spitz PW, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980;23:137–45. Naredo E, Collado P, Cruz A, Palop MJ, Cabero F, Richi P, et al. Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression. Arthritis Rheum 2007;57:116–24. Aletaha D, Nell VP, Stamm T, Uffmann M, Pflugbeil S, Machold K, et al. Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score. Arthritis Res Ther 2005;7:R796–806. Witt M, Mueller F, Nigg A, Reindl C, Leipe J, Proft F, et al. Relevance of grade 1 gray-scale ultrasound findings in wrists and small joints to the assessment of subclinical synovitis in rheumatoid arthritis. Arthritis Rheum 2013;65:1694–701. Yoshimi R, Hama M, Takase K, Ihata A, Kishimoto D, Terauchi K, et al. Ultrasonography is a potent tool for the prediction of progressive joint destruction during clinical remission of rheumatoid arthritis. Mod Rheumatol 2013;23:456–65. Van der Heijde DM, van ’t Hof MA, van Riel PL, Theunisse LM, Lubberts EW, van Leeuwen MA, et al. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis 1990;49:916–20. Dale J, Stirling A, McInnes IB, Porter D. Targeting ultrasound remission in early rheumatoid arthritis—results of the Taser study [abstract]. Arthritis Rheum 2013;65 Suppl:S338–9.
DOI 10.1002/art.38333
Lupus headache may not exist: comment on the article by Hanly et al To the Editor: We read with interest the recent article by Hanly and colleagues (1) in which they reported the frequency and characteristics of headache in 1,736 patients with systemic lupus erythematosus (SLE) over 10 years and the lack of association with global disease activity or autoantibodies. Several years ago, we observed no association of migraine with SLE in a controlled study (2). Our subsequent meta-analysis data suggested that the occurrence of headache in adult patients with SLE does not itself require further investigation, and that headache in those patients should be classified according to International Headache Society criteria and managed as primary headache if there is no specific indication for a role of SLE in the patient (3). This was confirmed in our prospective controlled study (not cited by Hanly et al), by examining patients with SLE versus healthy controls and comparing with the central nervous system–specific autoimmune disorder, multiple sclerosis (4). In an editorial accompanying the Hanly study, Dr. Lockshin addressed and clearly answered the issue of whether the headache criterion should be removed from the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) (5). According to Dr. Lockshin, “It is time for this criterion to be discarded . . . from the SLEDAI-2K”; we fully agree (6). On the other hand, Hanly et al report that 26 patients had “lupus headache” (1). Although there is no clear evidence
LETTERS
of such a headache type, this term refers to a severe, intractable headache with migrainous features that does not respond to treatment with narcotics. Lupus headache was reported both at enrollment and at followup in patients who were evaluated at only 15 of the 30 sites participating in the study (1). This inconsistency raises reasonable doubts for this particular diagnosis. Have these patients ever had neurologic consultation by a headache expert? For example, medication overuse is the most common cause of intractable headache worldwide and needs specific management, excluding narcotics, which are contraindicated in this case (7). Intractable headache also refers to continua, or paroxysmal hemicranias, or hypnic headaches that impressively respond to indomethacin (8). Comorbidity of migraine with depression and anxiety disorders is another principal reason for a poor response to symptomatic treatment and migraine progression from episodic to chronic, intractable migraine (9). Thus, we believe that physicians who provide care for patients with SLE should be assisted by headache experts to successfully diagnose and treat difficult headaches. Consensus of the headache and SLE experts may be required to review the available data and provide diagnostic and therapeutic guidelines for headache in patients with SLE. Dimos D. Mitsikostas, MD Athens Naval Hospital Athens, Greece Christina Katsiari, MD Larissa University Hospital Thessaly University Medical School Thessaly, Greece Petros P. Sfikakis, MD Laikon Hospital Athens University Medical School Athens, Greece 1. Hanly JG, Urowitz MB, O’Keeffe AG, Gordon C, Bae SC, Sanchez-Guerrero J, et al. Headache in systemic lupus erythematosus: results from a prospective, international inception cohort study. Arthritis Rheum 2013;65:2887–97. 2. Sfikakis PP, Mitsikostas DD, Manoussakis MN, Foukaneli D, Moutsopoulos HM. Headache in systemic lupus erythematosus: a controlled study. Br J Rheumatol 1998;37:300–3. 3. Mitsikostas DD, Sfikakis PP, Goadsby PJ. A meta-analysis for headache in systemic lupus erythematosus: the evidence and the myth. Brain 2004;127:1200–9. 4. Katsiari CG, Vikelis M, Paraskevopoulou ES, Sfikakis PP, Mitsikostas DD. Headache in systemic lupus erythematosus vs multiple sclerosis: a prospective comparative study. Headache 2011;51:1398–407. 5. Lockshin MD. Splitting headache (off) [editorial]. Arthritis Rheum 2013;65:2759–61. 6. Mitsikostas DD. Is migraine really comorbid with systemic lupus erythematosus? Cephalalgia 2004;24:1013–5. 7. Evers S, Jensen R; European Federation of Neurological Societies. Treatment of medication overuse headache: guideline of the EFNS headache panel. Eur J Neurol 2011;18:1115–21. 8. Dodick DW. Indomethacin-responsive headache syndromes. Curr Pain Headache Rep 2004;8:19–26. 9. Deligianni CI, Vikelis M, Mitsikostas DD. Depression in headaches: chronification. Curr Opin Neurol 2012;25:277–83.
13. 14.
15.
16.
17.
18.
