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Adverse childhood experiences (ACEs) are a risk factor for progression from episodic to chronic migraine. Risk factors for medication overuse headache (MOH) are incompletely understood, but opioid overuse may carry a higher risk than overuse of other medication types. We performed a retrospective chart review investigating the frequency and impact of ACEs in patients with MOH. Of 68 included patients, 37 (54.4%) reported ACEs. There was no significant inter-group difference in baseline migraine disability assessment (MIDAS) or monthly headache days. Patients with ACEs reported more opioid overuse, and worse headache-related disability at follow-up, despite similar monthly headache days. Patients with ACEs require complex, multidisciplinary treatment.
Reversible cerebral vasoconstriction syndrome presents with thunderclap headache and represents a group of conditions that show reversible multifocal narrowing of cerebral arteries. Some patients who undergo device closure of an atrial septal defect complain of headache, which are posited as a migraine. Here we report a case of severe headache due not to migraine but reversible cerebral vasoconstriction syndrome after device closure of a ventricular septal defect.
Behçet’s syndrome (BS), originally described in 1937 by the Turkish dermatologist Hulusi Behçet, as a distinct disease with oro-genital ulceration and uveitis known as the “triple-symptom complex”, is an idiopathic chronic relapsing multisystem vascular-inflammatory disease of unknown origin. The condition that features primary neurological involvement is termed as neuro-Behçet syndrome (NBS). Based on the clinical and neuroimaging features, primary BS neurological involvement may be divided into two major forms: 1) parenchymal NBS (p-NBS); and, 2) vascular NBS. Cranial neuropathy, dysarthria, ataxia, hemiparesis, and headache are the major symptoms of p-NBS, with headache being the most prevalent (in patients with both p-NBS and neuro-vascular involvement). Lesions revealed by magnetic resonance imaging are most common in the mesodiencephalic junction followed by the pons/medulla oblongata. Vascular involvement (the second most common form of neurological involvement) is associated with a better prognosis than p-NBS, and the clinical manifestations vary by the site and extension of venous thrombosis. During the acute phase of p-NBS, the cerebrospinal fluid shows inflammatory changes in most cases of p-NBS with an increased number of cells, up to a hundred and sometimes more per ml, neutrophils being mostly the predominating cells and modestly elevated protein levels. Patients with BS-CVST do not exhibit any remarkable cerebrospinal fluid finding apart from an increased pressure. Currently, the only drug that have been shown to be effective based on the Class IV evidence is infliximab for the treatment of p-NBS
Moyamoya disease (MMD) is a cerebrovascular disorder characterised by progressive stenosis of the terminal portion of the internal carotid artery (ICA). The perforating arteries in the basal ganglia and thalamus markedly dilate and serve as an important collateral circulation, known as “Moyamoya” vessels. The clinical presentations of MMD include TIA, ischemic strokes, haemorrhagic strokes, seizures, headaches, and cognitive impairments. We present a 26-year old female patient that was examined due to headaches. For eight months, she had been admitted daily into the emergency hospital due to acute, unbearable headaches, which woke her up from her sleep. The MRI showed abnormalities suspicious for Moyamoya disease, which were confirmed with angiography
Cerebral venous sinus thrombosis (CVST) is the thrombosis of dural sinuses and deep and/or superficial cerebral venous system. Sex specific risk factors in women such as oral contraceptive use, pregnancy and hormone therapy seem to be associated with increased risk of CVST. We present a 24 year-old female, primigravida, that was admitted to the emergency department with a generalized tonic clonic seizure two weeks after normal vaginal delivery and left sided weakness. She reported a severe headache in the previous three days, nausea and vomitting. Cortico-subcortical areas of higher signal intensity in bilateral parietal and left frontal regions with no arterial distribution were observed in the brain magnetic resonance imaging (MRI). Cranial MR venography revealed venous thrombosis in the anterior two thirds of the superior sagittal sinus. The patient was diagnosed as cerebral venous sinus thrombosis due to puerperium and treated with heparin transitioned to therapeutic oral warfarin. During her hospital stay in the fourth day she had another generalized tonic clonic seizure. Levetiracetam was initiated with an optimal dose of 1000 mg/daily. She was discharged with full recovery
Carotid dissection is found to be as high as 20% in stroke patients younger than 30 years of age. The most common presenting symptom (80-90%) is unilateral headache at the same side of the arterial dissection. We present a 17 year-old male that was admitted to the emergency department with a headache. Bilateral carotid ultrasound with color doppler was suspicious of right carotid artery dissection at the cervical segment, so digital substraction angiography was performed to verify the dissection. On digital substraction angiography, right internal carotid artery was found to thin out and go out of existence at 2-3 cm proximal of the bulbar segment that was compatible with dissection
As the population continues to age, clinicians will increasingly encounter neurological conditions in routine clinical practice. Neurological problems in the elderly have a profound impact on quality of life and can at times be life-threatening. Diagnosis and management of geriatric neurological problems is complicated by often vague presentations and the presence of comorbid conditions, as well as complex physiology and pharmacology in this age group. Moreover, when caring for these patients it is of utmost importance to have a holistic approach and include family and caregivers when developing care plans. In this chapter we review muscle weakness, sensory loss, seizure disorders, and headaches in the elderly patient. Causes, impact on quality of life, and available treatment options are discussed. Other topics including delirium, dementia, cerebrovascular disease, and gait disorders will be covered elsewhere.
