Virtual dynamic interaction games reveal impaired multisensory integration in women with migraine

OBJECTIVE

In this cross-sectional observational study, we aimed to investigate sensory profiles and multisensory integration processes in women with migraine using virtual dynamic interaction systems.

BACKGROUND

Compared to studies on unimodal sensory processing, fewer studies show that multisensory integration differs in patients with migraine. Multisensory integration of visual, auditory, verbal, and haptic modalities has not been evaluated in migraine.

METHODS

A 12-min virtual dynamic interaction game consisting of four parts was played by the participants. During the game, the participants were exposed to either visual stimuli only or multisensory stimuli in which auditory, verbal, and haptic stimuli were added to the visual stimuli. A total of 78 women participants (28 with migraine without aura and 50 healthy controls) were enrolled in this prospective exploratory study. Patients with migraine and healthy participants who met the inclusion criteria were randomized separately into visual and multisensory groups: Migraine multisensory (14 adults), migraine visual (14 adults), healthy multisensory (25 adults), and healthy visual (25 adults). The Sensory Profile Questionnaire was utilized to assess the participants' sensory profiles. The game scores and survey results were analyzed.

RESULTS

In visual stimulus, the gaming performance scores of patients with migraine without aura were similar to the healthy controls, at a median (interquartile range [IQR]) of 81.8 (79.5-85.8) and 80.9 (77.1-84.2) (p = 0.149). Error rate of visual stimulus in patients with migraine without aura were comparable to healthy controls, at a median (IQR) of 0.11 (0.08-0.13) and 0.12 (0.10-0.14), respectively (p = 0,166). In multisensory stimulation, average gaming score was lower in patients with migraine without aura compared to healthy individuals (median [IQR] 82.2 [78.8-86.3] vs. 78.6 [74.0-82.4], p = 0.028). In women with migraine, exposure to new sensory modality upon visual stimuli in the fourth, seventh, and tenth rounds (median [IQR] 78.1 [74.1-82.0], 79.7 [77.2-82.5], 76.5 [70.2-82.1]) exhibited lower game scores compared to visual stimuli only (median [IQR] 82.3 [77.9-87.8], 84.2 [79.7-85.6], 80.8 [79.0-85.7], p = 0.044, p = 0.049, p = 0.016). According to the Sensory Profile Questionnaire results, sensory sensitivity, and sensory avoidance scores of patients with migraine (median [IQR] score 45.5 [41.0-54.7] and 47.0 [41.5-51.7]) were significantly higher than healthy participants (median [IQR] score 39.0 [34.0-44.2] and 40.0 [34.0-48.0], p < 0.001, p = 0.001).

CONCLUSION

The virtual dynamic game approach showed for the first time that the gaming performance of patients with migraine without aura was negatively affected by the addition of auditory, verbal, and haptic stimuli onto visual stimuli. Multisensory integration of sensory modalities including haptic stimuli is disturbed even in the interictal period in women with migraine. Virtual games can be employed to assess the impact of sensory problems in the course of the disease. Also, sensory training could be a potential therapy target to improve multisensory processing in migraine.

Napex acupoint thread-embedding combined with metoprolol tartrate tablet for prophylactic treatment of migraine without aura: a randomized controlled trial

OBJECTIVES

To observe the efficacy of napex acupoint thread-embedding combined with metoprolol tartrate tablet for prophylactic treatment of migraine without aura, and to compare its efficacy with simple napex acupoint thread-embedding and simple metoprolol tartrate tablet.

METHODS

A total of 105 patients with migraine without aura were randomized into a combination group (35 cases, 5 cases dropped out), a thread-embedding group (35 cases, 4 cases dropped out) and a western medication group (35 cases, 2 cases dropped out). In the thread-embedding group, napex acupoint thread-embedding was applied at bilateral Fengchi (GB 20) and points of 1.5 cun nearby to the lower edge of spinous process of cervical 2. In the western medication group, metoprolol tartrate tablet was given orally, 12.5 mg a time, twice a day. In the combination group, napex acupoint thread-embedding combined with oral metoprolol tartrate tablet was delivered. The treatment of 8 weeks was required in the 3 groups. The days of headache attacks, frequency of headache attacks, headache severity (visual analogue scale [VAS] score) and the migraine specific quality of life questionnaire version 2.1 (MSQ) score were observed during baseline period (4 weeks before treatment to before treatment), observation period (1-4 weeks and 5-8 weeks in treatment) and follow-up period (1-4 weeks after treatment completion) respectively, the proportions of the days of headache attacks/frequency of headache attacks relieved by 50% were calculated, and the safety was evaluated in the 3 groups.

RESULTS

During the observation period and the follow-up period, the days of headache attacks, frequency of headache attacks and headache VAS scores in the 3 groups were reduced compared with those of the baseline period (P<0.05). During the observation period and the follow-up period, the days of headache attacks and the frequency of headache attacks in the combination group were lower than those in the thread-embedding group and the western medication group (P<0.05); during the observation period (1-4 weeks in treatment), the headache VAS scores in the combination group and the thread-embedding group were lower than that in the western medication group (P<0.05); during the observation period (5-8 weeks in treatment) and the follow-up period, the headache VAS scores in the combination group were lower than those in the thread-embedding group and the western medication group (P<0.05). During the observation period and the follow-up period, the scores of role restriction, role prevention and emotion function of MSQ in the combination group were increased compared with those of the baseline period (P<0.05); during the observation period (5-8 weeks in treatment) and the follow-up period, the role prevention scores of MSQ in the thread-embedding group and the western medication group were increased compared with those of the baseline period (P<0.05); during the follow-up period, the emotion function scores of MSQ in the thread-embedding group and the western medication group were increased compared with those of the baseline period (P<0.05). During the observation period and the follow-up period, the scores of role restriction, role prevention and emotion function of MSQ in the combination group were higher than those in the thread-embedding group and the western medication group (P<0.05). There was no statistical difference in the proportions of the days of headache attacks/frequency of headache attacks relieved by 50% among the 3 groups (P>0.05), and there were no serious adverse reactions in the 3 groups.

CONCLUSIONS

Napex acupoint thread-embedding combined with metoprolol tartrate tablet, simple napex acupoint thread-embedding and simple metoprolol tartrate tablet all can reduce the days of headache attacks and the frequency of headache attacks, relieve headache severity and improve the quality of life in patients with migraine without aura. Napex acupoint thread-embedding combined with metoprolol tartrate tablet has a better effect.

Contralateral acupuncture for migraine without aura: a randomized trial protocol with multimodal MRI

Introduction

Migraine is a common clinical disorder, ranks as the second most disabling disease worldwide, and often manifests with unilateral onset. Contralateral acupuncture (CAT), as a classical acupuncture method, has been proven to be effective in the treatment of migraine without aura (MWoA). However, its neural mechanisms have not been investigated using multimodal magnetic resonance imaging (MRI).

Methods and analysis

In this multimodal neuroimaging randomized trial, a total of 96 female MWoA participants and 30 female healthy controls (HCs) will be recruited. The 96 female MWoA participants will be randomized into three groups: Group A (CAT group), Group B [ipsilateral acupuncture (IAT) group], and Group C (sham CAT group) in a 1:1:1 allocation ratio. Each group will receive 30 min of treatment every other day, three times a week, for 8 weeks, followed by an 8-week follow-up period. The primary outcome is the intensity of the migraine attack. Data will be collected at baseline (week 0), at the end of the 8-week treatment period (weeks 1-8), and during the 8-week follow-up (weeks 9-16). Adverse events will be recorded. Multimodal MRI scans will be conducted at baseline and after 8-week treatment.

Discussion

This study hypothesized that CAT may treat MWoA by restoring pathological alterations in brain neural activity, particularly by restoring cross-integrated functional connectivity with periaqueductal gray (PAG) as the core pathological brain region. The findings will provide scientific evidence for CAT in the treatment of MWoA.

Ethics and dissemination

The Medical Ethics Committee of the Second Affiliated Hospital of Yunnan University of Chinese Medicine has given study approval (approval no. 2022-006). This trial has been registered with the Chinese Clinical Trials Registry (registration no. ChiCTR2300069456). Peer-reviewed papers will be used to publicize the trial's findings.

Clinical trial registration

https://clinicaltrials.gov/, identifier ChiCTR2300069456.

Causal association between systemic lupus erythematosus and the risk of migraine: A Mendelian randomization study

BACKGROUND

Numerous studies have found that patients with systemic lupus erythematosus (SLE) often have comorbid headache, especially migraine. However, the causal relationship between genetically determined SLE and migraine risk remains unclear. Therefore, we conducted a Mendelian randomization (MR) study to explore this causal association.

METHODS

Genome-wide association studies (GWAS) provided the instrumental variables. We selected summary data from GWAS of SLE as exposure (5201 SLE patients and 9066 controls). Both outcome GWAS data were from the Finnish Gene GWAS, including migraine with aura, migraine with aura and triptan purchases, and migraine without aura. The main MR approach was inverse-variance weighted. Pleiotropy and heterogeneity were detected using the MR pleiotropy residual sum and outlier, MR-Egger intercept test, leave-one-out analysis, and Cochran's Q test.

RESULTS

There was a significant association between genetically predicted SLE susceptibility and increased risk of migraine with aura [odds ratio (OR) = 1.05, 95% confidence interval (CI) = 1.02-1.08, p = .001]. The result was consistent when the outcome was migraine with aura and triptan purchases [OR = 1.05, 95% CI = 1.02-1.08, p = .001]. However, we found no association between SLE and migraine without aura. Our MR study showed no pleiotropy or heterogeneity.

CONCLUSIONS

Our study indicates that genetic susceptibility to SLE increases the incidence of migraine with aura but not migraine without aura. It is necessary for the routine evaluation and early recognition of migraine in patients with SLE in clinical settings.

