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Fernández-de-Las-Peñas C, Cuadrado ML, Gómez-Mayordomo V, García-Azorín D, Arendt-Nielsen L. Headache as a COVID-19 onset symptom or Post-COVID symptom according to the SARS-CoV-2 Variant. Expert Rev Neurother 2023; 23:179-186. [PMID: 36857191 DOI: 10.1080/14737175.2023.2185138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
INTRODUCTION COVID19 associated headaches are highly common and there is currently an unmet need to better understand their association with SARSCoV2 variants. Headaches are a prevalent symptom in the acute phase of COVID19 and are associated with a better prognosis and better immune response. They are also a relevant post-COVID symptom. AREAS COVERED This article analyses the differences in the prevalence of headache as an onset symptom and in post-COVID headache among the different SARS-CoV-2 variants: the historical strain, Alpha, Delta and Omicron. The different pathophysiological mechanisms by which SARS-CoV-2 infection may cause headache are also discussed. EXPERT OPINION The presence of headache at the acute phase is a risk factor for post-COVID headache, whereas a history of primary headache does not appear to be associated with post-COVID headache. The prevalence of headache as an onset symptom appears to be variable for the different SARS-CoV-2 variants, but current data are inconclusive. However, the current evidence also suggests that headache represents a prevalent symptom in the acute and post-infection COVID-19 phase, regardless of SARS-CoV-2 variant.
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Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Madrid. Spain
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Maria L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Victor Gómez-Mayordomo
- Department of Neurology, Institute of Neurosciences, Vithas Madrid La Milagrosa University Hospital. Madrid, Spain
| | - David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Neuroscience Research Unit, Institute for Biomedical Research of Salamanca, Salamanca, Spain
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Medical Gastroenterology, AMech-Sense, alborg University Hospital, Aalborg, Denmark
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Fernández‐de‐las‐Peñas C, Cuadrado ML, Gómez‐Mayordomo V, Torres‐Macho J, Pellicer‐Valero OJ, Martín‐Guerrero JD, Arendt‐Nielsen L. Headache as a
COVID
‐19 onset symptom and post‐
COVID
‐19 symptom in hospitalized
COVID
‐19 survivors infected with the Wuhan, Alpha, or Delta
SARS‐CoV
‐2 variants. Headache 2022; 62:1148-1152. [PMID: 36111527 PMCID: PMC9538062 DOI: 10.1111/head.14398] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/29/2022] [Indexed: 12/01/2022]
Abstract
Objective This study looked at differences in the presence of headache as an onset symptom of coronavirus disease 2019 (COVID‐19) and as a post‐COVID‐19 symptom in individuals previously hospitalized owing to infection with the Wuhan, Alpha, or Delta variants of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Background Headache can be present in up to 50% of individuals during the acute phase of SARS‐CoV‐2 infection and in 10% of subjects during the post‐COVID‐19 phase. There are no data on differences in the occurrence of headache in the acute‐ and post‐COVID‐19 phase according to the SARS‐CoV‐2 variants. Methods A cross‐sectional cohort study was conducted. Unvaccinated subjects previously hospitalized for COVID‐19 caused by the Wuhan (n = 201), Alpha (n = 211), or Delta (n = 202) SARS‐CoV‐2 variants were scheduled for a telephone interview 6 months after hospital discharge. Hospitalization data were collected from hospital medical records. Results The presence of headache as a COVID‐19 onset symptom at hospitalization was higher in subjects with the Delta variant (66/202, 32.7%) than in those infected with the Wuhan (42/201, 20.9%; odds ratio [OR] 1.83, 95% confidence interval [CI] 1.17–2.88) or Alpha (25/211, 11.8%; OR 3.61, 95% CI, 2.16–6.01) variants. The prevalence of post‐COVID‐19 headache 6 months after hospital discharge was higher in individuals infected with the Delta variant (26/202, 12.9%) than in those infected with the Wuhan (11/201, 5.5%; OR 2.52, 95% CI 1.22–5.31) or Alpha (eight of 211, 3.8%; OR 3.74, 95% CI 1.65–8.49) variants. The presence of headache as a COVID‐19 onset symptom was associated with post‐COVID‐19 headache in subjects infected with the Wuhan (OR 7.75, 95% CI 2.15–27.93) and Delta variants (OR 2.78, 95% CI 1.20–6.42) but not with the Alpha variant (OR 2.60, 95% CI 0.49–13.69). Conclusion Headache was a common symptom in both the acute‐ and post‐COVID‐19 phase in subjects infected with the Wuhan, Alpha, and Delta variants but mostly in those infected with the Delta variant.
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Affiliation(s)
- César Fernández‐de‐las‐Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation Universidad Rey Juan Carlos (URJC) Madrid Spain
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine Aalborg University Aalborg Denmark
| | - Maria L. Cuadrado
- Department of Neurology Hospital Clínico San Carlos Madrid Spain
- Department of Medicine, School of Medicine Universidad Complutense de Madrid Madrid Spain
| | | | - Juan Torres‐Macho
- Department of Medicine, School of Medicine Universidad Complutense de Madrid Madrid Spain
- Department of Internal Medicine Hospital Universitario Infanta Leonor‐Virgen de la Torre Madrid Spain
| | - Oscar J. Pellicer‐Valero
- Intelligent Data Analysis Laboratory, Department of Electronic Engineering, ETSE (Engineering School) Universitat de València (UV) Valencia Spain
| | - José D. Martín‐Guerrero
- Intelligent Data Analysis Laboratory, Department of Electronic Engineering, ETSE (Engineering School) Universitat de València (UV) Valencia Spain
| | - Lars Arendt‐Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine Aalborg University Aalborg Denmark
- Department of Medical Gastroenterology, Mech‐Sense Aalborg University Hospital Aalborg Denmark
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Santos-Lasaosa S, Belvís R, Cuadrado ML, Díaz-Insa S, Gago-Veiga A, Guerrero-Peral AL, Huerta M, Irimia P, Láinez JM, Latorre G, Leira R, Pascual J, Porta-Etessam J, Sánchez Del Río M, Viguera J, Pozo-Rosich P. Calcitonin gene-related peptide in migraine: from pathophysiology to treatment. Neurologia (Engl Ed) 2022; 37:390-402. [PMID: 35672126 DOI: 10.1016/j.nrleng.2019.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/07/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.
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Affiliation(s)
- S Santos-Lasaosa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
| | - R Belvís
- Unidad de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - M L Cuadrado
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - S Díaz-Insa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario La Fe, Valencia, Spain
| | - A Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - A L Guerrero-Peral
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Instituto de Investigación de Salamanca (IBSAL), Spain
| | - M Huerta
- Sección de Neurología, Hospital de Viladecans, Barcelona, Spain
| | - P Irimia
- Departamento de Neurología, Clínica Universidad de Navarra, Pamplona, Spain
| | - J M Láinez
- Servicio de Neurología, Hospital Clínico Universitario de Valencia, Universidad Católica de Valencia, Valencia, Spain
| | - G Latorre
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, Spain
| | - R Leira
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - J Pascual
- Hospital Universitario Marqués de Valdecilla e IDIVAL, Santander, Spain
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - M Sánchez Del Río
- Departamento de Neurología, Clínica Universidad de Navarra, Madrid, Spain
| | - J Viguera
- Consulta de Cefalea, Unidad de Gestión Clínica de Neurociencias, Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - P Pozo-Rosich
- Unidad de Cefalea, Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Grupo de Investigación en Cefalea, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
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Santos-Lasaosa S, Belvís R, Cuadrado ML, Díaz-Insa S, Gago-Veiga A, Guerrero-Peral AL, Huerta M, Irimia P, Láinez JM, Latorre G, Leira R, Pascual J, Porta-Etessam J, Sánchez Del Río M, Viguera J, Pozo-Rosich P. Calcitonin gene-related peptide in migraine: from pathophysiology to treatment. Neurologia 2022; 37:390-402. [PMID: 31326215 DOI: 10.1016/j.nrl.2019.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/07/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.
