Alessandro Panconesi

Alcohol and migraine: trigger factor, consumption, mechanisms. A review

This study investigates the importance of alcohol as a migraine trigger factor, the prevalence of alcohol consumers and the mechanism of headache provocation. A MEDLINE search from 1988 to October 2007 was performed for “headache and alcohol”, “headache and wine”, “migraine and alcohol” and “migraine and wine”. In retrospective studies, about one-third of the migraine patients reported alcohol as a migraine trigger, at least occasionally, but only 10% of the migraine patients reported alcohol as a migraine trigger frequently. Regional differences were reported, perhaps depending in part on alcohol habits. No differences were found between migraine and tension headache and different genders. However, prospective studies limit considerably the importance of alcohol as a trigger. Recent studies show that migraine patients consume less alcohol than controls. Red wine was reported to be the principal trigger of migraine, but other studies show that white wine or other drinks are more involved. Then, the discussion based on the different composition of the various alcoholic beverages, in order to discover the content of alcoholic drinks responsible for migraine attack, reflects this uncertainty. Biogenic amines, sulphites, flavonoid phenols, 5-hydroxytryptamine mechanisms and vasodilating effects are discussed. The fact that few headache patients cannot tolerate some alcoholic drinks does not justify the consideration that alcohol is a major trigger and the suggestion of abstinence. In fact, low doses of alcohol can have a beneficial effect on patients such as migraineurs, who were reported to have an increased risk of cardiovascular disease.

Migraine pain: reflections against vasodilatation

The original Wolff’s vascular theory of migraine was supported by the discovery of a class of drugs, the triptans, developed as a selective cephalic vasoconstrictor agents. Even in the neurovascular hypothesis of Moskowitz, that is the neurogenic inflammation of meningeal vessels provoked by peptides released from trigeminal sensory neurons, the vasodilatation provoked by calcitonin gene-related peptide (CGRP) is considered today much more important than oedema. The role of cephalic vasodilatation as a cause of migraine pain was recently sustained by studies showing the therapeutic effect of CGRP receptor antagonists. We discuss the evidence against vasodilatation as migraine pain generator and some findings which we suggest in support of a central (brain) origin of pain.

Triptans in the Italian population: a drug utilization study and a literature review

Previous studies performed in selected populations show a poor utilization of triptans for migraine. The objectives of our study were to establish patterns of triptans utilization in a large sample, covering 1/10 of Italian population (5.57 millions), and to perform a review of published studies on this topic. We investigated drug prescription database collected during 2006 from 33 health authorities distributed in 8 different regions. About 0.6% of the subjects received at least one prescription of triptans in 1 year: 77.7% were females and 22.3% males. Age distribution shows that 9.5% of patients were aged above 65, and received prescriptions for 8.2% of packages. The review of the literature suggests that these percentages of utilization are common to several countries, and shows that occasional triptan users who received only one prescription in 1 year are a large percentage (40–60%); moreover, a minor population of triptan users utilize a large amount of total triptans. Finally triptans are frequently prescribed in people aged above 65 years, a population in which triptans are contraindicated or not recommended. Our study and the analyzed ones indicate suboptimal treatment of migraine patients with triptans and also an incorrect use in some patients (triptan abusers, elderly).

Alcohol and Migraine: What Should We Tell Patients?

Alcoholic drinks are a migraine trigger in about one third of patients with migraine in retrospective studies on trigger factors. Many population studies show that patients with migraine consume alcohol in a smaller percentage than the general population. Moreover, research has shown a decreased prevalence of headache with increasing number of alcohol units consumed. The classification criteria of alcohol-related headaches remain problematic. We discuss the role and mechanism of action of alcohol or other components of alcoholic drinks in relation to alcohol-induced headache. In accordance with data from a recent prospective study, we believe that reports overestimate the role of alcohol, as well as other foods, in the triggering of migraine. If a relationship between the intake of alcohol and the migraine attack is not clear, a small dose of alcohol is not contraindicated either for enjoyment or its protective effect on cardiovascular disease.

Alcoholic Drinks as Triggers in Primary Headaches

OBJECTIVE This project aims to investigate the role of alcoholic drinks (ADs) as triggers for primary headaches. METHODS Patients followed in the Headache Centre and presenting with migraine without aura, migraine with aura (MA), chronic migraine (CM), and tension-type headache (TH) were asked if their headache was precipitated by AD and also about their alcohol habits. Individual characteristics and drink habits were evaluated within two binary logistic models. RESULTS About one half (49.7%) of patients were abstainers, 17.6% were habitual consumers, and 32.5% were occasional consumers. Out of 448 patients, only 22 (4.9%), all with migraine, reported AD as a trigger factor. None of 44 patients with MA and none of 47 patients with TH reported AD as a trigger factor. Among those patients with migraine who consume AD, only 8% reported that AD can precipitate their headache. Multivariate analyses showed that AD use, both occasional and habitual, is unrelated to TH. Moreover, analysis performed among migraine patients, points out that occasional and habitual drinkers have a lower risk of presenting with CM than abstainers, although statistical significance occurred only among occasional drinkers. Only 3% of migraine patients who abstain from AD reported that they do not consume alcohol because it triggers their headache. CONCLUSION Our study shows that AD acts as headache triggers in a small percentage of migraine patients. Differing from some prior studies, our data suggest that AD do not trigger MA and TH attacks. Moreover, the percentage of abstainers in our sample is higher compared with that reported in general population surveys.

