Ennio Pucci

Migraine with Aura and Reproductive Life Events: A Case Control Study

The course of migraine without aura (MO) is greatly influenced by the events of female reproductive life. Much less is known about migraine with aura (MA). The aim of this study was to evaluate the relationship between MA and the milestones of reproductive life. A retrospective case control study was carried out on 100 women affected by migraine with typical aura (cases) and 200 age-matched women with MO (controls). Pre-menstrual syndrome was found to be much more common among the patients with MA (odds ratio (OR) 6.0; confidence interval (CI) 3.1–11.6). Menstrually triggered migraine was more frequently encountered among MO than among MA patients (MA 15.0%; MO 53.5%; OR 0.1; CI 0.1–0.3). In both forms of migraine, pregnancy had a favourable effect; however, a lower percentage of MA (43.6%) than MO patients (76.8%; OR 0.2; CI 0.1–0.5) showed improvement or remission. The use of oral contraceptives worsened migraine in MA more frequently than in MO patients (MA 56.4%; MO 25.3%; OR 3.8; CI 1.6–9.3). The course of MA seems to be influenced by female reproductive life events, but in a different way with respect to MO.

Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches

Nitroglycerin administration provokes spontaneous-like migraine attacks in migraine and cluster headache (CH) patients. Nitroglycerin-induced migraine-like headache has been used as an experimental model of migraine. In this paper, we evaluate the possibility of using the nitroglycerin provocative test (NPT) as a supportive measure in the diagnosis of primary neurovascular headaches by assessing its reliability on a large population and adopting strict criteria for rating the response as positive or negative. Our population consisted of 197 migraineurs, 42 subjects suffering from cluster headache and 53 healthy controls. In migraine without aura, the test sensitivity was 82.1%, specificity 96.2% and accuracy 85.5%, while in subjects suffering from migraine with aura, the reliability of the NPT was less satisfactory (sensitivity 13.6%, specificity 96.2% and accuracy 72%). In CH patients tested during the active phase of the disease the sensitivity was 80.6%, specificity 100% and accuracy 92.9%. NPT is an easy, low-cost and reliable method for supporting the diagnosis of migraine without aura and cluster headache.

Comparative Study with EMG, Pressure Algometry and Manual Palpation in Tension-Type Headache and Migraine

According to International Headache Society classification criteria, the presence of pericranial muscle disorder in tension-type headache should be evaluated using one of the following methods: EMG, pressure algometry or manual palpation. The purpose of this study was to compare the results of these three methods in 15 patients with episodic tension-type headache, 29 with chronic tension-type headache and 22 presenting migraine without aura compared to those obtained in healthy individuals. Algometric and EMG recordings at the frontalis muscle during mental arithmetic were more impaired in episodic and chronic tension headache patients than in controls and migraine patients. Chronic tension headache patients were significantly impaired at the trapezius muscle in all three tests compared to controls. Our data indicate that when two or three tests were carried out the diagnostic capacity was significantly improved in comparison to only one test. Moreover, since a different pattern could be seen with pain and without pain, the existence of headache at the time of testing should be taken into consideration.

The Effect of Intranasal Cocaine and Lidocaine on Nitroglycerin‐Induced Attacks in Cluster Headache

The administration of nitroderivatives in cluster headache (CH) sufferers is the most reproducible experimental paradigm to induce spontaneous‐like pain attacks. Previous uncontrolled studies have reported that the local use of anaesthetic agents in the area of the sphenopalatine fossa is able to extinguish nitroglycerin (NTG)‐induced pain in CH. The present study, carried out according to a double‐blind placebo‐controlled design, included 15 CH patients, six with episodic CH (mean ± sd age of 36.8 ± 5.6 years), and nine with chronic CH (37.8 ± 10.4 years). Patients had undergone a standard NTG test (0.9 mg sublingually), during which the intensity of pain was scored using a visuo‐analogic scale (VAS, range 0–10). Nine patients (two with the episodic form, seven with the chronic form) experienced a typical, spontaneous‐like attack on the usual side, occurring in all cases within 45 min. In these patients, the test was repeated with an interval of 2 days, and once pain intensity reached 5 on the VAS, a 10% solution of cocaine hydrochloride (1 ml, mean amount per application 40–50 mg), or 10% lidocaine (1 ml), or saline was applied using a cotton swab in the area corresponding to the sphenopalatine fossa, under anterior rhinoscopy. This was done in both the symptomatic and the non‐symptomatic side, for 5 min. Treatments were always performed randomly, in separate sessions. All patients responded promptly to both anaesthetic agents, with complete cessation of induced pain occurring after 31.3 ± 13.1 min for cocaine and 37.0 ± 7.8 min for lidocaine (M ± sd). In the case of saline application, pain severity increased thereafter, and extinction of the provoked attacks occurred with a latency of 59.3 ± 12.3 min (P < 0.01 and P < 0.01 vs. cocaine and lidocaine, respectively, Mann–Whitney U‐test). While further suggesting that the sphenopalatine ganglion participates in the mechanisms of pain, these findings indicate that the local administration of the anaesthetic agents cocaine and lidocaine is effective on NTG‐induced CH attacks, and may be used in the symptomatic treatment of this disorder.