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Affiliation(s)
- S Santos-Lasaosa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto Aragonés de Ciencias de la Salud, Zaragoza, España.
| | - R Belvís
- Unidad de Cefaleas, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M L Cuadrado
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - S Díaz-Insa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - A Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, España
| | - A L Guerrero-Peral
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España; Instituto de Investigación de Salamanca (IBSAL), España
| | - M Huerta
- Sección de Neurología, Hospital de Viladecans, Barcelona, España
| | - P Irimia
- Departamento de Neurología, Clínica Universidad de Navarra, Pamplona, España
| | - J M Láinez
- Servicio de Neurología, Hospital Clínico Universitario de Valencia. Universidad Católica de Valencia, Valencia, España
| | - G Latorre
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario de Fuenlabrada. Universidad Rey Juan Carlos, Madrid, España
| | - R Leira
- Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - J Pascual
- Hospital Universitario Marqués de Valdecilla e IDIVAL, Santander, España
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - M Sánchez Del Río
- Departamento de Neurología, Clínica Universidad de Navarra, Madrid, España
| | - J Viguera
- Consulta de Cefalea, Unidad de Gestión Clínica de Neurociencias, Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - P Pozo-Rosich
- Unidad de Cefalea, Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España; Grupo de Investigación en Cefalea; VHIR; Universitat Autònoma de Barcelona, Barcelona, España
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Fernández-de-Las-Peñas C, Palacios-Ceña M, Valera-Calero JA, Cuadrado ML, Guerrero-Peral A, Pareja JA, Arendt-Nielsen L, Varol U. Understanding the interaction between clinical, emotional and psychophysical outcomes underlying tension-type headache: a network analysis approach. J Neurol 2022; 269:4525-4534. [PMID: 35229190 DOI: 10.1007/s00415-022-11039-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Evidence supports that tension-type headache (TTH) involves complex underlying mechanisms. The current study aimed to quantify potential multivariate relationships between headache-related, psychophysical, psychological and health-related variables in patients with TTH using network analysis. METHODS Demographic (age, height, weight), headache-related (intensity, frequency, duration, and headache-related disability), psychological and emotional (Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index), psycho-physical (pressure pain thresholds [PPTs] and myofascial trigger points) and health-related variables (SF-36 questionnaire) were collected in 169 TTH patients. Network connectivity analysis was unsupervised conducted to quantify the adjusted correlations between the modelled variables and to assess their centrality indices (i.e., the connectivity with other symptoms in the network and the importance in the modelled network). RESULTS The connectivity network showed local associations between psychophysical and headache-related variables. Multiple significant local positive correlations between PPTs were observed, being the strongest weight between PPTs over the cervical spine and temporalis area ([Formula: see text]: 0.41). The node with the highest strength, closeness and betweenness centrality was depressive levels. Other nodes with high centrality were vitality and headache intensity. DISCUSSION This is the first study applying a network analysis to understand the connections between headache-related, psychophysical, psychological and health-related variables in TTH. Current findings support a model on how the variables are connected, albeit in separate clusters. The role of emotional aspects, such as depression, is supported by the network. Clinical implications of the findings, such as developing TTH treatments strategies targeting these most important variables, are discussed.
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Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. .,Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark. .,Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain.
| | - María Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.,Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark
| | - Juan A Valera-Calero
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, Madrid, Spain.,VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Camilo Jose Cela University, Madrid, Spain
| | - Maria L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Juan A Pareja
- Department of Neurology, Hospital Quirón Pozuelo, Madrid, Spain
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Faculty of Medicine, SMI, Aalborg University, Aalborg, Denmark.,Department of Medical Gastroenterology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Umut Varol
- VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Camilo Jose Cela University, Madrid, Spain
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Fuensalida-Novo S, Palacios-Ceña M, Falla D, Cuadrado ML, Guerrero ÁL, Cescon C, Fernández-de-Las-Peñas C, Barbero M. In episodic cluster headache, pain extent is not related to widespread pressure pain sensitivity, psychological outcomes, or clinical outcomes. Physiother Theory Pract 2020; 38:1305-1310. [DOI: 10.1080/09593985.2020.1827468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Stella Fuensalida-Novo
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra de Investigación y Docencia en Fisioterapia, Terapia Manual, Punción Seca y Ejercicio, Universidad Rey Juan Carlos, Madrid, Spain
| | - María Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra de Investigación y Docencia en Fisioterapia, Terapia Manual, Punción Seca y Ejercicio, Universidad Rey Juan Carlos, Madrid, Spain
| | - Deborah Falla
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Maria L. Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ángel L. Guerrero
- Headache Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Corrado Cescon
- Rehabilitation Research Laboratory 2rLab, Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra de Investigación y Docencia en Fisioterapia, Terapia Manual, Punción Seca y Ejercicio, Universidad Rey Juan Carlos, Madrid, Spain
| | - Marco Barbero
- Rehabilitation Research Laboratory 2rLab, Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
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Palacios-Cena M, Gomez-Mayordomo V, Garcia-Azorin D, Gonzalez-Garcia N, Cuadrado ML, Fernandez-de-Las-Penas C, Arendt-Nielsen L, Guerrero AL. Dynamic Pressure Pain Hypersensitivity as Assessed by Roller Pressure Algometry in Episodic Cluster Headache. Pain Physician 2020; 23:219-227. [PMID: 32214304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND A method for assessing dynamic muscle hyperalgesia (dynamic pressure algometry) has been developed and applied in tension-type and migraine headaches. OBJECTIVES To investigate differences in dynamic pressure pain assessment over the trigeminal area between men with cluster headache (CH) and headache-free controls, and the association between dynamic and static pressure pain sensitivity. STUDY DESIGN A case-control study. SETTING Tertiary urban hospital. METHODS Forty men with episodic CH and 40 matched controls participated. Dynamic pressure pain sensitivity was assessed with a dynamic pressure algometry set consisting of 8 rollers with different fixed levels (500, 700, 850, 1,350, 1,550, 2,200, 3,850, and 5,300 g). Each roller was moved at a speed of 0.5 cm/sec over a diagonal line covering the temporalis muscle from an anterior to posterior direction. The dynamic pressure threshold (DPT; load level of the first painful roller) and the pain intensity perceived at the DPT level (roller-evoked pain) were assessed. Static pressure pain thresholds (PPT) were also assessed with a digital pressure algometer applied statically over the mid-muscle belly of the temporalis. Patients were assessed in a remission phase, at least 3 months from the last cluster attack, and without preventive medication. RESULTS Side-to-side consistency between DPTs (r = 0.781, P < 0.001), roller-evoked pain on DPT (r = 0.586; P < 0.001), and PPTs (r = 0.874; P < 0.001) were found in men with CH. DPT was moderately, bilaterally, and side-to-side associated with PPTs (0.663 > r > 0.793, all P < 0.001). Men with CH had bilateral lower DPT and PPT and reported higher levels of roller-evoked pain (all P < 0.001) than headache-free controls. LIMITATIONS Only men with episodic CH were included. CONCLUSIONS This study supports that a dynamic pressure algometry is as valid as a static pressure algometry for assessing pressure pain sensitivity in patients with CH. Assessing both dynamic and static pain sensitivity may provide new opportunities for differentiated diagnostics. KEY WORDS Cluster headache, dynamic pressure pain, pressure pain threshold.
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Affiliation(s)
- Maria Palacios-Cena
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - David Garcia-Azorin
- Headache Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Maria L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Angel L Guerrero
- Headache Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
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Gómez-Moreno SM, Cuadrado ML, Cruz-Orduña I, Martínez-Acebes EM, Gordo-Mañas R, Fernández-Pérez C, García-Ramos R. Validation of the Spanish-language version of the Montreal Cognitive Assessment as a screening test for cognitive impairment in multiple sclerosis. Neurologia 2020; 37:S0213-4853(19)30149-5. [PMID: 31983477 DOI: 10.1016/j.nrl.2019.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The neuropsychological batteries traditionally used for the assessment of cognitive impairment (CI) in patients with multiple sclerosis are complex tests requiring a long time to administer. Simpler tests are needed to detect cognitive impairment in daily clinical practice. OBJECTIVE We aimed to evaluate the diagnostic validity and reliability of the Montreal Cognitive Assessment (MoCA) test as a screening tool for CI in patients with multiple sclerosis, as compared against the Brief Neuropsychological Battery. MATERIAL AND METHODS We recruited 52 patients with multiple sclerosis (61.5% women; mean age [standard deviation]: 41.7 [11.5] years). We analysed the reliability (internal consistency, interobserver reliability, and test-retest reliability), construct validity (factor analysis, Pearson correlation coefficient, and coefficient of determination), and criterion validity (ROC curve, sensitivity, specificity, total agreement, positive and negative predictive values, positive and negative likelihood ratios, and Fagan nomogram) of the MoCA test in this population. RESULTS The prevalence of CI was 21.2% according to findings from the Brief Neuropsychological Battery, and 25% according to the MoCA test. The MoCA test showed good internal consistency (Cronbach alpha, 0.822) and interobserver and test-retest reliability (intraclass correlation coefficient 0.80 and 0.96, respectively). The correlation coefficient between total Brief Neuropsychological Battery and MoCA test scores was 0.82. The optimal cut-off point on the ROC curve was 25-26, yielding 91% sensitivity and 93% specificity. CONCLUSION The MoCA test is a valid and reliable tool for screening for CI in patients with multiple sclerosis.
