Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines

OBJECTIVE

To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC).

DESIGN

Retrospective cohort study.

SETTING

National Collegiate Athletic Association Division III collegiate programs.

PARTICIPANTS

Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023.

INTERVENTION

Preinjury migraines (yes/no) were self-reported by athletes.

MAIN OUTCOME MEASURES

Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores.

RESULTS

Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (β = 0.12, P <0 .001) and greater number of days to symptom evaluation (β = 0.08, P = 0.005) had higher PCSS scores.

CONCLUSIONS

Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.

The World Health Organization Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and the headache revolution: from headache burden to a global action plan for headache disorders

The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

Migraine drugs

According to recent studies, migraine affects more than 1 billion people worldwide, making it one of the world’s most prevalent diseases. Although this highly debilitating illness has been known since ancient times, the first therapeutic drugs to treat migraine, ergotamine (Gynergen) and dihydroergotamine (Dihydergot), did not appear on the market until 1921 and 1946, respectively. Both drugs originated from Sandoz, the world’s leading pharmaceutical company in ergot alkaloid research at the time. Historically, ergot alkaloids had been primarily used in obstetrics, but with methysergide (1-methyl-lysergic acid 1′-hydroxy-butyl-(2S)-amide), it became apparent that they also held some potential in migraine treatment. Methysergide was the first effective prophylactic drug developed specifically to prevent migraine attacks in 1959. On the basis of significantly improved knowledge of migraine pathophysiology and the discovery of serotonin and its receptors, Glaxo was able to launch sumatriptan in 1992. It was the first member from the class of triptans, which are selective 5-HT1B/1D receptor agonists. Recent innovations in acute and preventive migraine therapy include lasmiditan, a selective 5-HT1F receptor agonist from Eli Lilly, the gepants, which are calcitonin gene-related peptide (CGRP) receptor antagonists discovered at Merck & Co and BMS, and anti-CGRP/receptor monoclonal antibodies from Amgen, Pfizer, Eli Lilly, and others.

Graphical abstract

Is Botox Right for Me: When to Assess the Efficacy of the Botox Injection for Chronic Migraine in Pediatric Population

Botulinum toxin type A (BoNT-A) has shown to be a safe and effective treatment for children with chronic migraines. Our study was to assess the efficacy of the Onabotulinum toxin type A at different intervals after initiation of therapy. We conducted a retrospective and prospective analysis of 34 patients at a children's hospital where children received four rounds of the BoNT-A therapy for the treatment of chronic migraine. Among the 34 patients, 25 patients (age range: 13-21 years), who responded to the BoNT-A therapy, were included in the analysis. Patients received standard 31 injection, 155 unit's protocol. Patients were assessed every 3 months after their initial injection. Reasons for discontinuation of therapy were analyzed. After the first two BoNT-A sessions, significant improvement was observed with a decrease in headache frequency and intensity (p < 0.001). There was further reduction in headache frequency and intensity with the fourth round of BoNT-A therapy, with comparative analysis between the second and fourth round showing a p-value of <0.001. In terms of reduction of emergency room visits and hospitalization, a significant improvement was seen after the third round of BoNT-A therapy (p < 0.01). A significant decrease in the number of abortive and preventive medications was seen after the second round of BoNT-A therapy (p < 0.001). The efficacy of BoNT-A treatment in decreasing headache frequency, intensity, and the number of abortive and preventive medications can be assessed effectively after two treatment sessions. This trend continued to be observed with additional third and fourth sessions.

Investigating the Frequency of Infantile Colic in Children with Migraine

Infantile colic is a common problem observed within the first 3 months of life in infants and is a common cause of crying among infants. Migraine is a common cause of recurrent primary headaches during childhood. The pathogenesis of migraine and colic has remained unknown, but various factors seem to be involved. Patients with migraine may have a medical history of infantile colic, and infantile colic is considered an early manifestation of migraine. In this study, we investigate the frequency of history of infantile colic in 6- to 14-year-old children with migraines. In this case–control study, 80 children with the diagnosis of migraine and 100 children without migraine, all within the age range of 6 to 14 years, were included. A checklist was completed for each person about the background information and history of infantile colic as well as the history of migraine in parents. Among the children with migraine, 92.5%, and in the control group, 10%, had a familial history of migraine. Also, among the children with migraine, 61.25%, and in the control group, 4%, had a history of infantile colic. The obtained results showed that the frequency of a history of infantile colic was significantly higher in the case group than in the control group. This study provides some evidence regarding the presence of association between infantile colic as well as the familial history of migraines and developing migraines in the future. However, due to some limitations of the retrospective manner of the study, the results should be completed with future studies.

