Modular headache theory

Pharmacological Dissociation in Hemicrania Continua With Persistent Visual Aura Evolved From Episodic Migraine: A Case Report

OBJECTIVE

To report a case of hemicrania continua (HC) and persistent visual aura without infarction in a patient with previous episodic migraine with visual aura, whose persistent aura symptoms improved only after treatment with divalproex sodium.

BACKGROUND

Once regarded as highly specific for migraine, visual aura has been associated with trigeminal autonomic cephalalgias, including HC. In previous descriptions of HC and episodes of typical visual aura, the aura occurred exclusively with severe headache exacerbations and, like the pain, resolved with indomethacin.

METHODS

Case report and literature review.

RESULTS

A 54-year-old man with a history of episodic migraine with visual aura reported a gradual onset of HC with persistent visual aura of 15 months duration. General medical and neurological examinations were normal, including imaging studies. HC's headache responded to indomethacin, while the visual aura was recalcitrant, only improving with oral divalproex sodium treatment.

CONCLUSION

As our patient experienced HC, which evolved from episodic migraine, we hypothesize that migraine and HC may share a common pathophysiology. However, the persistence of the visual aura, despite the abolition of pain and autonomic features with a therapeutic dose of indomethacin, and the subsequent successful treatment of the aura with divalproex sodium, suggest that aura and HC headache arise from distinct and dissociable mechanisms.

Red Ear Syndrome and migraine: case report and review of this peculiar association

Introduction: The "Red Ear Syndrome" (RES) is a rare condition (about 100 cases were published in 25 years). It is characterized by episodes of hyperemia of the ear associated with burning pain. Although the association of this syndrome and primary headaches is contemplated in literature, its etiology and treatments are still poorly defined. The aim of this paper is to report a case of RES related to migraine and possible pathophysiologic mechanisms. Case Report: A 31-year-old woman presented with stabbing pain and marked erythema and edema of the right ear accompanied by burning and local hyperhidrosis. These attacks lasted 2 hours on average, and either occurred spontaneously or were associated with migraine without aura. The only means of relief during the attacks was cooling the local with ice. Extensive laboratory-chemical, microbiological, ear-nose-throat, clinical and neurological examinations, magnetic resonance of the brain and cervical spine were unremarkable. Conclusion: Uncertainty about the etiology of this syndrome is an obstacle to treatment. The frequent relationship between RES and migraine suggests that is necessary to investigate the syndrome in migraineurs. Furthermore, new reports about this disorder are important to increase the knowledge of physicians, to reduce the delay in diagnosis and suffering of patients.

Migraine and Tension-Type Headache Among Children and Adolescents: Application of International Headache Society Criteria in a Clinical Setting

INTRODUCTION

The International Headache Society criteria were written in order to help physicians establish a headache diagnosis. However, sometimes children with headache do not seem to fit any diagnosis. The purpose of our study was to assess the application of the criteria in a clinical setting.

METHODS

Medical records of children referred for primary headache to the pediatric neurology clinic at Bnai Zion Medical Center from 2008 to 2017 were assessed.

RESULTS

A total of 989 patients (range 6-18 years; 53% female) were assessed at our neurology clinic. Twenty-four percent (n = 241) were diagnosed with tension-type headache, 26% (n = 256) with migraine, and 4.5% (45) with mixed headache. In 41.5% (410), we were unable to reach a specific diagnosis. No differences in gender or age were found between the groups. Children in the migraine group used more analgesic treatments to stop the headache attacks compared with the tension-type headache group (50% vs 38%, P = .001). Patients diagnosed with tension-type headache reported having more emotional difficulties (P = .001). No significant differences were found in headache characteristics (ie, location, sidedness, character), frequency, or intensity between the younger children (ages 6-11) and the adolescents (ages 12-18) within either the tension-type headache or migraine groups.

CONCLUSIONS

Retrospective application of International Headache Society criteria in a large cohort of children with headaches failed to diagnose a specific type of headache in 41.5% of children. Migraine and tension-type headache were equally prevalent, and both constituted a major burden on our patients' everyday lives. We found no major differences in frequency, intensity, and characteristics of pain between younger children and adolescents.

Red ear syndrome in children: Review of literature and report of three cases

BACKGROUND

Red ear syndrome (RES) is a neurological syndrome that is characterized by attacks of redness and pain that is localized in the earlobe, accompanied by a burning sensation, swelling or otalgia. The exact pathophysiology of RES is not known. Several pediatric cases have been described. They show an extreme variability in clinical presentation and therapeutic response, and therefore there are numerous difficulties in the diagnostic-therapeutic approach and in the comprehension of the physiopathology. The goal of this report is to present three clinical cases of red ear syndrome in children. These cases show various characteristics that can give useful indications regarding the differential diagnosis and the pathogenetic mechanisms that are involved, particularly when they are compared with cases published in the literature.

CASE-REPORTS

We report three pediatric RES cases: 1) a boy whose condition offered a typical example of the association that occurs between migraine and RES. 2) a girl with idiopathic RES. 3) a child who suffered RES attacks that showed many similarities with trigeminal autonomic cephalalgias.