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Affiliation(s)
- S M Gómez-Moreno
- Sección de Neurología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - M L Cuadrado
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - I Cruz-Orduña
- Sección de Neurología, Hospital Universitario Infanta Leonor, Madrid, España
| | - E M Martínez-Acebes
- Sección de Neurología, Hospital Universitario Infanta Leonor, Madrid, España
| | - R Gordo-Mañas
- Sección de Neurología, Hospital Universitario Infanta Leonor, Madrid, España; La afiliación de R. Gordo-Mañas en el momento de la publicación de este artículo es: Servicio de Neurología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - C Fernández-Pérez
- Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, España
| | - R García-Ramos
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
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Fernández-de-las-Peñas C, Ambite-Quesada S, Fahandezh-Saddi Díaz H, Paras-Bravo P, Palacios-Ceña D, Cuadrado ML. The Val158Met polymorphism of the catechol-O-methyltransference gene is not associated with long-term treatment outcomes in carpal tunnel syndrome: A randomized clinical trial. PLoS One 2018; 13:e0205516. [PMID: 30321201 PMCID: PMC6188786 DOI: 10.1371/journal.pone.0205516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 09/23/2018] [Indexed: 11/18/2022] Open
Abstract
DESIGN Randomized clinical trial. OBJECTIVE To investigate the association of the Val158Met polymorphism with pain and function outcomes in women with carpal tunnel syndrome (CTS) who received surgery or manual therapy including desensitization manoeuvres of the central nervous system. METHODS A pre-planned secondary analysis of a randomized controlled trial investigating the efficacy of manual therapy including desensitization manoeuvres of the central nervous system vs. surgery in 120 women with CTS was conducted. Women were randomized to receive 3 sessions of manual therapy (n = 60) or decompression of the carpal tunnel (n = 60). The primary outcome was intensity of pain (mean pain and the worst pain), and secondary outcomes included function and symptoms severity subscales of the Boston Carpal Tunnel Questionnaire. Outcomes were assessed at baseline, and 1, 3, 6, and 12 months after the intervention. Rs4680 genotypes were determined after amplifying the Val158Met polymorphism by polymerase chain reactions. We classified subjects according to their Val158Met polymorphism: Val/Val, Val/Met, or Met/Met. The primary aim (treatment group*Val158Met*time) was examined with repeated measures ANCOVA with intention-to-treat analysis. RESULTS At 12 months, 111 (92%) women completed the follow-up. No interaction was observed between the Val158Met genotype and any outcome: mean pain intensity (F = 0.60; P = 0.69), worst pain intensity (F = 0.49; P = 0.61), function (F = 0.12; P = 0.88) or symptom severity (F = 0.01; P = 0.98). CONCLUSION The current clinical trial did not show an association between the Val158Met polymorphism and changes in pain and function outcomes after either surgery or physical therapy in women with CTS.
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Affiliation(s)
- César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Spain
- Grupo Excelencia Investigadora URJC-Banco Santander referencia Nº30VCPIGI03: Investigación traslacional en el proceso de salud—enfermedad (ITPSE), Universidad Rey Juan Carlos, Alcorcón, Spain
- * E-mail:
| | - Silvia Ambite-Quesada
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Spain
- Grupo Excelencia Investigadora URJC-Banco Santander referencia Nº30VCPIGI03: Investigación traslacional en el proceso de salud—enfermedad (ITPSE), Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Hommid Fahandezh-Saddi Díaz
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Paula Paras-Bravo
- Department of Nursing, Faculty of Nursing, University of Cantabria, Santander, Spain
| | - Domingo Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Spain
- Grupo Excelencia Investigadora URJC-Banco Santander referencia Nº30VCPIGI03: Investigación traslacional en el proceso de salud—enfermedad (ITPSE), Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Maria L. Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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Navarrete JJ, Ruiz M, Juanatey A, Barón J, Cuadrado ML, Guerrero AL. The Relationship of Auriculotemporal Neuralgia and Epicrania Fugax. Pain Medicine 2017; 19:635-636. [DOI: 10.1093/pm/pnx158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J J Navarrete
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - M Ruiz
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - A Juanatey
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - J Barón
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - M L Cuadrado
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - A L Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
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11
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Sánchez-Miranda I, González-Orero A, Gutiérrez-Viedma Á, Bilbao-Calabuig R, Cuadrado ML. Recurrent lacrimal neuralgia secondary to ophthalmological procedures. Neurologia 2017; 33:S0213-4853(17)30155-X. [PMID: 28431837 DOI: 10.1016/j.nrl.2017.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/17/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - A González-Orero
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | | | | | - M L Cuadrado
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.
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Abstract
This paper describes the differences in the presence of myofascial trigger points (TrPs) in the upper trapezius, sternocleidomastoid, temporalis and suboccipital muscles between unilateral migraine subjects and healthy controls, and the differences in the presence of TrPs between the symptomatic side and the nonsymptomatic side in migraine subjects. In addition, we assess the differences in the presence of both forward head posture (FHP) and active neck mobility between migraine subjects and healthy controls and the relationship between FHP and neck mobility. Twenty subjects with unilateral migraine without side-shift and 20 matched controls participated. TrPs were identified when there was a hypersensible tender spot in a palpable taut band, local twitch response elicited by the snapping palpation of the taut band and reproduction of the referred pain typical of each TrP. Side-view pictures were taken in both sitting and standing positions to measure the cranio-vertebral angle. A cervical goniometer was employed to measure neck mobility. Migraine subjects showed a significantly greater number of active TrPs ( P < 0.001), but not latent TrPs, than healthy controls. Active TrPs were mostly located ipsilateral to migraine headaches ( P < 0.01). Migraine subjects showed a smaller cranio-vertebral angle than controls ( P < 0.001), thus presenting a greater FHP. Neck mobility in migraine subjects was less than in controls only for extension ( P = 0.02) and the total range of motion in flexion/extension ( P = 0.01). However, there was a positive correlation between the cranio-vertebral angle and neck mobility. Nociceptive inputs from TrPs in head and neck muscles may produce continuous afferent bombardment of the trigeminal nerve nucleus caudalis and, thence, activation of the trigeminovascular system. Active TrPs located ipsilateral to migraine headaches might be a contributing factor in the initiation or perpetuation of migraine.
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Affiliation(s)
- C Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, and Department of Neurology, Fundación Hospital Alcorcón, Madrid, Spain.
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13
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Cuadrado ML, Fernández-de-Las-Peñas C, Santiago S, Vela L, Pérez-Conde C, Pareja JA. Hemifacial Spasm Induced by Trigeminal Stimuli and Coupled With Ipsilateral Migraine: A Spasmodic Migraine. Cephalalgia 2016; 26:1150-2. [PMID: 16919068 DOI: 10.1111/j.1468-2982.2006.01159.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M L Cuadrado
- Department of Neurology, Fundacion Hospital Alcorcón and Rey Juan Carlos University, Madrid, Spain.
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14
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Abstract
The aim of the present study was to investigate whether nummular headache (NH) patients show increased pericranial tenderness in relation to healthy subjects, and to compare pericranial tenderness between both NH and chronic tension-type headache (CTTH) patients. Three tenderness (total, cephalic and neck) scores were objectively and blinded assessed in 10 NH patients, 10 CTTH subjects and 10 healthy matched controls. No significant differences were found in any tenderness score between the symptomatic and non-symptomatic sides in NH, or between right and left sides in either CTTH or control groups. All tenderness scores were significantly greater in CTTH patients compared with both NH patients and controls ( P < 0.001), but not significantly different between NH patients and controls. Therefore, NH patients had lower tenderness than patients with CTTH and did not show increased tenderness when compared with healthy subjects. In addition, tenderness in NH patients was quite symmetrical between both the symptomatic and the non-symptomatic sides. The absence of increased pericranial tenderness could be clinically useful in distinguishing NH from CTTH. Current findings expand the evidence supporting the notion that NH is a non-generalized and rather limited disorder, marking the presence of a well-delimited painful zone.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Madrid, Spain.
