Carmela Pipia

Migraine headaches in adolescents: A five-year follow-up study

Background and Objectives.—Longitudinal studies of juvenile migraine are very few. We investigated the prevalence and evolution over 5 years of migraine without aura (MWOA) and migraineous disorder (MD) in an adolescent population.

Cognitive impairment in Behçet's disease patients without overt neurological involvement.

We investigated the prevalence of cognitive impairment in patients with Behçets disease (BD) without overt neurological involvement. The influence of disease duration, disease activity, prednisone dosage, and anxiety and depression levels was evaluated. Twenty-six consecutive BD outpatients and 26 healthy controls matched for age, education and sex completed a comprehensive neuropsychological battery including tests of memory, visuospatial and constructional abilities, language, attention and psychomotor speed, non-verbal reasoning and executive functioning. The Hamilton scales for anxiety and depression were administered. Disease activity was assessed using the Behçets Disease Current Activity Form (BDCAF). Compared to controls, BD patients were significantly impaired on tasks evaluating long-term verbal and non-verbal memory, and visuospatial skills. In addition, BD patients were significantly more anxious and depressed than controls. Cognitive impairment was evident in 46.1% of BD patients compared with none of control subjects (p<0.0001), with memory representing the cognitive domain most affected. Both high disease activity (OR 1.3, 95% CI 1.0-1.5, p<0.04) and high prednisone dosage (OR 1.3, 95% CI 1.0-1.7, p<0.03) were independently associated with cognitive impairment in BD after adjustment for demographic variables. Cognitive impairment, involving mainly memory functions, occurs frequently in BD patients. It may occur independently of clinically overt neurological involvement, and is more common in patients with an active disease and in those receiving prednisone.

Prognosis of migraine headaches in adolescents A 10-year follow-up study

Objective: To determine the long-term outcome of migraine headaches in adolescents and to identify possible predictors of prognosis. Methods: Fifty-five of 80 subjects with migraine headaches (ages 11 to 14 years), who attended the baseline examination of a population-based study conducted in southern Italy in 1989, were eligible for follow-up in 1999. All interviews and examinations were conducted by neurologists, and migraine diagnoses were based on the International Headache Society (IHS) criteria. The association between possible prognostic factors and the long-term persistence of migraine headaches was explored using logistic regression analysis. Results: Of 55 subjects with migraine headaches at baseline, 41.8% had persistent migraine, 38.2% had experienced remission, and 20.0% transformed to tension-type headache. Only migraine without aura persisted in the same IHS code after 10 years, whereas migrainous disorder and nonclassifiable headache did not. The family history of migraine significantly predicted the 10-year persistence of migraine headaches (odds ratio [OR] = 7.0; 95% CI: 1.7 to 26.8). The risk persisted when only subjects with migraine with or without aura were evaluated (OR = 5.0; 95% CI: 1.2 to 20.9). Conclusions: Migraine headaches in adolescents have a favorable long-term prognosis. Familial disposition for migraine predicted a poorer outcome, especially in subjects with migraine without aura.

Interictal executive dysfunction in migraineurs without aura: relationship with duration and intensity of attacks

Subjects with migraine are at increased risk of subcortical white matter lesions (WML). Reports of cognitive testing in adults with migraine have yielded inconsistent results. We performed a cross-sectional study to assess whether migraine without aura (MwA) is associated with impairment in executive functioning, a typical cognitive correlate of subcortical WML. Forty-five subjects with MwA and 90 controls, matched for age and education, underwent a cognitive battery of tests evaluating executive functions. The following migraine characteristics were collected: age at onset and length of migraine history, and frequency, duration and intensity of attacks. Subjects with MwA performed significantly lower than controls in tests evaluating complex, multifactorial executive functions. After multiple adjustments, the duration and intensity of migraine attacks significantly predicted cognitive disturbances. In the interictal phase of MwA there is evidence of mild executive dysfunction. The cumulative effects of repeated migraine attacks on prefronto-cerebellar loop probably account for our results.

Intracerebral haemorrhage associated with sildenafil citrate.