PREDICT was a Canadian, multicenter, prospective, observational study in adults naïve to onabotulinumtoxinA treatment for chronic migraine (CM). We descriptively assess health resource utilization, work productivity, and acute medication use.
OnabotulinumtoxinA (155–195 U) was administered every 12 weeks over 2 years (≤7 treatment cycles). Participants completed a 4-item health resource utilization questionnaire and 6-item Work Productivity and Activity Impairment Questionnaire: Specific Health Problem V2.0. Acute medication use was recorded in daily headache diaries. Treatment-emergent adverse events were recorded throughout the study.
A total of 197 participants were enrolled, and 184 received ≥1 treatment with onabotulinumtoxinA and were included in the analysis. Between baseline and the final visit, there were decreases in the percentage of participants who reported headache-related healthcare professional visit(s) (96.2% to 76.8%) and those who received headache-related diagnostic testing (37.5% to 9.9%). Reductions from baseline were also observed in the mean number of headache-related visits to an emergency room/urgent care clinic (2.5 to 1.4) and median headache-related hospital admissions (4.0 to 1.0). OnabotulinumtoxinA improved work productivity and reduced the mean (standard deviation) number of hours missed from work over a 7-day period (6.1 [9.7] to 3.0 [6.8]). Mean (standard deviation) acute medication use decreased from baseline (15.2 [7.6] to 9.1 [6.5] days). No new safety signals were identified.
Real-world evidence from PREDICT demonstrates that onabotulinumtoxinA treatment for CM in the Canadian population reduces health resource utilization and acute medication use and improves workplace productivity, supporting the long-term benefits of using onabotulinumtoxinA for CM.
We reported a case of ischaemic stroke with moyamoya disease with simultaneous occurrence of patent foramen ovale. The patient underwent percutaneous closure of patent foramen ovale and was scheduled for follow-up.
We investigated the association between clinical rotation at a specialized headache center and headache knowledge of resident trainees. Using standardized pre- and post-questionnaires, change in self-reported knowledge of headache disorders and management in 31 participants undertaking clinical rotations were evaluated. There was a statistically significant improvement in self-reported measures of headache disorder knowledge post-rotation [mean score (SD), 3.19(0.543), p < 0.001] and significant improvement in overall knowledge measured using case-based questionnaires pre- vs. post-rotation [7.1(1.4) vs. 7.9(1.5), p = 0.003]. Rotation at a specialized headache center improved trainees’ self-reported knowledge and test-based scores, suggesting that such rotation should be included in postgraduate curriculum.
Migraine is a complicated brain disorder which affects approximately 12 % of the population, whilst the presence of migraine headaches is typically higher in women than men. Several nutrients are posited to improve headache severity. The aim of this study was to investigate the relationship between dietary nutrients patterns and intensity and duration of migraine headaches. This cross-sectional study was conducted with 266 women. Physical activity, general characteristics, anthropometric values and dietary intake were collected. Nutrient patterns were derived using principal component analysis with varimax rotation, and based on the correlation matrix, after completing the 147 item semi-quantitative FFQ, we discerned three nutrients patterns. The validated Migraine Disability Assessment (MIDAS) questionnaire and visual analogue scale (VAS) were used for assessing migraine intensity. Duration of headaches were defined as the hours the participants had headache in 1 d in last month. ANOVA, χ2 and linear regression tests were used to interrogate the data. Linear regression showed there was a positive relationship between second pattern rich in vitamin B1, carbohydrate, vitamin B3, vitamin B9, protein, and total fibre and VAS and pain duration. Furthermore, there was an inverse relationship between MIDAS and the first nutrient pattern characterised by dietary Ca, vitamin A, vitamin K, vitamin C, vitamin B6, vitamin B2, and Mg among women. Furthermore, there was a positive significant association between vitamin D and B12 (pattern 3) and headache duration. Dietary nutrients patterns should be monitored closely in individuals suffering with migraine.
Red ear syndrome is a rare disorder in which the colour of the ear suddenly becomes red, with discomfort, pain and a burning sensation. This paper reports a case of primary red ear syndrome presenting with vestibular migraine.
