Gian Camillo Manzoni

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.

Double blind comparison of lithium and verapamil in cluster headache prophylaxis

SYNOPSIS

Epidemiology of typical and atypical craniofacial neuralgias

Trigeminal neuralgia (TN) has a prevalence of 0.1–0.2 per thousand and an incidence ranging from about 4–5/100 000/year up to 20/100 000/year after age 60. The female-to-male ratio is about 3:2. A review of several case series shows that pain is more predominant on the right side, but the difference is not statistically significant. TN is significantly associated with arterial hypertension, Charcot-Marie-Tooth neuropathy, glossopharyngeal neuralgia (GN) and multiple sclerosis. GN has an incidence of 0.7/100 000/year and epidemiological studies have shown it to be less severe than previously thought. Post-herpetic neuralgia has a comparable incidence to idiopathic TN. The epidemiology of the central causes of facial pain is still unclear, but it is known that persistent idiopathic facial pain is a widespread, not easily manageable problem.

Cluster Headache Course Over Ten Years in 189 Patients

One-hundred-and-eighty-nine cluster headache patients, referred to Parma and Pavia Headache Centres between 1976 and 1986 with a disease duration of over 10 years, were interviewed about the course of cluster headache. They were classified as episodic (n = 140) or chronic (n = 49) cluster headache patients on the basis of course during the year of onset. Episodic patients showed the following outcome: maintenance of an episodic form (primary episodic form) in 80.7% of cases, shift towards a chronic form (secondary chronic form) in 12.9% and shift towards an intermediate pattern (“combined” form) in 6.4%. In chronic patients, cluster headache was still chronic (primary chronic form) at the moment of observation in 52.4% of cases, while it turned into an episodic form (“secondary” episodic form) in 32.6% and into a “combined” form in 14.3%. Nineteen patients (10%) had had no attacks for at least three years at the moment of examination. We can conclude from our data that: cluster headache is a disease of long duration, perhaps lifelong; episodic cluster headache tends to worsen; chronic cluster headache may easily turn into a better prognostic episodic form; prophylactic drugs are unable to induce recovery. The following factors seem related to a poor outcome: a later onset, the male gender and a disease duration of over 20 years for the episodic forms.

Classification of chronic daily headache by International Headache Society criteria : limits and new proposals

We conducted a retrospective study of 150 patients with chronic daily headache (CDH) to determine how to categorize their headache according to the classification of the International Headache Society (IHS). All patients were first evaluated at Parma and Pavia Headache Centres (from January 1992 to March 1993) and had had headache for at least 15 days a month during the previous 6 months. Four patients were thereafter excluded due to poor reliability. The 146 patients who met our CDH criteria (92 with and 54 without clear-cut migraine attacks) could be classified into four groups: (i) chronic tension-type headache (CTTH)-27 patients; (ii) coexisting migraine plus CTTH-65 patients; (iii) unclassifiable daily headache-27 patients; and (iv) migraine and an unclassifiable interval headache-27 patients. Seventy-two percent of patients with CDH had migraine as the initial form of their headache. We therefore propose to revise the IHS classification for migraine, taking into account its evolution, and add two subcategories, migraine with interparoxysmal headache and chronic migraine.

Gender ratio of cluster headache over the years: a possible role of changes in lifestyle

Changes in the male-to-female (M/F) ratio of cluster headache (CH) over the years were investigated through a comparative analysis of the distribution of the disease by sex and decade of onset in 482 patients (374M and 108F). Variations over the last few decades were also investigated in the employment rate, level of school education, smoking habit, and coffee and alcohol intake of the population living in the same area as the CH patients. The M/F ratio has fallen from 6.2:1 for patients with CH onset before 1960, to 5.6:1, 4.3:1, 3.0:1, and 2.1:1 for patients with CH onset in the 1960s, 1970s, 1980s, and 1990s, respectively. Correspondingly, in those same decades, the M/F ratio has fallen from 2.6:1 to 2.4:1, 2.2:1, 2.0:1, and 1.7:1, respectively, for the employment rate, and from 8.6:1 to 7.8:1,3.3:1,2.5:1, and 1.9:1 for the smoking habit. Such a close correlation suggests that the significant changes that have occurred over the last few decades in the lifestyle of both sexes—and particularly that of women—may have played a major role in altering the gender ratio of CH.

Cluster headache prevalence in the Italian general population.

