Edoardo Mampreso

Osmophobia in Migraine and Tension-Type Headache and Its Clinical Features in Patients With Migraine

Intolerance to smell is often reported by migraine patients. This study evaluates osmophobia in connection with the diagnosis of migraine and episodic tension-type headache (ETTH). The characteristics of this symptom are also investigated. We recruited from our Headache Centre 1005 patients (772 female, 233 male; age 37 ± 11 years), of whom 677 were migraine without aura (MoA), 130 migraine with aura (MA) and 198 TTH. Patients with two or more forms of primary headache were excluded. Among migraine patients, 43.9% with MoA and 38.5% with MA reported osmophobia during the attacks; none of the 198 TTH patients suffered this symptom. Most frequently offending odours were scents (63.9%), food (55.2%) and cigarette smoke (54.8%). Osmophobia appears structurally integrated into the migraine history of the patient. It seems to be a peculiar symptom favouring the diagnosis of migraine (MoA and MA) in the differential diagnosis with ETTH.

Osmophobia in primary headaches

This study evaluates osmophobia (defined as an unpleasant perception, during a headache attack, of odours that are non–aversive or even pleasurable outside the attacks) in connection with the diagnosis of primary headaches. We recruited 775 patients from our Headache Centre (566 females, 209 males; age 38±12 years), of whom 477 were migraineurs without aura (MO), 92 with aura (MA), 135 had episodic tension–type headache (ETTH), 44 episodic cluster headache (ECH), 2 chronic paroxysmal hemicrania (CPH) and 25 other primary headaches (OPHs: 12 primary stabbing headaches, 2 primary cough headaches, 3 primary exertional headaches, 2 primary headaches associated with sexual activity, 3 hypnic headaches, 2 primary thunderclap headaches and 1 hemicrania continua). Among them, 43% with MO (205/477), 39% with MA (36/92), and 7% with CH (3/44) reported osmophobia during the attacks; none of the 135 ETTH and 25 OPH patients suffered this symptom. We conclude that osmophobia is a very specific marker to discriminate adequately between migraine (MO and MA) and ETTH; moreover, from this limited series it seems to be a good discriminant also for OPHs, and for CH patients not sharing neurovegetative symptoms with migraine. Therefore, osmophobia should be considered a good candidate as a new criterion for the diagnosis of migraine.

Migralepsy: Is the Current Definition Too Narrow?

The relationship between epilepsy and migraine is complex and remains to be determined. We report 3 cases that address 2 questions on this topic. The first and second cases showed an association between migraine without aura and the onset of epileptic seizures. The third case report describes a patient in whom migraine with aura occurred and was followed by the development of status epilepticus, which occurred 2 or 3 hours after the attack of migraine with aura. We discuss the present definition of migralepsy and reassess its definition by suggesting possible extensions to its current definition.

Exertional Headache as Unusual Presentation of the Syndrome of an Elongated Styloid Process

We present the case of a 34‐year‐old man with a 2‐year history of pain related to efforts in heavy lifting, beginning in the right ear and radiating to the neck and to the vertex. He underwent multiple negative neuroimaging examinations, until a 3‐dimensional computerized tomography scan of the pharyngeal region evidenced an elongated styloid process. A diagnosis of Eagles syndrome was made. The excision of the elongated styloid process was performed, resulting in complete and lasting pain relief. We focus on Eagles syndrome and in particular on this atypical presentation.

Efficacy of oxygen inhalation in sumatriptan refractory “high altitude” cluster headache attacks

We describe the case of a 40-year-old woman, affected by episodic cluster headache, who presented with a cluster headache triggered by exposure to high altitude. Her attacks were refractory to sumatriptan, very effective at sea level, but responded to oxygen. A pathophysiological mechanism is proposed.

Trigeminal neuralgia and trigeminal-autonomic cephalalgias: a continuum or simple co-existence?

Trigeminal neuralgia (TN) is a common unilateral disorder characterized by brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve. Indeed, pain is commonly evoked by trivial stimuli, including washing, shaving, smoking, talking, or brushing the teeth and frequently occurs spontaneously (1). Cluster headache (CH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms, and paroxysmal hemicrania (PH) are classified as trigeminal-autonomic cephalalgias (TACs). These cephalalgias, according to International Classification of Headache Disorders, 2nd edn (ICHD-II) criteria, share the clinical features of headache accompanied by cranial parasympathetic autonomic features (1). These syndromes seem to be different and wellcharacterized. However, in recent years some cases have been described in which syndromes co-existed or switched from one type to another in the same patient. This event raised doubt that there could be some common mechanisms among them. We describe a patient who resurrects this problem. She first presented with TN, later developed SUNCT, and then manifested TN attacks, followed by CH, and finally SUNCT without TN attacks.