A 39-year-old woman from Bangladesh reported dizziness and repeated headaches experienced since 18 years of age. She initially attended our hospital with dizziness aged 34 years. When dizzy, the colour of her right ear sometimes became red. Therefore, she was diagnosed with red ear syndrome with vestibular migraine.
This patient experienced repeated episodes of a red ear with discomfort, leading to the diagnosis of red ear syndrome. In addition, she had repeated dizziness and headaches, and was also diagnosed with vestibular migraine. The diagnosis of red ear syndrome with vestibular migraine should be considered in cases of dizziness and headache with recurrent redness of the ear.
There is mixed evidence on the association between headache and attention-deficit/hyperactivity disorder (ADHD), as well as headache and ADHD medications. This systematic review and meta-analysis investigated the co-occurrence of headache in children with ADHD, and the effects of ADHD medications on headache. Embase, Medline and PsycInfo were searched for population-based and clinical studies comparing the prevalence of headache in ADHD and controls through January 26, 2021. In addition, we updated the search of a previous systematic review and network meta-analysis of double-blind randomized controlled trials (RCTs) on ADHD medications on June 16, 2020. Trials of amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with a placebo arm and reporting data on headache as an adverse event, were included. Thirteen epidemiological studies and 58 clinical trials were eligible for inclusion. In epidemiological studies, a significant association between headache and ADHD was found [odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.63–2.46], which remained significant when limited to studies reporting ORs adjusted for possible confounders. The pooled prevalence of headaches in children with ADHD was 26.6%. In RCTs, three ADHD medications were associated with increased headache during treatment periods, compared to placebo: atomoxetine (OR = 1.29, 95% CI = 1.06–1.56), guanfacine (OR = 1.43, 95% CI = 1.12–1.82), and methylphenidate (OR = 1.33, 95% CI = 1.09–1.63). The summarized evidence suggests that headache is common in children with ADHD, both as part of the clinical presentation as such and as a side effect of some standard medications. Monitoring and clinical management strategies of headache in ADHD, in general, and during pharmacological treatment are recommended.
This study seeks to determine the prevalence and nature of cannabis use in patients with headache in a tertiary headache clinic and to explore patients’ empiric experience in using cannabinoids therapeutically.
Many patients with headache report cannabinoid use as an effective abortive and/or preventive therapy. Mounting evidence implicates cannabinoids in pain mechanisms pertaining to migraine and other headache types.
A cross-sectional study surveyed 200 patients presenting with any headache disorder to a tertiary headache clinic in Calgary, Alberta. Descriptive analyses were applied to capture information about headache diagnoses and the frequency, doses and methods of cannabinoid delivery employed, as well as patients’ perceptions of therapeutic benefit and selected negative side effects.
Active cannabinoid users comprised 34.0% of respondents. Approximately 40% of respondents using cannabinoids engaged in very frequent use (≥300 days/year). Of cannabinoid modalities, liquid concentrates were most popular (39.2%), followed by smoked cannabis (33.3%). Patients endorsed cannabinoid use for both prevention and acute therapy of headaches, often concurrently. Sixty percent of respondents felt cannabinoids reduced headache severity, while 29.2% perceived efficacy in aborting headaches. Nearly 5% of respondents volunteered that they had encountered a serious problem such as an argument, fight, accident, or work issue as a result of their cannabis use. Approximately 35.4% of users had attempted to reduce their use.
This survey shows that over one-third of patients with headache disorders in a tertiary headache clinic use cannabis as a treatment for their headaches. Of these, about 25% and 60% perceive improvements in headache frequency and severity, respectively. The results of this survey will aid neurologists and headache specialists in understanding the landscape of cannabinoid use in a more severely affected population and inform future-controlled studies of cannabinoids in headache patients.
Tension-type headaches is the most common type of headache among adults and it rises a challenge in findig an effective and safe treatment method.
The study aims to evaluate the corporal acupuncture therapy efficacy in patients with chronic tension-type headaches undergoing a complex treatment plan.
The study involved 132 patients (74% female and 26% men) aged 18-65 years, who were divided into two groups. Patients reported their pain lasted 0.4-12 years. All the patients received conventional treatment (central muscle relaxants and antidepressants). The study group additionally received classical corporal acupuncture 3 times per week, a course of 12 sessions. Treatment effectiveness was evaluated by measuring pain intensity using a subjective visual analogue scale (VAS) and McGill Pain Questionnaire (MPQ).
