Elisa Pari

Where SUNCT contacts TN: a case report.

Background.—Short‐lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and trigeminal neuralgia (TN) are unilateral painful conditions that can share the same triggering factors, autonomic features and the main location, as well as the cyclically recurrent crises. Both these syndromes are associated with a high percentage of findings of vascular malformation touching the trigeminal nerve, suggesting a pathophysiological relationship.

MR Neurography in Diagnosing Nondiabetic Lumbosacral Radiculoplexus Neuropathy

Here we describe the imaging findings in a 73‐year‐old woman who had pain in the right inguinal region, followed by progressive weakness of muscles innervated by the right femoral and obturator nerves, diagnosed as nondiabetic lumbosacral radiculoplexus neuropathy. Magnetic resonance neurography showed thickening and increase in signal intensity of the right femoral and obturator nerves.

Potentially Serious Drug-Drug Interactions in Older Patients Hospitalized for Acute Ischemic and Hemorrhagic Stroke.

Background: Polypharmacy is very common in older persons and it is associated with inappropriate prescribing and potential drug-drug interactions (DDIs). Aims of this study were to identify prevalence of DDIs in older persons with acute stroke and to evaluate the association between stroke and DDIs. Methods: One hundred forty-six patients admitted with diagnosis of acute stroke were enrolled. The therapeutic regimen of patients was analyzed at admission to identify the number of DDIs, prevalence and sorts of serious DDIs according to subtype of acute stroke (ischemic or hemorrhagic) and to its recurrence. Results: Five hundred eighty-two DDIs were identified: 18 mild, 415 moderate and 149 serious. Sixty-one percent of patients were exposed to at least one serious DDI. A higher percentage of patients were exposed to at least one serious DDI among those with a recurring ischemic event compared to those with a first event (74 vs. 50%; p < 0.01, respectively). Serious DDIs potentially associated with an increased risk of a cerebral event were identified in 19 (17%) patients with ischemic stroke, and in 7 (19%) patients with hemorrhagic stroke. Conclusions: The prevalence of serious DDIs was high in aging patients with acute stroke but different according to subtype and recurrence of the cerebrovascular event.

Postpartum headache: A prospective study

AIMS To prospectively assess the incidence and etiology (ie, primary vs symptomatic) of headache in women during the first month postdelivery, with particular emphasis on the type of presentation as a clue for identifying potentially harmful etiologies. A secondary aim was to evaluate the relative frequency of migraine- vs tension-type headache in cases of primary headache. METHODS A total of 900 consecutive women were enrolled in the study and examined within 3 days of delivery, both clinically and with transcranial color-coded sonography (TCCS). During the course of follow-up, all subjects presenting with headache suspected of being secondary to intracranial pathology underwent a complete clinical and instrumental assessment with TCCS and magnetic resonance imaging (MRI) and angiography. A telephone interview was administered to all subjects 1 month after delivery. Two-tailed t test, Mann-Whitney test, Pearson chi-square test, and multiple logistic regression were used to analyze the data. RESULTS At the end of the follow-up period, 241 women (26.8% of the sample) reported at least one headache attack. In 88 of these 241 cases (9.8%), the headache attack occurred soon after delivery and was already recorded at the first visit. Thunderclap headache occurred in 34 (3.8%) of the subjects. In all but one of these subjects, the course was spontaneously benign. None of the recorded variables allowed discrimination of the subjects with thunderclap headache from those without headache. Three subjects had thunderclap headache following dural anesthesia, and one subject was found to have reversible cerebral vasoconstriction syndrome. Headache with gradual onset was recorded in 207 subjects (23%). Three of these subjects fulfilled the criteria for pre-eclampsia, and 13 had postural headache after dural anesthesia. Migraine history and urinary protein were independent predictors of gradual onset headache, and migraine history and parity were significant independent predictors of pulsating pain with gradual onset headache. CONCLUSION Headache appeared early in the first days postdelivery, and its incidence increased in the first month thereafter. Predictors were different according to whether the headache had a gradual onset or a thunderclap presentation. Primary headache accounted for the overwhelming majority of the recorded cases.

OnabotulinumtoxinA in chronic migraine: long-term efficacy in a prophylactic medication free cohort

Chronic migraine (CM) is a debilitating neurologic disorder defined as headaches occurring on ≥ 15 days per month for more than 3 months, with headaches having migraine features on ≥ 8 days per month. Patients with chronic migraine typically have a history of episodic migraine headaches that increase in frequency over a period of months to years until patients experience daily or near-daily, low-grade migraineous and nonmigraineous headaches with intermittent attacks of severe migraine. CM affects approximately 1.4 to 2.2% of adults worldwide with an important economic burden and impact in quality of life. Both frequency of attacks, severity of pain, and associated symptoms have a major role on migraine-related disability. The current understanding of headache pathophysiology is evolving. For patients affected by CM, a prophylactic headache treatment regimen is highly recommended to reduce the frequency, severity, and disability. OnabotulinumtoxinA is a focally acting protein that inhibits the release of the neurotransmitter acetylcholine from the presynaptic nerve endings and blocks the neuronal release of nociceptive mediators such as substance P, glutamate, and calcitonin gene-related peptide (CGRP) in the periphery, which suggests it may possess peripheral antinociceptive activity. The inhibition of nociceptive mediators in the periphery may reduce central sensitization, perhaps by inhibiting afferent inputs to the central nervous system, thereby reducing inflammatory signals to sensitized regions in the brain. Its biological effects are transient, and within approximately 3 months, normal neuronal signaling is restored. The recently published PREEMPT [1] and COMPEL [2] studies established the safety and efficacy of OnabotulinumtoxinA for treatment of chronic migraine. The a im of the presen t s tudy was to assess OnabotulinumtoxinA long-term efficacy in CM patients as a prophylactic agent alone.Moreover, subjects who presented with a diagnosis of chronic migraine with medication overuse headache were treated directly with OnabotulinumtoxinA, sidestepping withdrawal interventions, althought such bridge therapies are generally regarded as crucial for subsequent prophylaxis’ efficacy. The study was conducted at the Headache Centre of Neurological Department of ASST Spedali Civili of Brescia. We evaluated prospectively all patients aged 18 to 65 years with CMwith orwithout a diagnosis ofmedical overuse headache between 1 January 2015 and 31 December 2017. Diagnosis was made according to the ICHD III beta criteria [3]. During the study, preventive treatments were not allowed. We collected data concerning demographic variables: pain site, disease duration, previous prophylaxis therapies, monthly number of days with headache (distinguished according with intensity of pain), and symptomatic drug consumption (triptans, NSAIDs and combination analgesics). We collected the same variables at each subsequent evaluation every 3 months by analysis of headache diary provided at our center. Migraine-induced disability was assessed using the Migraine Disability Assessment Score Questionnaire (MIDAS) at baseline and 3, 6, and 9 months after treatment. Patients were injected OnabotulinumtoxinA according to the PREEMPT protocol. We administered 155 units intramuscularly in 31 sites. At the investigator’s discretion, an additional 20 units could be administered using a follow-the-pain strategy based on the patient’s report of predominant pain location. The primary endpoint was to evaluate the reduction in the headache frequency at 3, 6, and 9 months after the discontinuance of the treatment. Secondary endpoints were evaluation of reduction in intensity of pain, symptomatic medication intake, * Francesca Schiano di Cola francescaschiano@hotmail.it