Christina Deligianni

Incremental Predictive Value of Carotid Inflammation in Acute Ischemic Stroke

Background and Purpose— Microwave Radiometry (MWR) allows in vivo noninvasive assessment of internal temperature of tissues. The aim of the present study was to evaluate in patients with ischemic stroke and bilateral carotid plaques (1) whether ipsilateral carotid arteries exhibit higher temperature differences (&Dgr;T), as assessed by MWR; (2) the predictive accuracy of MWR in symptomatic carotid artery identification. Methods— Consecutive patients with recent acute anterior circulation ischemic stroke because of large artery atherosclerosis were included in the study. Carotid arteries of all patients were evaluated by carotid ultrasound and MWR. Results— In total, 50 patients were included in the study. Culprit carotid arteries had higher &Dgr;T compared with nonculprit (0.93±0.58 versus 0.58±0.35°C; P<0.001). The addition of &Dgr;T to a risk prediction model based only on ultrasound plaque characteristics increased its predictive accuracy significantly (c-statistic: 0.691 versus 0.768; Pdif=0.05). Conclusions— Culprit carotid arteries show higher thermal heterogeneity compared with nonculprit carotid arteries in patients with acute ischemic stroke and bilateral carotid plaques. MWR has incremental value in culprit carotid artery discrimination.

Neck pain in episodic migraine: premonitory symptom or part of the attack?

BackgroundWhether neck pain (NP) is a prodromal migraine symptom or belongs to the migraine attack feature remains controversial.MethodsIn order to prospectively record neck pain (NP) and non-headache symptoms and to evaluate the percentage of patients having NP as clear premonitory, non-headache symptom of their migraine, a specific self fulfilled questionnaire was designed to record NP and premonitory symptoms in a migraine cohort. All patients who reported NP anytime during the migraine phase were allocated to 3 groups: A = NP starts with the onset of headache; B = NP starts < 2 h before the onset of headache; C = NP starts 2-48 h before the onset of headache.ResultsData were evaluated from 487 migraineurs with episodic migraine (73.1 % females; 77 % had migraine without aura). 338 patients (69.4 %) reported NP anytime during the migraine phase. 184 patients (group A; 54.4 %) noticed NP with the start of the headache phase; 118 patients (group B; 24.2 %) reported NP within 2 h before the headache phase; 36 patients (group C; 7.4 %) experienced NP 2-48 h before the headache phase. In group B we found a high proportion of typical migraine associated symptoms and NP progressed into the headache phase in 82.2 %.ConclusionsThese data indicate that NP is a very common feature of migraine attacks and is more likely to be part of the migraine attack than a prodromal migraine symptom.

Depression in headaches: chronification

PURPOSE OF REVIEW Recent evidence supports the suggestion that migraine is a chronic disorder with episodic attacks that increase in frequency in a subgroup of patients, transforming migraine into a refractory chronic condition with poor outcome and severe impact. Among the risk factors for migraine chronification depression figures notably. Early diagnosis and management of risk factors in migraineurs prevent migraine chronification and its consequences. The scope of this article is to review depression as a potential cofactor for migraine chronification. RECENT FINDINGS Population-based studies revealed that migraineurs often have symptoms of depression, with strongest associations for migraine with aura. Patients with depression also have an increased risk for migraine, migraine with aura in particular. Twin studies showed similar findings. This bidirectional relationship suggests that migraine and depression may share common causative factors, possibly genetically determined, that might control migraine chronification. Migraine patients may develop depression as a result of the demoralizing experience of recurrent and disabling headaches and depressed patients may develop migraine because of increased pain sensitivity, in the basis of a common genetic background. SUMMARY We suggest that clinicians consider depression as part of migraine management in order to optimize treatment and avoid migraine progression.

