[Clinical and diagnostic criteria and differential diagnosis in the first and second stages of the development of Ménière's disease - A modern view of the problem]

The results of a comprehensive examination of 82 patients with clinical signs of definite Ménière's disease, unilateral lesion and confirmed by extratympanic electrocochleography endolymphatic hydrops are presented. The results of the study showed that only 38% of patients had cochleovestibular syndrome due to Ménière's disease. In 45% of patients, Ménière's disease was combined with other diseases: benign paroxysmal positional vertigo, vestibular migraine, persistent postural-perceptual dizziness, superior semicircular canal dehiscence. In 17% of patients cochleovestibular syndrome was due to other reasons: vestibular migraine, tumor of the posterior cranial fossa, superior canal dehiscence syndrome, Cogan's syndrome, enlarged vestibular aqueduct, otosclerosis. Complaints, medical history of the disease and life, brain MRI, temporal bone CT and pure tone audiometry in dynamics are important in suspected Ménière's disease. For 1 and 2 Ménière's disease stages the most important characteristic are: progressive unilateral sensorineural hearing loss and reduced slow faze velocity values of caloric nystagmus in dynamics, mainly in warm response if attacks of vertigo is maintain; normal head impulse test between vertigo attacks and pathological result of this test in attack of vertigo with the normalization of gain during the first day.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Migraine pharmacology and brain ischemia

Introduction: The aim of this review article was to analyze in details the mechanism of drugs’ effects in the treatment and prevention of a migraine attack, as well as to discuss the hypotheses of migraine pathogenesis.

Migraine attack treatment agents: The main agents for migraine attack treatment have an anti-nociceptive activity.

Agents for migraine preventive treatment: β-blocker propranolol also has anti-serotonin and analgesic activities, and most drugs used for the prophylactic treatment of migraine have a vasodilating activity.

Vascular hypothesis of migraine pathogenesis: Despite numerous studies that have expanded our understanding of migraine pathogenesis, the importance of the vascular component in the pathogenesis of this disease has not questioned yet.

Neurogenic hypotheses of cortical spreading depression: It is necessary to take into account the points of this hypothesis in the context of the pathophysiology of migraine.

Neurochemical serotonin hypotheses of migraine pathogenesis: Serotonin plays an important role in the pathogenesis of migraine.

Trigemino-vascular hypotheses of migraine pathogenesis: The trigemino-vascular hypothesis claims to solve the problem of migraine pain.

Migraine and ischemic brain damage: Migraine is a risk factor for ischemic stroke and cognitive disorders.

Search for the new anti-ischemic anti-migraine preparations: A methodology for the search for new anti-ischemic anti-serotonin drugs for the treatment of migraine is proposed.

Conclusion: Belonging of a drug to one or another pharmacological group does not always correspond to its therapeutic effect on the pathogenetic processes of migraine. Migraine with its variety of forms cannot fit only one of the proposed hypotheses on the pathogenesis of this disease.

Graphical abstract:

[The Second Short Form of the McGill Pain Questionnaire as the useful additional tool for differential diagnostics of migraine and cervicogenic headache]

OBJECTIVE

To study the effectiveness of the Second Short Form of the McGill Pain Questionnaire (SF-MPQ-2) as an instrument for assessment and comparison of quantitative characteristics of pain in patients with chronic musculoskeletal impairment of the cervical spine and nonspecific neck pain accompanied by chronic migraine or cervicogenic headache (CeH).

MATERIAL AND METHODS

Forty-nine patients, aged from 19 to 60 years (mean age 42.8±10.4), were divided into 2 comparable by age and gender groups with migraine (n=18) and CeH (n=31). Neck pain and headache intensity was measured by the 11-points Numerical Rating Scale (NRS). Quality of pain and related symptoms were measured by SF-MPQ-2. Multidisciplinary and multimodal approaches were applied for treatment, including several modalities of manual therapy.

RESULTS

Headache intensity was higher in the migraine group in comparison with the CeH group (7.8±1.7 vs 6.0±1.5, respectively; p<0.05). No significant differences in neck pain intensity were found (6.2±1.8 vs 5.3±1.7; p=0.08). Patients with migraine usually chose more descriptors than patients with CeH (14 vs 4, respectively) and higher range of their intensity (p<0.001). By the end of treatment session, the number of descriptors and their intensity decreased significantly on all SF=MPQ-2 scales (p<0.001) in both groups. Most patients of migraine and CeH group were satisfied with treatment (83% and 97%, respectively) and marked «much improved» and «very much improved» on the 7-point Patient Global Impression of Change scale.

CONCLUSION

SF-MPQ-2 is a useful tool for differential diagnosis of migraine and CeH, as it contains the sufficient number of descriptors and the scale for measuring their intensity.

[Migraine burden and clinical inertia: what can we do?]