Headache in kidney transplantation.

The aim of this retrospective study was to determine the relevance of the symptom “headache” in kidney transplanted patients, since few studies have considered headache as a clinically significant complication in this condition. A total of 83 consecutive kidney transplant patients underwent to neurological examination and a detailed headache history was taken. The headache history considered the period before kidney disease, during renal failure, during dialysis treatment and after transplantation. Diagnosis was made according to International Headache Criteria (ICDH-II) (2004). Our results reveal an occurrence of headache after kidney transplantation in 44.5% of the patients, which is higher than rates reported for the general population and in the only specific comparable study on liver transplant patients. These data suggest the need for prospective studies to explore the causal mechanisms by which headache develops with frequency in kidney transplant patients, and in particular to determine the role of immunosuppressive therapy.

Topiramate‐Induced Intractable Cough During Migraine Prophylaxis

(Headache 2010;50:301‐304)

Quality indicators in headache care: an implementation study in six Italian specialist-care centres

BackgroundHeadache disorders are highly prevalent, and have a substantial and negative impact on health worldwide. They are largely treatable, but differences in structure, objectives, organization and delivery affect the quality of headache care. In order to recognize and remedy deficiencies in care, the Global Campaign against Headache, in collaboration with the European Headache Federation, recently developed a set of quality indicators for headache services. These require further assessment to demonstrate fitness for purpose. This is their first implementation to evaluate quality in headache care as a multicentre national study.MethodsBetween September and December 2016, we applied the quality indicators in six Italian specialist headache centres (Bologna, Firenze, Modena, Padova, Roma Campus Bio-Medico and Roma Sapienza). We used five previously developed assessment instruments, translated into Italian according to Lifting The Burden’s translation protocol for hybrid documents. We took data from 360 consecutive patients (60 per centre) by questionnaire and from their medical records, and by different questionnaires from their health-care providers (HCPs), including physicians, nurses, psychologists and nursing assistants.ResultsThe findings, comparable between centres, confirmed the feasibility and practicability of using the quality indicators in Italian specialist headache centres. The questionnaires were easily understood by HCPs and patients, and were not unduly time-consuming. Diagnoses were almost all (> 97%) according to ICHD criteria, and routinely (100%) reviewed during follow-up. Diagnostic diaries were regularly used by 96% of physicians. Referral pathways from primary to specialist care existed in five of the six clinics, as did urgent referral pathways. Instruments to assess disability and quality of life were not used regularly, a deficiency that needs to be addressed.ConclusionThis Italy-wide survey confirmed in six specialist centres that the headache service quality indicators are fit for purpose. By establishing majority practice, identifying commonalities and detecting deficits as a guide to quality improvement, the quality indicators may be used to set benchmarks for quality assessment. The next step is extend use and evaluation of the indicators into non-specialist care.

New recipes for old ingredients: high doses of methylprednisolone and verapamil in cluster headache

Corticosteroids (C) rapidly suppress Cluster Headache (CH) attacks during the time required for the preventative agent verapamil (V), to have effects [1]. However, both drugs are often unsatisfactory. We present the case of a woman, affected by Chronic Cluster Headache (CCH), successfully treated with high doses of C and V. Moreover, we treated similarly 20 Episodic Cluster Headache (ECH) patients with satisfactory results. A 62-years old housewife, in 2006 had an isolated cluster (ICHD-II) of 40 days duration, unresponsive to NSAIDs. In 2008, she had a second cluster, responsive to 6 mg sc sumatriptan; oxygen inhalation was ineffective. Patient was successfully treated with V 240 mg and prednisone (P) 50 mg/day per os for 7 days, tapered in a month.In January 2009, she had a new cluster, that became chronic with 2-8 attacks/24 hours, not responsive to P 50 mg/day, V 320 mg/day, lithium (750 mg/day), valproate (1000 mg/day). When we saw her, in August 2011, she had 5 attacks/24 h, despite taking V per os 320 mg/day. Patient was administered methylprednisolone (MP) 500 mg iv/day for 2 days, then 250 mg for 3 days, followed by P 25 mg per os for 2 days, tapered in 8 days. V was increased gradually to 600 mg/day. In the following month there were no attacks. In September, she presented 1-3 attacks/24h nocturnal and mild, lasting 15 min. V was increased to 680 mg/day with disappearance of attacks. In November, V was slowly reduced to 320 with no recurrence. To the best of our knowledge this is the first report about high doses of iv MP associated with high doses of V per os being effective in CCH. Data are being elaborated on a group of 20 ECH patients treated similarly with good results. If confirmed, our findings warrant the reevaluation of the doses and timing of these drugs in CH with appropriate clinical trials.