Ana Podgorac

Underestimated phenomena: Higher cortical dysfunctions during migraine aura

Introduction Aura occurs in 20–30% of patients with migraine. Some descriptions of aura go far beyond the most frequent visual and sensory symptoms, suggesting the involvement of different cortical areas. The aim of this prospective study was to evaluate the frequency and types of disorders of higher cortical functions (HCF) that occur during visual and/or sensory aura. Methods We interviewed 60 patients with visual and/or sensory aura about HCF disorders of praxia, gnosia, memory, and speech, during aura. Patients were divided into two groups, with and without HCF disorders, and were compared in terms of demographic data and aura characteristics. Results From all 60 patients, 65% reported at least one HCF disorder during aura. The patients with HCF disorders had longer-lasting auras (28.51 ± 16.39 vs. 19.76 ± 11.23, p = 0.016). The most common HCF disorders were motor dysphasia (82.05%) and dysnomia (30.74%). Motor dysphasia was more often reported by patients with visual as well as sensory aura (p = 0.002). The number of HCF disorders correlated with the aura duration (p = 0.003). Conclusion According to our results, HCF disorders during aura occur more often than previously thought. The aura duration has some influence on the HCF disorders.

Migraine-Like Accompanying Features in Patients With Cluster Headache. How Important Are They?

According to the International Classification of Headache Disorders diagnostic criteria, the differences between migraine and cluster headache (CH) are clear. In addition to headache attack duration and pain characteristics, the symptoms accompanying headache represent the key features in a differential diagnosis of these 2 primary headache disorders. Just a few studies of patients with CH exist examining the presence of nausea, vomiting, photophobia, phonophobia, and aura, the features commonly accompanying migraine headache.

Cluster headache: Is age of onset important for clinical presentation?

Background The age of onset of cluster headache (CH) attacks most commonly is between 20 and 40 years old, although CH has been reported in all age groups. There is increasing evidence of CH with early or late onset and a different course of the disorder. The aim of the study was to analyze the influence of the age of onset on clinical features, disorder course, and therapy effectiveness in CH patients. Methods A retrospective and cross-sectional analysis was performed on 182 CH patients divided into three groups according to the age of onset. The first group consisted of patients with the first CH attack before 20 years of age, the second group was patients with age of onset between 20 and 40 years of age, and the third group was patients with age of onset after 40 years of age. Demographic data, features of CH periods and attacks, and the response to standardized treatment were compared among the groups. Results Patients with CH onset after 40 years of age reported a lower number of autonomic features and less frequently had conjunctival injection and nasal congestion/rhinorrhea phenomena during their attacks. Diagnostic delay was the longest in the patients with CH onset before 20 years of age. Conclusion The influence of the age of onset of CH is intriguing for further studies and could possibly extend the knowledge about CH pathophysiology. From a clinical point of view, the differences in CH presentation are insufficient to preclude a correct diagnosis and treatment because the same criteria could be applied regardless of patient age.

Do interictal microembolic signals play a role in higher cortical dysfunction during migraine aura

Introduction The aim of this study was to evaluate the prevalence and clinical impact of interictal microembolic signals (MES) in patients suffering from migraine with higher cortical dysfunction (HCD), such as language and memory impairment, during an aura. Patients and methods This study was carried out on 34 migraineurs with language and memory impairment during aura (HCD group), 31 migraineurs with only visual or visual and somatosensory symptoms during aura (Control group I), and 34 healthy controls (Control group II). We used a Doppler instrument to detect microemboli. Demographic data, disease features and the detection of MES between these groups, as well as the predictors of HCD during the aura, were analyzed. Results The duration of aura was longer and the frequency of aura was higher among patients with language and memory impairment during aura compared to Control group I. MES was detected in 29.4% patients from the HCD group, which was significantly higher compared to 3.2% in Control group I and 5.9% in Control group II. Regarding the absence or presence of MES, demographic and aura features were not different in the HCD subgroups. A longer duration of aura, the presence of somatosensory symptoms during the aura and the presence of interictal MES were independent predictors of HCD during the aura. Conclusion The present findings indicate that HCD and MES are related in patients with migraine with aura. Further research is needed to better understand the exact pathophysiological mechanism.

Headache service quality: evaluation of quality indicators in 14 specialist-care centres

BackgroundThe study was a collaboration between Lifting The Burden (LTB) and the European Headache Federation (EHF). Its aim was to evaluate the implementation of quality indicators for headache care Europe-wide in specialist headache centres (level-3 according to the EHF/LTB standard).MethodsEmploying previously-developed instruments in 14 such centres, we made enquiries, in each, of health-care providers (doctors, nurses, psychologists, physiotherapists) and 50 patients, and analysed the medical records of 50 other patients. Enquiries were in 9 domains: diagnostic accuracy, individualized management, referral pathways, patient’s education and reassurance, convenience and comfort, patient’s satisfaction, equity and efficiency of the headache care, outcome assessment and safety.ResultsOur study showed that highly experienced headache centres treated their patients in general very well. The centres were content with their work and their patients were content with their treatment. Including disability and quality-of-life evaluations in clinical assessments, and protocols regarding safety, proved problematic: better standards for these are needed. Some centres had problems with follow-up: many specialised centres operated in one-touch systems, without possibility of controlling long-term management or the success of treatments dependent on this.ConclusionsThis first Europe-wide quality study showed that the quality indicators were workable in specialist care. They demonstrated common trends, producing evidence of what is majority practice. They also uncovered deficits that might be remedied in order to improve quality. They offer the means of setting benchmarks against which service quality may be judged. The next step is to take the evaluation process into non-specialist care (EHF/LTB levels 1 and 2).

EHMTI-0061. Do the interictal microembolic signals have a role in higher cortical dysfunctions during migraine aura?