CONCLUSION

Our clinical series shows the different ways in which RES can be expressed and they support the reported scientific literature. We suggest that the different forms of RES have a common final autonomic pathogenetic mechanism that is activated by parasympathetic hyperactivity and sympathetic inhibition. The different temporal characteristics, frequency, etc. may depend on the activation of distinct physiopathological modules that are related to the pain circuits, as suggested by the modular theory which describes that groups of neurons are defined as a module, where each module is responsible for a symptom and the individual's headache is defined by the activated modules.

Migraine screen questionnaire: further psychometric evidence from categorical data methods

BACKGROUND

Psychometric investigations of tools used in the screening of migraine including the migraine screen questionnaire (MS-Q), using an adequate statistical approach is needed. We assessed the psychometric properties of the migraine screen questionnaire (MS-Q) using categorical data methods.

MATERIAL AND METHODS

A total of 343 students at Mizan-Tepi University, Ethiopia, age range = 18-35 years were selected by a simple random sampling method to participate in a cross-sectional study. The respondents completed the MS-Q, a semi-structured socio-demographic questionnaire, and a visual analog scale for attention (VAS-A).

RESULTS

The cumulative variance rule (> 40%), the Kaiser's criteria (Eigenvalue> 1), the Scree test and, the parallel analysis (minimum rank) identified a 1-factor model for the MS-Q with the factor loadings in the range of 0.78 to 0.84. Fit indices favored a 1-factor model of the MS-Q as indicated by comparative fit index (0.993), weighted root mean square residual (0.048), root mean square error of approximation (0.067), the goodness of fit index (1.00), and non-normed fit index (0.987). The values of the Factor Determinacy Index (0.953), marginal reliability (0.909), H-latent (0.909), H-observed (0.727), explained common variance (0.906) and the mean item residual absolute loadings (0.225) further complimented finding of the 1-Factor model. McDonald's Omega (0.903) suggested adequate internal consistency. Discriminative validity was supported by significantly higher scores for the total and all the MS-Q items except one among those with complaints of attention.

CONCLUSION

The categorical methods support the psychometric validity of the MS-Q in the study population.

Prevalence of familial cluster headache: a systematic review and meta-analysis

INTRODUCTION

The population rate of familial cluster headache (CH) has been reported to be as high as 20% however this varies considerably across studies. To obtain a true estimate of family history in CH, we conducted a systematic review and meta-analysis of previously published data.

METHODS

Our systematic review involved a search of electronic databases (Medline, EMBASE, PubMed, CINAHL) to identify and appraise studies of interest utilising the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. To further ameliorate the accuracy of our analysis we included an additional unpublished cohort of CH patients recruited at a tertiary referral centre for headache, who underwent detailed family history with diagnostic verification in relatives. Data was extracted and meta-analysis conducted to provide a true estimation of family history.

RESULTS

In total, we identified 7 studies which fulfilled our inclusion criteria. The estimated true prevalence of CH patients with a positive family history was 6.27% (95% CI:4.65-8.40%) with an overall I² of 73%. Fitted models for gender subgroups showed higher estimates 9.26% (95% CI: 6.29-13.43%) in females. However the I² for the female model was 58.42% and significant (p = 0.047).

CONCLUSION

Our findings estimate a rate of family history in CH to be approximately 6.27% (95% CI: 4.65-8.40%). While estimates were larger for female probands, we demonstrated high heterogeneity in this subgroup. These findings further support a genetic role in the aetiology of CH.

Hemicrania Continua Associated with Classic Scintillating Scotoma

Hemicrania continua (HC) is a rare primary headache disorder, characterized by persistent unilateral pain associated with cranial autonomic symptoms and prompt response to indomethacin. While migrainous features (including aura) have been recognized in cluster headache, there have been only single reports of HC with aura. Here, we report the case of a 53-year-old man with constant right-sided headache and superimposed exacerbations to severe pain lasting for several hours. Secondary etiologies were excluded, and a diagnosis of HC was established after prompt and complete response to treatment with indomethacin. During an episode of pain exacerbation, for the first time the patient experienced an episode of transient visual disturbances compatible with scintillating scotoma. We propose a potential link between HC and visual aura, which parallels similar observations in other trigeminal autonomic cephalalgias and more specifically confirms previous observational data on aura in HC, thus highlighting potentially shared pathophysiological mechanisms.

Headache Related to a Specific Screen Flickering Frequency Band

The case of a 25-year-old white male, who had migrainous headaches each time he sat in front of his personal computer screen, is described. Changing the screen frequency from 60 to 75 Hz through a Windows command could abolish the headaches. In several surveys, computer screens have been reported to be a migraine trigger. We hypothesize that this environmental trigger may be related to the abnormal flicker fusion thresholds that have been described in migraineurs. It may be that modifying the frequencies of light sources, such as computer screens, could become a non-pharmacological approach to prevent migraine attacks.

