Role of Diet in Stem and Cancer Stem Cells

Diet and lifestyle factors greatly affect health and susceptibility to diseases, including cancer. Stem cells’ functions, including their ability to divide asymmetrically, set the rules for tissue homeostasis, contribute to health maintenance, and represent the entry point of cancer occurrence. Stem cell properties result from the complex integration of intrinsic, extrinsic, and systemic factors. In this context, diet-induced metabolic changes can have a profound impact on stem cell fate determination, lineage specification and differentiation. The purpose of this review is to provide a comprehensive description of the multiple “non-metabolic” effects of diet on stem cell functions, including little-known effects such as those on liquid-liquid phase separation and on non-random chromosome segregation (asymmetric division). A deep understanding of the specific dietetic requirements of normal and cancer stem cells may pave the way for the development of nutrition-based targeted therapeutic approaches to improve regenerative and anticancer therapies.

Medium-chain acyl CoA dehydrogenase protects mitochondria from lipid peroxidation in glioblastoma

Glioblastoma (GBM) is highly resistant to chemo- and immune-based therapies and targeted inhibitors. To identify novel drug targets, we screened orthotopically implanted, patient-derived glioblastoma sphere-forming cells (GSCs) using an RNAi library to probe essential tumor cell metabolic programs. This identified high dependence on mitochondrial fatty acid metabolism. We focused on medium-chain acyl-CoA dehydrogenase (MCAD), which oxidizes medium-chain fatty acids (MCFAs), due to its consistently high score and high expression among models and upregulation in GBM compared to normal brain. Beyond the expected energetics impairment, MCAD depletion in primary GBM models induced an irreversible cascade of detrimental metabolic effects characterized by accumulation of unmetabolized MCFAs, which induced lipid peroxidation and oxidative stress, irreversible mitochondrial damage, and apoptosis. Our data uncover a novel protective role for MCAD to clear lipid molecules that may cause lethal cell damage, suggesting that therapeutic targeting of MCFA catabolism could exploit a key metabolic feature of GBM.

HMGA1 negatively regulates NUMB expression at transcriptional and post transcriptional level in glioblastoma stem cells

Glioblastoma (GBM) is a lethal, fast-growing brain cancer, affecting 2-3 per 100,000 adults per year. It arises from multipotent neural stem cells which have reduced their ability to divide asymmetrically and hence divide symmetrically, generating increasing number of cancer stem cells, fostering tumor growth. We have previously demonstrated that the architectural transcription factor HMGA1 is highly expressed in brain tumor stem cells (BTSCs) and that its silencing increases stem cell quiescence, reduces self-renewal and sphere-forming efficiency in serial passages, suggesting a shift from symmetric to asymmetric division. Since NUMB expression is fundamental for the fulfillment of asymmetric division in stem cells, and is lost or reduced in many tumors, including GBM, we have investigated the ability of HMGA1 to regulate NUMB expression. Here, we show that HMGA1 negatively regulates NUMB expression at transcriptional level, by binding its promoter and counteracting c/EBP-β and at posttranscriptional level, by regulating the expression of MSI1 and of miR-146a. Finally, we report that HMGA1 knockdown-induced NUMB upregulation leads to the downregulation of the NOTCH1 pathway. Therefore, the data reported here indicate that HMGA1 negatively regulates NUMB expression in BTSCs, further supporting HMGA1 targeting as innovative and effective anti-cancer therapy.

p53 Is a Master Regulator of Proteostasis in SMARCB1-Deficient Malignant Rhabdoid Tumors

Alterations in chromatin remodeling genes have been increasingly implicated in human oncogenesis. Specifically, the biallelic inactivation of the SWI/SNF subunit SMARCB1 results in the emergence of extremely aggressive pediatric malignancies. Here, we developed embryonic mosaic mouse models of malignant rhabdoid tumors (MRTs) that faithfully recapitulate the clinical-pathological features of the human disease. We demonstrated that SMARCB1-deficient malignancies exhibit dramatic activation of the unfolded protein response (UPR) and ER stress response via a genetically intact MYC-p19^ARF-p53 axis. As a consequence, these tumors display an exquisite sensitivity to agents inducing proteotoxic stress and inhibition of the autophagic machinery. In conclusion, our findings provide a rationale for drug repositioning trials investigating combinations of agents targeting the UPR and autophagy in SMARCB1-deficient MRTs.

