[The prevalence of headache in a population of patients with coeliac disease]

INTRODUCTION

Headache is the commonest clinical symptom during childhood and adolescence, from a neurologist s point of view. The pathophysiology of migraine and tension headache involve personality and biochemical factors, such as serotonin, which are also common in coeliac disease.

OBJECTIVE

To establish the prevalence of headache in children and adolescents with coeliac disease, and any possible relation between these conditions.

PATIENTS AND METHODS

We made a randomized selection of 86 patients with coeliac disease. All were on gluten-free diets and had no current gastroenterological symptoms. They had direct interviews and full physical and neurological examinations. The diagnosis of headache was based on criteria of the International Headache Society in 1988.

RESULTS

The average age was 12.71 +/- 4.5 years (range 5-24). Headache occurred in 34 (39.5%) of the 86 patients studied. In 18 cases (20.9%) headache was of tension type and in 16 (18.6%) of migraine type. Of the latter, 10 cases had auras and 6 did not. There was no significant sex difference.

CONCLUSIONS

An increased prevalence of both migraine and tension headaches was observed in the coeliac patients studied as compared with data published in the literature. In the former patients there was also a lower frequency in histories of migraine in first degree family members. This data is probably related to the personality of the patient or to his family or social circumstances in the case of tension headaches. In the case of migraine it may be due to biochemical factors such as a lowered plasma serotonin, seen both in coeliac disease and in migraine.

Recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity in migraine and tension-type headache

Brain stem interneuronal excitability can be assessed by recording the recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity. Abnormal endogenous pain control mechanisms due to disturbed brain stem interneuronal activity have been implicated in the pathogenesis of tension-type headaches. The blink reflex, exteroceptive suppression of temporalis muscle activity, and the recovery curve of both the R2 component of the blink reflex and the ES2 component of the exteroceptive suppression of the temporalis muscle activity were studied in 20 patients with migraine without aura, 32 patients with tension-type headache, and 20 normal controls. In our study, the blink reflex was elicited by stimulation of the supraorbital nerve; the exteroceptive suppression of the temporalis muscle activity was elicited by applying electrical shocks to the labial commissure, both on the lower and upper sides. The recovery cycle was established by delivering paired shocks at different interstimulus intervals. Comparisons were made between normal control subjects, patients with migraine without aura, and patients with tension-type headache. The latency of R1, R2, and R2', the amplitude and size of the R2 and R2' components of the blink reflex, the latency and duration of the ES1 and ES2 components, and the recovery curve of the ES2 component of the temporalis muscle activity did not differ between groups. However, the recovery curve of the R2 component of the blink reflex diminished in patients with tension-type headache compared with the other groups. Our findings indicate reduced excitability of the brain stem interneurons in patients with tension-type headache.

Interictal and postictal contingent negative variation in migraine without aura

Cortical hyperexcitability is thought to explain the more enhanced contingent negative variation (CNV) amplitudes and impaired CNV habituation that have been found during the interictal period in migraine without aura. These CNV characteristics have been shown to normalize to the level of healthy controls during an attack. This study aimed to replicate the interictal findings, and additionally examine whether migraineurs show reduced CNV amplitudes during the postattack period. Of 12 patients with migraine without aura and their sex- and age-matched healthy controls, CNV characteristics were recorded once in an interictal period, once during the postattack period within 30 hours after an attack that was treated with sumatriptan, and once after an attack that was treated with habitual nonvasoactive medication (counterbalanced). The present results did not confirm the enhanced CNV early and late wave amplitudes or impaired habituation, and cortical hyperexcitability that have previously been reported in the interictal period in patients with migraine without aura. During the postattack period, a decrease in CNV early and late amplitudes was found but only after sumatriptan use. This reduction in CNV amplitudes was most prominent over the frontal cortex and could reflect cortical hypoexcitability, possibly related to a suppression of central catecholaminergic activity by sumatriptan.