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15
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Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Neck Mobility and Forward Head Posture are not Related to Headache Parameters in Chronic Tension-Type Headache. Cephalalgia 2016; 27:158-64. [PMID: 17257237 DOI: 10.1111/j.1468-2982.2006.01247.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The relationship between the changes in forward head posture (FHP), neck mobility and headache parameters was analysed in 25 patients with chronic tension-type headache (CTTH) undergoing a physical therapy programme. Side-view pictures were taken to measure the cranio-vertebral angle in the sitting and standing positions. A cervical goniometer was employed to measure the range of all cervical motions. A headache diary was kept to assess headache intensity, frequency and duration. All patients received six sessions of physical therapy over 3 weeks. Outcomes were assessed at baseline, after treatment and 1 month later. Neck mobility and headache parameters showed a significant improvement after the intervention, whereas posture changes did not reach statistical significance. No correlations were found between FHP, neck mobility and headache parameters at any stage. Changes in these outcomes throughout the study were not correlated either. FHP and neck mobility appear not to be related to headache intensity, duration or frequency in patients suffering from CTTH. Although patients showed a reduction in the range of motion in the neck, it is uncertain whether this is consistent with TTH.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Madrid, Spain.
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Muñoz I, Hernández MS, Santos S, Jurado C, Ruiz L, Toribio E, Sotelo EM, Guerrero AL, Molina V, Uribe F, Cuadrado ML. Personality traits in patients with cluster headache: a comparison with migraine patients. J Headache Pain 2016; 17:25. [PMID: 26975362 PMCID: PMC4791411 DOI: 10.1186/s10194-016-0618-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/09/2016] [Indexed: 12/21/2022] Open
Abstract
Background Cluster headache (CH) has been associated with certain personality traits and lifestyle features, but there are few studies assessing personality profiles in CH. We aimed to analyze personality traits in patients with CH, and to compare them with those found in migraine. Methods We included all consecutive patients with CH attending 5 outpatient offices between January and December 2013. Personality traits were evaluated using the Salamanca screening test, a validated inventory assessing 11 personality traits grouped in 3 clusters. We analyzed the test results in this population, and compared them with those of a migraine population previously assessed with the same test. Results Eighty patients with CH (75 men, 5 women; mean age, 43.2 ± 9.9 years) were recruited. The reference population consisted of 164 migraine patients (30 men, 134 women; mean age 36.4 ± 12.7 years). In CH patients, the most frequent personality traits were anancastic (52.5 %), anxious (47.5 %), histrionic (45 %), schizoid (42.5 %), impulsive (32.5 %) and paranoid (30 %). When compared to migraine patients, paranoid (p < 0.001; χ2 test), and schizoid traits (p = 0.007; χ2 test) were significantly more prevalent in CH patients. In logistic regression analysis the paranoid trait was significantly associated with CH (p = 0.001; OR: 3.27, 95 % CI [1.66–6.43]). Conclusion According to the Salamanca screening test, personality traits included in cluster A (odd or eccentric disorders) are more prevalent in CH patients than in a population of migraineurs. Larger studies are needed to determine whether certain personality traits are related to CH.
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Affiliation(s)
- I Muñoz
- Psychiatry Department Hospital Clínico Universitario, Valladolid, Spain
| | - M S Hernández
- Psychiatry Department Hospital Clínico Universitario, Valladolid, Spain
| | - S Santos
- Neurology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - C Jurado
- Neurology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - L Ruiz
- Neurology Department, Hospital Universitario del Henares, Coslada, Madrid, Spain
| | - E Toribio
- Neurology Department, Hospital Universitario del Henares, Coslada, Madrid, Spain
| | - E M Sotelo
- Psychiatry Department Hospital Clínico Universitario, Valladolid, Spain
| | - A L Guerrero
- Neurology Department, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47005, Valladolid, Spain.
| | - V Molina
- Psychiatry Department Hospital Clínico Universitario, Valladolid, Spain
| | - F Uribe
- Psychiatry Department Hospital Clínico Universitario, Valladolid, Spain
| | - M L Cuadrado
- Neurology Department. Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
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Ruiz M, Porta-Etessam J, Garcia-Ptacek S, de la Cruz C, Cuadrado ML, Guerrero AL. Auriculotemporal Neuralgia: Eight New Cases Report. Pain Med 2016; 17:1744-8. [PMID: 26921888 DOI: 10.1093/pm/pnw016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/18/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Auriculotemporal neuralgia (ATN) is an infrequent syndrome consisting in strictly unilateral pain in the temporal region associated with nerve tenderness, which can be successfully treated with anesthetic blockade. We analysed clinical characteristics and treatment response in a series of eight patients. METHODS Series of consecutive patients diagnosed with ATN at Headache Clinics of two university hospitals in Spain. Data on demographic and pain characteristics, as well as response to treatment are presented. RESULTS Eight patients (seven women). Mean age at onset was 52.8 ± 14.3 years. Pain was strictly unilateral (left-sided in five cases, right-sided in three), and triggered by pressing the preauricular area. Four patients presented background pain, mostly dull in quality, with an intensity of 5.75 ± 1.2 on the verbal analogical scale (VAS). In six, burning exacerbations occurred, ranging from 2 seconds to 30 minutes, with intensity 7.3 ± 1.5 on VAS. Complete relief was achieved with gabapentin in three cases, anaesthetic blockade in three and spontaneously in two. CONCLUSION ATN is uncommon in headache units. Gabapentin is a good alternative therapeutic option to anesthetic blockade.
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Affiliation(s)
- M Ruiz
- *Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Spain
| | - J Porta-Etessam
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - S Garcia-Ptacek
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain; Department of Geriatrics, Karolinska University Hospital, Huddinge, Sweden; Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - C de la Cruz
- *Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Spain
| | - M L Cuadrado
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - A L Guerrero
- *Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Spain;
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Ruiz M, Barón J, Pedraza MI, Rodriguez C, Guerrero A, Madeleine P, Cuadrado ML, Fernandez-de-las-Peñas C. EHMTI-0243. Pressure pain sensitivity maps of the head are similar in patients with unilateral or bilateral migraine. J Headache Pain 2014. [PMCID: PMC4182190 DOI: 10.1186/1129-2377-15-s1-e12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Valencia C, Cuadrado ML, Barahona-Hernando R, Ordás CM, González-Hidalgo M, Jorquera M, Porta-Etessam J. [Migraine-triggered hemifacial spasm: another case study]. Neurologia 2012; 29:61-2. [PMID: 22884700 DOI: 10.1016/j.nrl.2012.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 06/25/2012] [Indexed: 11/28/2022] Open
Affiliation(s)
- C Valencia
- Servicio de Neurología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España.
| | - M L Cuadrado
- Servicio de Neurología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
| | - R Barahona-Hernando
- Servicio de Neurología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
| | - C M Ordás
- Servicio de Neurología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
| | - M González-Hidalgo
- Servicio de Neurofisiología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
| | - M Jorquera
- Diagnóstico por Imagen, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
| | - J Porta-Etessam
- Servicio de Neurología, Hospital Clínico San Carlos, Universidad Complutense, Madrid, España
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Barahona-Hernando R, Cuadrado ML, García-Ptacek S, Marcos-de-Vega A, Jorquera M, Guerrero A, Ordás CM, Muñiz S, Porta-Etessam J. Migraine-triggered hemifacial spasm: three new cases. Cephalalgia 2012; 32:346-9. [PMID: 22421902 DOI: 10.1177/0333102412438976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The occurrence of hemifacial spasm (HFS) during an episode of migraine has been seldom reported. Here we describe three new cases presenting with HFS in association with migraine attacks. CASE RESULTS Three patients (one woman and two men, aged 31-36 years) developed HFS in close temporal relationship with migraine headaches. All of them started having the muscle spasms after pain onset. Two of them had electromyographic evidence of facial nerve damage, and continued having HFS once the pain abated. CONCLUSIONS Migraine attacks may be associated with HFS. The appearance of HFS could be related to migraine activity. A mechanism of central hyperexcitability in connection with nociceptive inputs on the trigeminal nucleus caudalis and/or a dilation of vessels compressing the facial nerve at the root exit zone could lead to the development of HFS in predisposed patients. 'Migraine-triggered hemifacial spasm' could possibly be regarded as a complication of migraine.
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Affiliation(s)
- R Barahona-Hernando
- Department of Neurology, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain.
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Vela A, Galán L, Valencia C, Torre PDL, Cuadrado ML, Esteban J, Guerrero A, García-Redondo A, Matías-Guiu J. [SOD1-N196 mutation in a family with amyotrophic lateral sclerosis]. Neurologia 2011; 27:11-5. [PMID: 21549454 DOI: 10.1016/j.nrl.2011.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 02/08/2011] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION N19S mutation is produced by substitution in the 139 position of SOD1 and was described by Mayeux in a patient with amyotrophic lateral sclerosis (ALS). He suggested that it did not have a causal effect as it was found in asymptomatic and sporadic cases. Other authors in later articles did not agree. MATERIAL AND METHODS We describe a family with 4 members with ALS patients and attempt to find the carrier of the N19S mutation of the propositus. Molecular studies were performed on 15 members of the family of a different order. RESULTS The ALS cases were found in the maternal line of the propositus. The presence of the mutation was detected in 3 people, the other two were asymptomatic. One of patients with ALS in the family, who died previously, did not have the mutation. Two of the sons of this case and another of the other case did not show it. On the other hand, N19S mutation was only present in paternal branch of the propositus, where there were no cases. CONCLUSION The described family supports the hypothesis by Mayeux and against that mutation N19S has pathological consequences, since mutation is only in the family line where there are no cases with ALS. In consequence, although the described case is included as a familiar form, it cannot be attributed to the mutation, and its relationship with N19S should be considered as casual.