Abnormal causal connectivity of anterior cingulate cortex-visual cortex circuit related to nonsteroidal anti-inflammatory drug efficacy in migraine

The anterior cingulate cortex (ACC) and visual cortex are integral components of the neurophysiological mechanisms underlying migraine, yet the impact of altered connectivity patterns between these regions on migraine treatment remains unknown. To elucidate this issue, we investigated the abnormal causal connectivity between the ACC and visual cortex in patients with migraine without aura (MwoA), based on the resting-state functional magnetic resonance imaging data, and its predictive ability for the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs). The results revealed increased causal connectivity from the bilateral ACC to the lingual gyrus (LG) and decreased connectivity in the opposite direction in nonresponders compared with the responders. Moreover, compared with the healthy controls, nonresponders exhibited heightened causal connectivity from the ACC to the LG, right inferior occipital gyrus (IOG) and left superior occipital gyrus, while connectivity patterns from the LG and right IOG to the ACC were diminished. Based on the observed abnormal connectivity patterns, the support vector machine (SVM) models showed that the area under the receiver operator characteristic curves for the ACC to LG, LG to ACC and bidirectional models were 0.857, 0.898, and 0.939, respectively. These findings indicate that neuroimaging markers of abnormal causal connectivity in the ACC-visual cortex circuit may facilitate clinical decision-making regarding NSAIDs administration for migraine management.

Structural and functional changes of anterior cingulate cortex subregions in migraine without aura: relationships with pain sensation and pain emotion

Migraine without aura is a multidimensional neurological disorder characterized by sensory, emotional, and cognitive symptoms linked to structural and functional abnormalities in the anterior cingulate cortex. Anterior cingulate cortex subregions play differential roles in the clinical symptoms of migraine without aura; however, the specific patterns and mechanisms remain unclear. In this study, voxel-based morphometry and seed-based functional connectivity were used to investigate structural and functional alterations in the anterior cingulate cortex subdivisions in 50 patients with migraine without aura and 50 matched healthy controls. Compared with healthy controls, patients exhibited (1) decreased gray matter volume in the subgenual anterior cingulate cortex, (2) increased functional connectivity between the bilateral subgenual anterior cingulate cortex and right middle frontal gyrus, and between the posterior part of anterior cingulate cortex and right middle frontal gyrus, orbital part, and (3) decreased functional connectivity between the anterior cingulate cortex and left anterior cingulate and paracingulate gyri. Notably, left subgenual anterior cingulate cortex was correlated with the duration of each attack, whereas the right subgenual anterior cingulate cortex was associated with migraine-specific quality-of-life questionnaire (emotion) and self-rating anxiety scale scores. Our findings provide new evidence supporting the hypothesis of abnormal anterior cingulate cortex subcircuitry, revealing structural and functional abnormalities in its subregions and emphasizing the potential involvement of the left subgenual anterior cingulate cortex-related pain sensation subcircuit and right subgenual anterior cingulate cortex -related pain emotion subcircuit in migraine.

No wearing-off effect of erenumab or fremanezumab for chronic migraine prevention: a single-center, real-world, observational study

BACKGROUND

The present study investigates the wearing-off effect in adults with chronic migraine treated with erenumab or fremanezumab.

METHODS

This real-world observational study was based on pre-collected headache diaries from chronic migraine patients in treatment with either monthly injections of 140 mg of erenumab or 225 mg of fremanezumab. Consistent wearing-off was defined as an increase of ≥2 weekly migraine days in the last week compared to the second week over two consecutive 4-week treatment periods. The primary endpoint was wearing-off in the total population. The secondary endpoints were difference in wearing-off in (i) a subgroup of patients treated with erenumab and fremanezumab and (ii) consistent wearing-off in patients with a ≥30% reduction in monthly migraine days, compared to baseline, in the two consecutive treatment months.

RESULTS

In total, 100 patients (erenumab: n = 60, fremanezumab: n = 40) were included. Sixty-two out of 100 (62%) patients had consistent ≥30% treatment response on antibody therapy in both months (erenumab: n = 36, fremanezumab: n = 26). There was no consistent wearing-off over the two consecutive months from week 2 to week 4 (3.04%, p = 0.558). There was no wearing-off within the erenumab (p = 0.194) or the fremanezumab (p = 0.581) groups. Among the ≥30% treatment responders, there was no consistent wearing-off over the two consecutive months (2.6%, p = 0.573).

CONCLUSIONS

There was no wearing-off in treatment responders, which is in alignment with premarketing data from placebo-controlled phase III studies. These data suggest that patients should be informed upfront that no wearing-off effect is expected because anxiety for attacks at the end of the month per se may generate migraine attacks.

Vestibular evoked myogenic and auditory brainstem evoked potentials in a female migraine population

Background and purpose

The purpose of the present study was to evaluate ocular vestibular evoked myogenic potential (oVEMP), cervical vestibular evoked myogenic potential (cVEMP), and brainstem auditory evoked potential (BAEP) response characteristics and to understand the pathophy­siology of vestibular dysfunction in female migraineurs with vertigo symptoms. We also aimed to assess the electrophysiological di­­agnostic significance of the VEMP respon­ses in vestibular migraine (VM). 

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Methods

23 patients with migraine without aura (MoA), 23 patients with VM, and 20 sex-and age-matched healthy controls, a total of 66 female participants were enrolled in this study. The outcome parameters were asymmetry ratios (ARs), amplitudes of oVEMP, cVEMP, N1P1, P13N23, and the respective latencies (mean ± SD). From the BAEP graphs, absolute and interpeak interval latencies of waves were analyzed. 

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Results

30.4% of the MoA group and 21.7% of the VM group had uni- or bilaterally absent cVEMP responses which were statistically significant only in the MoA group (p=0.035) in comparison to control group. Both groups displayed statistically insignificant absent or asymmetrical responses for oVEMP (13.1%). Cervical VEMP P13 and N23 latency, peak-to-peak amplitude, interaural latencies, and amplitude ARs did not show any significant difference between MoA and VM patients and healthy controls. No significant difference was detected among the three groups in the oVEMP and BAEP parameters.

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Conclusion

Although absent cVEMP responses were more common in MoA and VM patients than in healthy individuals, the VEMP and BAEP test results should not be used in the differential diagnosis of VM and MoA. 

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Unveiling the Role of Contingent Negative Variation (CNV) in Migraine: A Review of Electrophysiological Studies in Adults and Children

Migraine has been considered a chronic neuronal-based pain disorder characterized by the presence of cortical hyperexcitability. The Contingent Negative Variation (CNV) is the most explored electrophysiological index in migraine. However, the findings show inconsistencies regarding its functional significance. To address this, we conducted a review in both adults and children with migraine without aura to gain a deeper understanding of it and to derive clinical implications. The literature search was conducted in the PubMed, SCOPUS and PsycINFO databases until September 2022m and 34 articles were retrieved and considered relevant for further analysis. The main results in adults showed higher CNV amplitudes (with no habituation) in migraine patients. Electrophysiological abnormalities, particularly focused on the early CNV subcomponent (eCNV), were especially prominent a few days before the onset of a migraine attack, normalizing during and after the attack. We also explored various modulatory factors, including pharmacological treatments-CNV amplitude was lower after the intake of drugs targeting neural hyperexcitability-and other factors such as psychological, hormonal or genetic/familial influences on CNV. Although similar patterns were found in children, the evidence is particularly scarce and less consistent, likely due to the brain's maturation process during childhood. As the first review exploring the relationship between CNV and migraine, this study supports the role of the CNV as a potential neural marker for migraine pathophysiology and the prediction of pain attacks. The importance of further exploring the relationship between this neurophysiological index and childhood migraine is critical for identifying potential therapeutic targets for managing migraine symptoms during its development.

The Influence of Patent Foramen Ovale on the Clinical Features of Migraine without Aura: A Cross-Sectional Study

Objective

To investigate the influence of patent foramen ovale (PFO) on the clinical features of migraine without aura (MoA).

Methods

We consecutively enrolled 390 MoA patients and compared the frequency of headache, episode duration, and the Visual Analogue Scale (VAS), Headache Impact Test 6 (HIT-6), and European Health Interview Survey-Quality of Life 8-item index (EUROHIS-QOL8) scores of patients with and without PFO, those with the mild right-to-left shunt (RLS) and moderate to large RLS, and those with permanent RLS and latent RLS using a nonparametric Mann-Whitney U-test. In addition, we analyzed the clinical features of migraine in 39 MoA patients before and after PFO closure treatment using the paired Wilcoxon test.

Results

The prevalence of PFO in the 390 MoA patients was 44.4%. Patients with PFO had significantly higher frequency of headaches, VAS scores, HIT-6 scores, and incidence of white matter lesions than those without PFO (all p< 0.05). Patients with moderate to large RLS had significantly higher VAS scores than those with mild RLS (p = 0.002). Additionally, 39 MoA patients underwent PFO closure, which remarkably decreased their frequency of headache, episode duration, VAS scores, and HIT-6 scores, and increased their EUROHIS-QOL8 scores.

Conclusion

The migraine features in MoA patients could be influenced by PFO, especially in patients with moderate to large shunt, in whom PFO closure improved the symptoms.

[Heat-sensitive moxibustion for migraine without aura: a randomized controlled trial]

OBJECTIVE

To compare the clinical effect between heat-sensitive moxibustion and mild moxibustion for migraine without aura.

METHODS

A total of 54 patients with migraine without aura were randomized into an observation group (27 cases, 2 cases dropped off) and a control group (27 cases, 2 cases dropped off). The basic western medication treatment was adopted in the two groups. In the control group, mild moxibustion was applied at Shuaigu (GB 8), Fengchi (GB 20) and Yanglingquan (GB 34) on the affected side. In the observation group, the frequent acupoint areas of the affected side i.e. Shuaigu (GB 8), Fengchi (GB 20), Taiyang (EX-HN 5), Taichong (LR 3), Yanglingquan (GB 34) were determined, 3 acupoints with strong heat-sensitive sensation were selected each time and mild moxibustion was adopted. The treatment was given once a day, 5 times of treatment was as one course and 2 courses were required in the two groups. Before and after treatment, the scores of migraine symptom, visual analogue scale (VAS), migraine specific quality of life questionnaire (MSQ) were observed, and the clinical efficacy was evaluated after treatment in the two groups.

