G. Bruti

Aminergic tone correlates of migraine and tension-type headache : A study using the Tridimensional Personality Questionnaire

Background.—Aminergic neurotransmitter activity has been studied in many neuropsychiatric diseases by means of a self‐administered questionnaire proposed by Cloninger. Given that central aminergic modulation plays a major role in the pathophysiology of primary headaches, we investigated the personality dimensions related to aminergic neurotransmitter activity in patients with migraine and tension‐type headache.

Cerebral effects of hyperbaric oxygen breathing: a CBF SPECT study on professional divers.

We investigated the effects on cerebral blood flow (CBF) of pure oxygen breathing exposure during dives in a group of professional divers, in both the normobaric (NBO) and the hyperbaric oxygen (HBO) breathing conditions. Using single photon emission computerized tomography (SPECT) and Tc‐99m hexamethylpropylenamine oxime (HM‐PAO), we studied 10 young divers and six normal volunteers. Divers were studied by SPECT in the NBO and HBO conditions, in two different sessions. The HBO state was obtained in a hyperbaric chamber at 2.8 ATA for 15 min. By ANOVA, we did not observe any significant difference in CBF distribution between controls and divers in both NBO and HBO conditions. By individual analysis, divers showed a decreased CBF in a total of 33 regions of interest (ROIs) during NBO and 46 ROIs during HBO with respect to control values. In particular, two divers showed a remarkable increase in the number of hypoperfused ROIs during HBO (+7 and +5 ROIs, respectively). Pure oxygen breathing exposure in young divers is associated with a patchy distribution of brain areas of hypoperfusion. This phenomenon is more pronounced in the HBO state than in the NBO state. Further studies on CBF are needed to help identify divers potentially prone to harmful oxygen effects.

Primary headache in Emergency Department: prevalence, clinical features and therapeutical approach

Headache is one of the most common reported complaints in the general adult population and it accounts for between 1% and 3% of admissions to an Emergency Department (ED). The overwhelming majority of patients who present to an ED with acute primary headache (PH) have migraine and very few of them receive a specific diagnosis and then an appropriate treatment. This is due, in part, to a low likelihood of emergency physicians diagnosing the type of PH, in turn due to lack of knowledge of the IHS criteria, and also the clinical condition of the patients (pain, border type of headache, etc.) In agreement with the literature, another interesting aspect of data emerging from our experience is that few of the ED PH patients are referred to headache clinics for diagnosis and treatment, especially if they present with high levels of disability. This attitude promotes the high–cost phenomenon of repeater patients that have already been admitted to the ED for the same reason in the past. This is statistically important because it involves about 10% of the population with PH.

ID migraine questionnaire in temporomandibular disorders with craniofacial pain: a study by using a multidisciplinary approach

To evaluate the prevalence of migraine and related disability and the role of ID migraine questionnaire as a screening tool in patients with temporomandibular disorders (TMDs) and craniofacial pain (CFP). TMDs patients with CFP underwent stomatognathic (RDC/TMD criteria) and neurological visits (IHS criteria, 2004). ID migraine questionnaire and MIgraine Disability Assessment Scale (MIDAS) were also administered. Out of 45 patients, 69% met diagnosis of migraine plus chronic tension-type headache (CTTH); 9% presented CTTH and 20% were migraineurs. Out of 39 migraineurs who completed MIDAS, 56% presented the highest disability grade. Out of 37 patients who completed ID migraine questionnaire, 32 resulted affected by probable migraine with a diagnostic sensibility and specificity of 94% and 100%, respectively. Our findings showed a clinical association between TMDs and migraine. We support a clinical role of ID migraine and MIDAS in TMDs patients with CFP and we underline the importance of a multidisciplinary evaluation in this group of migraineurs.

The "repeater" phenomenon in migraine patients: a clinical and psychometric study.

(Headache 2010;50:348‐356)

Migraine in the Emergency Department: a psychometric study of a migraine "repeaters" sample.

To evaluate the influence of psychometric variables on the “repeater” phenomenon in an emergency department, 15 “repeaters” and 27 outpatient migraineurs were recruited. All patients were submitted to the Beck Depression Inventory (BDI), State and Trait Anxiety Inventory, Toronto Alexithymia Scale–20 (TAS–20), Tridimensional Personality Questionnaire and Migraine DIsability Assessment Scale (MIDAS). The “repeater” group showed higher MIDAS total scores (p=0.02) and higher scores in TAS–20 (p=0.02) than the outpatients. A higher frequency of alexithymic trait (p=0.02) and higher BDI scores (p=0.07) have also been observed in the “repeater” group than the outpatients. Alexithymia and depressive mood associated with high disability may be a specific psychosocial pattern of “repeater” migraineurs. The psychometric evaluation of this population may be important to explain the “repeaters” phenomenon.