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Affiliation(s)
- A Vela
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
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Cuadrado ML, Valle B, Fernández-de-las-Peñas C, Madeleine P, Barriga FJ, Arias JA, Arendt-Nielsen L, Pareja JA. Pressure pain sensitivity of the scalp in patients with nummular headache: a cartographic study. Cephalalgia 2011; 30:200-6. [PMID: 19489884 DOI: 10.1111/j.1468-2982.2009.01895.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nummular headache (NH) is characterized by focal pain fixed within a small round or elliptical area of the head surface. Sensory dysfunction is apparently restricted to the symptomatic area, but a thorough analysis of cranial pain sensitivity has not been performed. Pressure pain sensitivity maps were constructed for 21 patients with NH and 21 matched healthy controls. In each subject pressure pain thresholds (PPT) were measured on 21 points distributed over the scalp. In each patient PPT were also measured in the symptomatic area and at a non-symptomatic symmetrical point. In both groups an anterior to posterior gradient was found on each side, with no significant differences of PPT measurements between sides or groups. In patients with NH, only the symptomatic area showed a local decrease of PPT (significant in comparison with the non-symptomatic symmetrical point, P < 0.001). These findings further support that NH is a non-generalized disorder with a peripheral source.
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Affiliation(s)
- M L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos and Universidad Complutense, Madrid, Spain.
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Porta-Etessam J, García-Cobos R, Cuadrado ML, Casanova I, Lapeña T, García-Ramos R. Neuro-otological symptoms in patients with migraine. Neurologia 2010; 26:100-4. [PMID: 21163190 DOI: 10.1016/j.nrl.2010.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 06/21/2010] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Neurootological symptoms are common in patients with migraine, and have been reported to be associated with diverse conditions. PATIENTS AND METHODS A total of 70 patients with a diagnosis of episodic migraine, with or without aura, attending our Migraine Unit were selected. The specific variables studied were the diagnosis of instability, psycho-physiological dizziness, presyncopal symptoms, benign paroxysmal positional vertigo (BPPV), migraine associated recurrent vertigo (MARV), and Meniere's disease. RESULTS A total of 44.3% of cases had orthostatism or syncope, 15.7% with instability (possibly due to bilateral vestibular hypofunction), 14.2% with MARV and 8.6% with BPPV. The presence of BPPV was observed in older patients (40 years), whilst MARV was a condition seen in younger ones (35 years). These findings are of interest and remind us that benign paroxysmal vertigo is a childhood condition and age is a risk for BPPV. CONCLUSIONS Migraine patients often present with neuro-otological symptoms that can be classified as inter-episodic and episodic symptoms, and specific and non-specific migraine symptoms. This approach is of obvious pathophysiological interest, given that MARV and the possible vestibular hypofunction of migraine patients are symptoms that share physiological aspects with migraine, while the orthostatism symptoms and BPPV are non-specific and are seen to be associated with other conditions.
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Affiliation(s)
- J Porta-Etessam
- Unidad de Cefaleas, Hospital Universitario Clínico San Carlos, Madrid, Spain.
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Porta-Etessam J, Cuadrado ML, Galán L, Sampedro A, Valencia C. Temporal response to bupivacaine bilateral great occipital block in a patient with SUNCT syndrome. J Headache Pain 2010; 11:179. [PMID: 20232223 PMCID: PMC3452296 DOI: 10.1007/s10194-010-0204-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 02/17/2010] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jesús Porta-Etessam
- Headache Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Maria L. Cuadrado
- Headache Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Lucía Galán
- Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Arturo Sampedro
- Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Cristina Valencia
- Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
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25
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Affiliation(s)
- ML Cuadrado
- Department of Neurology, Hospital Clínico San Carlos and Universidad Complutense, Alcorcón, Madrid, Spain
| | - J Porta-Etessam
- Department of Neurology, Hospital Clínico San Carlos and Universidad Complutense, Alcorcón, Madrid, Spain
| | - JA Pareja
- Department of Neurology, Hospital Universitario Fundación Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - J Matías-Guiu
- Department of Neurology, Hospital Clínico San Carlos and Universidad Complutense, Alcorcón, Madrid, Spain
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Fernández-de-las-Peñas C, Madeleine P, Caminero AB, Cuadrado ML, Arendt-Nielsen L, Pareja JA. Generalized Neck-Shoulder Hyperalgesia in Chronic Tension-Type Headache and Unilateral Migraine Assessed by Pressure Pain Sensitivity Topographical Maps of the Trapezius Muscle. Cephalalgia 2009; 30:77-86. [DOI: 10.1111/j.1468-2982.2009.01901.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Spatial changes in pressure pain hypersensitivity are present throughout the cephalic region (temporalis muscle) in both chronic tension-type headache (CTTH) and unilateral migraine. The aim of this study was to assess pressure pain sensitivity topographical maps on the trapezius muscle in 20 patients with CTTH and 20 with unilateral migraine in comparison with 20 healthy controls in a blind design. For this purpose, a pressure algometer was used to assess pressure pain thresholds (PPT) over 11 points of the trapezius muscle: four points in the upper part of the muscle, two over the levator scapulae muscle, two in the middle part, and the remaining three points in the lower part of the muscle. Pressure pain sensitivity maps of both sides (dominant/non-dominant; symptomatic/non-symptomatic) were depicted for patients and controls. CTTH patients showed generalized lower PPT levels compared with both migraine patients ( P = 0.03) and controls ( P < 0.001). The migraine group had also lower PPT than healthy controls ( P < 0.001). The most sensitive location for the assessment of PPT was the neck portion of the upper trapezius muscle in both patient groups and healthy controls ( P < 0.001). PPT was negatively related to some clinical pain features in both CTTH and unilateral migraine patients (all P < 0.05). Side-to-side differences were found in strictly unilateral migraine, but not in those subjects with bilateral pain, i.e. CTTH. These data support the influence of muscle hyperalgesia in both CTTH and unilateral migraine patients and point towards a general pressure pain hyperalgesia of neck-shoulder muscles in headache patients, particularly in CTTH.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy,
Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey
Juan Carlos, Alcorcón, Madrid, Spain
- Centre for Sensory-Motor
Interaction (SMI), Department of Health Science and Technology, Aalborg
University, Aalborg, Denmark
- Aesthesiology Laboratory of
Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - P Madeleine
- Centre for Sensory-Motor
Interaction (SMI), Department of Health Science and Technology, Aalborg
University, Aalborg, Denmark
| | - AB Caminero
- Neurology Department of Hospital
Avila, Avila, Spain
| | - ML Cuadrado
- Aesthesiology Laboratory of
Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
- Departments of Neurology of
Fundación Hospital Alcorcón and Universidad Rey Juan
Carlos, Alcorcón, Madrid, Spain
- Neurology Department, Hospital
Clínico San Carlos and Universidad Complutense, Madrid, Spain
| | - L Arendt-Nielsen
- Centre for Sensory-Motor
Interaction (SMI), Department of Health Science and Technology, Aalborg
University, Aalborg, Denmark
| | - JA Pareja
- Aesthesiology Laboratory of
Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
- Departments of Neurology of
Fundación Hospital Alcorcón and Universidad Rey Juan
Carlos, Alcorcón, Madrid, Spain
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27
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Fernández-de-las-Peñas C, Madeleine P, Cuadrado ML, Ge HY, Arendt-Nielsen L, Pareja JA. Pressure Pain Sensitivity Mapping of the Temporalis Muscle Revealed Bilateral Pressure Hyperalgesia in Patients with Strictly Unilateral Migraine. Cephalalgia 2009; 29:670-6. [DOI: 10.1111/j.1468-2982.2008.01831.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Previous studies on pressure pain sensitivity in patients with migraine have shown conflicting results. There is emerging evidence suggesting that pain sensitivity is not uniformly distributed over the muscles, indicating the existence of topographical changes in pressure pain sensitivity. The aim of this study was to calculate topographical pressure pain sensitivity maps of the temporalis muscle in a blind design in patients with strictly unilateral migraine compared with controls. For this purpose, an electronic pressure algometer was used to measure pressure pain thresholds (PPT) over nine points of the temporalis muscle: three points in the anterior, medial and posterior parts, respectively. Pressure pain sensitivity maps of both sides (dominant or non-dominant; symptomatic or non-symptomatic) were calculated. The analysis of variance showed significant differences in PPT values between both groups ( F = 279.2; P < 0.001) and points ( F = 4.033; P < 0.001). Patients showed lower PPT at all nine points than healthy controls ( P < 0.001). We also found lower PPT in the centre of the muscle compared with the posterior part of the muscle within both groups ( P < 0.01). Interaction between group and points ( F = 1.9; P < 0.05) was also found. Within the migraine group, PPT levels were decreased bilaterally from the posterior to the anterior column of the temporalis muscle (Student-Newman-Keuls analysis; P < 0.05), with the most sensitive in the anterior part of the muscle. For controls, PPT did not follow such anatomical distribution, the most sensitive point being the centre of the mid-muscle belly. This study showed bilateral sensitization to pressure in unilateral migraine, suggesting the involvement of central components.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos
- Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Aesthesiology Laboratory of Universidad Rey Juan Carlos
| | - P Madeleine
- Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - ML Cuadrado
- Aesthesiology Laboratory of Universidad Rey Juan Carlos
- Departments of Neurology of Fundación Hospital Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - H-Y Ge
- Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - L Arendt-Nielsen
- Centre for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - JA Pareja
- Aesthesiology Laboratory of Universidad Rey Juan Carlos
- Departments of Neurology of Fundación Hospital Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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Abstract
Nummular headache (NH) has been defined as a focal head pain that is exclusively felt in a small area of the head surface. Here we describe three patients who presented with focal head pain in two separate areas. This finding seems to be consistent with bifocal NH and further enlarges the clinical diversity of this headache disorder. The pathogenic mechanisms of NH may be active in multiple cranial areas in some particular patients.
