Birgit Bauer

Cognitive Processing in Primary Headache A Study on Event-related Potentials

Background: There is experimental evidence for loss of cognitive habituation in migraine but not in other types of headache and not by visual event-related potentials (ERP). Objective: Determining the latencies (msec) and amplitudes (micro V) of ERP components and the differences of these values in a two-trial analysis representing the amount of cognitive habituation. Participants: Two hundred thirty-three patients with a headache diagnosis according to the criteria of the International Headache Society: migraine without aura (N = 77); migraine with aura (N = 31); cluster headache during period (N = 26); cluster headache during interval (N = 11); chronic paroxysmal hemicrania (N = 8); episodic tension-type headache (N = 33); ergotamine-induced headache (N = 47). Thirty age-matched healthy subjects served as a control group. Methods: ERPs were evoked by a visual oddball paradigm consisting of 2 x 200 flashes of light (85% white light; 15% red light). Evaluation of ERP components was done separately for the first 200 and the second 200 stimuli as well as for the entire series of stimuli. Results: We found an acceleration of the P3 latency during the second trial in migraine with and without aura, but not in the other headache types, and not in healthy controls. Ergotamine and sumatriptan abolished this loss of habituation in migraine patients. Increased ERP latencies as compared with healthy controls were present in patients with cluster headache, tension-type headache, ergotamine-induced headache, and migraine with aura, but not in migraine without aura. Conclusion: There is a loss of cognitive habituation in migraine, which may serve as a specific but not sensitive diagnostic tool. The pathophysiologies of migraine and cluster headache have a specific modifying property on cognitive processing reflected by a loss of cognitive habituation or an increased cognitive processing time. These effects can, in part, be counterbalanced by antimigraine medication. NEUROLOGY 1997;48: 108-113

Drug-induced headache: long-term results of stationary versus ambulatory withdrawal therapy

Drug-induced headache is a well-known complication of the treatment of primary headache disorders, and its successful management is only possible by withdrawal therapy. However, it is unknown whether ambulatory or stationary withdrawal is the therapy preferred. We conducted a prospective study on the outcome of stationary versus ambulatory withdrawal therapy in patients with drug-induced headache according to the International Headache Society criteria. Out of 257 patients with the diagnosis of drug-induced headache during the study period, 101 patients (41 after ambulatory and 60 after stationary withdrawal therapy) could be followed up for 5.9 ± 4.0 years. The total relapse rate after successful withdrawal therapy was 20.8% (14.6% after ambulatory and 25.0% after stationary withdrawal therapy, p <0.2). The main risk factors for a relapse were male sex (OR=3.9, CI=1.3-11.6), intake of combined analgesic drugs (OR=3.8, CI=1.4-10.3), administration of naturopathy (OR=6.0, CI=1.2-29.3), and a trend to tension-type headache as the primary headache disorder (OR=1.9, CI=0.6-53.0). Our data suggest that neither the method of withdrawal therapy nor the kind of analgesic and other antimigraine drugs has a major impact on the long-term result after successful withdrawal therapy. Patients with risk factors according to our findings should be informed and monitored regularly, and combined drugs should be avoided. Furthermore, our data suggest that there is a need for research on individual psychological and behavioral risk factors for relapse after successful withdrawal therapy in drug-induced headache.

Event-related potentials (P300) in primary headache in childhood and adolescence.

There is strong evidence for a loss of habituation during cognitive processing in migraine as measured by P300 and contingent negative variation in adults. Event-related potentials evoked by an oddball paradigm have not yet been studied in children and adolescents suffering from different primary headache types. We recorded visually evoked event-related potentials (two consecutive trials, 200 stimuli each) in 48 children and adolescents suffering from migraine without or with aura, from episodic tension-type headache, and from ergotamine-induced headache and analyzed the latencies, amplitudes, and reaction times. No statistically significant differences were noted between all headache types and healthy controls analyzing the averaged parameters for the whole measurement. However, a highly significant loss of cortical habituation as measured by P300 amplitude and latency could be observed in migraine without and with aura by analyzing the first and the second trial of measurement separately. This phenomenon increased with age and could not be seen in healthy controls, or patients with tension-type headache or ergotamine-induced headache. Our data suggest a specific cognitive processing in migraine even in children and adolescents. Measurement of the habituation effect in P300 latency and amplitude provides a specific method to differentiate between primary headache types in childhood and adolescence. (J Child Neurol 1998;13:322-326).