The Postdrome of the Acute Migraine Attack

This study was performed to document the frequency, duration and types of symptoms of postdrome in migraine patients. Eight hundred and twenty-seven consecutive headache clinic patients (IHS 1.1, 1.2 and 1.5.1) were evaluated at first visit. Postdrome frequency, duration and characteristics were analysed. Sixty-eight per cent of 827 patients reported postdrome (69.1% females; 56.8% males, P < 0.007). The average duration of the postdrome was 25.2 h. Fifty-six per cent had postdrome for ≤ 12 h, 32% for 12–24 h, 88% for ≤ 24 h, and 12% for > 24 h. The commonest symptoms were tiredness (71.8%), head pain (33.1%), cognitive difficulties (11.7%), ‘hangover’ (10.7%), gastrointestinal symptoms (8.4%), mood change (6.8%), and weakness (6.2%). Patients with postdrome compared with patients without postdrome have more characteristic and more frequent migraine features. This study demonstrated postdrome in 68% of patients, duration ≤ 24 h in most patients, more often associated with a full-blown migraine attack, more common in females, and with commonest symptoms being tiredness and low-grade headache.

A Report of Cranial Autonomic Symptoms in Migraineurs

The presence of cranial autonomic symptoms in migraine is well known and thought to represent activation of the trigeminal parasympathetic reflex pathway similar to trigeminal autonomic cephalalgias. However, studies regarding the prevalence of these symptoms are few. The characteristics of migraineurs with cranial autonomic symptoms and the association of cranial autonomic symptoms with laterality of headache have never been studied in a clinic population. Seventy-eight consecutive subjects with migraine were recruited from the Headache Clinic of the Department of Psychiatry after exclusion of subjects with secondary headache. Their demographic data and detailed history of headache were noted and leading questions were asked regarding cranial autonomic symptoms. χ2 test and Fisher's exact test was used for categorical variables, whereas an independent sample t-test was applied on numerical data. Spearman's correlation was used for correlational analysis of categorical variables. Female subjects (78.2%) outnumbered males and the average duration of illness in the whole sample was 3.81 years. Migraine without aura (53.8%) was the commonest diagnosis, followed by migraine with aura (24.4%). Cranial autonomic symptoms were present in 73.1% of subjects and, commonly, they were ipsilateral to headache. Moreover, strictly unilateral cranial autonomic symptoms were reported by only 32% of patients. The anatomical side of headache did not affect the presence of autonomic symptoms. Those with or without autonomic symptoms did not differ with respect to gender, diagnosis, laterality of headache or associated symptoms except phonophobia, which was more common in subjects with autonomic symptoms ( P = 0.05). Those with autonomic symptoms had longer duration of illness ( P = 0.03) and longer headache episodes ( P = 0.04). In addition, sleep was ineffective in relieving their headache ( P = 0.02). Cranial autonomic symptoms are frequent in migraineurs and are common in subjects with long duration of illness and longer headache episodes. Clinical evidence in the present study suggests that subjects with cranial autonomic symptoms have a hyperactive efferent arm of trigeminal autonomic reflex. The connections of trigeminal nucleus with the locus coeruleus and dorsal raphe nucleus may account for the observed phenotypic differences between the two groups. Further research, however, is required to elucidate the underlying neural mechanisms of cranial autonomic symptoms in migraine.

Subclinical Neuromuscular Transmission Abnormality Detected by Single-Fibre EMG is More Pronounced in Cluster Headache Than in Migraine With Aura

The aim was to investigate neuromuscular transmission (NMT) by single-fibre EMG (SFEMG) in a large series of patients having migraine with aura (MA) or cluster headache (CH). Recent studies using SFEMG have shown subclinical dysfunction of NMT in MA and CH. Forty-three patients having MA, 51 with CH and 38 healthy control subjects underwent nerve conduction studies, EMG and SFEMG during voluntary contraction of the extensor digitorum communis muscle. Twenty different potential pairs were recorded and individual, mean and total abnormal individual jitter values were calculated. The results obtained from MA patients were compared with those from CH patients. In MA patients, 32 of 860 jitters were abnormally high, whereas 73 of 1020 of the jitters showed this abnormality in CH patients. None of the control subjects, five MA patients (11.6%) and 11 CH patients (21.6%) were designated as having subclinical NMT abnormality. Thus, patients having junction dysfunction were significantly more common in the CH group. The subclinical NMT abnormality shown by SFEMG is more common in CH than in MA. These two primary headache syndromes may have some shared functional abnormality of NMT constituents which is more evident in CH.

Headache and ADHD in Pediatric Age: Possible Physiopathological Links

Primary headache and attention-deficit/hyperactivity disorder (ADHD) are common disorders in children and adolescences, frequently associated to severe cognitive, emotional, and behavioral impairments. They both are a disabling condition with consequences on family and child's quality of life. Literature data on their association are contrasting. Dopaminergic system dysfunction, brain iron deficiency, and sleep disturbance should be considered to better understand headache and ADHD overlap. In this review, we analyze the complex association between these two diseases and the potential impact on child neurodevelopment.

Migraine in a pediatric population: a clinical study in children younger than 7 years of age

AIM

Migraines in children younger than 7 years of age have received limited attention in the published literature. The aim of this study is to describe the characteristics of migraine phenotypes in children younger than 7 years, and to compare them with migraines in children older than 7 years of age.

METHOD

We reviewed all standard clinical files, collected over 4 years, related to children with a diagnosis of primary headache. We included all children younger than 7 years diagnosed with migraine in our study.

RESULTS

A total of 374 children (188 males, 186 females) were affected by migraine with/without aura: 40 of these patients (10.7%; 20 males, 20 females; mean age 5y 7mo, SD 1y 2mo) where younger than 7 years old. The frequencies of the main migraine features in the younger age group were similar to those of children older than 7 years, with the exception of a shorter duration of migraine and reduced frequency of attacks.

