Francesca Puledda

An update on migraine: current understanding and future directions

Migraine is a common brain disorder with high disability rates which involves a series of abnormal neuronal networks, interacting at different levels of the central and peripheral nervous system. An increase in the interest around migraine pathophysiology has allowed researchers to unravel certain neurophysiological mechanisms and neurotransmitter involvement culminating in the recent development of novel therapies, which might substantially change the clinical approach to migraine patients. The present review will highlight the current aspects of migraine pathophysiology, covering an understanding of the complex workings of the migraine state and the brain regions responsible for them. We will further discuss the therapeutic agents which have appeared in the most recent years for migraine care, from calcitonin gene-related peptide (CGRP) receptor antagonists, gepants; through serotonin 5-HT1F receptor agonists, ditans, and CGRP or CGRP receptor monoclonal antibodies to invasive and non-invasive neuromodulation techniques.

An Update on Non-Pharmacological Neuromodulation for the Acute and Preventive Treatment of Migraine

To review current neuromodulation treatments available for migraine therapy, both in the acute and preventive setting.

Current Approaches to Neuromodulation in Primary Headaches: Focus on Vagal Nerve and Sphenopalatine Ganglion Stimulation

Neuromodulation is a promising, novel approach for the treatment of primary headache disorders. Neuromodulation offers a new dimension in the treatment that is both easily reversible and tends to be very well tolerated. The autonomic nervous system is a logical target given the neurobiology of common primary headache disorders, such as migraine and the trigeminal autonomic cephalalgias (TACs). This article will review new encouraging results of studies from the most recent literature on neuromodulation as acute and preventive treatment in primary headache disorders, and cover some possible underlying mechanisms. We will especially focus on vagus nerve stimulation (VNS) and sphenopalatine ganglion (SPG) since they have targeted autonomic pathways that are cranial and can modulate relevant pathophysiological mechanisms. The initial data suggests these approaches will find an important role in headache disorder management going forward.

Serotonergic Correlation with Anger and Aggressive Behavior in Acute Stroke Patients: An Intensity Dependence of Auditory Evoked Potentials (IDAP) Study

Anger and aggressive behavior (AB) are two of the main post-stroke behavioral manifestations, which could imply both an anger trait (TA) or a state condition of anger (SA). Serotonergic system is thought to play an inhibitory control on aggressive impulse. Nevertheless, whether 5HT has the same role in TA and in SA, is still debated. Intensity dependence of auditory evoked potentials (IDAP) is thought to be inversely related to the central 5HT tone. The aim of this study was to evaluate, in acute stroke patients, the 5HT system involvement in AB by IDAP. Consecutive stroke patients were evaluated and compared with healthy controls. The Spielberger Trait Anger Scale (STAS) was used to assess AB, SA and TA. Patients with AB and TA showed a significantly increased IDAP value, whereas patients with SA had a significantly lower IDAP; this indicates an increased 5HT tone. In acute stroke patients with AB, there is a decreased central 5HT tone. Surprisingly, we found an opposite 5HT feature between patients with TA and those showing SA, suggesting that the hypothesis of aggression based on 5HT deficiency requires further investigations. This might open new strategies in the treatment of post-stroke AB.

Hemodynamic Features of Non-Aneurysmal Subarachnoid Hemorrhage in a Case of Familial Moyamoya Disease: A Transcranial Doppler Ultrasound Study

Willis circle with absence of the ACAs and of L-MCA and multiple tortuous vessels branching from the R-MCA (‘moyamoya vessels’). No aneurysms or vascular malformations were found ( fig. 1 ). Based on these findings, the patient was diagnosed with MMD. No neurological deficits were noted on the patient’s physical examination. Upon admission, we performed a Carotid Duplex ultrasound and a TCD, which showed an increase in mean blood flow velocity of R-MCA. This was initially attributed to vasospasm and nimodipine therapy was started. We also performed a progressive TCD follow-up; hemodynamic parameters of the first ultrasound examination as well as those from TCD follow-up are summarized in table 1 (we exclusively reported follow-up values from the R-MCA, which were the only ones that showed significant changes through time). The patient had a very favorable outcome and is currently asymptomatic. Particularly interesting is the monitoring of hemodynamic state of brain vessels done in our case. According to previous studies performed on asymptomatic MMD patients [6] , we found at T0 that both the ICAs showed normal flow velocity and low resistance, while the remaining intracranial vessels showed a consistent hemodynamic pattern in terms of high flow velocity and low resistance. This pattern re

Non-Pharmacological Approaches for Migraine

Migraine is one of the most common and debilitating neurological disorders. However, the efficacy of pharmacological therapies may have unsatisfactory efficacy and can be poorly tolerated. There is a strong need in clinical practice for alternative approaches for both acute and preventive treatment. Occasionally, this need might arise in the context of low-frequency migraneurs who are not keen to use medication or fear the potential side effects. At the opposite end of the spectrum, clinicians might be faced with patients who have proven refractory to numerous medications. These patients may benefit from invasive treatment strategies. In recent years, promising strategies for migraine therapy have emerged alongside a progressively better understanding of the complex pathophysiology underlying this disease. This review discusses the most recent and evidence-based advances in non-pharmacological therapeutic approaches for migraine, offering alternatives to drug treatment for both the commonly encountered episodic cases as well as the more complex migraine phenotypes, which are capable of challenging even the headache specialist.

Visual snow syndrome: what we know so far.

Purpose of review We provide an overview of the neurological condition known as visual snow syndrome. Patients affected by this chronic disorder suffer with a pan-field visual disturbance described as tiny flickering dots, which resemble the static noise of an untuned television. Recent findings The term ‘visual snow’ has only appeared in the medical literature very recently. The clinical features of the syndrome have now been reasonably described and the pathophysiology has begun to be explored. This review focuses on what is currently known about visual snow. Summary Recent evidence suggests visual snow is a complex neurological syndrome characterized by debilitating visual symptoms. It is becoming better understood as it is systematically studied. Perhaps the most important unmet need for the condition is a sufficient understanding of it to generate and test hypotheses about treatment.

The Role of Noninvasive Neuromodulation in Migraine Management

N euromodulation represents an exciting new approach that is being increasingly used as both acute and preventative treatment for migraine, providing a valid alternative option for patients for whom traditional drugs have failed, or for those who do not tolerate their side effects. This brief review aims at describing noninvasive neuromodulation techniques, which are currently the most used in clinical practice, specifically focusing on transcranial magnetic stimulation, vagus nerve stimulation and supraorbital nerve stimulation.