Individual differences of maladaptive brain changes in migraine and their relationship with differential effectiveness of treatments

Migraine is a difficult disorder to identify with regard to its pathophysiological mechanisms, and its treatment has been primarily difficult owing to interindividual differences. Substantial rates of nonresponsiveness to medications are common, making migraine treatment complicated. In this review, we systematically analyzed recent studies concerning neuroimaging findings regarding the neurophysiology of migraine. We linked the current imaging research with anecdotal evidence from interindividual factors such as duration and pain intensity of migraine, age, gender, hormonal interplay, and genetics. These factors suggested the use of nonpharmacological therapies such as transcranial magnetic stimulation, transcranial direct current stimulation, and placebo therapy for the treatment of migraine. Finally, we discussed how interindividual differences are related to such nondrug treatments.

Benign paroxysmal torticollis, benign paroxysmal vertigo, and benign tonic upward gaze are not benign disorders

AIM

Benign paroxysmal torticollis (BPT), benign paroxysmal vertigo (BPV), and benign tonic upward gaze (BTU) are characterized by transient and recurrent episodes of neurological manifestations. The purpose of this study was to analyse the clinical relationships between these syndromes, associated comorbidities, and genetic bases.

METHOD

In this cross-sectional study, clinical data of patients with BPT, BPV, or BTU were collected with a focus on developmental achievements, learning abilities, and rehabilitation. Neuropsychological assessment and genetic testing were performed.

RESULTS

Fifty patients (median age at inclusion 6y) were enrolled. Psychomotor delay, abnormal neurological examination, and low or borderline IQ were found in 19%, 32%, and 26% of the patients respectively. Cognitive dysfunction was present in 27% of the patients. CACNA1A gene mutation was identified in eight families, and KCNA1 and FGF14 mutation in one family respectively. The identification of a CACNA1A mutation was significantly associated with BTU (p=0.03) and with cognitive dysfunction (p=0.01). Patients with BPV were less likely to have cognitive dysfunction.

INTERPRETATION

Children with BPT, BPV, or BTU are at high risk of impaired psychomotor and cognitive development. These syndromes should not be regarded as benign and should be considered as part of the spectrum of a neurodevelopmental disorder.

WHAT THIS PAPER ADDS OK

Patients with benign paroxysmal torticollis (BPT), benign paroxysmal vertigo (BPV), and benign tonic upward gaze (BTU) have an increased risk of psychomotor delay. These patients also have an increased risk of abnormal neurological examination and cognitive dysfunction. Gene mutations, especially in CACNA1A, were identified in 21% of the families. BPT, BTU, and BPV should not be regarded as benign. BPT, BTU, and BPV should be considered as part of the spectrum of a neurodevelopmental disorder.

Neurological comorbidity in children with neurofibromatosis type 1

BACKGROUND

The aim of this study was to determine the frequency of central nervous system comorbidities in children with neurofibromatosis type 1 (NF1).

METHODS

We performed a nationwide survey to investigate neurological comorbidities in 3-15-year-old children with NF1 in Japan by sending questionnaires to pediatricians and pediatric neurologists. A secondary questionnaire was sent to the parents of identified NF1 patients to assess neurological comorbidities including headache, attention deficit-hyperactivity disorder (ADHD) Rating Scale (RS), and the Social Responsiveness Scale 2.

RESULTS

The primary survey identified 760 NF1 patients, and the parents of 565 patients were sent the secondary questionnaire. The parental response rate was 25.7% (145; 63 girls, 81 boys, one unspecified). Among the patients, 42.9% (55/128; 35 girls, 20 boys) were reported to exhibit intellectual problems. On the ADHD-RS, 40.2% (47/117) of NF1 patients aged 6-15 had ADHD (RS score >93rd percentile), with a rate of 47.7% in boys and 30.8% in girls. Furthermore, 20.2% of patients had suspected autism spectrum disorder (29/143; 10 girls, 19 boys), with Social Responsiveness Scale score ≥76. Headache was reported by 49.6% (61/123) of children over 5 years old, and 25.2% (31/123; 10 girls, 21 boys) reported migraine. Other neurological comorbidities included 20 cases of epilepsy (13.8%), 11 cases of optic nerve glioma (7.6%), five cases of brain tumor (3.4%), six cases of cerebrovascular disease (4.1%), and two cases of hydrocephalus (1.4%).