RESULTS

After treatment, the scores of migraine symptom and VAS were decreased compared with those before treatment (P<0.01), while the MSQ scores were increased compared with those before treatment (P<0.01) in the two groups. After treatment, the scores of migraine symptom and VAS in the observation group were lower than those in the control group (P<0.05), while the MSQ score in the observation group was higher than that in the control group (P<0.01). The total effective rate was 92.0% (23/25) in the observation group, which was superior to 72.0% (18/25) in the control group (P<0.05).

CONCLUSION

Both heat-sensitive moxibustion and mild moxibustion can effectively alleviate the clinical symptoms, improve the headache degree and life quality in patients with migraine without aura, the clinical efficacy of heat-sensitive moxibustion is superior to that of mild moxibustion.

Real-world efficacy and tolerability of fremanezumab in adults with chronic migraine: a 3-month, single-center, prospective, observational study

Background

Following the promising pre-marketing placebo-controlled randomized clinical trials of fremanezumab, post-marketing studies are necessary to verify efficacy and tolerability in various real-world settings. The present study assessed real-world efficacy and safety of fremanezumab.

Methods

A 3-month, single-center, prospective, observation study of adults with chronic migraine who were treated with monthly subcutaneous injections of 225 mg fremanezumab in Denmark. The primary outcome was defined as proportion of patients who achieved ≥30% reduction in monthly migraine days (MMDs) from baseline to weeks 9-12. Among secondary outcomes were ≥50 and ≥75% responder rates and the proportion of patients reporting adverse events.

Results

A total of 91 patients with chronic migraine were enrolled and received at least one dose of fremanezumab of whom 89 patients (98%) completed the 3-months treatment period. At baseline, the mean (SD) number of monthly headache days was 24.3 ± 5.8 and mean number of MMDs was 18.5 ± 7.4. The number of patients who achieved ≥30% reduction in MMDs from baseline to weeks 9-12 was 58 (65%), while 45 (51%) and 21 (24%) had ≥50 and 75% reduction in MMD, respectively. Twenty-one patients (23%) reported adverse event, in which the most common were constipation (4.4%), fatigue (4.4%) and dizziness (3.3%). No serious adverse events were reported.

Conclusion

In adult chronic migraine patients with previous failure of conventional oral migraine preventives, fremanezumab was found to be effective and well-tolerated.

A Scoping Review and Meta-Analysis of Anti-CGRP Monoclonal Antibodies: Predicting Response

Calcitonin gene-related peptide-targeted monoclonal antibodies (CGRP mAbs) are increasingly being used as preventive treatments for migraine. Their effectiveness and safety were established through numerous randomized placebo-controlled trials and real-world studies, yet a significant proportion of patients do not respond to this treatment, and currently, there is a lack of accepted predictors of response to guide expectations, as data from studies so far are lacking and inconsistent. We searched Embase and MEDLINE databases for studies reporting on predictors of response to CGRP and/or CGRP-receptor (CGRP-R) mAbs, defined as a 30% or 50% reduction in monthly headache or migraine days at varying durations of follow-up. Quantitative synthesis was performed where applicable. We found 38 real-world studies that investigated the association between various predictors and response rates. Based on these studies, good response to triptans and unilateral pain with or without unilateral autonomic symptoms are predictors of a good response to CGRP(-R) mAbs. Conversely, obesity, interictal allodynia, the presence of daily headaches, a higher number of non-successful previous prophylactic medications, and psychiatric comorbidities including depression are predictive of a poor response to CGRP(-R) mAbs. Future studies should confirm these results and help to generate more tailored treatment strategies in patients with migraine.

Is now the time to reconsider risks, benefits, and limitations of estrogen preparations as a treatment for menstrually related migraine?

INTRODUCTION

Estrogen fluctuations modulate pain threshold and play a pivotal role in the central and peripheral pathogenesis of menstrually related migraine (MRM). Estrogen-withdrawal during the perimenstrual phase of a spontaneous menstrual cycle or the hormone-free interval (HFI) of hormonal treatments seems to be the culprit.

AREA COVERED

The authors report the most relevant data on risks, benefits, and limitations of exogenous estrogens as a treatment for MRM considering gynecological comorbidities associated with chronic pelvic pain that may be effectively managed by the use of combined hormonal contraception (CHC). Given that migraine and CHC are both currently known as independent risk factors for stroke, levels of evidence contraindicate CHC in women with migraine with aura, whereas quality of evidence is low in women with migraine without aura, including MRM. Continuous/extended/flexible CHC regimens, shorter HFI, or estrogens supplementation during the HFI/perimenstrual spontaneous phase may be beneficial in women with MRM.

EXPERT OPINION

Safety is a main issue, and it is mandatory to investigate the impact of CHC containing natural estrogens, instead of ethinylestradiol, on clinical pattern of MRM and cardiovascular associated risk. Reproductive characteristics may be relevant and should be considered in a multidisciplinary approach to increase the power of endocrine management in MRM.

Diagnosis of comorbid migraine without aura in patients with idiopathic/genetic epilepsy based on the gray zone approach to the International Classification of Headache Disorders 3 criteria

Background

Migraine without aura (MwoA) is a very frequent and remarkable comorbidity in patients with idiopathic/genetic epilepsy (I/GE). Frequently in clinical practice, diagnosis of MwoA may be challenging despite the guidance of current diagnostic criteria of the International Classification of Headache Disorders 3 (ICHD-3). In this study, we aimed to disclose the diagnostic gaps in the diagnosis of comorbid MwoA, using a zone concept, in patients with I/GEs with headaches who were diagnosed by an experienced headache expert.

Methods

In this multicenter study including 809 consecutive patients with a diagnosis of I/GE with or without headache, 163 patients who were diagnosed by an experienced headache expert as having a comorbid MwoA were reevaluated. Eligible patients were divided into three subgroups, namely, full diagnosis, zone I, and zone II according to their status of fulfilling the ICHD-3 criteria. A Classification and Regression Tree (CART) analysis was performed to bring out the meaningful predictors when evaluating patients with I/GEs for MwoA comorbidity, using the variables that were significant in the univariate analysis.

Results

Longer headache duration (<4 h) followed by throbbing pain, higher visual analog scale (VAS) scores, increase of pain by physical activity, nausea/vomiting, and photophobia and/or phonophobia are the main distinguishing clinical characteristics of comorbid MwoA in patients with I/GE, for being classified in the full diagnosis group. Despite being not a part of the main ICHD-3 criteria, the presence of associated symptoms mainly osmophobia and also vertigo/dizziness had the distinguishing capability of being classified into zone subgroups. The most common epilepsy syndromes fulfilling full diagnosis criteria (n = 62) in the CART analysis were 48.39% Juvenile myoclonic epilepsy followed by 25.81% epilepsy with generalized tonic-clonic seizures alone.

Conclusion

Longer headache duration, throbbing pain, increase of pain by physical activity, photophobia and/or phonophobia, presence of vertigo/dizziness, osmophobia, and higher VAS scores are the main supportive associated factors when applying the ICHD-3 criteria for the comorbid MwoA diagnosis in patients with I/GEs. Evaluating these characteristics could be helpful to close the diagnostic gaps in everyday clinical practice and fasten the diagnostic process of comorbid MwoA in patients with I/GEs.

[Effect of acupuncture on migraine without aura: a resting-state functional magnetic resonance study]

OBJECTIVE

To observe therapeutic effect of acupuncture on migraine without aura and the changes of brain functional connectivity (FC) using resting-state functional magnetic resonance imaging (rs-fMRI).

METHODS

Thirty-four patients with migraine without aura were included into an observation group and treated with acupuncture at Baihui (GV 20), Xuanlu (GB 5), Shuaigu (GB 8), Taiyang (EX-HN 5), etc. Using G6805-Ⅱ electric acupuncture apparatus, the ipsilateral Fengchi (GB 20) and Shuaigu (GB 8) were connected and stimulated with continuous wave, 2 Hz in frequency and 0.1 mA to 1.0 mA in current intensity, depending on patient's tolerance. Acupuncture stimulation lasted 20 min each time, twice weekly (at the interval>2 days). A total of 6 weeks of treatment (12 times) was required. Matching the gender and age as those of the observation group, 16 healthy subjects were recruited into a control group and no any intervention was provided. The headache days, the score of visual analogue scale (VAS) for headache severity, the total score of headache symptoms, the score of migraine-specific quality of life questionnaire (MSQ), the score of self-rating anxiety scale (SAS), and the score of self-rating depression scale (SDS) were compared before and after acupuncture, and the clinical efficacy was assessed in the observation group. The data of the resting-state functional magnetic resonance were collected in the observation group before and after treatment as well as the control group at baseline. The periaqueductal gray (PAG) was taken as the seed to analyze the effect of acupuncture on the brain FC and the correlation between FC and VAS scores, headache days in the patients of migraine without aura.

RESULTS

After treatment, the headache days, VAS score, the total score of headache symptoms, SAS score and SDS score were all reduced (P<0.01); and the scores of the restrictive, preventive, and emotional functional domains of the MSQ were increased (P<0.01) in the observation group compared with those before treatment. The total effective rate was 94.1% (32/34). Compared with the control group, FC between PAG and the right cerebellum Ⅷ was decreased in the observation group before treatment (P<0.05). FC of PAG with the bilateral cerebellum Ⅷ and the left precuneus was increased in the observation group after treatment compared with those before treatment (P<0.05). In the observation group, the FC intensity of PAG and the right cerebellum Ⅷ was negatively correlated with VAS score (r =-0.41, P<0.05) before treatment, while the FC intensity of PAG and the left precuneus was positively correlated with the improvement in headache days (r =0.40, P<0.05) after treatment.