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Affiliation(s)
- ML Cuadrado
- Department of Neurology, Hospital Clinico San Carlos, Universidad Complutense, Madrid
- Laboratory of Aesthesiology
| | - B Valle
- Laboratory of Aesthesiology
- Department of Physical Therapy, Hospital Universitario Fundación Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - C Fernández
- Laboratory of Aesthesiology
- Department of Physical Therapy, Hospital Universitario Fundación Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - FJ Barriga
- Laboratory of Aesthesiology
- Department of Neurology, Hospital Universitario Fundación Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - JA Pareja
- Laboratory of Aesthesiology
- Department of Neurology, Hospital Universitario Fundación Alcorcón and Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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29
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Cuadrado ML, Pareja JA. [Patent foramen ovale and migraine: where is the connection]. Neurologia 2008; 23:475-483. [PMID: 18802796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Patent foramen ovale (PFO) is an anatomic remnant of the fetal circulation that is highly prevalent in the general population. Several observational studies show that migraine with aura and PFO have higher coincidences than expected by chance. Both conditions might be linked by certain pathophysiological mechanisms, such as right-to-left shunting of venous agents or paradoxical embolism. Alternatively, they might share a common genetic background. No relevant differences have been found between the clinical features of migraine with FOP and those of migraine without FOP. The results of several observational studies suggest that PFO closure may have a beneficial effect on migraine. However, the first randomized, double-blind, and sham-controlled trial has failed to support such conclusion. Until there is more evidence from ongoing trials, PFO closure should not be performed in clinical practice for the treatment of migraine.
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Fernández-de-las-Peñas C, Cleland JA, Cuadrado ML, Pareja JA. Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy. Cephalalgia 2008; 28:264-75. [PMID: 18254895 DOI: 10.1111/j.1468-2982.2007.01530.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with tension-type headache pain who are likely to benefit from muscle trigger point (TrP) therapy. The purpose of this study was to develop a preliminary clinical prediction rule (CPR) to identify chronic tension-type headache (CTTH) patients who are likely to experience a successful response from TrP therapy. Consecutive patients with CTTH underwent a standardized examination and then received six sessions of TrP therapy over 3 weeks (two sessions per week). They were classified as having experienced a successful outcome at short-term (1 week after discharge) and 1-month follow-up based on a 50% reduction on at least one headache parameter (intensity, frequency or duration) and self-report perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for identifying treatment success. Data from 35 patients were included, of which 19 (55%) experienced a successful outcome. A CPR with four variables for short-term (headache duration < 8.5 h/day, headache frequency < 5.5 days/week, bodily pain < 47 and vitality < 47.5) and a CPR with two variables for 1-month (headache frequency < 5.5 days/week and bodily pain < 47) follow-up were identified. At short-term follow-up, if three of four variables [positive likelihood ratio (LR) 3.4] were present, the chance of experiencing a successful outcome improved from 54% to 80%, and if all the variables (positive LR 5.9) were present, the probability of success was 87.4%. At 1-month follow-up, if one of two variables (positive LR 2.2) was present, the probability of success increased from 54% to 72%, and if both variables (positive LR 4.6) were present, the probability of success was 84.4%. The present CPR provides the potential to identify CTTH patients who are likely to experience short-term and 1-month follow-up success with a muscle TrP therapy approach. Future studies are necessary to validate the CPR.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, and Aesthesiology Laboratory of Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
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Pareja JA, Cuadrado ML, Fernández-de-las Peñas C, Nieto C, Sols M, Pinedo F. Nummular headache with trophic changes inside the painful area. Cephalalgia 2008; 28:186-90. [PMID: 18197886 DOI: 10.1111/j.1468-2982.2007.01490.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Nummular headache (NH) is a primary disorder characterized by chronic pain that is exclusively felt in a small area of the head surface. We describe five patients with circumscribed head pain and sensory dysfunction consistent with NH, who in addition developed colocalized trophic changes. All of them had a round or oval patch of skin depression (1-2 cm in diameter) inside of the painful area (2-4.5 cm in diameter). Three of them also showed hair loss, reddish colour, and local increased temperature. Skin biopsies were performed in three patients, and were not specific for any particular dermatological disease. Local trophic changes may be a clinical feature of NH. Together with pain and sensory disturbances, they could represent a restricted form of complex regional pain syndrome. This should be taken as a possible evolution of the underlying morbid process of NH.
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Affiliation(s)
- J A Pareja
- Department of Neurology, Fundación Hospital Alcorcón, Alcorcón, Madrid, Spain.
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Pareja JA, Cuadrado ML, Fernández-de-las-Peñas C, Caminero AB, Nieto C, Sánchez C, Sols M, Porta-Etessam J. Epicrania fugax: an ultrabrief paroxysmal epicranial pain. Cephalalgia 2008; 28:257-63. [PMID: 18201251 DOI: 10.1111/j.1468-2982.2007.01515.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ten patients (one man and nine women, mean age 48.8 +/- 20.1) presented with a stereotypical and undescribed type of head pain. They complained of strictly unilateral, shooting pain paroxysms starting in a focal area of the posterior parietal or temporal region and rapidly spreading forward to the ipsilateral eye (n = 7) or nose (n = 3) along a lineal or zigzag trajectory, the complete sequence lasting 1-10 s. Two patients had ipsilateral lacrimation, and one had rhinorrhoea at the end of the attacks. The attacks could be either spontaneous or triggered by touch on the stemming area (n = 2), which could otherwise remain tender or slightly painful between the paroxysms (n = 5). The frequency ranged from two attacks per month to countless attacks per day, and the temporal pattern was either remitting (n = 5) or chronic (n = 5). This clinical picture might be a variant of an established headache or represent a novel syndrome.
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Affiliation(s)
- J A Pareja
- Department of Neurology, Fundación Hospital Alcorcón and Rey Juan Carlos University, Alcorcón, Madrid, Spain.
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Cuadrado ML, Young WB, Fernández-de-las-Peñas C, Arias JA, Pareja JA. Migrainous Corpalgia: Body Pain and Allodynia Associated with Migraine Attacks. Cephalalgia 2007; 28:87-91. [DOI: 10.1111/j.1468-2982.2007.01485.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cephalic and extracephalic allodynia are recognized as a common sign of sensory sensitization during migraine episodes. However, the occurrence of body pain in migraine has not been thoroughly explored. Here we report three patients presenting with spontaneous body pain in association with migraine attacks. A 41-year-old woman experienced face and limb pain along with migraine headaches; it started before, during or after headache, was usually ipsilateral to head pain, and could last from minutes to days. A 39-year-old woman had pain in her right limbs, back and neck for 30-60 min prior to right-sided migraine headaches. A 30-year-old woman perceived pain in her left upper limb for 24-48 h prior to left-sided migraine headaches. All patients had allodynia to mechanical stimuli over the painful areas. Spontaneous body pain may be associated with migraine attacks. Together with allodynia, this might be a consequence of central sensitization.