Self-reported photophobic symptoms in migraineurs and controls are reliable and predict diagnostic category accurately

OBJECTIVES

To assess the reliability of self-reported photophobia across different patient populations and to examine how visual stress thresholds and photophobic symptoms may be predictive of diagnosis.

BACKGROUND

Relatively little is known about interictal photophobia in migraine. In particular, the variability of photophobia across different patient groups has not previously been studied, and a pathophysiological hypothesis to account for the symptoms is not agreed upon.

METHODS AND RESULTS

Study 1 compared 99 self-selected Dutch patients and 101 headache-free controls using survey methods. Patients both with and without aura were significantly more likely to report symptoms, such as the wearing of sunglasses in normal daylight, consistent with interictal photophobia. Study 2 replicated these findings in a series of consecutive referrals to a headache clinic in the United States. Study 3 used a specially designed laboratory test to examine the threshold for visual stress in those patients who had participated in study 2. Visual stress thresholds were significantly lower in patients than in controls. A discriminant function analysis of data from both studies 2 and 3 showed that diagnostic category (migraine; control) could be predicted from photophobic symptoms and visual stress thresholds at a level significantly better than chance.

CONCLUSIONS

We suggest that interictal photophobia is common in migraine and similar across different patient populations. One pathophysiological hypothesis is that interictal photophobia is associated with cortical hypersensitivity to stimulation. The predictive validity of interictal photophobic symptoms suggests that clinical diagnosis may be aided by questioning the patient about light sensitivity in the period between attacks.

Comparison of visual and auditory evoked cortical potentials in migraine patients between attacks

OBJECTIVE

As both habituation of pattern reversal visual evoked potentials (PR-VEP) (Schoenen J, Wang W, Albert A, Delwaide PJ. Potentiation instead of habituation characterizes visual evoked potentials in migraine patients between attacks. Eur J Neurol 1995;2:115-122) and intensity dependence of auditory evoked cortical potentials (IDAP) (Wang W, Timsit-Berthier M, Schoenen J. Intensity dependence of auditory evoked potentials in migraine: an indication of cortical potentiation and low serotonergic neurotransmission? Neurology 1996;46:1404-1409) were found abnormal in migraine between attacks, we have searched for intraindividual correlations between both tests in 59 migraine patients (22 with aura [MA], 37 without aura [MO]) and in 23 healthy volunteers (HV).

METHODS

Amplitude change of the PR-VEP N1-P1 was measured between the 1st and 5th block of 50 sequential averagings during continuous stimulation at 3.1 Hz. IDAP was computed from N1-P2 amplitudes of 100 averagings during stimulations at 40, 50, 60 and 70 dB SL. Amplitude-stimulus intensity function (ASF) slopes and amplitude changes between 40 and 70 dB were calculated. MO and MA differed from HV in PR-VEP amplitude change (P=0.007) and IDAP slope (P = 0.0004).

RESULTS

There was no significant correlation between VEP amplitude changes and IDAP slopes, nor between the latter two and attack frequency or disease duration. A negative correlation was found between the amplitude of the first block of averaged responses and potentiation of VEP in all subject groups (P = 0.03) as well as between the amplitude of the auditory evoked potential, at 40 dB, and the percentage of amplitude increase between 40 and 70 dB in MO (P = 0.004) and MA (P = 0.007). ASF slopes and 40 dB amplitudes were significantly correlated only in the MA group (P = 0.002). These results confirm the interictal deficit of habituation in cortical processing of repetitive visual and auditory information in migraine. Since there is no intraindividual correlation between the cortical responses to these sensory modalities they are complementary tools for the study of migraine and may help to identify subgroups of patients with distinct pathophysiological mechanisms.

CONCLUSIONS

The strong negative correlation between the initial amplitude of evoked potentials and their amplitude increase during subsequent averaging confirms that the response potentiation in migraine is likely to be due to a reduced preactivation level of sensory cortices.