CONCLUSION

Acupuncture is effective on migraine without aura. The brain functional connectivity is abnormal in the patients. The effect onset of acupuncture is obtained probably by regulating the abnormal brain regions and activating brain regions relevant with pain and emotions.

Consensus of the Brazilian Headache Society (SBCe) for prophylactic treatment of episodic migraine: part II

BACKGROUND

Migraine affects 1 billion people worldwide and > 30 million Brazilians; besides, it is an underdiagnosed and undertreated disorder.

OBJECTIVE

The need to disseminate knowledge about the prophylactic treatment of migraine is known, so the Brazilian Headache Society (SBCe, in the Portuguese acronym) appointed a committee of authors with the objective of establishing a consensus with recommendations on the prophylactic treatment of episodic migraine based on articles from the world literature as well as from personal experience.

METHODS

Meetings were held entirely online, with the participation of 12 groups that reviewed and wrote about the pharmacological categories of drugs and, at the end, met to read and finish the document. The drug classes studied in part II of this Consensus were: antihypertensives, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, calcium channel blockers, other drugs, and rational polytherapy.

RESULTS

From this list of drugs, only candesartan has been established as effective in controlling episodic migraine. Flunarizine, venlafaxine, duloxetine, and pizotifen were defined as likely to be effective, while lisinopril, enalapril, escitalopram, fluvoxamine, quetiapine, atorvastatin, simvastatin, cyproheptadine, and melatonin were possibly effective in prophylaxis of the disease.

CONCLUSIONS

Despite an effort by the scientific community to find really effective drugs in the treatment of migraine, given the large number of drugs tested for this purpose, we still have few therapeutic options.

Headaches and obesity

Obesity and headache disorders are two very common conditions in the general population that have been increasing in incidence over the last decades. Recent studies have shown a significant relationship between obesity and headaches, particularly migraine, with an important role in whether the disease is chronic. On the other hand, no such association was found with tension-type headaches. Studies showing an overlapping of hunger-control pathways and those involved in the pathophysiology of migraine may justify the close association between obesity and migraine. Moreover, a secondary headache for which obesity is a strong risk factor is idiopathic Intracranial Hypertension (pseudotumor cerebri), with several studies showing the impact of weight reduction/bariatric surgery in the treatment of the disease. In conclusion, since obesity is a modifiable risk factor, it is important for physicians treating patients with headaches, and particularly migraine, to be aware of the association between these two disorders.

Is Acupuncture Safe and Effective Treatment for Migraine? A Systematic Review of Randomized Controlled Trials

Migraine is a debilitating condition that places a substantial economic burden on society and seriously affects patients' quality of life. Currently, there is no known "cure" for migraines, and pharmacologic treatments or prophylaxis carry many unwanted effects. Acupuncture has been accepted as an alternative treatment. However, its effectiveness is still debated. This is a systematic review of randomized controlled trials (RCT) that investigate acupuncture safety and efficacy in migraine versus various control groups. We searched PubMed, Google Scholar, Science Direct, and Cochrane library using keywords: migraines, migraine with aura, migraine without aura, headache, acupuncture, and needling therapy. Two independent reviewers participated in data extraction and assessment. Fifteen randomized controlled trials involving 2,056 participants that met the inclusion criteria were obtained and analyzed. Based on the findings, seven out of 10 trials that compared acupuncture with sham acupuncture showed a more significant reduction in the frequency of migraine attacks and headache intensity. Four studies revealed acupuncture is just as effective and has fewer side effects than any western medicine. Acupuncture can be recommended as an alternative or adjunct to drug treatment for patients suffering migraines. However, further clinical trials that utilized the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) recommendation are still needed to strongly present an evidence-based strategy.

Headache Worsening after COVID-19 Vaccination: An Online Questionnaire-Based Study on 841 Patients with Migraine

Vaccines have represented the breakthrough in the fight against COVID-19. Based on reported headache attacks after vaccination in randomized controlled trials, we focused on the effects of COVID-19 vaccine administration on the migraine population, using an online questionnaire published on Italian Facebook groups oriented to headache patients. We collected data about the demographics and clinical parameters of migraine severity, COVID-19 infection, vaccination, and characteristics of headaches following vaccination. Out of 841 migraine patients filling in the questionnaire, 66.47% and 60.15% patients experienced a headache attack (from 1 hour to 7 days) after the first and the second vaccine dose, respectively. The main finding concerns headaches perceived by 57.60% of patients: attacks following vaccination were referred to as more severe (50.62% of patients), long-lasting (52.80% of patients) and hardwearing (49.69% of patients) compared to the usually experienced migraine attacks. This could be related to the production of inflammatory mediators such as type Iβ interferon. Considering the high prevalence of migraine in the general population, awareness of the possibility of headaches worsening following COVID-19 vaccination in these patients may allow both patients and clinicians to face this clinical entity with conscious serenity, and to reduce the waste of resources towards inappropriate health-care.

Neuropsychological Profile in Pediatric Migraine without Aura: A Pilot Study

Despite the high prevalence of headache in developmental age, current reports about its neuropsychological effects are still lacking. The aim of the present pilot study is to assess the neuropsychological skills among children affected by migraine without aura (MwoA). Fifteen children (7M/8F) (mean age 10.73 ± 2.13) with MwoA, consecutively referred to the Center for Childhood Headache at Università degli Studi della Campania “Luigi Vanvitelli”, underwent the Italian version of the NEPSY-2 after cognitive evaluation. Moreover, to assess the pain level and disability grade during daily activity, the VAS and PedMIDAS scales were used. MwoA children were comparable with the control group of 38 children with respect to age, gender, language, and education level. Written informed consent was obtained from all parents and from children directly, when appropriate. MwoA children differed from controls significantly among the NEPSY-2 subscales, with a relevant relationship between the frequency and intensity of the attacks. In conclusion, the results of the present pilot study may suggest that MwoA could impact significantly neuropsychological functioning in children.

Attention Impairment During the Interictal State in Migraineurs without Aura: A Cross-Sectional Study

Background and Purpose

Migraine suffering is more than the onset of head pain. The broad non-painful clinical symptoms associated with migraine are not well recognized. Recent researches support that migraineurs suffer attention deficits, but these findings are not conclusive. The purpose of our study was to assess whether patients with migraine without aura (MwoA) during the interictal period have attention impairment and to identify the migraine characteristics related to attention deficits.

Methods

We enrolled subjects with MwoA during the interictal period and healthy controls matched for age, gender, and education level in this cross-sectional study. The attention network test (ANT) and a battery of neuropsychological tests, including the trail-making test (TMT), the digit span test (DST), and the Stroop test, were administered to the participants during the headache-free period.

Results

Forty-four subjects with MwoA (4 males, 40 females) and 20 controls matched for age, gender, and literacy education were included. Patients in MwoA were more anxious (P = 0.007) and depressed (P = 0.001) than healthy subjects. Significant differences between the two groups were detected in the executive network (P = 0.006) but not in the alerting and orienting networks of ANT. Mean reaction time of ANT in the MwoA group was significantly longer than that in the control group (P = 0.028). Patients showed worse performance on DST-forward (P < 0.001), DST-backward (P < 0.001), DS Total (P < 0.001), TMT-A (P < 0.001), TMT-B (P < 0.001) and TMT-d (P = 0.002). Differences found in executive functions between the two groups were unrelated to gender, age, literacy, anxiety, and depression. Multiple regression analysis revealed no relation between clinical characteristics of headache and scores on the executive function with MwoA.

Conclusion

Our study suggested that patients in MwoA present worse performances on the executive control of attention networks during the headache-free period, which appear not be associated with measures of migraine severity. Although more studies are needed in this area, our results could be useful to find specific neuropsychological biomarker for migraine pathophysiology.

Pediatric Chronic Migraine Severity and Maternal Stress

Primary headache is an increasing phenomenon in pediatric age, and very often, it causes disabling limitations in children's daily activities, negatively affecting family well-being. There are conflicting data in the literature on the impact of children's migraines on parental experienced stress. This study aimed to evaluate maternal stress in a sample of school-aged children with a migraine without aura (MwoA) and its correlation with migraine intensity and frequency. A total of 474 mothers aged between 31 and 55 participated in the study: 237 were mothers of children with MwoA, and 237 were mothers of typical developing children. All participants were administered the Parent Stress Index-Short Form (PSI-SF) for the assessment of parental stress; the Pediatric Migraine Disability Assessment (PedMIDAS) was administered to children with MwoA to assess the presence of a related disability migraine. The results showed a significantly higher rate of stress in mothers of MwoA children (p < 0.001) in all the domains explored by the PSI-SF and a statistically significant correlation between the maternal stress total score and the intensity and frequency of migraine attacks (p < 0.0001). This study highlights the need for the holistic contribution of the family to be considered in the clinical management of pediatric migraines.

Acupuncture Modulation Effect on Pain Processing Patterns in Patients With Migraine Without Aura

Introduction

In this retrospective study, resting-state functional connectivity (FC) in patients with migraine was analyzed to identify potential pathological pain processing patterns and compared them to those in healthy controls (HCs). The FC patterns in patients between pre- and post-acupuncture sessions were also analyzed to determine how acupuncture affects neurological activity and pain perception during the migraine interictal period.

Methods

In total, 52 patients with migraine without aura (MwoA) and 60 HCs were recruited. Patients with migraine were given acupuncture treatment sessions for 4 weeks. As a primary observation, functional magnetic resonance images were obtained at the beginning and end of the sessions. HCs received no treatment and underwent one functional magnetic resonance imaging (fMRI) scan after enrollment. After the fMRI data were preprocessed, a region of interest (ROI)-to-ROI analysis was performed with predefined ROIs related to pain processing regions.