CONCLUSION

Intellectual problems, ADHD, autism spectrum disorder, and migraine are major neurological comorbidities in NF1.

Considerations for ADHD in the child with epilepsy and the child with migraine

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a common comorbid condition in children with epilepsy and migraine. Treatment of ADHD in children with epilepsy or migraine is essential but clinicians may overlook symptoms of ADHD and avoid appropriate use of medications that may reduce symptoms of ADHD without compromising treatment of epilepsy or migraine. Areas covered: PubMed was searched for articles on ADHD and epilepsy or migraine. Key papers were reviewed for additional articles. Areas of interest were: epidemiology, etiological factors, and treatment with emphasis on therapy. Expert commentary: Stimulant medication, especially methylphenidate, appears to be safe and effective in the treatment of ADHD in children with epilepsy or migraine. Unfortunately, data is limited with very few controlled trials of methylphenidate and very limited information on the use of amphetamines or non-stimulant drugs.

The Childhood and Adolescent Migraine Prevention (CHAMP) Study: A Report on Baseline Characteristics of Participants

OBJECTIVE

To describe baseline headache characteristics of children and adolescents participating in a multicenter, randomized, double-blinded, placebo-controlled, comparative effectiveness study of amitriptyline, topiramate, and placebo for the prevention of migraine (CHAMP Study).

METHODS

Children and adolescents (age 8-17 years old, inclusive) diagnosed with migraine with or without aura, having headaches at least four times per month were enrolled from 2012 through 2014. The trial involved a baseline period (minimum of 28 days) during which prospective diaries were completed and demographics and headache features obtained.

RESULTS

A total of 488 children and adolescents (mean age 14.0 ± 2.4 years) agreed to participate in the trial, with 361 randomized and 127 not randomized. Randomized subjects had a 5.5 ± 3.1 year history of headaches, with 15.1 ± 7.1 headache days per month (based upon retrospective report at screening visit). Prospective diaries reported 11.5 ± 6.1 headache days per 28 day baseline. Across this 28 day period, reported headache days per week were stable (about 3 headache days per week). Recording of individual headache features by diary (n = 4136 headache days) showed characteristics consistent with migraine (mean duration 10.5 ± 8.1 hours, mean severity 6.0 ± 2.1, 60% throbbing, 55% with activity worsening headaches, 55% with photophobia, and 47% with phonophobia).

CONCLUSIONS

Baseline data from the CHAMP Study suggested that the randomized sample was representative of the real world population of children and adolescents that present for treatment of migraine. Headaches in children and adolescents recorded during a 28 day prospective baseline period in this multi-site comparative effectiveness study did not change over the course of the baseline period, even though a clear diagnosis, recommendation for effective acute treatment, and standardized education about healthy habits occurred prior to the diary collection period.

[Gluten migraine]

OBJECTIVE

to study the prevalence of migraine among patients with celiac disease (CD) and clinical features of «gluten migraine» syndrome and to assess the efficacy of gluten diet in its treatment.

MATERIAL AND METHODS

Authors examined 200 CD patients (main group) and 100 patients with reflux esophagitis and without CD (control group). All patients fulfilled the headache diary during three months before the diagnosis of migraine was made and six months during gluten diet.

RESULTS AND CONCLUSION

CD group had migraine syndrome four times more often than the control group (48.5%; p<0.001). In CD group migraine attacks were 2.5 times more frequent than in the control group (р=0.004), but the duration of the attacks was less long, 8 hours in average. The migraine attacks measured by the Visual Analog Scale were less intensive, 55% in average, and had a later onset. The attacks were more frequent in CD patients who were older than 50 years old (р<0.05). The attacks disappeared in 25% of patients with migraine syndrome who were on the gluten diet and the reduction in the intensity and/or frequency of attacks was observed in 38% of patients. We revealed the clear association between migraine syndrome and CD and the high efficacy of gluten diet in the treatment of migraine symptoms.