INTERPRETATION

In children younger than 7 years of age, the clinical phenotype of migraine is similar to that seen in older children. We propose that there is a general genetic migraine susceptibility that, in the presence of activating environmental factors, may induce typical attacks of migraine in individuals already predisposed to migraine attacks. Therefore, different modules induce different clinical features within the different age groups, but there is no difference in the frequencies of clinical phenotypes between the two age groups.

Headache and attention deficit and hyperactivity disorder in children: common condition with complex relation and disabling consequences

The aim of this review was to analyze literature data on the complex association between headache and attention deficit and hyperactivity disorder (ADHD) in children, in order to explore its possible consequences on child neurological development. Headache and ADHD are two common conditions in the pediatric population. They both are disabling diseases that impact the child's quality of life and are associated with severe cognitive, emotional, and behavioral impairments. To assess and analyze literature data about the association of ADHD and headache in children and possible physiopathogenesis relationships, we searched for the following terms: headache, migraine, tension-type headache, ADHD, and children (MESH or text words). We found different studies that assess the clinical, epidemiological, and physiopathogenetic overlap between these two diseases, with contrasting results and unresolved questions. Structural and functional abnormalities in brain networks have been found to be central in both headache and ADHD pathophysiology. It will be crucial to gain a better understanding of how subcortical-cortical and corticocortical network development is altered during the onset of the disorders.

Vertigo as a migraine phenomenon

Migraine is a complex disorder with many different manifestations. There has been an increasing interest in the association of migraine and vertigo. Many different terms have been developed to describe this concept, the more popular being vestibular migraine, migrainous vertigo, and migraine-associated vertigo. The most commonly cited diagnostic criteria are that of Neuhauser though this has yet to be included in the International Classification of Headache Disorders (2nd edition). At this time, there is a lack of consensus regarding migraine-related vertigo and its pathomechanism. Regardless, a few randomized controlled prospective studies have been performed to evaluate the efficacy of various medications. Topiramate has been shown to be effective for migraine-related vertigo. At this time there is no specific treatment for migraine-related dizziness outside of conventional migraine management. The genetics have yet to be fully realized though an autosomal dominant familial migraine vertigo disorder has been identified.

Primary headaches, attention deficit disorder and learning disabilities in children and adolescents

Background

Primary headaches and Learning difficulties are both common in the pediatric population. The goal of our study was to assess the prevalence of learning disabilities and attention deficit disorder in children and adolescents with migraine and tension type headaches.

Methods

Retrospective review of medical records of children and adolescents who presented with headache to the outpatient pediatric neurology clinics of Bnai-Zion Medical Center and Meyer Children’s Hospital, Haifa, during the years 2009–2010. Demographics, Headache type, attention deficit disorder (ADHD), learning disabilities and academic achievements were assessed.

Results

243 patients met the inclusion criteria and were assessed: 135 (55.6%) females and 108 (44.4%) males. 44% were diagnosed with migraine (35.8% of the males, 64.2% of the females, p = 0.04), 47.7% were diagnosed with tension type headache (50.4% of the males, 49.6% of the females). Among patients presenting with headache for the first time, 24% were formerly diagnosed with learning disabilities and 28% were diagnosed with attention deficit disorder (ADHD). ADHD was more prevalent among patients with tension type headache when compared with patients with migraine (36.5% vs. 19.8%, p = 0.006). Poor to average school academic performance was more prevalent among children with tension type headache, whereas good to excellent academic performance was more prevalent among those with migraine.

Conclusions

Learning disabilities and ADHD are more common in children and adolescents who are referred for neurological assessment due to primary headaches than is described in the general pediatric population. There is an association between headache diagnosis and school achievements.

Migraine-like accompanying features in patients with cluster headache. How important are they?

BACKGROUND

According to the International Classification of Headache Disorders diagnostic criteria, the differences between migraine and cluster headache (CH) are clear. In addition to headache attack duration and pain characteristics, the symptoms accompanying headache represent the key features in a differential diagnosis of these 2 primary headache disorders. Just a few studies of patients with CH exist examining the presence of nausea, vomiting, photophobia, phonophobia, and aura, the features commonly accompanying migraine headache. The aim of this study was to determine the presence of migraine-like features (MF) in patients with CH and establish the significance of these phenomena related to other clinical features and response to treatment.

METHODS

One hundred and fifty-five patients with CH were studied, and 24.5% of them experienced at least one of MF during every CH attack. Nausea and vomiting were the most frequently reported MF. The clinical presentation between CH patients with and without MF was not significantly different with the exception of aggravation of pain by effort (20.6% vs 4.1%) and facial sweating (13.2% vs 0.85%), both more frequent in CH patients with MF.

CONCLUSION

Inferred from the results of our study, the presence of MF in CH patients had no important influence on the diagnosis and treatment of CH patients. The major differences of these 2 primary headache disorders, attack duration, lateralization, and the nature of associated symptoms, as delineated in the International Classification of Headache Disorders, are still useful tools for effective diagnosis.