Results

The first analysis showed significantly different FCs between patients with MwoA and HCs [false discovery rate corrected p-value (p-FDR) < 0.05]. The FCs were found to be mainly between the cingulate gyrus (CG) and the insular gyrus, the CG and the inferior parietal lobule (IPL), the CG and the superior frontal gyrus, and the middle frontal gyrus and the IPL. The second analysis indicated that acupuncture treatment partly restored the different FCs found in the first analysis (p-FDR < 0.05). Furthermore, subgroup analysis found different brain activity patterns in headache-intensity restored condition and headache-frequency restored condition. Lastly, the correlation analysis suggested a potential correlation between FCs and clinical symptoms (p < 0.05).

Conclusion

This study suggests that pain processing is abnormal in migraine, with significantly abnormal FCs in the frontal, parietal, and limbic regions. This finding could be a typical pathological feature of migraine. Acupuncture has been identified to relieve headache symptoms in two ways: it restores the pain processing function and regulates pain perception.

Assessment of inflammation with hematological parameters in patients with migraine and tension-type headache: a prospective study from a tertiary care center

Aim: To investigate the role of inflammatory markers in patients with an acute headache attack. Materials & methods: This prospective controlled observational study comprised 150 subjects (migraine with aura [MA] n = 51, migraine without aura [MO] n = 51, tension-type headache n = 48, healthy controls n = 80). White blood cells (WBC), neutrophil, lymphocyte and platelet counts, mean platelet volume, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were documented. Results: MA and MO constituted 14.2% of the admissions to the emergency department due to headaches. In addition, MA and MO had higher WBC and MO showed higher neutrophil count during the attacks than healthy control (p < 0.05). Conclusion: Although inflammatory parameters, including WBC and neutrophil counts, were high in headache patients, neutrophil-to-lymphocyte ratio did not show a significant rise. Clinical trial registration: NCT04891848.

Differential Modulating Effect of Acupuncture in Patients With Migraine Without Aura: A Resting Functional Magnetic Resonance Study

Introduction: Migraine is a recurrent neurological disorder, the symptoms of which can be significantly relieved by acupuncture. However, the central mechanism via which acupuncture exerts its therapeutic effect in migraine is unclear. The aim of this study was to compare the differences in regional homogeneity (ReHo) between patients with migraine without aura (MwoA) and healthy controls (HCs) and to explore the immediate and cumulative therapeutic effect of acupuncture in patients with MwoA using resting-state functional magnetic resonance imaging (fMRI).

Methods: The study subjects were 40 patients with MwoA and 16 matched HCs. The patients with MwoA received acupuncture on 2 days per week for 6 weeks for a total of 12 sessions followed by 24 weeks of follow-up. The primary clinical efficacy outcomes were the number of days with migraine and the average severity of headache. Secondary outcomes were the Migraine-Specific Quality of Life Questionnaire, Self-Rating Anxiety Scale, and Self-Rating Depression Scale scores. In the migraine group, resting-state blood-oxygen-level-dependent fMRI scans were obtained at baseline and after the first and 12th acupuncture sessions to measure the ReHo value. In the HCs, only a baseline resting-state blood-oxygen-level-dependent fMRI scan was obtained.

Results: Compared with the control group, the migraine group had a significantly lower ReHo value in the cerebellum, which increased after the first acupuncture session. Long-term acupuncture significantly improved migraine symptoms and mood with a therapeutic effect that lasted for at least 6 months. After 12 acupuncture sessions, there were significant increase of cerebellum and angular gyrus in the migraine group.

Conclusion: These findings suggest that migraine is related to cerebellar dysfunction. Acupuncture can relieve the symptoms of migraine, improve dysfunction of cerebellum, and activate brain regions involved in modulation of pain and emotion The cumulative therapeutic effect of acupuncture is more extensive and significant than its immediate effect.

Revealing the Neural Mechanism Underlying the Effects of Acupuncture on Migraine: A Systematic Review

Background: Migraine is a chronic neurological disorder characterized by attacks of moderate or severe headache and various neurological symptoms. Migraine is typically treated by pharmacological or non-pharmacological therapies to relieve pain or prevent migraine attacks. Pharmacological therapies show limited efficacy in relieving headache and are often accompanied by adverse effects, while the benefits of acupuncture, a non-pharmacological therapy, have been well-documented in both the treatment and prevention of acute migraine attacks. However, the underlying mechanism of the effect of acupuncture on relieving migraine remains unclear. Recent advances in neuroimaging technology have offered new opportunities to explore the underlying neural mechanism of acupuncture in treating migraine. To pave the way for future research, this review provides an overview neuroimaging studies on the use of acupuncture for migraine in the last 10 years.

Methods: Using search terms about acupuncture, neuroimaging and migraine, we searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure from January 2009 to June 2020 for neuroimaging studies that examined the effect of acupuncture in migraine. All published randomized and non-randomized controlled neuroimaging studies were included. We summarized the proposed neural mechanism underlying acupuncture analgesia in acute migraine, and the proposed neural mechanism underlying the sustained effect of acupuncture in migraine prophylaxis.

Results: A total of 619 articles were retrieved. After removing reviews, meta-analyses, animal studies and etc., 15 articles were eligible and included in this review. The methods used were positron emission computed tomography (PET-CT; n = 2 studies), magnetic resonance spectroscopy (n = 1), and functional magnetic resonance imaging (fMRI; n = 12). The analyses used included the regional homogeneity (ReHo) method (n = 3), amplitude of low frequency (ALFF) method (n = 2), independent component analysis (ICA; n = 3), seed-based analysis (SBA; n = 1), both ICA and SBA (n = 1), Pearson's correlation to calculate functional connectivity (FC) between brain regions (n = 1), and a machine learning method (n = 1). Five studies focused on the instant effect of acupuncture, and the research objects were those with acute migraine (n = 2) and migraine in the interictal phase (n = 3). Ten studies focused on the lasting effect of acupuncture, and all the studies selected migraine patients in the interictal phase. This review included five task-based studies and 10 resting-state studies. None of the studies conducted a correlation analysis between functional brain changes and instant clinical efficacy. For studies that performed a correlation analysis between functional brain changes and sustained clinical efficacy, the prophylactic effect of acupuncture on migraine might be through regulation of the visual network, default mode network (DMN), sensory motor network, frontoparietal network (FPN), limbic system, and/or descending pain modulatory system (DPMS).

Conclusion: The neural mechanism underlying the immediate effect of acupuncture analgesia remains unclear, and the neural mechanism of sustained acupuncture treatment for migraine might be related to the regulation of pain-related brain networks. The experimental design of neuroimaging studies that examined the effect of acupuncture in migraine also have some shortcomings, and it is necessary to standardize and optimize the experimental design. Multi-center neuroimaging studies are needed to provide a better insight into the neural mechanism underlying the effect of acupuncture on migraine. Multi-modality neuroimaging studies that integrate multiple data analysis methods are required for cross-validation of the neuroimaging results. In addition, applying machine learning methods in neuroimaging studies can help to predict acupuncture efficacy and screen for migraineurs for whom acupuncture treatment would be suitable.

Effect and Safety of Penetrating Moxibustion in Treatment of Migraine without Aura: A Randomized Controlled Trial

OBJECTIVE

To observe the clinical effect of penetrating moxibustion on migraine without aura (MO) patients.

METHODS

Totally 60 MO patients from the Acupuncture Clinic of the Third Affiliated Hospital of Henan University of Chinese Medicine were collected from November 2015 to February 2017. All patients were assigned to a treatment group and a control group using a random number table, 30 cases in each group. The treatment group was treated with penetrating moxibustion, and the control group was treated with mild moxibustion, thrice a week for 4 consecutive weeks. The total effective rate, Visual Analogue Scale (VAS) scores, headache intensity, and Migraine Specific Quality of Life Questionnaire (MSQ) scores of patients after treatment were compared between the two groups. The moxibustion sensation and reaction after moxibustion were observed, and the adverse reactions were evaluated. All patients were followed up at 4 and 16 weeks after treatment.

RESULTS

The total effective rate of the treatment group was significantly higher than that of the control group (93.33% vs. 80.00%, P<0.05). The improvement of VAS scores, headache intensity, and the role restrictive and role preventive scores in MSQ in the treatment group was better than those in the control group (P<0.05). The person-time of moxibustion sensations of itching, numbness and cold as well as flushing and sweating after moxibustion in the treatment group was all significantly higher than that in the control group (P<0.01). There was no significant difference in safety evaluation between the two groups (P>0.05).

CONCLUSIONS

Penetrating moxibustion can significantly relieve pain and improve quality of life of MO patients. After penetrating moxibustion, flushing and sweating of patients were obvious, and the curative effect was superior to the mild moxibustion.

The Altered Functional Connectivity With Pain Features Integration and Interaction in Migraine Without Aura

Introduction

Migraine without aura (MwoA) is a primary type of migraine, a common disabling disorder, and a disabling neurological condition. The headache is a complex experience, a common form of pain, in which multiple sensory information dimensions are combined to provide a unified conscious event. Migraine ictal have unique neuroimage biomarkers, but the brain is also affected during the inter-ictal phase. According to the current studies, a hypothesis was constructed that the altered integration of pain spatial and intensity information impacts headache intensity in the inter-ictal period.

Methods

In this study, we applied theory-based region-to-region functional connectivity (FC) analyses to compare the differences in resting-state FC between MwoA participants and healthy controls with the pain integration hypothesis. After the correlation matrices between FC edges and clinical symptoms were constructed, the moderating effect and simple slope tests were investigated to explain whether and how the dysfunction of pain features discrimination affects the clinical symptoms.

Results

Functional connectivity analyses showed significantly decreased FC edges between the left dorsolateral superior frontal gyrus (SFGdor) and left insula, and an increased FC edge between the left SFGdor and bilateral angular gyrus. The correlation matrix showed no significant correlation between significantly altered FC edge and headache duration, frequency, Zung self-rating anxiety scale, and Zung self-rating depression scale. Only one significantly altered edge in the MwoA condition was significantly correlated with headache intensity. Moderating Module 1 and 2 manifested the moderator variable (altered rs-FC edge) moderated the link between the normal edges and headache intensity.