HMGA1 silencing reduces stemness and temozolomide resistance in glioblastoma stem cells

OBJECTIVE

Glioblastoma multiforme (GBM) develops from a small subpopulation of stem-like cells, which are endowed with the ability to self-renew, proliferate and give rise to progeny of multiple neuroepithelial lineages. These cells are resistant to conventional chemo- and radiotherapy and are hence also responsible for tumor recurrence. HMGA1 overexpression has been shown to correlate with proliferation, invasion, and angiogenesis of GBMs and to affect self-renewal of cancer stem cells from colon cancer. The role of HMGA1 in GBM tumor stem cells is not completely understood.

RESEARCH DESIGN AND METHODS

We have investigated the role of HMGA1 in brain tumor stem cell (BTSC) self-renewal, stemness and resistance to temozolomide by shRNA- mediated HMGA1 silencing.

RESULTS

We first report that HMGA1 is overexpressed in a subset of BTSC lines from human GBMs. Then, we show that HMGA1 knockdown reduces self-renewal, sphere forming efficiency and stemness, and sensitizes BTSCs to temozolomide. Interestingly, HMGA1 silencing also leads to reduced tumor initiation ability in vivo.

CONCLUSIONS

These results demonstrate a pivotal role of HMGA1 in cancer stem cell gliomagenesis and endorse HMGA1 as a suitable target for CSC-specific GBM therapy.

High mobility group a proteins as tumor markers

Almost 30 years ago, overexpression of HMGA proteins was associated with malignant phenotype of rat thyroid cells transformed with murine retroviruses. Thereafter, several studies have analyzed HMGA expression in a wide range of human neoplasias. Here, we summarize all these results that, in the large majority of the cases, confirm the association of HMGA overexpression with high malignant phenotype as outlined by chemoresistance, spreading of metastases, and a global poor survival. Even though HMGA proteins’ overexpression indicates a poor prognosis in almost all malignancies, their detection may be particularly useful in determining the prognosis of breast, lung, and colon carcinomas, suggesting for the treatment a more aggressive therapy. In particular, the expression of HMGA2 in lung carcinomas is frequently associated with the presence of metastases. Moreover, recent data revealed that often the cause for the high HMGA proteins levels detected in human malignancies is a deregulated expression of non-coding RNA. Therefore, the HMGA proteins represent tumor markers whose detection can be a valid tool for the diagnosis and prognosis of neoplastic diseases.

miR-142-3p down-regulation contributes to thyroid follicular tumorigenesis by targeting ASH1L and MLL1

CONTEXT

A previous micro-RNA expression profile of thyroid follicular adenomas identified miR-142 precursor among the miRNAs downregulated in the neoplastic tissues compared to normal thyroid gland.

OBJECTIVE

The aim of this work has been to assess the expression of miR-142-3p in a large panel of follicular thyroid adenomas and carcinomas and evaluate its effect on thyroid cell proliferation and target expression.

DESIGN

The expression of miR-142-3p was analyzed by qRT-PCR in thyroid follicular adenomas and carcinomas, compared to normal thyroids. MiR-142-3p expression was restored in WRO cells and the effects on cell proliferation and target expression were evaluated.

RESULTS

Here we show that miR-142-3p is downregulated in FTAs, FTCs, and FVPTCs. MiR-142-3p was demonstrated to reduce the proliferation rate of WRO and FTC133 cells, supporting its tumor suppressor role in thyroid cancerogenesis. Moreover, this microRNA was able to downregulate the expression of ASH1L and MLL1, by direct and indirect mechanisms, respectively. Consistently, an inverse correlation between miR-142-3p expression and ASH1L and MLL1 proteins was found in thyroid follicular adenomas and carcinomas. ASH1L and MLL1, which belong to the Trithorax group (TrxG) proteins and are major regulators of Homeobox gene expression, maintain active target gene transcription by histone 3 lysine 4 methylation. Interestingly, we found that FTCs and FTC cell lines express tumor specific, shorter forms of the two proteins. The capability of miR-142-3p to modulate the levels of these tumor-associated forms and to reactivate thyroid-specific Hox gene expression, likely contributes to its tumor suppressive function.