Epidemiological and clinical features of migraine in the pediatric population of Northern Italy

Aim

The aim of this article is to analyze the epidemiological and clinical features of migraine in a pediatric headache center.

Methods

A retrospective study was performed over six years. Hospital record databases were screened for the diagnosis of migraine with aura (MA) or without aura (MO), based on the ICHD-II criteria. Statistical analysis: Fisher’s test or Mann-Whitney U test, significance at p < 0.05.

Results

Migraine was diagnosed in 495 children (29.7% MA, 70.3% MO). The majority of diagnoses were made between ages 9 and 14 years. After stratification for age into five groups, we observed an increase of diagnoses in females, with a peak after the age of 15 years, and an increase of MA. In both groups, the attacks were usually severe, infrequent (<1–3/month) lasting <2 hours, and associated with nausea/vomiting, photophobia, phonophobia (more frequent in MO). Osmophobia was reported in 24.7% of the patients with MO. Dizziness was more frequent in patients with MA. Visual auras were the most common occurrence (87.1%). Confusional state was observed in 10.88% of the patients. A positive family history of headache was observed in >88% of the patients.

Conclusion

We describe the characteristics of pediatric migraine based on the ICHD-II criteria, showing a likely significant loss of diagnoses using the ICHD-III beta. The incidence of migraine increases with age. MO occurs more commonly and shows more frequent attacks and a higher prevalence of associated symptoms, in particular osmophobia. Although males are prevalent in the entire sample, the proportion of females is higher among patients with MA in all of the age groups. Phenotype and sexual prevalence of migraine acquire adult characteristics and become more frequent in females from the onset of puberty.

Prevalence and disability of headache among Norwegian adolescents: A cross-sectional school-based study

Background

Headache is common in adolescents and affects schoolwork and relations with friends and family. In most previous epidemiological surveys, only the most bothersome headache has been documented. The aim was to determine headache prevalence not only taking into account the most bothersome headache, but also to compare characteristics of the most bothersome and less bothersome headaches, and to investigate headache-related disability.

Methods

A cross-sectional school-based study was conducted in which 493 representative adolescents aged 12–18 years were recruited by stratified cluster sampling and interviewed. Headache diagnosis was made according to the new classification system of the International Headache Society (ICHD-3 beta), and the Pediatric Migraine Disability Assessment (PedMIDAS) was used to evaluate disability.

Results

The one-year prevalence of any headache type, definite migraine, probable migraine and tension-type headache was 88%, 23%, 13% and 58%, respectively. The point prevalence of any headache was 38%. Nine percent of participants fulfilled criteria for more than one headache diagnosis. The most bothersome headache had a significantly longer duration ( p < 0.001) and higher intensity ( p < 0.001) than the less bothersome headache, but similar frequency ( p = 0.86). Adolescents with headaches lost up to nine days of activity each year, implicating headache as a major health issue.

Conclusions

Headaches are very common and disabling among adolescents. The full extent of this health problem is better appreciated if inquiry is not limited to the most bothersome subtypes.

The McMaster Pediatric Migraine Questionnaire: a prospective validation study

OBJECTIVE

Migraine affects approximately 4%-11% of elementary school children; yet reaching a diagnosis in this age group can be challenging. The goal of this study was to develop a screening migraine questionnaire that could be easily implemented by a general pediatrician and validate its use in diagnosing migraine in children 5-12 years old.

METHODS

A questionnaire, the McMaster Migraine Tool, was developed using the International Classification of Headache Disorders-II criteria for migraine. The validity of the questionnaire was assessed by comparing the diagnosis based on the results of the questionnaire compared with the diagnosis made by a pediatric neurologist.

RESULTS

The questionnaire was used to assess a cohort of 69 children referred to the Pediatric Neurology Clinic for headache. The sensitivity and specificity of the McMaster Migraine Tool were determined to be 84% and 69%, respectively. Families graded its ease of use to be 9 of 10 (10 being easy to use).

CONCLUSION

The McMaster Migraine Tool may be useful in diagnosing migraine in 5-12-year-old children, as it is readily completed and regarded as easy to use. Application of this tool could lead to expedited diagnosis and management of migraine.