Conclusion

The pain features integration processes in migraineurs vary from HCs, related to the clinical symptoms during a migraine attack. Moreover, the clinical symptoms will be affected by one or more discrimination modules. And the spatial or intensity discrimination modules have a higher impact when combined with another module on clinical symptoms than the single module.

Supersaturation of VEP in Migraine without Aura Patients Treated with Topiramate: An Anatomo-Functional Biomarker of the Disease

Migraine is a primary headache with high prevalence among the general population, characterized by functional hypersensitivity to both exogenous and endogenous stimuli particularly affecting the nociceptive system. The hyperresponsivity of cortical neurons could be due to a disequilibrium in the excitatory/inhibitory signaling. This study aimed to investigate the anatomo-functional pathway from the retina to the primary visual cortex using visual evoked potentials (VEP). Contrast gain protocol was used in 15 patients diagnosed with migraine without aura (at baseline and after 3 months of topiramate therapy) and 13 controls. A saturation (S) index was assessed to monitor the response of VEP’s amplitude to contrast gain. Non-linear nor monotone growth of VEP (S < 0.95) was defined as supersaturation. A greater percentage of migraine patients (53%) relative to controls (7%) showed this characteristic. A strong inverse correlation was found between the S index and the number of days separating the registration of VEP from the next migraine attack. Moreover, allodynia measured through the Allodynia Symptoms Check-list (ASC-12) correlates with the S index both at baseline and after 3 months of topiramate treatment. Other clinical characteristics were not related to supersaturation. Topiramate therapy, although effective, did not influence electrophysiological parameters suggesting a non-intracortical nor retinal origin of the supersaturation (with possible involvement of relay cells from the lateral geniculate nucleus). In conclusion, the elaboration of visual stimuli and visual cortex activity is different in migraine patients compared to controls. More data are necessary to confirm the potential use of the S index as a biomarker for the migraine cycle (association with the pain-phase) and cortical sensitization (allodynia).

Altered Dynamic Amplitude of Low-Frequency Fluctuations in Patients With Migraine Without Aura

Migraine is a chronic and idiopathic disorder leading to cognitive and affective problems. However, the neural basis of migraine without aura is still unclear. In this study, dynamic amplitude of low-frequency fluctuations (dALFF) analyses were performed in 21 patients with migraine without aura and 21 gender- and age-matched healthy controls to identify the voxel-level abnormal functional dynamics. Significantly decreased dALFF in the bilateral anterior insula, bilateral lateral orbitofrontal cortex, bilateral medial prefrontal cortex, bilateral anterior cingulate cortex, and left middle frontal cortex were found in patients with migraine without aura. The dALFF values in the anterior cingulate cortex were negatively correlated with pain intensity, i.e., visual analog scale. Finally, support vector machine was used to classify patients with migraine without aura from healthy controls and achieved an accuracy of 83.33%, sensitivity of 90.48%, and specificity of 76.19%. Our findings provide the evidence that migraine influences the brain functional activity dynamics and reveal the neural basis for migraine, which could facilitate understanding the neuropathology of migraine and future treatment.

Exploring the Hereditary Nature of Migraine

Migraine is a common neurological disorder which affects 15-20% of the population; it has a high socioeconomic impact through treatment and loss of productivity. Current forms of diagnosis are primarily clinical and can be difficult owing to comorbidity and symptom overlap with other neurological disorders. As such, there is a need for better diagnostic tools in the form of genetic testing. Migraine is a complex disorder, encompassing various subtypes, and has a large genetic component. Genetic studies conducted on rare monogenic subtypes, including familial hemiplegic migraine, have led to insights into its pathogenesis via identification of causal mutations in three genes (CACNA1A, ATP1A2 and SCN1A) that are involved in transport of ions at synapses and glutamatergic transmission. Study of familial migraine with aura pedigrees has also revealed other causal genes for monogenic forms of migraine. With respect to the more common polygenic form of migraine, large genome-wide association studies have increased our understanding of the genes, pathways and mechanisms involved in susceptibility, which are largely involved in neuronal and vascular functions. Given the preponderance of female migraineurs (3:1), there is evidence to suggest that hormonal or X-linked components can also contribute to migraine, and the role of genetic variants in mitochondrial DNA in migraine has been another avenue of exploration. Epigenetic studies of migraine have shown links between hormonal variation and alterations in DNA methylation and gene expression. While there is an abundance of preliminary studies identifying many potentially causative migraine genes and pathways, more comprehensive genomic and functional analysis to better understand mechanisms may aid in better diagnostic and treatment outcomes.

Abnormal Whole Brain Functional Connectivity Pattern Homogeneity and Couplings in Migraine Without Aura

Previous studies have reported abnormal amplitude of low-frequency fluctuation and regional homogeneity in patients with migraine without aura using resting-state functional magnetic resonance imaging. However, how whole brain functional connectivity pattern homogeneity and its corresponding functional connectivity changes in patients with migraine without aura is unknown. In the current study, we employed a recently developed whole brain functional connectivity homogeneity (FcHo) method to identify the voxel-wise changes of functional connectivity patterns in 21 patients with migraine without aura and 21 gender and age matched healthy controls. Moreover, resting-state functional connectivity analysis was used to reveal the changes of corresponding functional connectivities. FcHo analyses identified significantly decreased FcHo values in the posterior cingulate cortex (PCC), thalamus (THA), and left anterior insula (AI) in patients with migraine without aura compared to healthy controls. Functional connectivity analyses further found decreased functional connectivities between PCC and medial prefrontal cortex (MPFC), between AI and anterior cingulate cortex, and between THA and left precentral gyrus (PCG). The functional connectivities between THA and PCG were negatively correlated with pain intensity. Our findings indicated that whole brain FcHo and connectivity abnormalities of these regions may be associated with functional impairments in pain processing in patients with migraine without aura.

The Spontaneous Activity Pattern of the Middle Occipital Gyrus Predicts the Clinical Efficacy of Acupuncture Treatment for Migraine Without Aura

The purpose of the present study was to explore whether and to what extent the neuroimaging markers could predict the relief of the symptoms of patients with migraine without aura (MWoA) following a 4-week acupuncture treatment period. In study 1, the advanced multivariate pattern analysis was applied to perform a classification analysis between 40 patients with MWoA and 40 healthy subjects (HS) based on the z-transformed amplitude of low-frequency fluctuation (zALFF) maps. In study 2, the meaningful classifying features were selected as predicting features and the support vector regression models were constructed to predict the clinical efficacy of acupuncture in reducing the frequency of migraine attacks and headache intensity in 40 patients with MWoA. In study 3, a region of interest-based comparison between the pre- and post-treatment zALFF maps was conducted in 33 patients with MwoA to assess the changes in predicting features after acupuncture intervention. The zALFF value of the foci in the bilateral middle occipital gyrus, right fusiform gyrus, left insula, and left superior cerebellum could discriminate patients with MWoA from HS with higher than 70% accuracy. The zALFF value of the clusters in the right and left middle occipital gyrus could effectively predict the relief of headache intensity (R ² = 0.38 ± 0.059, mean squared error = 2.626 ± 0.325) and frequency of migraine attacks (R ² = 0.284 ± 0.072, mean squared error = 20.535 ± 2.701) after the 4-week acupuncture treatment period. Moreover, the zALFF values of these two clusters were both significantly reduced after treatment. The present study demonstrated the feasibility and validity of applying machine learning technologies and individual cerebral spontaneous activity patterns to predict acupuncture treatment outcomes in patients with MWoA. The data provided a quantitative benchmark for selecting acupuncture for MWoA.

Retinal nerve fiber layer changes in migraine: A protocol for systematic review and meta-analysis

BACKGROUND

Migraine is a common neurological disease, which seriously affects the quality of life and daily activities of patients. Although migraine is a transient phenomenon of cerebral vasoconstriction, it is well documented that recurrent attacks of migraine may lead to abnormalities in retinal structure. Optical coherence tomography (OCT) is a sensitive method to detect subtle damage in retinal nerve fiber layer (RNFL). There have been many studies investigating the difference in RNFL thickness with optical coherence tomography (OCT) between migraine patients and healthy controls. However, the results were not consistent. Our purpose is to perform a meta-analysis to investigate RNFL alterations in migraine.

METHODS

We will search PubMed, Embase, Web of science for studies assessing the differences in RNFL measured by OCT between patients with migraine and healthy controls. Case-control studies published in English will be included. Two reviewers will independently screen eligible articles, extract data, and assess quality. This meta-analysis will synthesize selected research data and compare the difference in RNFL thickness between patients with migraine and healthy controls. We will use Stata 15 in this meta-analysis. I statistics will be used to assess heterogeneity. If I ≤ 50%, the data are synthesized will use a fixed effect model. Otherwise, a random effect model will be performed. Publication bias will be determined by the Egger test. The methodological quality of all included studies will be evaluated by the Newcastle-Ottawa Scale (NOS). We will perform subgroup analysis, sensitivity analysis, and meta-regression analysis to test the robustness of the results.

RESULTS

We will obtain quantitative results regarding the difference in RNFL thickness between migraine patients and healthy controls. The results will be published in a peer-reviewed journal.

CONCLUSIONS

The results of this study provide a high-quality synthesis of existing evidence and provide a basis for assessing the effect of migraine on the thickness of RNFL.

REGISTRATION NUMBER

INPLASY 202060033.