Influence of disease duration on visual evoked potentials in migraineurs

OBJECTIVE

To determine the possible influence of the duration of migraine on pattern-reversal visual evoked potentials.

METHODS

An investigation was conducted in 49 patients with migraine without aura according to the International Headache Society criteria. Twenty-two of these patients had had migraine for 2 years or less (group 1), and the other 27 patients had had the disease for 10 years or more (group 2). The control group consisted of 17 healthy subjects.

RESULTS

Comparison of the mean P100 latency and amplitude showed no significant difference among the groups. There was, however, a good negative correlation between age and latency (r = -0.59, P =.003) in group 1, but no such correlation was observed for group 2 or the control group.

CONCLUSIONS

It was concluded that the duration of migraine has no influence on pattern-reversal visual evoked potentials and that the pathogenesis of early- and late-onset migraine may be different.

Investigation of the cerebral response to flicker stimulation in patients with headache

Migraine affects 10% of the population, yet there is no proven diagnostic test. To date the most promising neurophysiological diagnostic technique has been the analysis of cerebral responses to photic stimulation or flicker (the "H" response). This test has proved to be sensitive in patients with "classic" migraine, but has not been re-evaluated since the introduction of the 1988 International Headache Society (IHS) classification system. In 33 migraineurs, we found that the "H" response was sensitive (86.4%) and specific (97.5%) in those with migraine defined according to IHS Committee as type 1.2.1 (typical aura) and type 1.1 (without aura), but not in basilar migraine (1.2.4).

Visual contrast gain control in migraine: measures of visual cortical excitability and inhibition

The present study examined the extent to which migraineurs demonstrate interictal visual cortical hyperexcitability as a result of poor inhibitory control in the visual system. We employed a well-established psychophysical measure of inhibition, visual contrast gain control. The task involved detecting a briefly presented target that was superimposed on a highly excitable high contrast masking pattern. The strength of inhibition was assessed by comparing target detection thresholds with and without the operation of gain controls. Migraineurs with and without aura (n=25, n=22, respectively) were compared with those with no history of migraine (n=25). Our results do not indicate a loss of inhibition in migraine; the strength of inhibitory feedback contrast gain controls was similar between migraineurs and controls. We did however, find a statistically greater masking effect in migraineurs compared with controls in the zero delay condition, suggesting cortical hyperexcitability in migraine. Possible mechanisms of cortical hyperexcitability are discussed in light of the results.

Migraine in childhood--are periodically occurring migraine attacks related to dynamic changes of cortical information processing?

Amplitudes and habituation of contingent negative variation (CNV) were analyzed in relation to spontaneously occurring migraine attacks in ten children suffering from migraine without aura. Recording took place during feedback training and instrumental conditioning of slow brain potentials. Both the amplitude of the early CNV component and its habituation deficit increase during the 5 days prior to a migraine attack, with maximum abnormalities the day before the ictal episode. Abrupt reduction of the amplitude and normalization of the CNV habituation were observed during the attack. This study provides evidence for neurophysiological periodicity in young migraineurs and emphasizes that the time relative to the migraine attacks must be considered in studies of juvenile migraine during the headache-free period.

Perfusion weighted imaging during migraine: spontaneous visual aura and headache

Using perfusion weighted imaging, we studied 28 spontaneous migraine episodes; 7 during visual aura (n = 6), 7 during the headache phase following visual aura (n = 3), and 14 cases of migraine without aura (n = 13). The data were analyzed using a region-of-interest-based approach. During aura, relative cerebral blood flow (rCBF) was significantly decreased (27% +/- 0.07) in occipital cortex contralateral to the affected hemifield. rCBV was decreased (15% +/- 0.12) and mean transit time increased (32% +/- 0.3), persisting up to 2.5 h into the headache phase. Other brain regions did not show significant perfusion changes. During migraine without aura, no significant hemodynamic changes were observed. In one patient who experienced both migraine with and without aura, perfusion deficits were observed only during migraine with aura. These findings suggest that decremental blood flow changes in occipital lobe are most characteristic of migraine with aura.