Sirs: Sildenafil is an orally active, potent and selective inhibitor of phosphodiesterase type 5 (PDE–5), an important regulator of cyclic guanosine monophosphate (cGMP) in the human corpus cavernosum which has recently been introduced for the treatment of erectile dysfunction. Sildenafil acts by increasing the concentration of cGMP in the corpus cavernosum smooth muscle cells leading to muscle relaxation, vasodilatation and penile erection [1]. Adverse effects include headache, visual and retinal disturbances, dizziness and a pupil-sparing third nerve palsy [2, 5, 7]. We report a patient who developed intracerebral haemorrhage (ICH) after sildenafil consumption. A 67-year-old dentist was referred to our clinic in a confusional state together with speech, numeracy and memory disturbances. From the history it appeared that 5 days before admission, approximately 30 minutes after the ingestion of one tablet of sildenafil 25 mg, the patient complained of headache, confusion and nervousness without improvement in sexual function. One hour after the ingestion of the first tablet the patient took another 25 mg tablet, again without sexual intercourse. According to his wife, these symptoms increased together with language difficulty. The patient was admitted to our department 5 days later. He had never used sildenafil before. The history revealed no arterial hypertension or migraine or haemostatic risk factors (e. g. use of anticoagulants or antiplatelet drugs, thrombolytic treatment), history of head trauma, hypercholesterolaemia, diabetes mellitus, pre-existing cardiovascular disease or cerebrovascular episodes such as stroke or transient ischaemic attacks. There was no family history of cerebral arteriovenous malformation, intracerebral aneurysms, or intracerebral haemorrhages. He had a 40-year history of tobacco abuse (approximately 15 cigarettes a day) and denied regular alcohol intake. He took no other medications. On admission his blood pressure was 140/90 mmHg and pulse was 68/min. Neurological examination showed a right superior homonymous quadrantopsia and psychiatric examination a dysphoretic mood. Ophthalmoscopic examination was normal. Neuropsychological testing revealed a moderate impairment of comprehension, naming, reading and writing with a relative sparing of repetition, acalculia, finger agnosia, colour anomia, and discrete involvement of episodic memory. Routine blood examination, platelet count and coagulation factors were normal, as well as electrocardiography, and colour-coded duplex sonography of extracranial vessels. Transcranial colour-coded duplex sonography revealed a sharply demarcated hyperechogenic area confined to the left temporal lobe. Two days after admission basal and gadolinium-enhanced T1-/T2-weighted cerebral magnetic resonance imaging revealed a large left temporal subcortical haemorrhage with moderate surrounding oedema (see Fig. 1). Although the chance of finding a clinically relevant vascular lesion in a patient 67 years old is very small, we would have liked to have performed cerebral angiography. However, the patient’s wife, informed of the potential risk of cerebral angiography, refused her consent due to her husband’s advanced age and the presence of a deep lobar ICH. The patient was treated with intravenous bolus of 1 g/kg mannitol, followed by 0.5 g/kg every 4 h for 7 days. He was discharged 5 days later with mild comprehension, reading, writing and episodic memory deficits, moderate acalculia, finger agnosia and colour anomia. The field defect was still present. The close temporal relationship between sildenafil ingestion and onset of the neurological symptoms due to the ICH in a patient without a history of cerebrovascular accident or obvious risk factors for ICH suggest that sildenafil was causally related to the ICH. Smoking is currently not considered a primary risk factor for ICH [4, 6]. Since the symptoms started before any attempt at sexual intercourse, sexual exertion cannot be regarded LETTER TO THE EDITORS

Association between plasma lipid levels and migraine in subjects aged ≥50 years: preliminary data from the Zabùt Aging Project

We evaluated the association between lipid levels and migraine using cross-sectional, population-based data of 1809 subjects aged ≥50 years; 151 subjects with migraine and 1658 nonmigraineurs were included. Diagnosis of migraine was carried out using the criteria of the International Headache Society. The following plasma lipids were collected: total cholesterol (TC), lowdensity lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG). Only TC (p<0.003) and LDL-C levels (p<0.004) were significantly higher in migraineurs than nonmigraineurs. After multiple adjustments, only elevated TC (≥220 mg/dl) was significantly associated with migraine (OR [95% CI]=1.6 [1.1–2.3]); this association increased in elderly males with migraine (OR [95% CI]=3.8 [1.4–9.9]). According to our results, TC plasma levels should be closely monitored in elderly males with migraine.

Movements execution in amnestic mild cognitive impairment and Alzheimer's disease.

We evaluated the relationship between motor and neuropsychological deficits in subjects affected by amnestic Mild Cognitive Impairment (aMCI) and early Alzheimer’s Disease (AD). Kinematics of goal-directed movement of aMCI and AD subjects were compared to those of age-matched control subjects. AD showed a slowing down of motor performance compared to aMCI and controls. No relationships were found between motor and cognitive performances in both AD and aMCI. Our results suggest that the different motor behaviour between AD and aMCI cannot be related to memory deficits, probably reflecting the initial degeneration of parietal-frontal circuits for movement planning. The onset of motor dysfunction in early AD could represent the transition from aMCI to AD.

Comorbidity between depressive symptoms and migraine: preliminary data from the Zabút Aging Project.