Examining a possible association between human papilloma virus (HPV) vaccination and migraine: results of a cohort study in the Netherlands

Since the introduction of the bivalent human papilloma virus (HPV) vaccine in the Netherlands, migraine has been reported as a notable event in the passive safety surveillance system. Research on the association between HPV vaccination and migraine is needed. Therefore, potential migraine cases in 2008-2010 were selected from a group of general practitioners and linked to the vaccination registry. Data were analysed in three ways: (i) incidences of migraine postvaccination (2009/2010) were compared to pre-vaccination incidences (2008); (ii) in a cohort, incidence rates of migraine in vaccinated and unvaccinated girls were compared and (iii) in a self-controlled case series analysis, the relative incidence of migraine in potentially high-risk periods was compared to non-high-risk periods. Incidence rates of migraine for 12- to 16-year-old girls and boys postvaccination were slightly higher than pre-vaccination incidence rates. Incidence rate ratios (IRRs) for vaccinated compared to unvaccinated girls were not statistically significantly higher. Furthermore, the RR for migraine in the high-risk period of 6 weeks following each dose versus non-high-risk period was 4.3 (95% confidence interval (CI) 0.69-26.6) for certain migraine.

CONCLUSION

Using different methods, no statistically significant association between HPV vaccination and incident migraine was found. However, the number of cases was low; to definitively exclude the risk, an increased sample size is needed.

Migraine is frequent in children and adolescents with neurofibromatosis type 1

BACKGROUND

Despite the high prevalence of headache in patients with neurofibromatosis type 1 (NF1), little data exist regarding the classification and characterization of headaches experienced by these patients. This paper describes a study of headache in patients with NF1 compared with healthy controls.

METHODS

In this transversal study, participants (aged 4-19 years) were classified into two groups: NF1 patients or control subjects. The diagnosis of NF1 was performed according to the diagnostic criteria of the National Institutes of Health Consensus Conference, and the headache diagnosis was performed according to the diagnostic criteria of the International Classification of Headache Disorders, Second Edition. All participants underwent physical and neurologic evaluation and completed a detailed headache questionnaire.

RESULTS

The comparison of 50 patients with NF1 and 50 age-matched controls revealed that the complaint of headache was significantly more frequent in the NF1 group than in the control group (CG) (62% vs 14%, χ(2)(1) = 22.4; P < 0.001). Migraine was significantly more frequent in patients with NF1 than in the CG (54% vs 14%, χ(2)(1) = 17.82; P < 0.001). No differences were found between the two groups regarding the use of simple analgesics (NF1: 14% vs CG: 5%, χ(2)(1) = 1.18; P = 0.276).

CONCLUSIONS

Children and adolescents with NF1 are prone to migraines. Complaints of headache are very frequent in this population.

The associations between preexisting mental disorders and subsequent onset of chronic headaches: a worldwide epidemiologic perspective

Although there is a significant association between preexisting depression and later onset of chronic headache, the extent to which other preexisting mental disorders are associated with subsequent onset of headache in the general population is not known. Also unknown is the extent to which these associations vary by gender or by life course. We report global data from the WHO's World Mental Health surveys (n = 52,095), in which, by means of the Composite International Diagnostic Interview-3.0, 16 mental disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were retrospectively assessed in terms of lifetime prevalence and age of onset. Frequent or severe headaches were assessed using self-reports. After adjustment for covariates, survival models showed a moderate but consistent association between preexisting mood (odds ratios [ORs] = 1.3-1.4), anxiety (ORs = 1.2-1.7), and impulse-control disorders (ORs = 1.7-1.9) and the subsequent onset of headache. We also found a dose-response relationship between the number of preexisting mental disorders and subsequent headache onset (OR ranging from 1.9 for 1 preexisting mental disorder to 3.4 for ≥5 preexisting mental disorders). Our findings suggest a consistent and pervasive relationship between a wide range of preexisting mental disorders and the subsequent onset of headaches. This highlights the importance of assessing a broad range of mental disorders, not just depression, as specific risk factors for the subsequent onset of frequent or severe headaches.

PERSPECTIVE

This study shows that there is a temporal association between a broad range of preexisting mental disorders and the subsequent onset of severe or frequent headaches in general population samples across the world.