Emerging target-based paradigms to prevent and treat migraine

Migraine is a primary brain disorder resulting from altered modulation of normal sensory stimuli and trigeminal nerve dysfunction. The second edition of the International Classification of Headache Disorders (ICHD-2) defines seven subtypes of migraine. Migraine treatment can be acute or preventive. New targeted therapies include 5-HT(1F) receptor agonists, calcitonin gene-related peptide (CGRP) antagonists, nitric oxide synthetase inhibitors, and ion channel antagonists. A recent development is the creation of antibodies to CGRP and its receptor for migraine prevention.

Attention in children and adolescents with headache

OBJECTIVE

The previous studies reporting consistent visual reaction times slowing in patients with migraine prompted us to verify if headache could be associated to a broader impairment of attention. This study aims to undertake a thorough investigation of attentional performance by extending the evaluation to children with primary headache of different types.

METHODS

We compared 62 children with headache (14 migraineurs with aura, 29 without aura and 19 with tension type headache) and 52 controls without headache, matched for age, sex, and intelligence using Conners' Continuous Performance Test.

RESULTS

The 3 clinical groups did not differ in attentional measures. The headache patients, collapsed in 1 single sample, had mean scores in Hit Reaction Time significantly different from those of controls and also had a higher percentage of atypical scores in 2 indices of the Conners' Continuous Performance Test (faster mean reaction time and more commissions).

CONCLUSIONS

Our results confirm the presence of an association between attentional problems and headache that may impact academic learning and daily activities on the long term. The finding that the 3 clinical groups did not show significant differences in attentional performance supports the hypothesis that migraine and tension headache form a continuum that may share the same pathophysiological mechanisms. These results are discussed considering that neurotransmitters and the cerebral circuits subserving headache, personality profile, and attention could overlap, thus predisposing these children to even mild attention malfunctioning.

Comparison of clinical characteristics of migraine and tension type headache

CONTEXT

Migraine and tension type headache (TTH) are two most common types of primary headaches. Though the International Classification of Headache Disorders-2 (ICHD-2) describes the diagnostic criteria, even then in clinical practice, patients may not respect these boundaries resulting in the difficulty in diagnosis of these pains.

MATERIALS AND METHODS

This cross-sectional study involved 50 subjects in each of the two groups - migraine and TTH - after screening for the inclusion and exclusion criteria. Diagnosis was made according to the ICHD-2 criteria. Their clinical history was taken in detail and noted in a semi-structured performa. They were examined for the presence of a number of factors like pericranial tenderness and muscle parafunction. Statistical analysis was done with the help of SPSS v 11.0. To compare the non-parametric issues, chi-square test was run and continuous variables were analyzed using independent sample t test.

RESULTS

In general, migraineurs had progressive illness (χ(2)=9.45; P=0.002) with increasing severity (χ(2)=21.86; P<0.001), frequency (χ(2)=8.5; P=0.04) and duration of each headache episode (χ(2)=4.45; P=0.03) as compared to TTH subjects. Along with the headache, they more commonly suffered orthostatic pre-syncope (χ(2)=19.94; P<0.001), palpitations (42%vs.18% among TTH patients; χ(2)=6.87; P=0.009), nausea and vomiting (68% vs. 6% in TTH; χ(2)=41.22; P<0.001, and 38% vs. none in TTH; χ(2)=23.45, P<0.001, respectively), phonophobia (χ(2)=44.98; P<0.001), photophobia (χ(2)=46.53; P<0.001), and osmophobia (χ(2)=15.94; P<0.001). Their pain tended to be aggravated by head bending (χ(2)=50.17; P<0.001) and exercise (χ(2)=11.41; P<0.001). Analgesics were more likely to relieve pain in migraineurs (χ(2)=21.16; P<0.001). In addition, post-headache lethargy was more frequent among the migraineurs (χ(2)=22.01; P<0.001). On the other hand, stressful situations used to trigger TTH (χ(2)=9.33; P=0.002) and muscle parafunction was more common in TTH patients (46% vs. 20%; χ(2)=7.64; P=0.006). All the cranial autonomic symptoms were more common in migraineurs as compared to TTH subjects (conjunctival injection: χ(2)=10.74, P=0.001; lacrimation: χ(2)=17.82, P<0.001; periorbital swelling: χ(2)=23.45, P<0.001; and nasal symptoms: χ(2)=6.38, P=0.01).

CONCLUSION

A number of symptoms that are presently not included in the ICHD-2 classification may help in differe-ntiating the migraine from the TTH.

Migraine features, associated symptoms and triggers: a principal component analysis in the Women's Health Study

AIMS

Migraine has a wide clinical spectrum. Our aim was to group information on migraine characteristics into meaningful components and to identify key components of the migraine phenotype.

METHODS

We performed two principal component analyses, one among participants in the Women's Health Study enrollment cohort and one in a sub-cohort with additional migraine-specific information.

RESULTS

Among the 9427 women with migraine attack-related information at enrollment, the three most important components pertained to central nervous system (CNS) sensitization, attack frequency/pain location and aura/visual phenomena. In the subgroup of 1675 women with more detailed information, food triggers and unspecific symptoms constituted two principal components that explain more of the variance of the migraine phenotype than the three attack-related components.