CONCLUSIONS

These data demonstrate that miR-142-3p downregulation has a role in thyroid tumorigenesis, by regulating ASH1L and MLL1.

Can anti-Müllerian hormone be predictive of spontaneous onset of pregnancy in women with unexplained infertility?

The objective of the study was to assess anti-Müllerian hormone's (AMH) role in predicting spontaneous onset of pregnancy. This observational cohort study included 83 women with unexplained infertility and normal or low ovarian reserve. Serum AMH, FSH, LH, 17β-oestradiol, inhibin B levels were measured and the number of early antral follicles (2-9 mm) was evaluated on days 2-5 of the cycle. Spearman's correlation was used for comparison of strength of correlation. The diagnostic power of AMH in predicting spontaneous pregnancy was evaluated by receiver operating characteristic (ROC) curves. Markers of ovarian reserve in pregnant women and women without pregnancy were similar. In the entire study population, any markers (AMH, FSH, AFC, age), correlated with each other, but no marker was correlated with pregnancy. The area under the ROC curve for AMH reached a value of 0.385 ± 0.07 (0.25-0.52, 95% confidence interval, CI); for FSH 0.415 ± 0.08 (0.25-0.58, 95% CI); for AFC 0.418 ± 0.08 (0.26-0.57, 95% CI), for age 0.496 ± 0.08 (0.34-0.65, 95% CI). The study did not find a predictive role for AMH in predicting spontaneous onset of pregnancy. Even when AMH levels are very low, a spontaneous pregnancy may still occur.

Reduced habituation to experimental pain in migraine patients: a CO2 laser evoked potential study

The habituation to sensory stimuli of different modalities is reduced in migraine patients. However, the habituation to pain has never been evaluated. Our aim was to assess the nociceptive pathway function and the habituation to experimental pain in patients with migraine. Scalp potentials were evoked by CO(2) laser stimulation (laser evoked potentials, LEPs) of the hand and facial skin in 24 patients with migraine without aura (MO), 19 patients with chronic tension-type headache (CTTH), and 28 control subjects (CS). The habituation was studied by measuring the changes of LEP amplitudes across three consecutive repetitions of 30 trials each (the repetitions lasted 5 min and were separated by 5-min intervals). The slope of the regression line between LEP amplitude and number of repetitions was taken as an index of habituation. The LEPs consisted of middle-latency, low-amplitude responses (N1, contralateral temporal region, and P1, frontal region) followed by a late, high-amplitude, negative-positive complex (N2/P2, vertex). The latency and amplitude of these responses were similar in both patients and controls. While CS and CTTH patients showed a significant habituation of the N2/P2 response, in MO patients this LEP component did not develop any habituation at all after face stimulation and showed a significantly lower habituation than in CS after hand stimulation. The habituation index of the vertex N2/P2 complex exceeded the normal limits in 13 out of the 24 MO patients and in none of the 19 CTTH patients (P<0.0001; Fisher's exact test). Moreover, while the N1-P1 amplitude showed a significant habituation in CS after hand stimulation, it did not change across repetitions in MO patients. In conclusion, no functional impairment of the nociceptive pathways, including the trigeminal pathways, was found in either MO or CTTH patients. But patients with migraine had a reduced habituation, which probably reflects an abnormal excitability of the cortical areas involved in pain processing.

Nociceptive temporalis inhibitory reflexes evoked by CO2-laser stimulation in tension-type headache

The aim of the study was to evaluate the laser-induced suppression periods of the temporalis muscle in patients with tension-type headache, compared with the pattern of temporalis activity suppression induced by electrical stimulation. Fifteen patients with chronic and 10 with episodic tension-type headaches were selected. Suppression periods were recorded simultaneously from both temporalis muscles using both electrical stimuli and CO2-laser stimuli. A significant reduction in the later electrically induced suppression period was found in both tension-type headache groups. Laser stimulation induced a first suppression period (LSP1) with a latency of about 50 ms in all patients. The features of LSP1 were similar across groups. The LSP1 should correspond to the first suppression period induced by electrical stimulus, which is partly a nociceptive response, whereas the second period seemed negligibly linked with the activation of pain-related afferents, though probably their activation may contribute to increase the reflex duration and to emphasize abnormalities in tension-type headache.