A retrospective long-term analysis of the epidemiology and features of drug-induced headache

Abstract Drug-induced headache is well known to resul from the abuse of compounds taken for the treatment of primary headache. The features of drug-induced headache depend on various features including the availability of drugs, the regional health system, and psychogenic factors of the patients. We performed a retrospective study on a series of 257 consecutive German patients presenting with drug-induced headache during the period 1983–1996. Our aim study was to evaluate the demographic features, the frequency of various drugs used, in particular of ergotamine derivates, and changes in these features during the study period. The frequency of drug-induced headache among all headache patients was 8%, with a female preponderance of 81%. Drug-induced headache occurred in all age groups, predominantly in migraine patients (35%). The mean number of substances used was 2.7, mainly, acetaminophen (47.9%), ergotamine tartrate (45%), and combined analgesics (56%). We did not find a significant difference between the associations with ergotamine tartrate and dihydroergotamine, although the latter was taken less frequently. Comparing the early and late years of our study period, there were no changes in the frequency of drug-induced headache (8% versus 7%), although changes in the frequency of some drugs changed (barbiturates, ergotamine tartrate, and codeine intake decreased whereas nonsteroidal anti-inflationary drugs, combined analgesics, and sumatriptan intake increased). Our data suggest that changes in drug availability and the introduction of classification criteria and treatment recommendations did not have a major impact on the frequency of drug-induced headache.

Cognitive processing is involved in cluster headache but not in chronic paroxysmal hemicrania

Background: Cognitive processing in migraine is characterized by a loss of habituation during the interval and increased latencies in an attack. No studies are available on event-related potentials (ERPs) in cluster headache or chronic paroxysmal hemicrania. Objective: To determine the involvement of cognitive processing in cluster headache and chronic paroxysmal hemicrania as measured by ERPs. Methods: Visually evoked ERPs were measured in 50 patients with episodic cluster headache, 11 patients with chronic cluster headache, and 12 patients with chronic paroxysmal hemicrania. Measurements were performed in the cluster period outside an attack with and without prophylactic medication and not in the cluster period. Results: Latencies of the endogenous ERP components were significantly increased during the cluster period as compared with outside the cluster period and with healthy subjects. In chronic cluster headache, latencies of both endogenous and exogenous components were increased. Medication with prophylactic drugs normalized the ERP latencies in episodic cluster headache; in chronic cluster headache, ERP latencies were decreased without complete normalization. No changes of ERP latencies and amplitudes could be observed in chronic paroxysmal hemicrania. A loss of cognitive habituation as it is known in migraine could not be observed in either cluster headache or chronic paroxysmal hemicrania. Conclusions: Our data suggest that central structures generating ERPs are involved in the pathophysiology of cluster headache during the cluster period but not outside the cluster period. This is in concordance with recent neuroimaging findings on the central role of the hypothalamus and the right frontal cortex in cluster headache and supports the hypothesis of a central origin of cluster headache. Furthermore, the data suggest that cluster headache and chronic paroxysmal hemicrania are distinct entities.

The impact of ergotamine-induced headache and ergotamine withdrawal on information processing.