AIM

To study the compliance of neurologists and headache specialists to chronic headache and chronic migraine (CM) diagnosis and treatment guidelines.

MATERIAL AND METHODS

The survey included 634 neurologists from all regions of the Russian Federation. Mean age of respondents was 40.7±8.5 years, mean years of experience 14.2±7.8 years.

RESULTS

Most doctors work in outpatient or hospital settings (49% and 24%, respectively), 7% were headache specialists. Tension-type headache (TTH) was diagnosed in 30% and CM in 17% of patients while 44% of patients were presumed to have a mixed headache disorder (TTH+CM). Only 10% of physicians do not use instrumental diagnostic methods in chronic headache. This study has shown sufficient attention to comorbid conditions and frequent prescription of headache preventative treatment. Botox prescription data is equivocal: 35% of physicians recommend such treatment, 27% do not, while other doctors prescribe it for off-label indications.

CONCLUSION

To overcome clinical inertia, further education in chronic headaches and their optimal treatment is warranted.

Internal hernia as one of the causes of abdominal pain

Abdominal pain is often observed in clinical practice, causing diagnostic difficulties for doctors of different specialties. Internal hernias are a surgical pathology and may be the cause for the development of acute small bowel obstruction and the occurrence of pain. A modern classification of internal hernias is presented and their topographic-anatomical description is given. The analysis of the results of computed tomography (CT) scan of the abdominal cavity in 20 patients with an unidentified cause of abdominal pain was performed. According to the CT data, three patients had internal hernias that caused the development of pain syndrome. A pathological displacement of intestinal loops with partial disruption of intestinal permeability and curvature of the mesentery without critical disturbance of blood supply was demonstrated in 4 patients with abdominal pain. The findings suggest that CT may be the method of choice when examining patients with an unknown cause of abdominal pain syndrome.

[Real-world migraine burden: clinical and economic aspects]

AIM

To evaluate the rationale for different approaches to preventive chronic migraine (CM) treatment by comparing clinical outcomes and financial burden of the disease in the real-world practice.

MATERIAL AND METHODS

Sixty-six patients with CM were enrolled at the Alexander Vein Headache Clinic (60 women and 6 men, aged 28-51). All patients were divided into 3 groups: group 1 (n=22) received oral preventative treatment with topiramate, up to 100 mg daily, for three months; group 2 (n=20) received 12 acupuncture sessions (3 sessions a week); group 3 (n=24) received 155-195 units of botulinum toxin type A (botox, BTA). The follow-up period in all groups was 3 months. Efficacy was evaluated by clinical examination, the Headache Impact Test (HIT-6) and questionnaires to assess subjective patient satisfaction and treatment tolerability.

RESULTS

BTA demonstrated the highest efficacy in this study. Compared to the oral preventative treatment and acupuncture, BTA reduced the frequency of headache faster and more significantly facilitating CM transformation into episodic migraine (headache frequency was 16.1±0.1; 18.0±0.02; and 13.9±0.3 in groups 1, 2 and 3, respectively, after one month of treatment). BTA also improved the quality of life faster and more significantly and was better tolerated (good - 51%, 75% and 85% in groups 1, 2 and 3, respectively; satisfactory - 35%, 25% and 15% in groups 1, 2 and 3, respectively; bad 14% in the oral prevention group). In the BTA group, the majority of patients demonstrated earlier treatment satisfaction. Despite higher (compared to topiramate) direct costs in the BTA group (RUB 29 931.51 and RUB 32 085.87, respectively), the predicted cost of a headache-free day was the smallest and totaled RUB 652.15 (compared to RUB 692.86 and RUB 1017.60 in the topiramate and acupuncture groups, respectively).

CONCLUSION

The data on the efficacy and costs of different CM prevention strategies would facilitate optimal treatment choice for neurologists and patients.

[Migraine in women: clinical and therapeutical aspects]

Migraine is one of the most common neurological disorders, affecting women. Physiological changes in the hormonal status can modulate the functional status of pain and analgesic systems of the brain and, by involving different pathophysiological mechanisms, change the course of migraine. In addition to an analysis of epidemiological data, the review provides current views on the clinical features of the disease in women population at different periods of life, particular attention was focused on menstrual migraine. It has certain features, such as acute and long attacks and treatment difficulties. One of main issues is the use of oral contraceptives in women with migraine according to the ratio of potential benefit to cardiovascular risk. The problems of treatment headaches in pregnant and breastfeeding women are also considered. An influence of migraine on the course and outcome of pregnancy was shown. The authors analysed the results of the studies on the course of migraine during perimenopause and postmenopause and recommendations for women with migraine attacks and climacteric syndrome. The data presented in the review are useful for clinicians, because this information represents new views on pathogenetic mechanisms, clinical features and treatment of migraine in women.