CONCLUSIONS

Our results indicate that information on migraine-associated features, symptoms and triggers is highly correlated, allowing the extraction of principal components. Migraine attack-related symptoms are best summarized by symptoms related to CNS sensitization, attack frequency/pain location and aura/visual phenomena. Taking a more general view, unspecific symptoms and food triggers appear to carry stronger importance in characterizing the migraine phenotype. These components are useful for future research on the pathophysiology and genetics of migraine and may have implications for diagnosing and treating patients.

Prevalence of red ear syndrome in juvenile primary headaches

BACKGROUND

Previous studies have suggested a relationship between 'red ear syndrome' (RES) and pediatric migraine. Aims of this study were (i) to assess the frequency, specificity and sensitivity of RES in a population of pediatric migraineurs and (ii) to establish the pathophysiological mechanisms of RES associated with migraine.

METHODS AND RESULTS

A total of 226 children suffering from headache (aged 4-17 years) were enrolled. One hundred and seventy-two (76.4%) were affected by migraine, the remaining 54 (23.6%) by other primary headaches. RES was followed significantly more frequently by migraine (23.3%; p < .0001), and was characterized by high specificity and positive predictive value (96.3 and 95.3%, respectively). According to the univariate statistical analysis, RES showed a statistically significant association with male gender, throbbing quality of the pain, vomiting and phonophobia. It was confirmed by a multivariate stepwise logistic regression model only for the throbbing quality of the pain, vomiting and male gender.

CONCLUSIONS

Our study showed that (i) in children, RES is a highly specific sign for migraine. In addition, the evidence of an association of RES with some migraine features partially provoked by the parasympathetic system supports the hypothesis of a shared pathophysiological background (e.g. via the activation of the trigeminal-autonomic reflex).

A comparative ID migraine screener study in ophthalmology, ENT and neurology out-patient clinics

Migraine is more likely to be misdiagnosed in patients with comorbid diseases. Not only primary care physicians, but also specialists might misdiagnose it due to the lack of diagnostic criteria awareness. The ID migraine test is a reliable screening instrument that may facilitate and accelerate migraine recognition. This study aimed to compare the prevalence and characteristics of migraine in a large sample of patients admitted to clinics of ophthalmology (OC), ear, nose and throat diseases (ENTC) and neurology (NC), as well as to validate the use of the ID migraine test in OC and ENTC settings. This was a multicentre (11 cites) study of out-patients admitting either to NC, ENTC or OC of the study sites during five consecutive working days within 1 week. From each of the clinics, 100 patients were planned to be recruited. All recruited patients were interviewed and those having a headache complaint received an ID migraine test and were examined for headache diagnosis by a neurologist, blinded to the ID migraine test result. A total of 2625 subjects were recruited. Only 1.3% of OC patients and 5.4% of ENTC patients have been admitted with a primary complaint of headache, whereas the percentage of NC patients suffering from headache was 37.6%. Whereas 138 patients (19.3%) in OC, 154 (17.3%) in ENTC and 347 (34%) in NC were found to be ID migraine test positive, 149 patients (20.8%) in OC, 142 (16%) in ENTC and 338 (33.1%) in NC were diagnosed with migraine. The sensitivity, specificity, and positive and negative predictive ratios of the ID migraine test were found to be similar in all clinics. An important fraction of the patients admitted to NC, as well as to OC and ENTC, for headache and/or other complaints were found out to have migraine by means of a simple screening test. This study validated the ID migraine test as a sensitive and specific tool in OC and ENTC, encouraging its use as a screening instrument.

Impact of primary headaches on subjective sleep parameters among adolescents

CONTEXT

Headache patients commonly report sleep disruption and sleep disorders. Available literature suggests that the sleep pattern of headache sufferers is different from the control group. Patients in these studies were recruited from headache clinics; they did not include tension type headache.

AIMS

The aim of this study is to find out whether primary headaches affect sleep patterns.

SETTINGS AND DESIGN

Community based cross sectional study

MATERIALS AND METHODS

This study was conducted in three high schools. Children in the 12-19 age group were allowed to participate. They were given a questionnaire in the presence of at least one of the authors, who assisted them in filling it. They were asked to provide responses based on most severe recurrent headache that they had experienced rather than the more frequent ones. The questionnaire included questions regarding demographic data and the characteristics of headache according to International Classification of Headache Disorders-2 criteria. Part B of the questionnaire contained questions regarding sleep habits. The children were asked to provide data regarding sleep habits on a normal school day. Diagnosis was based upon the information contained in the questionnaire. A telephonic interview was also done, where the information provided was found inadequate.

STATISTICAL ANALYSIS USED

Analysis was done with the help of SPSS v. 11.0., descriptive analysis, Chi square, and one way ANOVA with post hoc analysis. Kruskall-Wallis tests were run.

RESULTS

A total of 1862 subjects were included in the study. Migraineurs and tension type headache sufferers comprised 35.7% and 13.4% of the group respectively. Migraineurs had the highest prevalence of nocturnal awakenings (P < 0.001), abnormal movements (P=0.001) and breathing problems during sleep (P < 0.001). Approximately half the migraineurs felt sleepy during the day (P< 0.001) and spent around 1.17 hours in sleep during the day (P = 0.007). Similarly, values for frequency of nocturnal awakenings per week (P < 0.001), wake time after sleep onset and offset (P < 0.001 and 0.002 respectively) were the maximum in migraineurs. Only 32.8% migraineurs reported refreshing sleep (P< 0.001). Post hoc analysis revealed that migraineurs were different from the other two groups on most of the parameters.