Occipital neuroma triggered cluster headache responding to greater occipital nerve blockade

Dr. Fabrizio Di Stani – Dipartimento di Scienze Neurologiche / Università di Roma “La Sapienza” Roma, Italy. E-mail: fabrizio.distani@uniroma1.it Cluster headache (CH) is characterised by attacks of severe unilateral pain in the orbital, supraorbital and/or temporal areas that last from 15 to 180 min, with recurrence up to 8 times daily and accompanied by ipsilateral autonomic symptoms. Although effective acute treatments are available for CH attacks (e.g. subcutaneous sumatriptan injections), most patients also require preventive therapy. Several drugs, such as verapamil, methysergide and lithium carbonate, have proved to effectively prevent CH attacks and shorten bouts. Oral steroids are considered to provide the most effective transitional preventive treatment, though they may provide limited relief in some cases; moreover, some patients become steroid-dependent and develop serious steroid-related adverse effects within months. CH is marked by its circadian rhythmicity. Episodic cluster periods start at the same time each year, occur at the same time each day and the duration of each CH is almost the same for every attack. These clinical features, along with the hormonal alterations documented in CH patients, suggest that the hypothalamus plays a role in the genesis of CH. PET studies by May et al., revealed hypothalamic activation during CH attacks, supporting the hypothesis of hypothalamic involvement. The concept of the hypothalamus acting as a CH generator has also been entertained. However, not all CH patients present the same symptoms, nor do all respond to the same medications, which suggests that atypical or even non-hypothalamic forms of CH may exist. Although the cervico-occipital onset of CH is not contemplated by the International Headache Diagnostic Criteria II-version (IHDC II), it is not uncommon to find patients with this painful symptomatology in clinical practice. Anatomical and clinical data suggest that the greater occipital nerve (GON) may trigger pain that has the typical cluster characteristics and is associated with the autonomic symptoms noted in CH. Sensory neurons in the trigeminocervical complex receive ipsilateral and contralateral input from the GON. We describe an atypical cluster headache with trigeminal symptoms that improve after the blocked of the greater occipital nerve in one patient with occipital neuroma.

Topiramate Versus Migraine: Which Is the Cause of Glaucomatous Visual Field Defects?

We recently reported there to be a significantly higher occurrence of subclinical optic disc changes and visual field defects in migraineurs compared with patients with tension-type headache. 10 As reported also by McColl and Wilkinson, 11 these findings are consistent with abnormalities in the magnocellular visual pathway and are similar to those described in glaucomatous patients via perimetry using frequency-doubling technology. This technique provides a rapid screening for visual field defects in the earliest stages of glaucoma. 12 In particular, we found that the incidence of glaucomatous-like visual field defects was significantly higher in patients with migraine experiencing a high frequency of attacks, the very patients for whom prophylactic treatment typically is indicated. Thus, we are dealing with a two-headed problem: on the one hand, migraineurs with a high frequency of attacks may be more likely to spontaneously develop glaucoma or glaucoma-like visual field defects; conversely, the patients with migraine who are at a higher risk of developing glaucoma are those who may benefit most from prophylactic treatment . . . treatment that itself may promote glaucoma. The relationship between the drugs used for migraine prophylaxis and glaucomatous-like visual field defects remains unclear. Until we know more, clinical trials involving drugs potentially harmful to the eye should include monitoring of visual function.

Combination of pharmacotherapy and lidocaine analgesic block of the peripheral trigeminal branches for trigeminal neuralgia: a pilot study.

Classical trigeminal neuralgia (CTN) is treated predominantly by pharmacotherapy but side effects and unsuccessful occurs. The current study was carried out to evaluate the therapeutic effect of combination of pharmacotherapy and lidocaine block. Thirteen patients with CTN managed with pharmacotherapy were recruited and assigned either to no additional treatment (Group I) or to additional analgesic block (Group II). The primary endpoint was the reduction in the frequency of pain episodes in a month assessed at 30 and 90 days. Comparisons of measurements of pain, general health and depression scales were secondary endpoints. The results from the follow-up visits at 30 and 90 days showed the Group II to have larger reduction in the frequency of pain and exhibited a bigger improvement in the scores of the pain, general health and depression scales. The results from this preliminary study suggest a clinical benefit of the combination of pharmacotherapy and lidocaine block.

Atypical primary headache responding to finger pressure: possible involvement of the vagus nerve?

We describe a case of atypical primary headache strongly responsive to prolonged pressure in the anterior aspect of the neck. We hypothesize that, at least in this case, the trigemino-cervical system and its connections with the vagus nerve are involved.