Specific Triggers of Migraine Headache in Adolescents

AIM: Purpose of the study was to recognize specific migraine triggers in adolescents.MATERIAL AND METHODS: Study was conducted on 20,917 adolescents in Serbia.RESULTS: Lack of sleep, passive tobacco smoking, alcohol intakes, and "not eating in time" are triggers that provoke migraine in adolescents.CONCLUSION: Avoiding migraine triggers in 68% of adolescents reduced drug therapy for 75%.

The evolution of headache from childhood to adulthood: a review of the literature

Headache is one of the most common disorders in childhood, with an estimated 75% of children reporting significant headache by the age of 15 years. Pediatric migraine is the most frequent recurrent headache disorder, occurring in up to 28% of older teenagers. Headaches rank third among the illness-related causes of school absenteeism and result in substantial psychosocial impairment among pediatric patients. The aim of this study was to clarify the evolution of the clinical features of primary headache in the transition from childhood to adulthood through a review of relevant data available in the PubMed and Google Scholar databases for the period 1988 to July 2013.The search strategy identified 15 published articles which were considered eligible for inclusion in the analysis (i.e., relevant to the investigation of pediatric headache outcome). All were carried out after the publication of the first version of the International Classification of Headache Disorders (ICHD-I). The availability of data on the evolution of primary headaches over a period of time is important from both a clinical and a public health perspective. The identification of prognostic factors of the evolution of headache (remission or evolution into another headache form) over time should be an objective of future headache research for the development of prevention strategies. Given that headache is a major factor contributing to school absenteeism and poorer quality of life not only in childhood but also in adolescence, understanding the natural history and the management of the different headache forms is vital for our future.

Diagnosis of migraine in the pediatric emergency department

BACKGROUND

Migraine criteria lack sensitivity in children and are not designed to be used in the emergency department. This study's aim was to compare the diagnosis of migraine in children with moderate to severe headache made by pediatric emergency physicians to the International Classification of Headache Disorders II migraine criteria with annotation for children and a new criteria, the Irma emergency department criteria, using the neurologist's diagnosis as the gold standard.

METHODS

This was part of a prospective study with a convenience sample of patients <18 years old, diagnosed with migraine by pediatric emergency physicians and treated with intravenous medication due to severity of symptoms. A standardized questionnaire on the patient's present and past headaches description was completed by the patient and his or her family during their stay in the emergency department. Each patient was assessed by a pediatric neurologist within 3 months to confirm the final diagnosis.

RESULTS

Between July 2007 and July 2009, 79 children completed a questionnaire. Of these, 11 were not evaluated by the neurologist (eight never reported for follow-up and three were not referred). Of the remaining, four had another final diagnosis, leaving 64 (94%) patients with confirmed diagnoses of migraine. Among these patients, 29 (45%) had headaches that fulfilled the International Classification of Headache Disorders II migraine criteria with annotation for children and 55 (86%) fulfilled the new criteria, the Irma emergency department criteria.

CONCLUSIONS

Physicians' clinical judgment performed better than the published migraine criteria, which did not have adequate sensitivity to be of use to pediatric emergency physicians.

Adolescents with chronic migraine commonly exhibit depressive symptoms

Psychiatric comorbidity in patients with headache contributes to poorer prognosis, chronification of disease, poor response to treatment, increased cost of treatment, and decreased quality of life. The purpose of the present study was to evaluate the depressive symptoms in adolescents with chronic and episodic migraines and healthy adolescents. The study was performed between November 2010 and November 2011. All patients completed a detailed headache questionnaire comprising of demographical and clinical data and were instructed to fill out a headache diary over a 2-month period. The subjects ranged in age from 13 to 19 years. To evaluate depression symptoms, all of the subjects were asked to fill out the Beck Depression Inventory (BDI). A total of 137 participants were evaluated; 44 had episodic migraine (EM), 46 had chronic migraine (CM) and 47 were control subjects. Patients with a history of chronic migraine had significantly higher scores on the BDI than the other participants. Patients with chronic migraine had BDI scores that were 8.8 points higher than controls [95 % CI (β) = 5.0, 12.6] and 5.8 points higher than patients with EM [95 % CI (β) = 2.2, 9.4]. The main finding of this study was that chronic migraine is strongly associated with depression symptoms, regardless of demographic data. Comorbid depression may increase the total burden of migraine and diagnosis and treatment of depression in adolescents with migraine is likely to result in a better prognosis.