CONCLUSIONS

Sleep disruption is more common in migraineurs than those in the tension type headache sufferers and the control group.

Side-shifting hemicrania continua with aura (migraine with aura with autonomic symptoms responsive to indomethacin?)

Atypical features of hemicrania continua (HC), including both visual aura and side shifting, have been reported previously. However, auras and variable unilaterality have never been reported together in HC. We report two patients with side-shifting HC with aura. These patients' symptoms are unilateral headaches, visual aura, autonomic features, throbbing pain, nausea and photo/phonophobia. One could speculate that the unilaterality and/or the autonomic symptom modules are indomethacin responsive. The patients can also be classified as chronic migraine with aura, with autonomic symptoms, responsive to indomethacin. Neither migraine subtype nor side-shifting HC with aura is included in the current International Headache Society (IHS) classification, so these patients are not classifiable. Side-shifting HC with aura implies the need to revisit the traditional IHS categorization of headaches into unique diagnostic groups. The modular headache theory may be a tool for the understanding of these rare and complex cases.

Black, white and shades of grey: SUNCT or short-lasting chronic paroxysmal hemicrania?

AIM OF THE STUDY: To report a case of unilateral headache with two possibilities of diagnosis. METHOD: Case report. RESULTS: Patient with unilateral, intense, stabbing periocular headache with conjuntival injection and tearing. Although the duration of attacks was typical of SUNCT, there was complete remission of the pain with indomethacin, suggesting that this was a case of chronic paroxysmal hemicrania with unusually short attack duration. CONCLUSION: Therapeutic trials of indomethacin on younger patients presenting clinical diagnosis of SUNCT could be tried on a more regular basis.

The relationship between migraine pain and other associated symptoms

This study explores the relationship of the pain of the migraine headache and the associated features of migraine. Migraineurs (n=1025) (ICHD-2, 1.1-1.2 and 1.5.1) were evaluated retrospectively using a detailed database (daily unremitting excluded). Variables studied included headache intensity and duration, associated symptoms and pain characteristics. Non-parametric correlations were used to evaluate relationships among variables. Headache intensity correlated with nausea, vomiting, photophobia, phonophobia, dizziness (all P=0.000), running of the nose/tearing of the eyes (P=0.007), and osmophobia (P=0.044), but not with diarrhoea or taste abnormality. Headache duration correlated only with osmophobia (P=0.002) and taste abnormality (P=0.005). Throbbing, pressure and stabbing pain correlated with most of the associated symptoms. Aching correlated only with taste abnormality. This correlational study demonstrates that migraine pain is clearly related to nausea, but is also correlated with other associated migraine symptoms. Taste abnormality and osmophobia are better correlated with headache duration rather than headache intensity.

Seasonal, extratrigeminal, episodic paroxysmal hemicrania successfully treated with single suboccipital steroid injections

This case report describes a case of extratrigeminal, episodic paroxysmal hemicrania with a clear seasonal temporal pattern, successfully treated with repeated single suboccipital steroid injections. The pathophysiological and clinical implications of this observation are discussed.

Melatonin, the pineal gland and their implications for headache disorders

There is now evidence that melatonin may have a role in the biological regulation of circadian rhythms, sleep, mood, and ageing. Altered melatonin levels in cluster headache and migraine have been documented. Melatonin mechanisms are related to headache pathophysiology in many ways, including its anti-inflammatory effect, toxic free radical scavenging, reduction of proinflammatory cytokine up-regulation, nitric oxide synthase activity and dopamine release inhibition, membrane stabilization, GABA and opioid analgesia potentiation, glutamate neurotoxicity protection, neurovascular regulation, serotonin modulation, and the similarity of chemical structure to that of indomethacin. Treatment of headache disorders with melatonin and other chronobiotic agents is promising. A double-blind, placebo-controlled trial shows melatonin is effective in cluster headache prevention, other studies also show benefit in other disorders. Melatonin plays an important role in headache disorders, offering new avenues for studying their pathophysiology and treatment.

The Premonitory Symptoms (Prodrome): A Tertiary Care Study of 893 Migraineurs

OBJECTIVES

This study of premonitory symptoms in migraine was performed to document the frequency, duration, and types of symptoms in a large group of migraine patients.

BACKGROUND

Prodrome importance continues to be debated. Intervention early in the migraine attack is assuming more importance and necessitates better knowledge of the prodrome.

METHODS

A total of 893 migraine patients (IHS 1.1-1.7) were evaluated at first visit. Prodrome frequency, duration, and characteristics were analyzed in the total migraine population IHS 1.1-1.7 and IHS 1.1-1.6 migraine.