Features of the blink reflex in individuals at risk for Huntington's disease

The aim of the study was to correlate the features of the blink reflex (BR) with the genetic abnormalities and the clinical findings in patients with Huntington's disease (HD) and asymptomatic gene carriers. Twenty patients with HD and 20 relatives were studied. Mutation analysis was performed for the CAG expansion within the HD gene using HD 333-HD 447 as oligonucleotide primers. The BR was elicited transcutaneously by electrical stimulation of the right supraorbital nerve. The recovery curve of the R2 and R3 responses after a conditioning stimulus was evaluated. R2 latency and duration and R3 duration were significantly increased in HD patients and in presymptomatic carriers in comparison with controls; reduced R2 recovery was also clear in both HD and gene-carrier relatives. In HD patients, the R2 latency increase correlated significantly with the severity of facial chorea. The R2 abnormalities are probably caused by impaired suprasegmental control by the basal ganglia over brainstem interneurons, which may precede the onset of involuntary movements, probably conditioning the severity of facial chorea during development of the disease.

The blink reflex and the corneal reflex are followed by cortical activity resembling the nociceptive potentials induced by trigeminal laser stimulation in man

Laser stimulation of the supraorbital regions evokes brain potentials (LEPs) related to trigeminal nociception. The aim of this study was to record the R2 component of the blink reflex and the corneal reflex in 20 normal subjects, comparing the scalp activity following these reflexes with the nociceptive potentials evoked by CO2 laser stimulation of supraorbital regions. Cortical and muscular reflexes evoked by stimulation of the first trigeminal branch were recorded simultaneously. The R2 component of the blink reflex and the corneal reflex were followed by two cortical peaks, which resembled morphologically N-P waves of LEPs. The two peaks demonstrated a difference in latency of approximately 40 ms, which is consistent with activation time of nociception. This finding suggests that these reflexes are induced by activation of small pain-related fibers.

Zolmitriptan reverses blink reflex changes induced during the migraine attack in humans

The question about the 5-hydroxytryptamine (5-HT)(1B-1D) receptors agonists, if the clinical efficacy in migraine attacks is linked with the action at the central level or at the peripheral one, is still unresolved. We evaluated the effects of zolmitriptan and sumatriptan on blink reflex in thirty migraine without aura patients during the attacks in order to assess the central action on the trigeminal system. Both drugs were effective in reducing headache severity compared to placebo. In the migraine attack an increased area of the R3 component on the pain side was observed; it was suppressed by zolmitriptan, which confirmed its action on the central trigeminal circuits, though the clinical relevance of this effect could be questioned.

The three responses of the blink reflex in adult and juvenile migraine

Recent theories about migraine pathogenesis have emphasized the role of the trigeminal system in the pathogenesis of migraine attacks (Moskowitz, 1997). The blink reflex (BR) could be a suitable method to evaluate the trigeminal system in migraine, as it is generally elicited by stimulation of the trigeminal ophthalmic division (Kimura et al., 1967), involved in migraine attacks. Sixty one adult and 15 juvenile migraine without aura subjects were selected, in order to evaluate the BR features, including the subjective perceptive and pain thresholds and the R1, R2 and R3 components intensity thresholds and amplitudes. The electrophysiological procedure was carried out during the pain free phase. The findings were compared with those of 28 healthy controls, 18 adults and 10 children. In both adult and juvenile migraine sufferers an early appearance of the R3 response at almost the R2 threshold was observed in comparison with age-matched controls. Unfortunately, the anatomic and physiologic organization of the R3 component is uncertain: its early onset could suggest a dysfunction of the inhibitory control system on the trigeminal networks, which may predispose to migraine attacks.