Chronic daily headache in children and adolescents: science and conjecture

SUMMARY Chronic daily headache comprises a group of headache disorders in which headaches occur almost daily or continuously over several months. Although chronic daily headache is one of the most common chronic pain disorders in pediatrics, data on pathophysiological mechanisms and relative efficacy of treatments remain sparse. In this review, we aim to provide contemporary information on classification, epidemiology, etiology and treatment of pediatric chronic daily headache based on extant empirical data when available, or general consensus in the field when not.

Clinical correlates and diagnostic utility of osmophobia in migraine

Background: Osmophobia is an under-investigated associated symptom in migraine.

Objective: To evaluate the clinical correlates and diagnostic utility of osmophobia.

Methods: Adult patients with migraine (with or without aura), probable migraine (PM), tension-type headache (TTH), and cluster headache (CH) were recruited retrospectively from our headache registration system. Migraine patients with and without osmophobia were compared. The newly proposed criteria for migraine requiring at least two of photo-, phono-, or osmophobia instead of both photo- and phonophobia were validated.

Results: In total, 2883 patients were included: 1809 migraine, 792 PM, 138 TTH, and 144 CH. Osmophobia was more common in migraine (62.2%) than in PM (33.8%), TTH (14.5%), and CH (31.3%) (all p < 0.001). Migraine patients with osmophobia scored higher on the Hospital Anxiety and Depression Scale (HADS) than those without (15.6 ± 7.6 vs. 13.3 ± 7.8, p < 0.001). The concordance in headache diagnoses between ICHD-2 (International Classification of Headache Disorders, Second Edition) and the newly proposed criteria was “almost perfect” (κ = 0.886, p < 0.001). Additionally, 16.9% of ICHD-2 PM patients were reclassified as migraine using the newly proposed criteria.

Conclusions: Osmophobia was prevalent in migraineurs, and was associated with higher HADS scores. The newly proposed criteria appear comparable to the ICHD-2 criteria, and may increase the diagnostic yield for Asian migraineurs, among whom photophobia was less common.

Understanding migraine through the lens of maladaptive stress responses: a model disease of allostatic load

The brain and body respond to potential and actual stressful events by activating hormonal and neural mediators and modifying behaviors to adapt. Such responses help maintain physiological stability ("allostasis"). When behavioral or physiological stressors are frequent and/or severe, allostatic responses can become dysregulated and maladaptive ("allostatic load"). Allostatic load may alter brain networks both functionally and structurally. As a result, the brain's responses to continued/subsequent stressors are abnormal, and behavior and systemic physiology are altered in ways that can, in a vicious cycle, lead to further allostatic load. Migraine patients are continually exposed to such stressors, resulting in changes to central and peripheral physiology and function. Here we review how changes in brain states that occur as a result of repeated migraines may be explained by a maladaptive feedforward allostatic cascade model and how understanding migraine within the context of allostatic load model suggests alternative treatments for this often-debilitating disease.

Sex differences in the inflammatory mediator-induced sensitization of dural afferents

Approximately 20% of the adult population suffers from migraine. This debilitating pain disorder is three times more prevalent in women than in men. To begin to evaluate the underlying mechanisms that may contribute to this sex difference, we tested the hypothesis that there is a sex difference in the inflammatory mediator (IM)-induced sensitization of dural afferents. Acutely dissociated retrogradely labeled dural afferents from adult Sprague-Dawley rats were examined with whole cell patch-clamp recordings. Baseline passive and active electrophysiological properties of dural afferents from both sexes were comparable. However, while IM-induced increases in the excitability of dural afferents from male and female rats were also comparable, the proportion of dural afferents from female rats sensitized by IM (~100%) was significantly greater than that of dural afferents from male rats (~50%). This appeared to be due to differences downstream of IM receptors, as tetrodotoxin-resistant sodium current was increased by IM in a majority of male dural afferents (13/14). These data indicate that there are both quantitative and qualitative differences in the IM-induced sensitization of dural afferents that may contribute to the sex difference in the manifestation of migraine.