Nitric Oxide Pathway and Response to Nitroglycerin in Cluster Headache Patients: Plasma Nitrite and Citrulline Levels:

Nitric oxide (NO) may participate in the mechanisms underlying vascular headaches, such as migraine and cluster headache (CH), by triggering neurogenic inflammation and activation of fibres conveying nociceptive inputs to the trigeminal ganglion. Similarly to migraine, the administration of the NO donor glyceryltrinitrate (GTN) to CH patients is a known model of inducing spontaneous-like attacks. We carried out a GTN test (0.9 mg, sublingually) in 18 patients with episodic CH in active phase and 12 controls. The plasma levels of NO metabolite nitrites (NO2 -), after conversion of nitrates to NO2 -, were measured spectrophotometrically at baseline, at the maximum intensity of the induced response (or 45 min after GTN in controls), and 120 min after GTN administration. The basal plasma levels of L-citrulline were also assayed in patients and controls using highperformance liquid chromatography. Basal NO2 - levels, similar in GTN-responsive patients and controls (48.3 ± 10.6 and 44.6 ± 9.5 μmol/l, respectively) were found to be increased significantly at pain peak in patients (76.1 ± 10.2 μmol/l) and after 45 min in controls (78.2 ± 9.6 μmol/l) (P < 0.01 vs. respective baseline values), but not after 120 min, without differences between groups. L-citrulline levels in basal conditions showed no differences between groups (patients 64.8 ± 11.7, controls 67.3 ± 10.8 μmol/l). These data do not support the presence of a basal hyperactivity of the L-arginine-NO pathway in CH patients. Increased NO production may be of importance in the mechanisms leading to CH attacks, but other factors are likely to render CH patients hyperresponsive to NO, and ultimately to cause the occurrence of pain and associated features.

Recent advances in migraine therapy

Abstract Migraine is a common and highly disabling neurological disorder associated with a high socioeconomic burden. Effective migraine management depends on adequate patient education: to avoid unrealistic expectations, the condition must be carefully explained to the patient soon as it is diagnosed. The range of available acute treatments has increased over time. At present, abortive migraine therapy can be classed as specific (ergot derivatives and triptans) or non-specific (analgesics and non-steroidal anti-inflammatory drugs). Even though acute symptomatic therapy can be optimised, migraine continues to be a chronic and potentially progressive condition. In addition to the drugs officially approved for migraine prevention by international governmental regulatory agencies, numerous different agents are commonly used for this indication, showing various levels of evidence of efficacy and tolerability. Guidelines published in recent years, based on evidence-based medicine data on migraine prophylaxis, are a useful source of guidance, especially for primary care physicians and neurologists without specific expertise in headache medicine. Although the field of pharmacological migraine prevention has seen few advances in recent years, potential novel approaches are now being developed. This review looks at emerging pharmacological strategies for acute and preventive migraine treatment that are nearing or have already entered the clinical trial phase. Specifically, it discusses preclinical and clinical data on compounds acting on calcitonin gene-related peptide or its receptor, the serotonin 5-HT1F receptor, nitric oxide synthase, and acid-sensing ion channel blockers.

Pain pressure threshold in cluster headache patients

Pain perception threshold (PFT) in the head was assessed with a pressure algometer in 58 cluster headache (CH) patients (52M, 6F; 41 episodic and 17 chronic). Fourteen patients in cluster period were retested in remission. Thresholds were assessed at 10 symmetrical points on each side of the head and at the deltoid. Compared with controls (n = 80), CH patients had lower PPT in the head and in the deltoid. PPT was lower on the symptomatic side than on the non-symptomatic side in patients with episodic CH during a cluster period (p<0.001) and in patients with chronic CH (p<0.05). This pattern was more evident during a cluster period than during remission (p<0.05). A reduced PPT did not correlate with illness duration and pain side. The lowest PPT mean values were found at the anterior and intermediate levels of the temporal muscle on the symptomatic side. These results imply a central mechanism underlying the pathogenesis of CH.

Alien hand syndrome in left posterior stroke

Alien hand syndrome is a rare neurological disorder characterized by involuntary and uncontrollable motor behaviour, usually of an arm or hand. The patient perceives the affected limb as alien, and may personify it. The case of a 61-year-old right-handed woman who developed right posterior AHS after ischaemic stroke in the left posterior cerebral artery territory is reported. Neuroimaging studies disclosed no frontal or parietal involvement, while a posterior thalamic lesion was detected. A possible role of the thalamus in the genesis of AHS is discussed.

Patients with headache and functional dyspepsia present meal–induced hypersensitivity of the stomach

Headache is a frequent feature of functional gastrointestinal disorders but there is no data on the responsible pathophysiological mechanism. The aim of this study was to verify whether alteration of post–prandial gastric tone or sensitivity might explain this association. Fourteen patients affected by functional dyspepsia (7 migraine without aura) and 7 healthy volunteers (HV) underwent gastric tone measurement in fasting condition and after the administration of a liquid meal by barostat. Gastric volume (GV) and accommodation were calculated as difference between mean post–prandial and mean fasting volume. Mean postprandial GV increase and fasting perception and discomfort threshold (DTh) were similar among the 3 groups. DTh after meal was lower in dyspeptic headache patients than in HV and dyspeptic without headache patients. Patients with migraine and functional dyspepsia may be characterised by meal-induced hypersensitivity of the stomach.

P035. Headache prevalence and disability among Italian adolescents aged 11-15 years: a population cross-sectional study

Methods Three hundred and seventy-six adolescents aged 11-15 years, living in the Pavia province (Italy), were recruited for this cross-sectional school-based study. They were assessed about their headache using a medical history questionnaire; headache diagnosis was made according to the new classification system of the International Headache Society (ICDH-3 Beta). Headache-related disability was assessed by means of PedMIDAS (Pediatric Migraine Disability Assessment Score).