Patients’ preferences for headache acute and preventive treatment

BackgroundWe aimed to explore patients’ preferences for headache treatments with a self-administered questionnaire including the Q-No questionnaire for nocebo.MethodsQuestionnaires from 514 outpatients naïve to neurostimulation and monoclonal antibodies were collected.ResultsPatients assessed that the efficacy of a treatment is more important than safety or route of administration. They preferred to use an external neurostimulation device for both acute (67.1%) and preventive treatment (62.8%). Most patients preferred to take a pill (86%) than any other drug given parenterally for symptomatic pharmaceutical treatment. For preventive pharmaceutical treatment, most patients preferred to take a pill once per day (52%) compared to an injection either subcutaneously or intravenously each month (9% and 4%), or three months (15% and 11%). 56.6% of all participants scored more than 15 in Q-No questionnaire indicating potential nocebo behaviors that contributed significantly in their choices.ConclusionThese patient preferences along with efficacy and safety data may help physicians better choose the right treatment for the right person.

Placebo and Nocebo Effects

Placebo refers to the positive expectation that a treatment will help patients, and nocebo refers to adverse events related to patient’s negative expectations that a medical treatment will likely harm instead of healing. Both conditions illustrate the power of human brain and are strongly related to treatment outcome and adherence. Placebos and nocebos display particular role in pain conditions, such as headache. There is evidence that placebo analgesia and hyperhedonia associated with pain relief are mediated by activation of shared emotion appraisal neurocircuitry, which regulates early sensory processing, depending on whether the expectation is reduced pain or increased pleasure. It has been suggested that dopaminergic, cyclooxygenase/prostaglandins and opioid brain pathways reward circuitries, and decision-making processes play a crucial role in the mechanisms that underlie nocebo. For migraine prophylaxis, the mean placebo effect for responders (those who report at least 50 % reduction in headache days after treatment) has been estimated at 23.5 ± 8 % (95 % CI 18.3–28.8 %) vs. 45.5 ± 15.5 % (95 % CI 37.4–53.6 %) in the active groups. Correspondently, a reduction in migraine attacks of 16.8 ± 12.7 % (95 % CI 10.9–22.6 %) was observed in the placebo groups and 41.8 ± 11.7 % (95 % CI 36.9–46.6 %) in the active groups. In preventive treatments for migraine, dropout ratio due to adverse events in placebo-treated patients has been estimated up to 5 %, showing that 1 out of 20 patients treated for migraine prophylaxis discontinues treatment due to nocebo. Placebos and nocebos therefore affect migraine treatment outcomes significantly.

Headache in Systemic Diseases

A right-hand 47-year-old man, officer at the Hellenic Navy, has been presented at the outpatient headache clinic complaining of new-onset headaches. Headaches started 3–4 months ago gradually; they were mild to severe (rated 5–8/10), located within the whole head, pressing, lasting from 30 min to 2 h and worsening by physical activity but not associated with nausea, vomiting, phonophobia, photophobia or osmophobia. Headache attacks were more frequent during the morning and responded to paracetamol 500 mg in the beginning but later on did not any more. Two months ago he had visited the emergency room at the Athens Naval Hospital to report those headaches. Physical and neurological examination was normal at that time. He had a brain CT scan that did not show any abnormality. He was advised to keep a headache diary, treat the headache attacks with naproxen 500 mg and schedule appointment with the headache clinic. In the diary, headaches followed the pattern the patient reported in the emergency room, responded to naproxen, but slowly the intensity and frequency increased. Headaches became pulsating and accompanying with face flush. When the pain was severe, it was accompanied with nausea but not vomiting. He reported no photophobia or phonophobia. Physical activity typically triggered headaches, and during the attack, pain severity did not change by body position. The mean frequency was 25 days with headache per month. He reported no recent or previous trauma. His wife, who was present at the interview, did not mention snoring. Sleep was normal as usual and he reported no anxiety or depressive symptoms. Recent blood tests in the context of the annual check-up were normal. He described no recent surgical or dental procedure or regional or general anaesthesia. At the time of interview, the Hamilton rating scales for anxiety and depression scores were 12 and 8 (normal values). No medication overuse was noted in the headache diary nor reported by the patient. His wife agreed on this.