Outcome of juvenile headache in outpatients attending 23 Italian headache clinics. Italian Collaborative Study Group on Juvenile Headache (Società Italiana Neuropsichiatria Infantile [SINPI])

A multicenter 3-year follow-up study was carried out on young patients with headache referred to tertiary headache centers or pediatric clinics. Three years after the first examination in 1993, 442 (of an original sample of 719) young outpatients with headache (226 females and 216 males) were re-examined. The diagnostic criteria of the International Headache Society (IHS) and those modified for migraine without aura by Winner et al were applied at both the baseline evaluation and the 3-year re-examination. At the follow-up, 290 children still had headache, 101 were in clinical remission, and 51 had dropped out. Using the current diagnostic criteria, only 46.2% of patients having migraine without aura, 50% of those having migraine with aura, and 35.3% of those suffering from migraine disorders which do not fulfill IHS criteria for migraine received the same diagnosis at the time of follow-up. The percentage of patients receiving a diagnosis of migraine without aura rose significantly when new modified criteria were used (60.5%), whereas a drop in the frequency of migraine disorders not fulfilling IHS criteria was observed at follow-up, both in patients with the diagnosis of migraine without aura at the first examination (4.6%) and in patients with migraine not always fulfilling IHS criteria at the first examination (6.2%). Among all patients who received this latter diagnosis at the first examination, it was possible to make a diagnosis of migraine with aura at the follow-up in 8.8% of cases and that of migraine without aura in 26.5%. No significant variations in the frequency of either episodic tension-type headache or chronic tension-type headache were found, with the exception of a slight decrease in the percentage of tension-type headache which did not fulfill IHS criteria, but the difference between the first examination and the follow-up values does not reach the level of statistical significance (5% versus 12%). As far as the evolution of migraine is concerned, 17.4% of patients with migraine were headache-free at the 3-year follow-up. In tension-type headache, the percentage of patients who were headache-free was particularly high in those with the episodic form (32.9%) and in those suffering from tension-type headache not fulfilling IHS criteria (29.1%). The majority of patients who had been diagnosed as having unclassifiable headache at the first examination received a correct diagnosis at the follow-up with the exception of one patient. As observed in adult patients, variations in the headache characteristics were also observed in children and adolescents (that is, migraine with aura can change to migraine without aura, or the latter can transform into episodic tension-type headache or chronic tension-type headache can change into the episodic form). This follow-up study was aimed at reaching a better understanding of headache disturbances in children and adolescents, examining, in particular, variations of headache with time in this stage of life.

Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches

A multicenter study was carried out in 10 Italian Headache Centers to investigate the prevalence of psychosocial stress and psychiatric disorders listed by the IHS classification as the "most likely causative factors" of tension-type headache (TTH). Two hundred and seventeen TTH adult outpatients consecutively recruited underwent a structured psychiatric interview (CIDI-c). The assessment of psychosocial stress events was carried out using an ad hoc questionnaire. The psychiatric disorders that we included in the three psychiatric items of the fourth digit of the IHS classification were depressive disorders for the item depression, anxiety disorders for the item anxiety, and somatoform disorders for the item headache as a delusion or an idea. Diagnoses were made according to DSM-III-R criteria. At least one psychosocial stress event or a psychiatric disorder was detected in 84.8% of the patients. Prevalence of psychiatric comorbidity was 52.5% for anxiety, 36.4% for depression, and 21.7% for headache as a delusion or an idea. Psychosocial stress was found in 29.5% of the patients and did not differ between patients with and without psychiatric comorbidity. Generalized anxiety disorder (83.3%) and dysthymia (45.6%) were the most frequent disorders within their respective psychiatric group. The high prevalence of psychiatric disorders observed in this wide sample of patients emphasizes the need for a systematic investigation of psychiatric comorbidity aimed at a more comprehensive and appropriate clinical management of TTH patients.

Clinical neurophysiology in childhood headache

Electrophysiological studies in childhood headache are of interest because of the need to make a clinical diagnosis and also because of the efficacy of physiopathological studies in juvenile age attributable to the recent outcome of the illness, with less clinical modification by environmental factors or drug use. Electrophysiological studies in childhood headache are concerned with migraine and electroencephalographic (EEG) evaluations; evoked potentials, event-related potentials and, less often, electromyographic studies are also reported. Visual analysis of EEG suggests an association between migraine and epilepsy; quantitative EEG, visual and event-related evoked potentials show fluctuating abnormalities, depending on the occurrence of the migraine attacks and permanent anomalous patterns related to the basic mechanisms underlying the disease. Blink reflex studies might suggest a primary dysfunction of the nociceptive control central system in children affected by tension-type headache and migraine. The use of neurophysiological procedures in juvenile migraine is considered limited in clinical practice and of particular interest in neurophysiological studies of headache.