Abstract Ergotamine abuse and subsequent ergotamine-induced headache is a common problem in the pharmacological treatment of migraine and other headache types; often, withdrawal therapy is necessary. This study investigated whether ergotamine abuse affects information processing and whether withdrawal therapy can lead to an improvement of information processing. We designed a standardized neurophysiological retrospective (ergotamine abuse) and prospective (ergotamine withdrawal) study in a supraregional headache outpatient clinic. Seventy-one patients abusing ergotamine derivatives with subsequent daily headache were enrolled and compared to 36 migraine patients without ergotamine intake and 36 healthy subjects. Information processing was evaluated by latencies and amplitudes of visually evoked event-related potentials (ERP) before and after ergotamine withdrawal therapy. P3 latency of the ERP was significantly increased in ergotamine abuse (442 ± 45 ms) versus migraine (415 ± 40 ms) and healthy subjects (410 ± 33 ms), there was no difference between ergotamine tartrate and dihydroergotamine abuse. The migraine specific loss of habituation in information processing as measured by P3 latency could not be observed in migraine patients with ergotamine abuse. After successful withdrawal therapy in 36 patients, the abnormally prolonged P3 latency was significantly shortened (452 ± 47 ms versus 433 ± 30 ms; P < 0.004). Our findings imply that information processing is impaired by ergotamine abuse and can be improved but not normalized after withdrawal therapy. Furthermore, our data provide strong evidence that ergotamine, besides its peripheral effects, has a central mode of action.

Peripheral Autonomic Potentials in Primary Headache and Drug-Induced Headache

Autonomic functions of different primary headache types have been investigated in several studies, most of them analyzing cardiovascular reflex mechanisms or biochemical changes. The results are contradictory; only in tension-type headache and in cluster headache has a sympathetic hypofunction been shown in a preponderance of studies. We analyzed the peripheral autonomous potentials (PAPs) in different primary headache types and in drug-induced headache and compared the results with those of healthy subjects and of patients with low back pain. Latencies of PAPs were significantly increased in all headache types but not in low back pain; amplitudes of PAPs did not show significant differences compared to healthy subjects. Patients with a long duration of drug abuse had increased PAP latencies, whereas patients with a high number of migraine attacks per year had decreased latencies. Our data suggest that sympathetic hypo-function as measured by PAP latencies is a general phenomenon in headache but not in all pain syndromes. Drug abuse leads to an increase of this hypofunction. While measuring PAPs is not an appropriate method by which to differentiate between headache disorders, it allows assessment of autonomic disturbances in primary and drug-induced headache.

Headache Caused by a Sphenoid Mucocele but Presenting as an Ergotamine‐Induced Headache

In a 65‐year‐old woman, symptomatic headache caused by a mucocele of the sphenoid sinus led to ergotamine abuse and subsequent ergotamine‐induced headache. Since there were no neurological symptoms initially and the patient previously suffered from migraine, the mucocele was not recognized. Only after unsuccessful drug withdrawal therapy and an MRI, was the correct diagnosis made. Surgical removal of the mucocele led to complete relief of headache within 3 weeks. We conclude that ergotamine‐induced headache can develop on the basis of symptomatic headache. In spite of the effectiveness of ergotamine tartrate, an MRI should be performed if focal neurological symptoms occur.

Side-to-side differences in visual event-related potentials but not VEP in patients with multiple sclerosis: A report of three cases

Three patients with definite multiple sclerosis (MS) and acute loss of visual acuity on one side but without side-to-side differences in visual evoked potential (VEP) latencies revealed prolongation of visual event-related potentials (ERP) on the impaired side. These patients represent 5.1 % of a cohort with clinical optic mononeuritis and 21.4% of a cohort with clinical optic mononeuritis but no side-to-side differences in VEP. The data suggest, that in some cases, side different measurement of ERP (rather than VEP) is an appropriate method to prove the sensory or cognitive impairment in patients with MS and clinical optic mononeuritis.

Visual Event-Related Potentials in Childhood and Adolescence Primary Headache

Measurements of event-related potentials (ERP) , especially of contingent negative variation (CNV), in the migraine interval in adults and children show an increased amplitude. This has been interpreted as an expression of a specific cognitive processing in migraine and (in adults) as a loss of habituation. We measured visually evoked ERP in children and adolescents with primary headache and compared our results to a healthy control group.