SUNCT syndrome or first division trigeminal neuralgia associated with cerebellar hypoplasia

Short-lasting unilateral neuralgiform headache (SUNCT) and first division trigeminal neuralgia (TN) are rare and very similar periorbital unilateral pain syndromes. Few cases of SUNCT are associated with posterior skull lesions. We describe a 54-year-old man with symptoms compatible with both the previous painful syndromes, associated with a small posterior skull and a cerebellar hypoplasia. The short height and the reported bone fractures could be compatible with a mild form of osteogenesis imperfecta, previously described in one case associated with SUNCT. However, a hypoplastic posterior cranial fossa characterizes also Chiari I malformation. The difficult differential diagnosis between SUNCT and TN and their relation with posterior skull malformations is debated.

O022. Migraineurs: seriously ill or basically healthy?

Materials and methods We evaluated prospectively the prevalence of some comorbidities in the first 1,000 migraine patients (aged 15-65 years), classified according to the IHS diagnostic criteria, presenting to the Headache Center (HC) in the period 2011 to 2013 and resident in the district of the Empoli Health Authority (HA11). In addition to a detailed semistructured face to face interview, health information was researched in the database of specialist visits, hospitalization or the Emergency Department. Drug prescription rates of the HA11 pharmaceutical database (PD) of 155,829 residents aged 15-65 years were also analyzed, as were the subgroup of 1,108 triptan users. To increase the strength of the study, the data was compared to a large database of Health Search (HS) of the Research Institute of the Italian Society of General Practice, to which general practitioners contributed with shared modalities for the regular and complete recording of the principal health data [2].

P023. Reasons for headache investigation and findings in an experimental headache center

Background Warning symptoms or “red flags” are useful in targeting which patients with headache require investigation. Many red flags, even with normal neurological examination, are the cause of neuroimaging (CT or MRI) overutilization, in addition to patient reassurance. Optimizing headache neuroimaging practices should be a major priority. The aim of our study was to evaluate the investigation rate in patients referred for the first time in the period from 2011 to 2013 to our Headache Center (HC) conducted by a general practitioner particularly an expert in headache management, and to correlate the reasons of investigation with neuroradiological findings.

P021. Investigation on occipital headache associated with vertigo and vomiting discovers a familial clustering of Chiari I malformation and a “puzzle”

A 16-year-old male (patient 4) experienced an episode of bilateral parietal headache, preceded by vertigo and associated with vomiting, lasting about two weeks. An MRI scan performed for a subsequent episode of occipital and neck pain with vomiting and vertigo showed an imaging to the limit of Chiari I malformation (CMI): cerebellar tonsils below the foramen magnum, not reaching posterior arch of C1, but with obliteration of peribulbar posterior liquoral space, cyst septum pellucidum and cavum vergae. Left facial nerve palsy at the age of 12, frequent alimentary vomiting and abdominal pain, episodes of exercise-induced asthma although not confirmed through respiratory tests, were found in the patients history. An MRI was performed on his father for otoneurological symptoms characterized by a recurrent sensation of disequilibrium when suddenly changing position, on one occasion preceded by a sensation of right ear pressure (diagnosed as sudden hearing loss). Two years ago he experienced an episode of stabbing occipital headache with shoulder pain irradiation, nausea and phonophobia. The MRI revealed cerebellar tonsils slightly below the foramen magnum, to the limit of CMI. MRI was performed also on his mother (patient 1), who suffers from tension-type headache even for long periods of time (months), showing no alterations, and on his 21-year-old brother (patient 5) suffering from episodic tension-type headache, showing cerebellar tonsils slightly below the foramen magnum, to the limit of CMI. His mothers interview revealed that her sister (patient 3) has five sons, two of them with CMI: 1) a 13-year-old male (patient 7), suffering from West syndrome, who at 3 years of age had an MRI that showed approximately 10 mm caudal descent of cerebellar tonsils with a reduction of the liquoral flow at the craniocervical junction and associated syringomyelia extending from C6 to D2 vertebral body; 2) a 26-year-old female (patient 11) with a cerebellar tonsils extending 11 mm below the foramen magnum, associated with posterior fossa hypoplasia. The “puzzle” comes from the fact that both the husbands of the two sisters (patients 1, 3) have the same surname but with no recognized relationship. The doubt seems to be resolved by the MRI performed on the 34-year-old daughter (patient 6) of the third sister (patient 2) showing slight tonsillar descent but without obstacle to liquoral flow (Figure ​(Figure11). Figure 1 oval = female, rectangle = male, shaded = tonsillar descent diagnostic or to the limit of CMI, ? = MRI not performed This report adds to other descriptions of familial clustering of CMI malformations, which suggest an underlying genetic basis. Written informed consent to publish was obtained from the patient(s).