We evaluated the association between depressive symptoms and migraine using cross-sectional data from the Zabút Aging Project, a population-based study including subjects aged ≥50 years. A total of 1285 nonmigraineurs and 151 migraineurs were included. Diagnosis of migraine was carried out using the criteria of the International Headache Society. The Center for Epidemiologic Studies Depression scale (CES-D) was used to score depressive symptoms. Depressive symptoms were clustered in four groups: depressed and positive affects, somatic activity and intrapersonal feelings. Migraineurs showed higher total and specific depressive symptoms than controls (p from 0.005 to <0.0001). Mild-to-moderate depressive symptoms (CES-D score of ≥16) were present in 47.2% of migraineurs compared to 15.8% of controls (p<0.0001). After adjustment for demographics, mild-to-moderate depressive symptoms were strongly associated with migraine (OR [95% CI]=4.7 [3.1–7.0]). This association significantly increased in males (OR [95% CI]=6.2 [2.8–14.6]). Depressive features represent highly frequent comorbid symptoms of adult-to-elderly migraineurs.

Vascular Risk Factors, Vascular Diseases, and Imaging Findings in a Hospital- based Cohort of Mild Cognitive Impairment Types

BACKGROUND Mild Cognitive Impairment (MCI) is a transitional state between normal cognition and dementia. OBJECTIVE The aim of this study is to investigate the role of vascular risk factors, vascular diseases, cerebrovascular disease and brain atrophy in a large hospital-based cohort of MCI types including 471 amnestic MCI (a-MCI), 693 amnestic MCI multiple domain (a-MCImd), 322 single non-memory MCI (snm-MCI), and 202 non amnestic MCI multiple domain (na-MCImd). For comparison, 1,005 neurologically and cognitively healthy subjects were also evaluated. METHOD Several vascular risk factors and vascular diseases were assessed. All participants underwent neurological, neuropsychological and behavioural assessments as well as carotid ultrasonography and standard brain MRI. Multinomial logistic regression models on the MCI cohort with the NCH group and a-MCI type as reference categories were used to assess the effects of the variables evaluated on the estimated probability of one of the four MCI types. RESULTS This study demonstrates that cerebrovascular disease contributes substantially to the risk of non-memory MCI types and a-MCImd type, and that brain atrophy is present in all MCI types and is greater in multiple domain types particularly in the na-MCI type. CONCLUSION Improving detection and control of cerebrovascular disease in aging individuals should be mandatory. Since the incidence of MCI and dementia will be expected to rise because of the progressive life expectancy, a better management of cerebrovascular disease could indeed prevent or delay the onset of MCI, or could delay progression of MCI to dementia.

Association Between Atrophy of the Caudate Nuclei, Global Brain Atrophy, Cerebral Small Vessel Disease and Mild Parkinsonian Signs in Neurologically and Cognitively Healthy Subjects Aged 45-84 Years: A Crosssectional Study

BACKGROUND Mild Parkinsonian signs (MPS) are commonly seen in aging, and have been related to cerebral Small Vessel Diseases (SVD) with no univocal results. OBJECTIVE The aim of this study was to investigate the cross-sectional relation between MPS and White Matter Hyperintensities (WMH), lacunes, caudate atrophy, and global cerebral atrophy in a large cohort of Neurologically and Cognitively Healthy (NCH) aging individuals. METHOD 1,219 NCH individuals were included in the analysis, and underwent standard brain MRI. The items of the motor section of the Unified Parkinsons Disease Rating Scale were used to evaluate tremor, rigidity, bradykinesia, and gait/balance/axial dysfunction. Caudate atrophy and global cerebral atrophy were assessed through the bicaudate ratio and the lateral ventricles to brain ratio, respectively. WMH were assessed through two visual rating scales. Lacunes were also rated. Associations of MPS with vascular risk factors/diseases and imaging findings were determined through the logistic regression analysis. RESULTS Frontal and basal ganglia lacunes, frontal WMH, caudate atrophy, and global cerebral atrophy were associated with bradykinesia. Basal ganglia lacunes, caudate atrophy, and global cerebral atrophy were associated with gait/balance/axial dysfunction. Rigidity was associated with frontal WMH, and tremor with caudate atrophy and global cerebral atrophy. NCH subjects with MPS, performed less than subjects without MPS in tests evaluating global cognition and language. CONCLUSION This study demonstrates that in NCH aging individuals, MPS are associated with cortical and subcortical vascular and atrophic changes, and are probably, a warning sign of incipient cognitive decline. Subjects with MPS should manage rigorously cerebral SVD to prevent future physical and cognitive disabilities.