Background: Prevalence of cluster headache (CH) is estimated at 56 to 69 per 100,000. Objective: To calculate the CH lifetime prevalence in a sample representative of the Italian general population over age 14 years. Methods: Possible CH cases according to the diagnostic criteria of the 1988 International Headache Society classification were screened from a sample of 10,071 patients (5,311 women and 4,760 men; mean age 50.4 years, SD 19.7 years) registered in the lists of seven Parma-based general practitioners (GPs), using a previously validated, specially designed, self-administered questionnaire. Results: Seven thousand five hundred twenty-two subjects (74.7%; 3,971 women and 3,551 men; mean age 50.8 years, SD 19.0 years) responded to the questionnaire in their GP’s office (n = 3,338; 1,885 women and 1,453 men) or at home by mail (n = 1,914; 1,030 women and 884 men) or by phone (n = 2,270; 1,056 women and 1,214 men). Of the 111 suspected cases (76 women and 35 men), 105 were seen by a neurologist and 6 were contacted on the phone. The diagnosis of CH was confirmed in 21 (9 women and 12 men), including 7 already followed at the authors’ center for CH. Seventeen patients had episodic CH, and four (all men) had chronic CH. The estimated prevalence rate was 279 per 100,000 (95% CI 173 to 427), 227 per 100,000 (95% CI 104 to 431) in women, and 338 per 100,000 (95% CI 175 to 592) in men. Conclusion: These results point to a higher cluster headache lifetime prevalence than previous reports.

Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks.

Acetylsalicylic acid (ASA) in combination with metoclopramide has been frequently used in clinical trials in the acute treatment of migraine attacks. Recently the efficacy of a new high buffered formulation of 1000 mg effervescent ASA without metoclopramide compared to placebo has been shown. To further confirm the efficacy of this new formulation in comparison with a triptan and a nonsteroidal anti-inflammatory drug (ibuprofen) a three-fold crossover, double-blind, randomized trial with 312 patients was conducted in Germany, Italy and Spain. Effervescent ASA (1000 mg) was compared to encapsulated sumatriptan (50 mg), ibuprofen (400 mg) and placebo. The percentage of patients with reduction in headache severity from moderate or severe to mild or no pain (primary endpoint) was 52.5% for ASA, 60.2% for ibuprofen, 55.8% for sumatriptan and 30.6% for placebo. All active treatments were superior to placebo (P < 0.0001), whereas active treatments were not statistically different. The number of patients who were pain-free at 2 h was 27.1%, 33.2%, 37.1% and 12.6% for those treated with ASA, ibuprofen, sumatriptan or placebo, respectively. The difference between ASA and sumatriptan was statistically significant (P = 0.025). With respect to other secondary efficacy criteria and accompanying symptoms no statistically significant differences between ASA and ibuprofen or sumatriptan were found. Drug-related adverse events were reported in 4.1%, 5.7%, 6.6% and 4.5% of patients treated with ASA, ibuprofen sumatriptan or placebo. This study showed that 1000 mg effervescent ASA is as effective as 50 mg sumatriptan and 400 mg ibuprofen in the treatment of migraine attacks regarding headache relief from moderate/severe to mild/no pain at 2 h. Regarding pain-free at 2 h sumatriptan was most effective.

Epidemiology of headache

Epidemiological studies conducted in the general population point to average headache prevalence rates of 46% for 1-year prevalence and of 64% for lifetime prevalence. For migraine, most studies conducted in the adult general population of western Europe and North America indicate rates between 5% and 9% in men, and between 12% and 25% in women. Non-western countries report lower figures. Migraine shows no gender differences in children, while in the elderly its frequency appears much reduced in both genders. About one-third of migraineurs suffer from migraine with aura. For tension-type headache, prevalence data reports in the literature are few and conflicting: rates range from 11% in Singapore to 20-40% in the USA and over 80% in Denmark. It is worth noting that the highest figures are found in studies where a personal interview has been employed. This probably indicates that the prevalence of this headache subtype is particularly sensitive to the method of data collection. Cluster headache occurs in 1-3 per thousand of the general population, with a gender (M:F) ratio of about 3:1. About 4% of the adult general population suffers from chronic daily headache.

Accompanying symptoms of cluster attacks : their relevance to the diagnostic criteria

Two-hundred-and-fifty-one consecutive cluster headache (CH) patients referred to the Pavia and Parma Headache Centers were evaluated in order to verify the presence and recurrence of one or more autonomic symptoms. Data obtained show that in 2.8% of patients cluster attacks were not accompanied by localized autonomic symptoms, thus confirming the report of Ekbom. We observed a high prevalence of photophobia, nausea and vomiting. The IHS diagnostic criteria for CH may need to be modified. The high frequency of “general” autonomic symptoms seems to suggest a component of “central” drive in the physiopathology of cluster headache.