Screening general practice patients for migraine without aura: construction and validation of the Balkan Migraine Screening Questionnaire (BMSQ)

Aim To develop and validate a screening questionnaire for migraine without aura with sufficient diagnostic accuracy to be used in primary care settings. Methods The study was designed as cross-sectional, multicentric, diagnostic accuracy trial of new questionnaire for screening patients who visit general practitioners, with an aim to reveal migraine without aura. The instrument was constructed for the purpose of this study, and validated on the sample of 429 primary care outpatients. The gold standard of diagnosing migraine without aura was clinical estimate by a neurologist based on the International Classification of Headache Disorders 3rd edition (ICHD-III) criteria. Diagnostic accuracy of the instrument was tested through construction of the Receiver Operator Curve. Results The Balkan Migraine Screening Questionnaire (BMSQ) instrument showed good diagnostic accuracy (sensitivity 83.4% and specificity 79.9%) for migraine without aura, with significant screening yield among previously undiagnosed patients of 75.9%. The study also confirmed a high percentage of patients with hidden migraine without aura (MWA) (52.9%) revealed by the BMSQ and the ICHD-III criteria that would otherwise remain undiagnosed. Conclusion The BMSQ is a valid and reliable clinical instrument for revealing migraine without aura, which could be easily selfadministered by patients. It has high screening yield, discovering majority of patients with previously undiagnosed migraine without aura, whose definite diagnosis should later on be confirmed by the attending physicians using the ICHD-III criteria.

Association of Depression with Migraine without Aura; A Cross-Sectional Study

OBJECTIVE

Migraine is ranked as the seventh leading cause of disability worldwide, and it is characterized by a manifestation of combined neurological, gastrointestinal, and autonomic symptoms linked with different provoking factors. Aim of the study: This study investigates the association between migraine without aura and depression.

METHOD

A total number of 100 patients were enrolled in the study and were divided into two groups: 50 individuals with confirmed migraine without aura (the study group) and 50 individuals with no history of headaches (control group). All individuals were evaluated using the ICHD- II diagnostic criteria for migraine, as well as the Beck test for depression.

RESULTS

Statistical analysis showed a significant relationship between migraine without aura and depression (p=0.023), but no significant association between depression and BMI, migraine length, gender, family history of depression, alcoholism, smoking cigarettes and number of drugs consumed.

CONCLUSIONS

Based on our data we can confirm an association between depression and migraine without aura.

Translation and Transcultural Validation of Migraine Screening Questionnaire (MS-Q)

Introduction:

Between 30 to 59% of patients with migraine without aura are undiagnosed and improperly treated, because primary care physicians are either too busy or unfamiliar with criteria for diagnosing migraine.

Aim:

The aim of our study was to translate the Migraine Screen Questionnaire (MS-Q) to BHS (Bosnian/Croatian /Serbian) language and to test reliability and validity of the translation on a sample of primary care patients.

Material and Methods:

The study was designed as cross-sectional, multi centric, diagnostic accuracy trial of an instrument for screening patients who visit general practitioners, with an aim to reveal migraine without aura. The instrument was the MS-Q, originally written in English and validated in Spanish population, and in this study being translated to BHS language.

Results:

Translation of the MS-Q to BHS language showed good diagnostic accuracy (sensitivity 80.0% and specificity 87.2%) and reliability (Cohen kappa 0.648) for migraine without aura, with significant screening yield among previously undiagnosed patients of 72.7%. The study also confirmed high percentage of patients with hidden MWA (52.9%) revealed by the MS-Q and ICH criteria that would otherwise remain undiagnosed.

Conclusion:

The MS-Q translation to BHS language could be considered as valid and reliable clinical instrument for revealing migraine without aura, similar by its performance to original questionnaire. It has considerable screening yield, discovering majority of patients with previously undiagnosed migraine without aura, whose definite diagnosis should later on be confirmed by the attending physicians using the ICH criteria.

Alexithymia, Metacognition, and Theory of Mind in Children and Preadolescents With Migraine Without Aura (MWoA): A Case-Control Study

Background: Some studies have demonstrated the high impact of headache and migraine in several areas of children and adolescents' life. In recent years, there has been an increase in scientific interest in the relationship between migraine and emotional regulation, investigating the possible consequences of emotional dysregulation on physical and mental health. While some studies have been carried out on the relationship between alexithymia and headache or migraine (especially in adults), no data exist on relationship between Theory of Mind (TOM), metacognition, and alexithymia in children and adolescents with migraine. Methods: Children with diagnosis of migraine without aura (MWoA) (36 males and 34 females) were compared to a healthy control group (31 males and 39 females). The age range was from 8 to 13 years in both groups. All children completed the Alexithymia Questionnaire for Children (AQC) for the assessment of alexithymia levels and the Domain of Social Perception included in the NEPSY-II to evaluate levels of TOM. Metacognitive development was evaluated with Io e La Mia Mente for children aged between 8 and 10 years and with Metacognitions Questionnaire for Children (MCQ-C) for children from 11 to 13. Results: There were no differences between children with MWoA and the control group in metacognitive abilities; only in the subscale "Negative Meta Worrying" of MCQ-C girls scored higher than boys, regardless of the group they were part of. Also, in the NEPSY-II subscale there were no statistically significant differences between the two groups. Children with MWoA scored higher in the AQC subscales "Difficulty Identifying Feelings" and "Difficulty Describing Feelings" than controls. Moreover, children between 8 and 10 years statistically differed from older children in "Difficulty Identifying Feelings" and in Total Score. Conclusion: Our data suggest that children with MWoA have no metacognitive and TOM problems compared to a healthy group. The experimental group showed higher traits of alexithymia, confirming what suggested by other studies in the literature. Future research will have to focus on migraine with aura and tension-type headache to evaluate any differences with children with MWoA.

Effect of desogestrel 75 µg on headache frequency and intensity in women with migraine: a prospective controlled trial

Objective: In contrast with combined hormonal contraception, progestin-only contraception is not associated with an increase in venous thromboembolism or stroke. Women with migraine are at increased risk of ischaemic stroke. Several studies have reported a reduction in migraine frequency and intensity with desogestrel 75 µg, a progestin-only pill. At present the quality of data is limited by retrospective study designs, lack of control groups and small sample sizes. We present the first prospective nonrandomised controlled trial. Methods: A total of 150 women with migraine visiting our clinic for contraceptive counselling were screened. The intervention group comprised women who opted for contraception with desogestrel (n = 98); the control group comprised women who continued their usual contraceptive (n = 36). Participants completed daily diaries for 90 days before the intervention and 180 days after the intervention. Results: In the intervention group, we found improvements in migraine frequency (p < .001), migraine intensity (p < .001) and the number of triptans used (p < .001). These improvements were already significant after 90 days of desogestrel use (p < .001). Disability scores also decreased significantly. No improvement was seen in the nonintervention group. Conclusion: These data demonstrate for the first time in a prospective controlled setting that daily use of the progestin desogestrel is associated with a decrease in migraine frequency, migraine intensity and pain medication use in women with migraine, with and without aura, who had previously been experiencing at least three days of migraine per month. Trial registration: The study is registered in the University of Zürich database ( www.research-projects.uzh.ch/unizh.htm ).

Thrombophilia Testing in High Pediatric Migraine Risk Children With Migraine

This study sought to investigate the need for thrombophilia screening in pediatric migraineurs. The cohort included 45/824 children (5.5%) aged 3-18 years with migraine who were tested for thrombophilia at a tertiary pediatric headache clinic. Results were analyzed by background factors and indications for screening. Rates of thrombotic factors were compared with a healthy historical control group. At least 1 thrombotic factor was positive in 19/45 patients (42%). The total thrombophilia risk rate was higher in patients with aura (n = 32). Lipoprotein(a) was the factor most often abnormal in the thrombophilia group of all factors tested (8/19, 42%), regardless of migraine type or gender. It was the only factor with a significantly higher prevalence in the migraine than the historical control group. Full thrombophilia testing in migraine in pediatric headache clinics does not seem to be justified. The high prevalence of elevated lipoprotein(a) in children with migraine warrants further investigation.

Subclinical hypothyroidism is associated with migraine: A case-control study

BACKGROUND

Recent studies suggested a potential association between both overt and subclinical hypothyroidism and migraine. Aims of this study were to estimate the comorbidity of migraine in patients with subclinical hypothyroidism and to evaluate associated clinical characteristics.

METHODS

Using a case-control strategy, 151 consecutive subclinical hypothyroidism patients (mean age 48.36 ± 15.86 years) and 150 controls (mean age 50.86 ± 9.19 years) were recruited. In all subjects, migraine characteristics were collected through a direct interview. Clinical and biochemical parameters (thyroid-stimulating hormone, free triiodothyronine, free thyroxine, and anti-thyroid antibodies) were compared between subclinical hypothyroidism patients in comorbidity with migraine and subclinical hypothyroidism patients without migraine.

RESULTS

The prevalence of lifetime migraine was significantly higher in subclinical hypothyroidism patients in comparison with controls (46% vs. 13%, p < 0.001; OR 5.80; 95% CI = 3.35-10.34). Both migraine without and with aura were significantly higher in subclinical hypothyroidism patients than controls ( p < 0.001 and p = 0.010, respectively). Thyroid hormones and concentrations of antibodies did not differ between subclinical hypothyroidism patients with and without migraine. Interestingly, a comorbidity for autoimmune diseases was observed in subclinical hypothyroidism patients with migraine in respect to those without migraine ( p = 0.005).

CONCLUSIONS

Our data suggest that migraine is more frequent in patients with subclinical hypothyroidism in respect to controls. Further studies are needed in order to confirm this association.

Cerebral blood flow velocity in migraine and chronic tension-type headache patients

Introduction

The present study seeks to use transcranial Doppler ultrasound to evaluate cerebral blood flow velocities in anterior and posterior circulation arteries, during an attack-free episode in migraine patients, with and without aura, as well as in chronic tension-type headache patients who were not receiving prophylactic medication.

Methods

A total of 50 patients (35 female, 15 male) were evaluated during a headache-free episode: 30 migraine patients without aura (mean age: 32±8 years), 10 migraine patients with aura (mean age: 34±4 years), and 10 patients with chronic tension-type headache (mean age: 34±5 years).