Coexistence of cervicogenic headache and migraine without aura (?)

It is well known that migraine with aura may coexist with various unilateral headaches, like cluster headache and chronic paroxysmal hemicrania. It may also coexist with cervicogenic headache. The diagnosis of migraine without aura ("common migraine") poses greater problems than the diagnosis of migraine with aura. Cervicogenic headache diagnosis also poses problems when these two headaches coexist, since they have symptoms in common. Therefore, the scientific demonstration of coexistence of migraine without aura and cervicogenic headache is bound to be a difficult task. In the present study, migraine without aura and cervicogenic headache seemed to coexist in 4 patients (3 F and 1 M, mean age 50). Attacks with migraine characteristics fulfilled the IHS and IASP migraine criteria. Out of a maximum of 13 migraine characteristics based on the IHS/IASP migraine criteria, such as unilaterality, aggravation on minor physical activity, etc., none of the patients presented less than 11, as opposed to a mean of < or = 4 of these criteria in the cervicogenic type attacks. A similar system, based on criteria such as: reduction of range of motion in the neck, mechanical precipitation of attacks, etc., was also developed for cervicogenic headache. The mean number of cervicogenic headache criteria was 4.3 (out of a total of 5) in the "cervicogenic part of the picture", as opposed to 1.5 (1.8 if laterality is considered, see text) in the "migraine part of the picture". Drug regimens and anaesthetic blocks also showed different results in the two different headaches in the same patient. All in all, this study seems to support a coexistence of the two headache types.

Migraine associated with panic attacks

Migraine headache and panic disorder are two conditions that have a number of underlying physiological and psychological abnormalities in common. The temporal relationship between the occurrence of migraine headache and panic attacks could be different, however. According to our observations, some migraine subjects develop panic attacks with the typical symptoms (palpitation, dyspnea, anxiety/fear, shiver, sweating, polyuria) on the "peak" of their attacks. This variant of migraine without aura was conditionally defined as "panic migraine". Here we describe two patients suffering from migraine without aura in whom migraine was associated with the typical panic attack. It is suggested that a pronounced autonomic dysregulation along with marked psychological abnormalities could be responsible for the constellation of migraine and panic symptoms during one episode. Taking into account the previously obtained results, it is concluded that compared to "pure" migraine, "migraine associated with panic attacks" is characterized by a severe course, marked autonomic and emotional disturbances during pain-free intervals, seriously impaired quality of life, and requires a specific therapeutic approach.

Migraine in a specialist menopause clinic

OBJECTIVES

Epidemiological studies suggest that migraine and headache worsen during the climacteric. The authors noted that women attending a specialist hospital-based menopause clinic frequently reported vasomotor and other common climacteric symptoms but few spontaneously reported headache or migraine. The aim of this study was to assess the prevalence of migraine and headache in women attending this clinic.

METHODS

Seventy-four women consecutively attending the menopause clinic at St. Bartholomew's Hospital were questioned about headache. Those with a positive response were further interviewed to obtain a headache diagnosis.

RESULTS

Headache was found to be a common symptom affecting 57% of women in the 3 months before attending a specialist menopause clinic. Migraine affected 29% of patients in the preceding 3 months. This condition was associated with significant disability: 80% of women reported that attacks were more frequent than once a month; 75% reported that the attacks were severe; 50% reported that the duration of treated attacks was longer than 1 day.

DISCUSSION

The high prevalence of headache and migraine in this group suggests that perimenopausal women should routinely be asked about headache and offered appropriate advice. This should include optimal attack therapy and strategies for preventing attacks, which may include hormone replacement therapy (HRT). Further studies are warranted to evaluate the relationship between climacteric symptoms, headaches, migraine and HRT.

Migraine: clinical features and diagnosis

Migraine is a syndrome characterized by recurrent headaches with or without aura. Triggers include foods, hormonal changes, and stressors. Migraine must be differentiated from other unilateral headache disorders and from headaches due to other neurologic and systemic diseases.