Higher cortical functions (HCF) impairment during aura in migraine patients is more frequent than previously thought. The aim of this study was to evaluate prevalence and clinical impact of interictal microembolic signals (MES) in migraine patients with HCF disturbances during aura.

EHMTI-0097. Long-term outcome in 201 patients with chronic headache with medication overuse

From the cohort of 240 patients with chronic headache with medication overuse (MOH), treated with drug withdrawal and prophylactic medications and evaluated at 1-year follow-up, 57.1% were without chronic headache and without medication overuse, 3.3% did not improve after drug withdrawal and 39.6% relapsed developing recurrent overuse (Cephalalgia 2007; 27:1219-25). The aim of the present study was to evaluate the long-term outcome of these patients. During the next 1-12 years, follow-up examinations were performed in 201 (83.8%) patients. There were no significant differences between patients lost for further examination and other patients regarding age and gender, as well as the outcome on 1-year follow-up. On the last follow-up, 66 (32.8%) patients had chronic headache with medication overuse. Without overuse were 130 (64.7%) patients with episodic and five (2.5%) patients with chronic headaches. During the follow-up period, 47 (23.4%) patients had relapsed developing recurrent overuse. The recurrent overuses occurred once in 33 (16.4%), twice in 13 (5.0%) and thrice in four (2.0%) patients. MOH recurrence occurred during the first three years after the first-year follow-up in three quarters of patients. The majority of patients, 33 (70.2%), overused the same medication. Treatment of MOH recurrence was efficacious in 93.6% patients, with strong advice to cease overused drug in 79.0% and prophylactics in 83.0% patients. During the examined period 20 (23.3%) of the patients with MOH on the first-year follow-up had remission of chronic headache with subsequent decrease of medication use. No conflict of interest.

More About Migraine-Like Features in Cluster Headache

We appreciate the interest of Professor Goadsby in our study. Two questions were raised, the first one regarding the study design and the second regarding migraine biology. The first question pointed to the lower prevalence of migraine-like features in our cohort of cluster headache (CH) patients comparing with the results of other studies dealing with the similar issues. According to results from our study, about a quarter of CH patients regularly experienced the symptoms that are, according to the Classification, related to migraine. From a clinical standpoint, because the presence of migraine-like features during the CH attack could possibly be misleading for establishing the proper CH diagnosis and consequently efficacious treatment, our intention was not solely directed to its clinical utility. We attempted to test the possibility that different clinical expressions of associated features would possibly reveal more profound differences between the two groups of CH patients in terms of demographic data, headache characteristics, and disease course or treatment response.To choose the applied study design segregating only the CH patients that regularly experience migraine-like features during CH attacks was, in fact, the natural consequence of this intention. We strongly believe that the obtained results are reliable because of the fact that almost all of the patients included had been examined repeatedly by the same neurologist over a period of several years, which provided us with an opportunity to check-up data. We must also, however, not deny the possibility of selection bias. Because our Headache Centre serves the tertiary level of a health-care system, it is possible that some CH patients with milder clinical presentation were not included. Still, our study failed to expose substantial differences and in this sense could be estimated as a negative one. Regardless of the quite strict criteria of Classification, there is a growing body of evidence surrounding overlaps in the clinical presentations of different primary headache disorders. Besides the overlaps between CH and migraine, even more evidence has been obtained in regards to overlaps between migraine and tension-type headache. The most obvious examples are the natural lifetime course of migraine or clinical presentation of migraine complicated with medication overuse when it often loses the majority of migraine features and thus resembles tension-type headache. This is related to the second question: is there any feature that is typical only for migraine? We sincerely hope that the answer to this question is not expected from clinicians because, based on the current knowledge, without reliable headache markers, for example, and taking into account variability of clinical presentation within the each primary headache disorder, it is impossible to answer.The possibility that yet undiscovered headache markers will significantly change current classiffication in the future cannot, however, be ruled out.

Comment on “Central scotoma and ‘muddled thinking’ as migraine aura” by Daroff

Dear Editor, We are very grateful to Professor Daroff, as well to our patients, for their goodwill in sharing with us their experience of aura. The letter by Professor Daroff (1) is a nice example of the fact that, in spite of contemporary technology, description of symptoms is the first and necessary step to answer the questions ‘why’ and ‘how’. We are in line with Professor Daroff when it comes to using term ‘‘Confused thinking’’ rather than ‘‘Muddled thinking’’ as a better description of such a cognitive state. We could also propose ‘‘Delusional thinking’’ as more appropriate terminology, which more precisely points out the higher cortical dysfunctions associated with visual aura. The appropriate descripter for his described symptoms (2) could be ‘‘Delusional scotoma state’’, for the inability to recognize the nature and duration of his own symptoms that is manifested during reading. We agree that ‘‘. . . failure to recognize negative scotoma at once’’ (3) could be explained by higher cortical dysfunctions due to the cortical spreading depression. While ‘‘delusional’’ thinking may be a scientifically accurate term, introducing such a term could create the erroneous interpretation of a psychiatric cause for the denial during migraine. Migraine was considered to be a psychiatric or, at least a personality disorder, for a long time, before the neurobiology of the disorder became evident. We would like to have more opportunities to study these phenomena (4) in order to determine the timing and sequence of events during aura, as well as the possible localization and mechanism of the particular disorder, before labeling them with a scientific term.

Usefulness and applicability of web-based headache diagnostic software

Headache diagnostic software (HDS), developed by Headache center, Neurology Clinic in Belgrade integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient’s headache have been collected. Purpose The aim of this pilot study was to test its diagnostic accuracy, the usefulness and applicability in the diagnosis of primary headache disorders and medication overuse headache (MOH).