RESULTS

A total of 32.9% of IHS migraine 1.1-1.6 patients reported prodrome symptoms with an average of 9.42 hours. IHS 1.1-1.7 migraine reported 29.7% and 6.8 hours, respectively. The most commonest symptoms were tiredness, mood change, and gastrointestinal symptoms; all three of these symptoms were present together in 17% of the patients with prodrome. The duration of prodrome was less than 1 hour in 45.1%, 1-2 hours in 13.6%, 2-4 hours in 15.0%, 4-12 hours in 13.1%, and greater than 12 hours in 13.2%. IHS 1.1-1.7 patients showed similar findings. IHS 1.1-1.6 patients with prodrome differed from patients without prodrome in having more triggers as a whole (P <.01), more individual triggers including alcohol (P <.01), hormones (P <.01), light (P <.001), not eating (P <.05), perfume (P <.01), stress (P <.01), and weather changes (P <.05), a longer duration of aura (P <.05), longer time between aura and headache (P <.05), more aura with no headache (P <.05), longer time to peak of headache (P <.05), longer time to respond to triptan (P <.05), longer maximum duration of headache (P <.05), and more headache associated nausea (P <.05), more headache associated running of the nose or tearing of the eyes (P <.05), more postdrome syndrome (P <.05), and longer duration of postdrome syndrome (P <.001).

CONCLUSIONS

This study provides a portrait of prodrome in a large cohort of patients. It highlights differences between patients with prodrome and patients not having prodrome, and it draws attention to the potential of preventing the headache phase of the acute migraine attack.

Changes in Cortical Dynamics in the Preictal Stage of a Migraine Attack

Neurophysiologic studies suggest that migraineurs without aura have a dysfunction of cortical information processing in the pain-free interval. In this study, the advanced method of nonlinear multielectrode sleep-EEG analysis is used to investigate changes of cortical activity in the preictal time span. Five patients (four women, one man; age range, 29 to 58 years) experiencing migraine without aura participated in the study. The patients spent two blocks in the sleep laboratory. The first block was taken in a headache-free interictal time interval, and the second block when the onset of a migraine attack was most likely. After a nocturnal migraine attack, the patient was asked to mark the maximum of migraine pain in a surface-head scheme. The comparison of preictal and interictal EEGs enabled the authors to obtain a topographical view of changes in cortical dynamics. In each patient map, an area was found that displayed a pronounced focus indicating the region of maximum change in dimensional complexity. It shows a clearly recognizable correspondence with the scalp topography of the later pain perception. These findings indicate an association between cortical status and pain lateralization in the preictal time span.

Migraine

Migraine is a very common neurobiological headache disorder that is caused by increased excitability of the CNS. It ranks among the world's most disabling medical illnesses. Diagnosis is based on the headache's characteristics and associated symptoms. The economic and societal effect of migraine is substantial: it affects patients' quality of life and impairs work, social activities, and family life. There are many acute and preventive migraine treatments. Acute treatment is either specific (triptans and ergots) or non-specific (analgesics). Disabling migraine should be treated with triptans. Increased headache frequency is an indication for preventive treatment. Preventive treatment decreases migraine frequency and improves quality of life. More treatments are being developed, which provides hope to the many patients whose migraines remain uncontrolled.

Therapeutic implications of the modular headache theory

A theoretical approach to understanding the primary headaches not yet classified by the International Headache Society classification system has been developed by the authors. It is proposed that groups of neurons, called modules, become activated to produce each symptom of a primary headache disorder and these modules are linked together to produce a headache. Headaches develop phenotypic stability through the process of learned stereotypy. This theory explains the huge diversity of headache phenomenology. It has implications for the classification, research and treatment of headache patients. The modular headache theory has therapeutic implications by directing us to focus on treatable modules and avoiding unnecessary treatment for less treatable symptoms. This allows for rational approaches to CNS hyperexcitability and incorporates the temporal patterns of modular activation into the patient's treatment plan.

Fibromyalgia, fatigue, and headache disorders

Fibromyalgia, chronic fatigue, and primary headaches are common and debilitating disorders, and their related symptoms of widespread pain, fatigue, and headache have complex interactions and different implications for classification, diagnosis, mechanisms, and treatment. The "continuum" or "spectrum" idea and the modular headache theory are fundamental concepts in understanding these interactions. The overlap between symptom-based conditions leads the reasons to consider them as "functional somatic syndromes." Management of these patients includes a correct diagnosis, appropriate investigation for associated conditions, adequate treatment, and considering the therapeutic opportunities and limitations the comorbid disorders may impose.

Hemicrania continua: recent treatment strategies and diagnostic evaluation

Hemicrania continua (HC) is a primary headache disorder that is characterized by a continuous unilateral headache of moderate severity, exacerbations of severe pain, and complete responsiveness to indomethacin. HC was once thought to be a rare headache disorder, but now many cases have been reported. It is an underecognized headache syndrome. HC can be of continuous or remitting form. Variants such as hemicrania continua with aura have been described, and secondary cases may occur. Indomethacin is the best treatment, although HC could respond to other nonsteroidal anti-inflammatory drugs, such as the selective cyclo-oxygenase-2 inhibitors.

Modular headache theory: a new approach

Many people experience headaches that do not fulfill the International Headache Society's criteria for a specific headache disorder, yet behave biologically like that disorder. Others fulfill criteria for one headache disorder but have features of another. To explain these observations, we propose that groups of neurons, called modules, become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. Headaches develop phenotypic stability through a process referred to as learned stereotypy. This theory has implications for the classification, research, and treatment of primary and secondary headache patients.