CBF changes during headache-free periods and spontaneous/induced attacks in migraine with and without aura: a TCD and SPECT comparison study

BACKGROUND

The aim of the present study was to compare cranial arteries blood flow velocity as measured by means of transcranial Doppler sonography (TCD) with mean regional cerebral blood flow (rCBF) as measured by means of single photon emission computed tomography (SPECT) in migraine with and without aura during headache-free periods and spontaneous and/or induced attacks.

METHODS

Regional cerebral blood flow (rCBF) and systematic ultrasonic Doppler flow were studied by Technetium-99m hexamethylpropilaminoxime (99mTc-HM-PAO) single photon emission computed tomography (SPECT) and transcranial Doppler sonography (TCD) respectively in controls (n=14) and in migraine with (n=13) and without aura (n=35) during headache free-intervals and spontaneous/histamine-induced attacks.

RESULTS

In the migraine without aura group, Doppler flow examinations of the common carotid artery, external and internal carotid artery, ophthalmic artery and middle cerebral artery bilaterally did not reveal significant changes as compared with controls. During attacks, TCD examinations showed a moderate, although not statistically significant, reduction of blood flow velocity in the middle cerebral artery and in the internal carotid artery bilaterally as related to the interictal phase, concomitant with an increase of the flow velocity in the ophthalmic and external carotid artery. SPECT of these patients did not show, on the average, rCBF asymmetries during pain-free periods, although positive findings (i.e., focal hypoperfusion) were found in approximately half of the cases. During attacks, 74% of patients displayed a unilateral hypoperfusion, mainly in the occipital region. Low-flow areas were generally but not always consistent with the site of pain. In the migraine with aura group, significant reduction of blood flow velocity in middle cerebral artery was recorded by TCD on the affected side during attacks, as compared with the pain-free side. Hypoperfusion was registered between attacks by SPECT in approximately 2/3 of the patients. During attacks, a marked reduction of rCBF occurred in most patients (85%), mainly in the parieto-occipital region. The posterior rCBF asymmetries revealed at the SPECT and consistent with the general reduction of blood flow velocity documented by TCD may be related to cerebrovascular tone instability.

CONCLUSIONS

Our findings do not support the paradigm that migraine with and without aura are two different entities.

Photic driving response in primary headache: diagnostic value tested by discriminant analysis and artificial neural network classifiers

The aim of this study was to discriminate migraine patients (MWoA) from tension-type headache (TTH) patients and normals in order to confirm that the photic driving response in the medium frequency range is a marker of migraine and to test the hypothesis that MWoA and TTH are separate disorders based on electrophysiological pattern. We recruited 120 MWoA patients, 64 TTH patients, and 51 healthy controls without any history of headache or of migraine inheritance, according to International Headache Society (IHS) criteria. The classification method was discriminant analysis using both linear discriminant analysis with a stepwise selection of predictors and an artificial neural network classifier (NNs). The mean amplitude of the first harmonic elicited by flash stimulation in the 15-27 Hz range was significantly increased over Fp1, C3, C4, P4, O2, and O1 electrodes in MWoA and TTH patients in comparison with normal subjects. Using both classification methods, only the control subjects were correctly distinguished. When only the patient groups were matched, no significant difference was detectable. The increased brain response to visual stimulation detected in both migraine and TTH suggests a common neuronal dysfunction in the two headache subtypes.

Autonomic Dysfunction in Migraineurs

OBJECTIVE

To evaluate autonomic function and sympathovagal balance in migraineurs and healthy controls.

BACKGROUND

The pathophysiology of migraine is still largely unknown. An imbalance of the autonomic nervous system could explain many of the clinical manifestations of the disorder.