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Affiliation(s)
- ML Cuadrado
- Department of Neurology, Fundación Hospital Alcorcón and Rey Juan Carlos Universit
| | - WB Young
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - JA Arias
- Faculty of Health Sciences, Alfonso X el Sabio University, Madrid, Spain,
| | - JA Pareja
- Department of Neurology, Fundación Hospital Alcorcón and Rey Juan Carlos Universit
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Abstract
OBJECTIVE To assess the differences in the presence of trigger points (TrPs) in head and neck muscles, forward head posture (FHP) and neck mobility between episodic tension-type headache (ETTH) subjects and healthy controls. In addition, we assess the relationship between these muscle TrPs, FHP, neck mobility, and several clinical variables concerning the intensity and the temporal profile of headache. BACKGROUND TTH is a headache in which musculoskeletal disorders of the craniocervical region might play an important role in its pathogenesis. Design.-A blinded, controlled pilot study. METHODS Fifteen ETTH subjects and 15 matched controls without headache were studied. TrPs in both upper trapezius, both sternocleidomastoids, and both temporalis muscles were identified according to Simons and Gerwin diagnostic criteria (tenderness in a hypersensible spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation). Side-view pictures of each subject were taken in both sitting and standing positions, in order to assess FHP by measuring the craniovertebral angle. A cervical goniometer was employed to measure neck mobility. All measures were taken by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration. RESULTS The mean number of TrPs for each ETTH subject was 3.7 (SD: 1.3), of which 1.9 (SD: 0.9) were active, and 1.8 (SD: 0.9) were latent. Control subjects only had latent TrPs (mean: 1.5; SD: 1). TrP occurrence between the 2 groups was significantly different for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of TrPs were significant for the right upper trapezius muscles (P= .04), the left sternocleidomastoid (P= .03), and both temporalis muscles (P < .001). Within the ETTH group, headache intensity, frequency, and duration outcomes did not differ depending on TrP activity, whether the TrP was active or latent. The craniovertebral angle was smaller, ie, there was a greater FHP, in ETTH patients than in healthy controls for both sitting and standing positions (P < .05). ETTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions, though differences were only significant for certain muscles. Finally, ETTH patients also showed lesser neck mobility than healthy controls in the total range of motion as well as in half-cycles (except for cervical extension), although neck mobility did not seem to influence headache parameters. CONCLUSIONS Active TrPs in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in ETTH subjects than in healthy controls, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. ETTH patients showed greater FHP and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.
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Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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35
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Fernández-de-Las-Peñas C, Bueno A, Ferrando J, Elliott JM, Cuadrado ML, Pareja JA. Magnetic resonance imaging study of the morphometry of cervical extensor muscles in chronic tension-type headache. Cephalalgia 2007; 27:355-62. [PMID: 17376113 DOI: 10.1111/j.1468-2982.2007.01293.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This study analyses the differences in the relative cross-sectional area (rCSA) of several cervical extensor muscles, assessed by magnetic resonance imaging (MRI), between patients with chronic tension-type headache (CTTH) and healthy controls. MRI of the cervical spine was performed on 15 CTTH females and 15 matched controls. The rCSA values for the rectus capitis posterior minor (RCPmin), rectus capitis posterior major (RCPmaj), semispinalis capitis and splenius capitis muscles were measured from axial T1-weighted images using axial MR slices aligned parallel to the C2/3 intervertebral disc. A headache diary was kept for 4 weeks in order to substantiate the diagnosis and record the pain history. CTTH patients showed reduced rCSA for both RCPmin and RCPmaj muscles (P < 0.01), but not for semispinalis and splenius capitis muscles, compared with controls. Headache intensity, duration or frequency and rCSA in both RCPmin and RCPmaj muscles were negatively correlated (P < 0.05): the greater the headache intensity, duration or frequency, the smaller the rCSA in the RCPmin and RCPmaj muscles. CTTH patients demonstrate muscle atrophy of the rectus capitis posterior muscles. Whether this selective muscle atrophy is a primary or secondary phenomenon remains unclear. In any case, muscle atrophy could possibly account for a reduction of proprioceptive output from these muscles, and thus contribute to the perpetuation of pain.
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Affiliation(s)
- C Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Spain.
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36
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Fernández-de-las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Simons DG, Pareja JA. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia 2007; 27:383-93. [PMID: 17359516 DOI: 10.1111/j.1468-2982.2007.01295.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Present pain models for tension-type headache suggest that nociceptive inputs from peripheral tender muscles can lead to central sensitization and chronic tension-type headache (CTTH) conditions. Such models support that possible peripheral mechanisms leading to pericranial tenderness include activation or sensitization of nociceptive nerve endings by liberation of chemical mediators (bradikinin, serotonin, substance P). However, a study has found that non-specific tender points in CTTH subjects were not responsible for liberation of algogenic substances in the periphery. Assuming that liberation of algogenic substances is important, the question arising is: if tender muscle points are not the primary sites of on-going neurogenic inflammation, which structure can be responsible for liberation of chemical mediators in the periphery? A recent study has found higher levels of algogenic substances, and lower pH levels, in active myofascial trigger point (TrPs) compared with control tender points. Clinical studies have demonstrated that referred pain elicited by head and neck muscles contribute to head pain patterns in CTTH. Based on available data, an updated pain model for CTTH is proposed in which headache can at least partly be explained by referred pain from TrPs in the posterior cervical, head and shoulder muscles. In this updated pain model, TrPs would be the primary hyperalgesic zones responsible for the development of central sensitization in CTTH.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Madrid, Spain.
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37
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Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study. Cephalalgia 2006; 26:314-9. [PMID: 16472338 DOI: 10.1111/j.1468-2982.2005.01042.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Forward head posture (FHP) and neck mobility were objectively assessed in 25 patients with chronic tension-type headache (CTTH) and 25 healthy controls. Side-view pictures were taken in a sitting position to measure the cranio-vertebral angle. A cervical goniometer was employed to measure the range of all cervical motions. Patients with CTTH showed a smaller cranio-vertebral angle (45.3 degrees +/- 7.6 degrees) than controls (54.1 degrees +/- 6.3 degrees), thus presenting a greater FHP (P < 0.001). Patients also had lesser neck mobility for all cervical movements, except for right lateral flexion (P < 0.01). There was a positive correlation between the cranio-vertebral angle and neck mobility. Within the CTTH group, a negative correlation was found between the cranio-vertebral angle and headache frequency, but neck mobility did not correlate with headache parameters. Further research is needed to define a potential role of FHP and restricted neck mobility in the origin or maintenance of TTH.
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Affiliation(s)
- C Fernández-de-las-Peñas
- Department of Physical Therapy & Occupational Therapy, Physical Medicine and Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
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Abstract
Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 +/- 11.4 years, and the mean age at onset 64.0 +/- 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 +/- 6.1 s. The unweighted mean was 8.8 +/- 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.
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Affiliation(s)
- J A Pareja
- Department of Neurology, Fundación Hospital Alcorcón and Rey Juan Carlos University, Alcorcón, Madrid, Spain.
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39
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Abstract
The aim of this study was to compare the results of radionuclide bone scans of the jaws with data obtained at the nuclear medicine department from a brief and feasible dental history, taking special account of cases with a positive scan and no recent dental events. Ninety-eight patients undergoing radionuclide bone scan as part of their diagnosis in non-dental, oncological and non-oncological diseases were imaged with 99mTc-labelled oxidronate. Superior and inferior halves of the mandible and maxilla (392 quadrants) were regarded as normal or having an abnormally high uptake. A recent (1 year) dental history was also obtained through a brief questionnaire and data were referred to each quadrant of the jaws. The association between the bone scan and dental disease was assessed by means of the chi-squared test. The overall results of scintigraphy and history coincided in 66 patients (46 with abnormal and 20 with normal findings; P = 0.002). Twenty-five patients had a positive scintigram without any known dental disorder. Results of scintigraphy and history coincided in 254 quadrants (78 with abnormal and 176 with normal findings; P < 0.001). Eighty-three quadrants had hot spots in the scintigram without any known dental lesion. It can be concluded that abnormal jaw scintigrams are frequent in patients without known dental disease, and this may indicate silent osteoblastic activity. These observations should be reported to the dentist for several reasons. First, they may reveal asymptomatic dental lesions. Second, the use of oral prostheses and implants is increasing and they require the support of healthy alveolar bone.