Results

No significant difference was present between anterior, middle, and posterior cerebral and vertebral arteries' blood flow velocities between migraine patients, with and without aura, or in patients with a tension-type headache, and normal controls (p>0.05). However, a significant increase in basilar artery cerebral blood flow velocities relative to controls was present in patients with a tension-type headache (p>0.001).

Conclusion

It is difficult to predict the main reason for the significant increase in basilar artery blood flow velocities in patients with chronic tension-type headache. It may be due to constriction of conductance or the dilatation of the resistance vessels.

A novel PRRT2 pathogenic variant in a family with paroxysmal kinesigenic dyskinesia and benign familial infantile seizures

Paroxysmal kinesigenic dyskinesia (PKD) is a rare neurological disorder characterized by recurrent attacks of dyskinetic movements without alteration of consciousness that are often triggered by the initiation of voluntary movements. Whole-exome sequencing has revealed a cluster of pathogenic variants in PRRT2 (proline-rich transmembrane protein), a gene with a function in synaptic regulation that remains poorly understood. Here, we report the discovery of a novel PRRT2 pathogenic variant inherited in an autosomal dominant pattern in a family with PKD and benign familial infantile seizures (BFIS). After targeted Sanger sequencing did not identify the presence of previously described PRRT2 pathogenic variants, we carried out whole-exome sequencing in the proband and her affected paternal grandfather. This led to the discovery of a novel PRRT2 variant, NM_001256442:exon3:c.C959T/NP_660282.2:p.A320V, altering an evolutionarily conserved alanine at the amino acid position 320 located in the M2 transmembrane region. Sanger sequencing further confirmed the presence of this variant in four affected family members (paternal grandfather, father, brother, and proband) and its absence in two unaffected ones (paternal grandmother and mother). This newly found variant further reinforces the importance of PRRT2 in PKD, BFIS, and possibly other movement disorders. Future functional studies using animal models and human pluripotent stem cell models will provide new insights into the role of PRRT2 and the significance of this variant in regulating neural development and/or function.

The first comparative double-blind trial on efficacy and safety of ergotamine based five-component combination and sumatriptan in migraine without aura

BACKGROUND

Dihydroergotamine or ergotamine are the most effective preparations for aborting acute attacks of migraine without aura.

OBJECTIVE

The aim of our study was to compare the efficacy and safety of ergotamine based five-component drug combination and sumatriptan in the treatment of moderate to severe acute attacks of migraine without aura.

METHODS

The study was designed as a randomized, double-blind, double-dummy, placebo-controlled, parallel arm, multi-center clinical trial. The enrolled patients having migraine without aura were randomized to one of the study arms, ergotamine based five-component drug combination or sumatriptan.

RESULTS

In total, 201 patients were randomized to one of the treatment arms. Higher percentage of patients was completely free of the headache two hours after dose administration in the ergotamine-based medication group compared to the sumatriptan group, regardless whether all (51.12 % vs 33.70 %) or only repeated attacks were taken into account (50.91 % vs 23.73 %); the salvage therapy (diclofenac) utilization rate was also lower in the ergotamine-based medication group (relative risk 0.61). Photophobia, phonophobia, and osmophobia were reversed more frequently in the ergotamine-based medication group (51.12 % vs 33.70 %), and failure to abort an attack of the migraine without aura occurred more frequently in the group treated with sumatriptan (1.1 % vs 4.9 %). The headache intensity two hours after ingestion of the study medication increased more frequently with sumatriptan, while other adverse events were rare in both groups.

CONCLUSIONS

This study demonstrated higher efficacy and similar safety of ergotamine based fixed drug combination in comparison to sumatriptan, when used in the treatment of an acute attack of the migraine. HIPPOKRATIA 2018, 22(1): 17-22.

Migraine in young females with irritable bowel syndrome: still a challenge

Migraine without aura is frequently reported in female patients with irritable bowel syndrome (IBS), but knowledge about the relationship between these two conditions is still lacking. This study was aimed to explore the particularities of migraine without aura in young female patients with IBS in order to establish a possible link between them. From a cohort of young female patients hospitalized with IBS in the Internal Medicine Department, 30 joined this pilot study, and they were assigned into two groups on the basis of presence or absence of migraine. In this sample, 15 patients have mild to moderate migraine without aura, with a recently taken normal brain scan, and 15 were without migraine. Diseases and conditions not related to migraine and other possible specific female comorbidities were ruled out. Patients undertook a thorough clinical examination in order to assess fibromyalgia (FM) and chronic pelvic pain (CPP), Questionnaires for migraine disability assessment (MIDAS) and generalized anxiety disorder (GAD) were performed. Laboratory testing of blood, urine, and stool were also performed. Optimized lymphocyte proliferation test for food allergy (FA) and a fecal microbiota (microbiological semiquantitative method) for dysbiosis (DB) assessment were performed. Based on the results, migraine-positive group displayed more severe comorbidities: FM (p=0.0002), FA (p=0.0006), CPP (p=0.026), higher scores of anxiety (GAD, p=0.0008), and more severe DB (p=0.0009). We noticed a strong positive correlation between MIDAS and GAD (r=0.83), a good positive correlation between MIDAS and DB (r=0.56), and a moderate positive correlation between MIDAS, FM, and FA (r=0.46 and 0.41). In conclusion, young female patients with IBS and migraine without aura displayed more severe associated issues - anxiety, intestinal DB, FM, FA, and CPP. The severity of migraine correlated well with anxiety range and DB magnitude and moderately with FM and FA.

The Rorschach Test Evaluation in Chronic Childhood Migraine: A Preliminary Multicenter Case-Control Study

OBJECT

About 1.2-3.2% of children at 7 years of age with increasing age up to 4-19% in adolescents are suffering from migraine without aura (MwA). The aim of the present study is investigating the personality style associated with children and adolescents affected by MwA, administrating the Rorschach test, and comparing with typical developing healthy controls (TD).

METHODS

137 patients (74 males), aged 7.3-17.4 years (mean age 11.4, SD 3.02 years), affected by MwA according to the IHs-3 criteria. The Rorschach variables were treated as numerical variables and statistically tested with t-Student's analysis.

RESULTS

No statistical differences were found between the MwA and TD for age (p = 0.55), and gender (p = 0.804). From the comparison between the two samples, MwA group shows lower W responses (p < 0.001), good quality W responses (p < 0.001), high frequency of detailed responses (p < 0.001), the presence of even minor form of good quality responses (p < 0.001), increased presence of animals answers (A%) (p < 0.001), more frequent trivial answers (Ban%) (p < 0.001).

DISCUSSION

Rorschach interpretation pinpointed many interesting and, perhaps, peculiar aspects in our MwA population such as a trend predisposition for: analytical reasoning rather than synthetic, ease/practicality rather than creativity, oppositionality rather than external adaptation to the environment that may be interpreted as effect of general maladaptivity.

[Migraine without aura treated with balance acupuncture therapy:a randomized controlled trial]

OBJECTIVE

To assess the effect of balance acupuncture for migraine without aura.

METHODS

Blind evaluation was conducted. Forty patients with migraine without aura were randomized into an observation group and a control group, 19 cases in each one with 1 patient dropped out respectively. In the observation group, Toutongxue, the middle point was used in the hollow before the 1, 2 metatarsal combination, and in the control group, a sham point was applied in the hollow before the 3, 4 metatarsal combination. The manipulation in the two groups was the same. The treatment was given for 4 weeks, once a day, 5 times a week. The comprehensive score and visual analogue scale (VAS) were used before and after treatment, as well as 4 weeks after treatment.

RESULTS

The comprehensive score and VAS score after treatment in the observation group decreased after treatment (both P<0.05), of which the total headache time and attack number for one month were lower than those before treatment (both P<0.05), but at follow-up the VAS score was higher than that after treatment (P<0.05). The above indices in the control group were not significantly different from those before treatment (allP>0.05). All the indices in the observation group after treatment and at follow-up were lower than those in the control group (all P<0.05). The different values for the comprehensive score and VAS score before and after treatment, before treatment and at follow-up in the observation group were better than those in the control group (all P<0.05). The different values after treatment and at follow-up had no significant difference between the two groups (bothP>0.05).

CONCLUSIONS

Balance acupuncture at Toutongxue achieves obvious effect for migraine without aura, which can relieve pain.

Visual-spatial training efficacy in children affected by migraine without aura: a multicenter study

Routinely in the clinical practice, children affected by migraine without aura (MwA) tend to exhibit severe and persistent difficulties within cognitive processes such as attention, memory, and visual-motor integration (VMI) skills. The aim of this study was to assess the visual-spatial and visual-motor abilities among a sample of children with MwA and the effects of a specific computerized training. The study population was composed of 84 patients affected by MwA (39 girls and 45 boys; mean age: 8.91±2.46 years), and they were randomly divided into two groups (group A and group B) comparable for age (P=0.581), gender (P=0.826), socioeconomic status (SES), migraine frequency (P=0.415), and intensity (P=0.323). At baseline (T0), the two groups were comparable for movement assessment battery for children (M-ABC) and VMI performances. After 6 months of treatment (T1), group A showed lower scores in the dexterity item of M-ABC test (P<0.001) and higher scores in M-ABC global performance centile (P<0.001) and total (P<0.001), visual (P=0.017), and motor (P<0.001) tasks of VMI test than group B. Moreover, at T1, group A showed higher scores in total (P<0.001) and motor (P<0.001) tasks of VMI test and in M-ABC global performance centile (P<0.001) and lower scores in the dexterity item of M-ABC test (P<0.001) than at T0. Group B showed, at T1, performances comparable to T0 for all evaluations. As reported by recent studies about alteration MwA among children in motor abilities, our study confirmed these difficulties and the efficacy of a specific software training, suggesting a new rehabilitative proposal in childhood.