Most of the patients (79% and 88% of study and control groups respectively) demonstrated moderate cervical musculoskeletal dysfunctions. At admission pain intensity was 4.2±1.5 and 3.8±1.7 VAS points in the control and study groups respectively, MPQ sensory rank pain index (RPI) was 5.92±1.49 points, affective RPI 3.41±0.84, the total RPI – 7.12±2.56 in the control group, and 6.22±1.74; 2.98±0.62 and 7.14±1.65 points in the study group. 4 weeks after treatment measurements showed following pain intensity changes: 4.21±0.74 vs 3.1±0.95 points in the control and study groups respectively. 3- and 6-month period revealed 3.1±0.57, 2.4±0.74 points and 2.1±0.62, 1.1±0.49 points in the control and study groups respectively.
Classical corporal acupuncture course may benefit chronic tension-type headaches patients providing an effective treatment in a safe way.
Migraine is a common primary headache disorder diagnosed in the emergency department (ED). This systematic review sought to compare the efficacy of sodium valproate (SV) to dopamine antagonists (DA) in relieving pain due to acute migraine.
Two research librarians helped create a search strategy including Embase, Ovid Medline, and the Cochrane Database of Clinical Trials from inception to June 1, 2020, updated May 19, 2021. Two investigators identified randomized control trials (RCTs) including adult patients with acute migraine presenting to the ED or acute clinical setting comparing SV to a DA with the aim of relieving pain. Primary outcome was headache relief at 1 hour from treatment. Secondary outcomes included pain relief at 24 hours, relief of associated symptoms (e.g. nausea, photo-/phonophobia, etc.), and need for rescue analgesia. Meta-analysis was performed and presented as odds ratios.
Four RCTs with 470 patients were identified from an initial pool of 454 titles. Two studies compared SV to a DA alone and two compared SV to a DA plus one other agent (sumatriptan or dihydroergotamine). Three studies were included for meta-analysis. Pain relief had a pooled odds ratio of 1.14 at 1 hour and 0.42 at 24 hours. Three articles reporting the need for rescue analgesia had pooled odds ratio of 2.76.
Sodium valproate is not more effective than DA at reducing migraine headache pain at 1 hour and less effective at 24 hours. Dopamine antagonists should be used over SV for the management of patients with acute migraine.
The PREDICT study assessed real-world, long-term health-related quality of life in adults with chronic migraine (CM) receiving onabotulinumtoxinA.
Canadian, multicenter, prospective, observational study in adults naïve to onabotulinumtoxinA for CM. OnabotulinumtoxinA (155–195 U) was administered every 12 weeks over 2 years (≤7 treatment cycles). Primary endpoint: mean change in Migraine-Specific Quality of Life Questionnaire (MSQ) at treatment 4 (Tx4) versus baseline. Secondary endpoints: mean change in MSQ at final visit versus baseline, and headache days.
184 participants (average age 45 years; 84.8% female; 94.6% Caucasian) received ≥1 onabotulinumtoxinA treatment; 150 participants completed 4 treatments (1 year) and 123 completed all 7 treatment cycles (2 years). Mean (SD) onabotulinumtoxinA dose per treatment cycle was 171 (18) U and treatment interval was 13.2 (1.8) weeks. Baseline mean (SD) 20.9 (6.7) headache days/month decreased (Tx1: −3.5 [6.3]; Tx4: −6.5 [6.6]; p < 0.0001 versus baseline). Mean (SD) increased from baseline in MSQ at Tx4 (restrictive: 21.5 [24.3], preventive: 19.5 [24.7], emotional: 22.9 [32.9]) and the final visit (restrictive: 21.3 [23.0], preventive: 19.2 [23.7], emotional: 27.4 [30.7]), exceeding minimal important differences (all p < 0.0001). Seventy-seven (41.8%) participants reported 168 treatment-emergent adverse events (TEAEs); 38 TEAEs (12.0%) were considered treatment-related. Four (2.2%) participants reported six serious TEAEs; none were considered treatment-related. No new safety signals were identified.
Real-world evidence from PREDICT demonstrates that onabotulinumtoxinA for CM in Canada improved MSQ scores and reduced headache frequency and severity, adding to the body of evidence on the long-term safety and effectiveness of onabotulinumtoxinA for CM.
It is well established that migraine is a multifactorial disorder. A deep understanding of migraine should be based upon both the underlying traits and the current states affected by different physiological, psychological, and environmental factors. At this point, there is no framework fully meeting these criteria. Here, we describe a broader view of the migraine disorder defined as a dysfunctional brain state and trait interaction. In this model, we consider events that may enhance or diminish migraine responsivity based on an individual’s trait and state. This could provide an expanded view for considering how migraine attacks are sometimes precipitated by “triggers” and sometimes not, how these factors only lead to migraine attacks in migraine patients, or how individuals with an increased risk for migraine do not show any symptoms at all. Summarizing recent studies and evidence that support the concept of migraine as a brain state–trait interaction can also contribute to improving patient care by highlighting the importance of precision medicine and applying measures that are able to capture how different traits and states work together to determine migraine.