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Affiliation(s)
- Jose A Arias
- Faculty of Health Sciences, Alfonso X el Sabio University, Villanueva de la Canada, Madrid, Spain.
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Cuadrado ML, Arias JA. Bilateral movement enhances ipsilesional cortical activity in acute stroke: a pilot functional MRI study. Neurology 2001; 57:1740-1. [PMID: 11706135 DOI: 10.1212/wnl.57.9.1740] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Cuadrado ML, Arias JA, Palomar MA, Linares R. [The pyramidal tract: new pathways]. Rev Neurol 2001; 32:1151-8. [PMID: 11562847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
OBJECTIVE To review some anatomofunctional aspects of the pyramidal tract which are relevant in clinical practice, especially the newer concepts. DEVELOPMENT a) Although the motor function is best known, the pyramidal tract also has sensory functions, modulating the transmission of impulses in the spinal cord. In fact, motor function is a recent acquisition on the evolutionary scale. b) Other descending pathways, such as the cortico reticulospinal path, participate in voluntary movements. However, the pyramidal pathway is necessary for fine movements of the hand. c) Most of the pyramidal fibres control movements of the contralateral side of the body, but there are a few fibres which do not cross to the other side and play a part in ipsilateral body movements. These fibres seem to contribute to motor recovery following a brain lesion. d) Classically it is recognized that the motor cortex and pyramidal fibres follow a somatotopical distribution. Nevertheless territories corresponding to different parts of the body are superimposed to a considerable extent and may be modified on very diverse occasions. e) Experimentally it has been proved that a circumscribed lesion of the pyramidal pathway does not cause hyper reflexia or spasticity. The hyper reflexia and spasticity habitually seen in patients with pyramidal syndrome is due to lesions of other descending pathways. CONCLUSION The pyramidal tract is anatomically and functionally related to other nerve structures and its activity is therefore integrated within the nervous system.
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Affiliation(s)
- M L Cuadrado
- Universidad Rey Juan Carlos, Madrid, 28922, España.
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Cuadrado ML, Egido JA, González-Gutiérrez JL, Varela-De-Seijas E. Bihemispheric contribution to motor recovery after stroke: A longitudinal study with transcranial doppler ultrasonography. Cerebrovasc Dis 1999; 9:337-44. [PMID: 10545692 DOI: 10.1159/000016009] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Both cerebral hemispheres seem to contribute to motor recovery after stroke. We studied the effect of motor activity on cerebral blood flow in both hemispheres at different stages of stroke evolution. METHODS Thirty patients with hemiplegic stroke and 30 controls were included. Patients were examined within the first week (T1), 1 month (T2) and 6 months after stroke (T3). All subjects performed a 2-min sequential thumb-to-finger opposition task while blood flow velocities in both middle cerebral arteries were measured with transcranial Doppler ultrasonography (TCD). RESULTS Contralateral movement caused a higher increase in blood flow velocity than ipsilateral movement in controls (p < 0.0001). On the healthy side, patients showed a striking increase with ipsilateral movement (affected hand), which was similar to the increase with contralateral movement (normal hand) at all stages. On the damaged side, the increase with contralateral movement (affected hand) was low and was similar to the increase with ipsilateral movement (normal hand) at T1 and T2; however, at T3 the increase with contralateral movement was higher and the pattern of response was similar to that found in controls. CONCLUSIONS TCD can trace the evolution of brain motor output following stroke. Compensatory activation of the healthy side of the brain may be already present soon after stroke, whereas function of the damaged side may improve during several months.
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Affiliation(s)
- M L Cuadrado
- Cerebrovascular Unit, Neurology Department, Hospital Clínico de San Carlos, Madrid, Spain.
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Cuadrado ML, Arias JA, González-Gutiérrez JL, Egido JA, Varela de Seijas E. [Cerebral activation during movement of both hands. A study with transcranial Doppler]. Rev Neurol 1999; 29:793-6. [PMID: 10696648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION AND OBJECTIVE In healthy persons, the force carried out by a group of muscles doing bilateral exercise with maximum effort is less than that done during unilateral exercise. The nervous control of movement is probably different in these two cases. Our objective was to study and compare cerebral activation on movement of one and of both hands by means of transcranial Doppler (TCD). MATERIAL AND METHODS We studied 30 healthy volunteers (19 men and 11 women; average age 65.4 +/- 9.5 years). Using transtemporal TCD we assessed the relative changes in average velocity of flow in both middle cerebral arteries during the exercise of sequential opposition of the fingers of one hand and of both hands. RESULTS The activity due to the exercise of the hand contralateral to the hemisphere being studied was greater than that due to exercise of both hands together, both on the right side (p < 0.001) and on the left (p < 0.001). CONCLUSIONS The functional activity of each cerebral hemisphere is not necessarily greater when both hands are exercised than when the contralateral hand is used, and may even be less. The possible increase in activity due to the additional contribution to ipsilateral movement in the first case may be compensated by simultaneous transhemispherical inhibition.
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Affiliation(s)
- M L Cuadrado
- Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, España.
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Martín-Estefanía C, Cuadrado ML, Egido JA, González JL. [Oculocerebral syndrome: an infrequent pathological manifestation of carotid occlusion]. Rev Neurol 1998; 27:610-3. [PMID: 9803508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The simultaneous occurrence of impaired visual and ipsilateral hemisphere symptoms is uncommon. It is associated with carotid pathology. CLINICAL CASES We present three cases under the name of oculocerebral syndrome, in which there were symptoms of monocular ischemia and ipsilateral cerebral ischemia. In two of these cases the monocular vision loss was transient, and in the third case it was permanent due to occlusion of the central retinal artery. In all three cases there was evidence of obstruction of the internal carotid artery. CONCLUSION The pathological process involved may be mixed, embolic-hemodynamic.
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Affiliation(s)
- C Martín-Estefanía
- Servicio de Neurología, Hospital Universitario San Carlos, Madrid, España
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Veira C, Castro-Vilanova D, Ferreiro A, Sánchez-Suárez C, Cuadrado ML, Simón R, Mateos F. [Spontaneous intracranial hemorrhages in childhood]. Rev Neurol 1997; 25:1381-2. [PMID: 9377294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Spontaneous or non-traumatic intracranial haemorrhages seen in children of under 15 years old are most frequently due to cerebral vascular malformations, followed at a considerable distance by blood disorders, vasculopathies, tumours and the complications of radio-therapy. OBJECTIVE To present the cases of spontaneous and non-traumatic cerebral haemorrhage seen at our hospital. MATERIAL AND METHODS We reviewed all the paediatric cases of spontaneous cerebral haemorrhage diagnosed in our hospital over the previous sixteen years, excluding bleeding in the neonatal period. Computerized tomography was done in all cases, study of the cerebrospinal fluid, angiography and/or magnetic resonance in some cases. RESULTS We selected 44 patients, of who the aetiology could be determined in 30. Of these, 20 cases were due to vascular malformations, 7 were associated with haematological disorders, 2 with cerebral tumours and one case with meningococcal sepsis. The commonest form of presentation was that of an acute intracranial hypertension syndrome, also showing focal deficits, partial crises and meningism. CONCLUSIONS The commonest cause of spontaneous intracranial haemorrhage in children is due to rupture of a vascular malformation, namely an arterio-venous malformation. Angiography and/or magnetic resonance are the techniques of choice for diagnosis. The various causes of disorders of haemostasia also are important in giving rise to intracranial bleeding.
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Affiliation(s)
- C Veira
- Unidad de Neuropediatría, Hospital Doce de Octubre, Madrid, España
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Egido JA, Carod J, Cuadrado ML, González JL. [Dolichoectasia of multiple cranial arteries. Findings on neuroimaging and transcranial Doppler]. Rev Neurol 1997; 25:872-4. [PMID: 9244617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Dolichoectasia of the intracranial arteries may give rise to ischaemic or haemorragic pathology and to compression phenomena. Joint dolichoectasia of the whole circle of Willis, in both the anterior and basilar portions extending to the main basal arteries is an unusual finding. CLINICAL CASE We describe a 76 year old man who presented with vertigo with vertically downward nystagmus. On neuroimaging studies there was aneurysmal dilation of the left vertebral, basilar and both carotid arteries (in their supra-clinoid portion) and of both medial cerebral arteries. Transcraneal Doppler showed marked reduction in flow rate with normal morphology and pulsation. CONCLUSION The combination of non-invasive techniques allows full, reliable evaluation of the swollen arteries and possible complications.
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Affiliation(s)
- J A Egido
- Unidad de Patologia Cerebrovascular, Hospital Universitario San Carlos, Madrid, Espana
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