19.
behalf of the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials. Assessing disease activity in rheumatoid arthritis: the EULAR handbook of standard methods. Zurich: European League Against Rheumatism; 1993. Fries JF, Spitz PW, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980;23:137–45. Naredo E, Collado P, Cruz A, Palop MJ, Cabero F, Richi P, et al. Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression. Arthritis Rheum 2007;57:116–24. Aletaha D, Nell VP, Stamm T, Uffmann M, Pflugbeil S, Machold K, et al. Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score. Arthritis Res Ther 2005;7:R796–806. Witt M, Mueller F, Nigg A, Reindl C, Leipe J, Proft F, et al. Relevance of grade 1 gray-scale ultrasound findings in wrists and small joints to the assessment of subclinical synovitis in rheumatoid arthritis. Arthritis Rheum 2013;65:1694–701. Yoshimi R, Hama M, Takase K, Ihata A, Kishimoto D, Terauchi K, et al. Ultrasonography is a potent tool for the prediction of progressive joint destruction during clinical remission of rheumatoid arthritis. Mod Rheumatol 2013;23:456–65. Van der Heijde DM, van ’t Hof MA, van Riel PL, Theunisse LM, Lubberts EW, van Leeuwen MA, et al. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis 1990;49:916–20. Dale J, Stirling A, McInnes IB, Porter D. Targeting ultrasound remission in early rheumatoid arthritis—results of the Taser study [abstract]. Arthritis Rheum 2013;65 Suppl:S338–9.
DOI 10.1002/art.38333
Lupus headache may not exist: comment on the article by Hanly et al To the Editor: We read with interest the recent article by Hanly and colleagues (1) in which they reported the frequency and characteristics of headache in 1,736 patients with systemic lupus erythematosus (SLE) over 10 years and the lack of association with global disease activity or autoantibodies. Several years ago, we observed no association of migraine with SLE in a controlled study (2). Our subsequent meta-analysis data suggested that the occurrence of headache in adult patients with SLE does not itself require further investigation, and that headache in those patients should be classified according to International Headache Society criteria and managed as primary headache if there is no specific indication for a role of SLE in the patient (3). This was confirmed in our prospective controlled study (not cited by Hanly et al), by examining patients with SLE versus healthy controls and comparing with the central nervous system–specific autoimmune disorder, multiple sclerosis (4). In an editorial accompanying the Hanly study, Dr. Lockshin addressed and clearly answered the issue of whether the headache criterion should be removed from the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) (5). According to Dr. Lockshin, “It is time for this criterion to be discarded . . . from the SLEDAI-2K”; we fully agree (6). On the other hand, Hanly et al report that 26 patients had “lupus headache” (1). Although there is no clear evidence
LETTERS
of such a headache type, this term refers to a severe, intractable headache with migrainous features that does not respond to treatment with narcotics. Lupus headache was reported both at enrollment and at followup in patients who were evaluated at only 15 of the 30 sites participating in the study (1). This inconsistency raises reasonable doubts for this particular diagnosis. Have these patients ever had neurologic consultation by a headache expert? For example, medication overuse is the most common cause of intractable headache worldwide and needs specific management, excluding narcotics, which are contraindicated in this case (7). Intractable headache also refers to continua, or paroxysmal hemicranias, or hypnic headaches that impressively respond to indomethacin (8). Comorbidity of migraine with depression and anxiety disorders is another principal reason for a poor response to symptomatic treatment and migraine progression from episodic to chronic, intractable migraine (9). Thus, we believe that physicians who provide care for patients with SLE should be assisted by headache experts to successfully diagnose and treat difficult headaches. Consensus of the headache and SLE experts may be required to review the available data and provide diagnostic and therapeutic guidelines for headache in patients with SLE. Dimos D. Mitsikostas, MD Athens Naval Hospital Athens, Greece Christina Katsiari, MD Larissa University Hospital Thessaly University Medical School Thessaly, Greece Petros P. Sfikakis, MD Laikon Hospital Athens University Medical School Athens, Greece 1. Hanly JG, Urowitz MB, O’Keeffe AG, Gordon C, Bae SC, Sanchez-Guerrero J, et al. Headache in systemic lupus erythematosus: results from a prospective, international inception cohort study. Arthritis Rheum 2013;65:2887–97. 2. Sfikakis PP, Mitsikostas DD, Manoussakis MN, Foukaneli D, Moutsopoulos HM. Headache in systemic lupus erythematosus: a controlled study. Br J Rheumatol 1998;37:300–3. 3. Mitsikostas DD, Sfikakis PP, Goadsby PJ. A meta-analysis for headache in systemic lupus erythematosus: the evidence and the myth. Brain 2004;127:1200–9. 4. Katsiari CG, Vikelis M, Paraskevopoulou ES, Sfikakis PP, Mitsikostas DD. Headache in systemic lupus erythematosus vs multiple sclerosis: a prospective comparative study. Headache 2011;51:1398–407. 5. Lockshin MD. Splitting headache (off) [editorial]. Arthritis Rheum 2013;65:2759–61. 6. Mitsikostas DD. Is migraine really comorbid with systemic lupus erythematosus? Cephalalgia 2004;24:1013–5. 7. Evers S, Jensen R; European Federation of Neurological Societies. Treatment of medication overuse headache: guideline of the EFNS headache panel. Eur J Neurol 2011;18:1115–21. 8. Dodick DW. Indomethacin-responsive headache syndromes. Curr Pain Headache Rep 2004;8:19–26. 9. Deligianni CI, Vikelis M, Mitsikostas DD. Depression in headaches: chronification. Curr Opin Neurol 2012;25:277–83.