MATERIALS AND METHODS

We undertook autonomic function tests in 17 women suffering from migraine (8 with aura) (average age 36 +/- 7 years) and 16 healthy women (average age 34 +/- 7 years). Autonomic nervous system studies consisted of tests of sympathetic function (the quantitative sudomotor axon reflex test, beat-to-beat blood pressure responses to the Valsalva maneuver, sustained handgrip, cold pressor test, and head-up tilt and tests of parasympathetic function (heart rate responses to deep breathing and the Valsalva maneuver). The data from the tilt test were further evaluated by time-frequency analysis (Wigner distribution).

RESULTS

Subjects with migraine with aura had a smaller increase of mean blood pressure during phase IV of the Valsalva maneuver (P<0.05) and a lower blood pressure increment during the handgrip test (P=0.08); their time-frequency distribution showed reduced power at the nonrespiratory frequencies in the R-R interval at both minutes 1 (P<0.03) and 5 (P<0.04) of head-up tilt. Sympathovagal balance (a ratio of spectral power of nonrespiratory frequency variations in blood pressure to that at respiratory frequency variations in the R-R interval) was significantly increased in migraineurs, both with and without aura, by 10 minutes of head-up tilt.

CONCLUSION

Subjects with migraine with aura had resting supine sympathetic hypofunction and intact parasympathetic function. With head-up tilt, sympathovagal balance is increased. The dynamic alterations in autonomic nervous system function may contribute to the development of aura in patients with migraine.

Transformed Migraine Is a Cause of Chronic Daily Headaches

Chronic daily headaches (CDH) consist of episodes of head pain occurring daily; more than 15 days each month; often associated with a history of migraine, with or without aura; or with a history of tension-type headaches occurring alone or both occurring together. Chronic daily headaches are frequently associated with rebound headaches after ergotamine, barbiturate, caffeine, and analgesic abuse. We previously reported that migraineurs with typical intermittent headaches exhibited excessive cerebral cortical vasodilation after oral acetazolamide which usually precipitated and reproduced their typical headaches. In the present study, cerebral vasodilator responses were tested by measuring changes in local cerebral blood flow (Delta LCBF) utilizing xenon-contrasted CT scanning, before and after oral administration of 14.3 mg/kg of acetazolamide, in 11 patients with CDH. The results were compared with 12 age-matched typical migraineurs, with and without aura, who had a history of migraine attacks occurring at intervals of 1 month or longer. Global and subcortical gray and white matter Delta LCBFs were quantitated and compared between both groups. After acetazolamide, Delta LCBF increased in cortical gray matter by 11.8% among patients with CDH and by 16.7% among migraineurs, with no significant differences between groups. Typical migraine attacks were provoked by acetazolamide in 9 patients (82%) with CDH and in 11 (92%) migraineurs with intermittent headaches. These observations are taken as evidence that at least 82% of patients with CDH have transformed migraine as judged by the provocation by acetazolamide of typical migraine attacks associated with excessive Delta LCBF increases. Serotonin agonists should be considered in the treatment of CDH to avoid ergotamine, caffeine, barbiturate, and analgesic abuse.

Musculoskeletal Abnormalities in Chronic Headache: A Controlled Comparison of Headache Diagnostic Groups

The presence of postural, myofascial, and mechanical abnormalities in patients with migraine, tension-type headache, or both headache diagnoses was compared to a headache-free control sample. Twenty-four control subjects were obtained from a convenience sampling and each was matched by age and sex to three patients with headache (one with migraine [with or without aura], one with tension-type headache, and one with diagnoses of both migraine and tension-type headache [combined diagnosis]) who had been previously assessed by a physical therapist at a headache clinic. Physical therapy assessment findings were compared among the four groups. There was a significant difference in the presence of postural abnormalities between the controls and the patients, with posture abnormalities more likely to be present in those with headache. The patients were also significantly more likely to have active trigger points and trigger points in the neck than were the control subjects. There were no significant group differences identified in the mechanical measures, nor were there any significant differences among the three headache categories. Determination of the clinical significance of these musculoskeletal abnormalities in patients with headache will require the development and testing of further standardized assessments as well as physical therapy treatment programs.