Fabio Antonaci

Migraine and psychiatric comorbidity: a review of clinical findings

Migraine is an extremely common disorder. The underlying mechanisms of this chronic illness interspersed with acute symptoms appear to be increasingly complex. An important aspect of migraine heterogeneity is comorbidity with other neurological diseases, cardiovascular disorders, and psychiatric illnesses. Depressive disorders are among the leading causes of disability worldwide according to WHO estimation. In this review, we have mainly considered the findings from general population studies and studies on clinical samples, in adults and children, focusing on the association between migraine and psychiatric disorders (axis I of the DSM), carried over after the first classification of IHS (1988). Though not easily comparable due to differences in methodology to reach diagnosis, general population studies generally indicate an increased risk of affective and anxiety disorders in patients with migraine, compared to non-migrainous subjects. There would also be a trend towards an association of migraine with bipolar disorder, but not with substance abuse/dependence. With respect to migraine subtypes, comorbidity mainly involves migraine with aura. Patients suffering from migraine, however, show a decreased risk of developing affective and anxiety disorders compared to patients with daily chronic headache. It would also appear that psychiatric disorders prevail in patients with chronic headache and substance use than in patients with simple migraine. The mechanisms underlying migraine psychiatric comorbidity are presently poorly understood, but this topic remains a priority for future research. Psychiatric comorbidity indeed affects migraine evolution, may lead to chronic substance use, and may change treatment strategies, eventually modifying the outcome of this important disorder.

PRESSURE ALGOMETRY IN HEALTHY SUBJECTS: INTER-EXAMINER VARIABILITY

The purpose of this study was to estimate inter-examiner reliability of head and neck algometry. Pain perception thresholds were assessed with a mechanical pressure algometer in 21 healthy individuals. Thresholds were assessed at 13 symmetrical points on each side of the head and neck, at the deltoid muscle and at the median finger. The pressure range of the instrument proved insufficient to study the pain perception threshold on the finger, however. Two different examiners carried out one or two examinations in each subject during one day. The sequence of investigations was varied randomly. The inter-examiner reliability was found to be good, with a mean intra-class correlation coefficient (ICC) of 0.75. Intra-examiner reproducibility was excellent (mean ICC = 0.84). The mean inter-examiner coefficient of variation was 18.7%, while the mean coefficient of repeatability (CR) was 1.60 kg/cm2. In comparison, the mean intra-examiner coefficient of variation was 15% while the mean CR was 1.29 kg/cm2. Statistically significant differences between examiners were found for the frontal point (p < 0.01), while a trend towards lower thresholds in one of the two observers was seen in 10 of the 13 non-significant points. Inter-examiner reliability of side differences was excellent, with CR = 1.23 kg/cm2. In conclusion, manual algometry with a rather inexpensive mechanical device has a good to excellent inter-rater reliability. When studying patients, however, the possible bias introduced by different examiners should be taken into account, both regarding study design and data analysis.

Chronic Paroxysmal Hemicrania (CPH): A Review of the Clinical Manifestations

SYNOPSIS

'Hemicrania continua': A clinical review

SYNOPSIS

Chronic paroxysmal hemicrania and hemicrania continua. Parenteral indomethacin : The 'indotest'

The interval between indomethacin administration and clinical response may be clinically relevant in the assessment of chronic paroxysmal hemicrania and hemicrania continua and other unilateral headache disorders with which they can be confounded. Eight patients with chronic paroxysmal hemicrania (6 women and 2 men) and 12 patients with hemicrania continua (8 women and 4 men) were entered into the study. The patients were given 50 mg of indomethacin intramuscularly (IM) on day 1 and some of them 100 mg IM on day 2 in an open fashion. The usual attack pattern was reestablished prior to the second test.

Cervicogenic headache: evaluation of the original diagnostic criteria.

A variety of headaches are frequently associated with the occurrence of neck pain. The purpose of this paper was to describe the adherence to diagnostic criteria of a series of patients enrolled on the basis of two clinical criteria: (1) unilateral headache without side-shift, and (2) pain starting in the neck and spreading to the fronto-ocular area. One hundred and thirty-two patients (36 male and 96 female) entered the study. Sixty-two patients were assigned to Group A (patients fulfilling criteria 1 and 2), 40 to Group B (criterion 2 only) and 12 to Group C (criterion 1, only). Eighteen subjects were excluded because X-rays of the neck were not available. Patients were evaluated regardless of whether or not they fell into one or more of the following diagnostic categories: cervicogenic headache (CEH), migraine without aura (M) and headache associated with disorders of the neck (HN) (IHS definitions). Fulfilment of the diagnostic criteria for CEH was found to be particularly frequent in Group A. A higher frequency of CEH diagnosis was found when two criteria were used (Group A) than in Group B (P = 0.001); in the former group a higher mean number of diagnostic criteria for CEH were also present (P = 0.001). Group A patients more frequently presented pain episodes of varying duration or fluctuating, continuous pain and moderate, non-excruciating, non-throbbing pain than Group B patients (P = 0.04 and P = 0.08, respectively). In Group C patients, the frequency of these two criteria was relatively low (17%) especially of the first mentioned variable. The presence of at least five of the seven ‘pooled’ CEH criteria (present in ≥ 50% of the patients) might be deemed a reliable cut-off point, allowing the headache to be diagnosed as ‘probable’ CEH. If patients fulfilling M or HN criteria in addition to the CEH criteria are added to the ‘pure’ CEH group a total of 74% of Group A patients may have a CEH picture. The temporal pattern of pain and the quality of pain in Group A showed good sensitivity and specificity (≥ 75) when compared with Group B; therefore, the chances of diagnosing a definite CEH are significantly more frequent in patients presenting with unilateral pain that also begins as a neck pain. Head/neck trauma and radiological abnormalities in the cervical spine were not significantly associated with CEH, M or HN diagnoses. An improvement of the current diagnostic IHS criteria might make it possible to avoid the existing, partial overlap of CEH with HN and M. Extensive use should be made of the GON, and other, blockades in the routine work-up of CEH, both in the differential diagnosis and in the mixed forms (CEH + M, and CEH + HN), in order to improve the efficiency of the current diagnostic system.

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.

CPH and Hemicrania Continua: Requirements of High Indomethacin Dosages ‐An Ominous Sign?

Two female patients, one with chronic paroxysmal hemi‐crania and one with hemicrania continua, had a continuously high requirement of indomethacin, ie, 3 225 mg per day, for 4 and 7 years, respectively. In the hemicrania continua patient, a right (symptomatic side) C7 root affection due to disc herniation was demonstrated. Removal of the disc relieved the arm pain completely, and reduced the head pain and indomethacin requirement considerably initially. The other patient suffered from the unremitting form of chronic paroxysmal hemicrania with right‐sided attacks from the age of 16. Indomethacin, 200 to 250 mg per day generally kept the headache at bay, but during exacerbations, especially during menstrual periods, the dosage transitorily had to be increased to 250 to 350 mg per day. ACT scan with contrast at aged 18 (1987) was negative. In 1992, she started having new symptoms, including numbness on the ipsilateral side of the face and arm and difficulty swallowing. An MR scan showed a meningioma originating in the roof of the cavernous sinus on the symptomatic side. The meningioma was surgically removed. The postoperative indomethacin requirement was reduced, but only transiently. Patients with chronic paroxysmal hemicrania (CPH) and hemicrania continua (HC) with a continuously high indomethacin requirement may have grave additional disorders and should consequently be followed closely.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.