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

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

Steady-state visual-evoked potentials in headache: diagnostic value in migraine and tension-type headache patients

We tested the hypothesis that migraine and tension-type headache are separate disorders based on visual evoked potentials. We recruited 120 migraine without aura patients (MwoA), 64 tension-type headache patients (TTH), and 51 healthy controls. We performed discriminant analysis combined with a stepwise selection of predictors. Mean values of the F1 component were significantly increased over Fp1, C3, P4, O2 and O1 electrodes in MwoA and TTH patients compared with normal subjects. Only the control subjects were correctly distinguished. The increased brain response to visual stimulation detected in both MwoA and TTH may suggest a common neuronal dysfunction in the two headache subtypes.

Discrimination between migraine patients and normal subjects based on steady state visual evoked potentials: discriminant analysis and artificial neural network classifiers

Fifty-one migraine patients and 19 control subjects were examined by steady state visual evoked potentials (SSVEPs) procedure. The aim of this study was to develop a discriminant analysis and an artificial neural network (NN) classifier in order to discriminate between migraneurs during attack-free periods and normal subjects. Discriminant analysis correctly classified 72.5% of migraine patients with a false positive rate of 36.8%. The NN method had a sensitivity of 100% with a false positive rate of 15%. The results of this study confirm SSVEP pattern as a marker of migraine and demonstrate that NNs could be a useful method in the statistical analysis of topographic EEG data.

Somatosensory evoked potentials in migraine

Twenty-six patients suffering from migraine with aura and without aura were examined using somatosensory evoked potentials (SEPs) during the intercritical phase. The mean amplitude of the prerolandic component was significantly reduced in migraine patients with and without aura on the right hemisphere; the ratio between the parietal N20/P25 and the prerolandic P22/N30 was significantly enhanced in migraine groups over the left and the right hemisphere. A significant interside asymmetry of the N30 amplitude was observed in the migraine with aura group in comparison with control subjects. The occurrence of SEP abnormalities was not correlated with the age of the patients, with illness duration or with the frequency of migraine attacks. SEP abnormalities observed in migraine with and without aura may have an underlying primary neural disorder probably based on a chronic dopaminergic dysfunction.

Applicability of the 1988 IHS criteria to headache patients under the age of 18 years attending 21 Italian headache clinics. Juvenile Headache Collaborative Study Group

Seven hundred nineteen young patients attending 21 Italian headache care settings were evaluated by a diagnostic headache interview and a neurological examination. Headache disorders were classified according to the current 1988 criteria of the International Headache Society (IHS); 54.9% of the patients suffered from migraine, 33.9% from tension-type headache, 1.9% from secondary headache, and 3.4% had non-classifiable headache. A further 5.9% of the patients were not classified due to incomplete questionnaires. Of the 395 patients with migraine, 44.5% were affected by migraine without aura, 29.9% by migraine with aura, 1.3% from other migraine forms, and 24.3% by migrainous disorders which do not fulfill the 1988 IHS diagnostic criteria for headache. Among the 244 patients with tension-type headache, 51.6% had episodic tension-type headache, 15.2% chronic tension-type headache, and 33.2% headache of the tension-type which does not fulfill the 1988 IHS criteria for episodic and chronic tension-type headache. In young migraine patients, pain was of a pulsating type in 55.7%, severe in 57.8%, unilateral in 42.6%, and aggravated by routine physical activity in 38.9%. Tension-type headache was described as pressing in 73.8%, mild or moderate in 75.7%, bilateral in 87.4%, and not aggravated by routine physical activity in 85.5%. The duration of pain was less than 2 hours in 35% of the cases in migraine sufferers and less than 30 minutes in 26.7% of tension-type headache sufferers. Nausea, phonophobia, and photophobia were present in at least half of the migraine patients and in one third of tension-type headache patients, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)