Jorge Leston

A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study.

Introduction The management of medication-overuse headache (MOH) is often difficult and no specific guidelines are available as regards the most practical and effective approaches. In this study we defined and tested a consensus protocol for the management of MOH on a large population of patients distributed in different countries. Subjects and methods The protocol was based on evidence from the literature and on consolidated expertise of the members of the consensus group. The study was conducted according to a multicentric interventional design with the enrolment of 376 MOH subjects in four centres from Europe and two centres in Latin America. The majority of patients were treated according to an outpatient detoxification programme. The post-detoxification follow-up lasted six months. Results At the final evaluation, two-thirds of the subjects were no longer overusers and in 46.5% of subjects headache had reverted back to an episodic pattern of headache. When comparing the subjects who underwent out-patient detoxification vs those treated with in-patient detoxification, both regimens proved effective, although the drop-out rate was higher in the out-patient approach. Conclusions The present findings support the effectiveness and usability of the proposed consensus protocol in different countries with different health care modalities.

Disability, anxiety and depression associated with medication-overuse headache can be considerably reduced by detoxification and prophylactic treatment. Results from a multicentre, multinational study (COMOESTAS project).

Objective The objective of this article is to investigate whether headache-related disability, depression and anxiety can be reduced by detoxification and prophylactic treatment in patients with medication-overuse headache (MOH). Methods Patients with MOH were included from six centres in Europe and Latin America in a seven-month cohort study. Before and six months after treatment, the degree of disability was measured by the Migraine Disability Assessment (MIDAS) questionnaire, while anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS). Results A total of 694 patients with MOH were included, of whom 492 completed the study. Headache days were reduced by 58.4% from 23.6 to 9.8 days per month at six months (p < 0.001). The MIDAS score was reduced by 57.1% from baseline 59.9 to 25.7 (p < 0.001). Number of patients with depression was reduced by 50.7% from 195 to 96 and number of those with anxiety was reduced by 27.1% from 284 to 207 (both p < 0.001). Conclusions Disability, depression and anxiety were considerably reduced in patients with MOH by detoxification and prophylactic treatment. This emphasises the urgent need for increased awareness about avoiding overuse of headache medications and demonstrates that not only headache frequency but also disability are remarkably improved by adequate intervention.

Intracranial hypotension: the nonspecific nature of MRI findings.

We present three patients who complained of postural headache related to different types of intracranial hypotension: spontaneous or primary, and secondary, but presenting the same findings on brain magnetic resonance imaging. Diffuse pachymeningeal gadolinium enhancement supports the belief that the enhancement is a nonspecific meningeal reaction to low pressure.

SUNCT syndrome responding absolutely to steroids in two cases with different etiologies

SUNCT is a syndrome of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. We are presenting now two cases absolutely responders to steroid therapy, one of them a SUNCT-like secondary to a prolactinoma and the other primary.

SUNCT Syndrome: Clinical and 12-Year Follow-up Case Report

In 1978, Sjaastad et al. (1) described the SUNCT syndrome. The clinical features were: unilateral brief attacks of moderate to severe orbital or periorbital pain with conjunctival injection, tearing, sweating and rhinorrhoea, with a duration of 15–60 s and a frequency of up to 5–30 times per hour, occurring spontaneously or triggered by precipitating mechanisms within trigeminal or extratrigeminal topography, with symptomatic periods alternating with periods of remission in an erratic fashion (2). The new defined criteria for SUNCT according to the International Classification of Headache Disorders 2nd Edition (ICHD-II) are given in Table 1. We report a case of SUNCT syndrome, which was diagnosed in 1997. The aim of the present case report (several have already been published) is to show not only the variable clinical features but also the evolution of the clinical picture during a long-term longitudinal follow-up.

The added value of an electronic monitoring and alerting system in the management of medication-overuse headache: A controlled multicentre study

Background Medication-overuse headache (MOH) is a chronic disabling condition associated with a high rate of relapse. Methods We evaluated whether the adoption of electronic-assisted monitoring, advice and communication would improve the outcome over a follow-up of 6 months in a controlled, multicentre, multinational study conducted in six headache centres located in Europe and Latin America. A total of 663 MOH subjects were enrolled and divided into two groups: the Comoestas group was monitored with an electronic diary associated with an alert system and a facilitated communication option, and the Classic group with a paper headache diary. Results We observed a significantly higher percentage of overuse-free subjects in the Comoestas group compared with the Classic group: 73.1 vs 64.1% (odds ratio 1.45, 95% confidence interval 1.07–2.09, p = 0.046). The Comoestas group performed better also regarding the number of days/month with intake of acute drugs and the level of disability [Migraine Disability Assessment Score: Comoestas group – 42.5 ± 53.6 (35.5–49.3) and Classic group – 27.5 ± 56.1 (20.6–34.3) (p < 0.003)]. Conclusion The adoption of the electronic tool improved the outcome of patients suffering from MOH after withdrawal from overused drugs. Information and communication technology represents a valid aid for optimizing the management of chronic conditions at risk of worsening or of relapsing. Trial registration The trial was registered at ClinicalTrials.gov (no. NCT02435056).

Cluster headache attack due to sildenafil intake

Cluster headache (CH) is a distinct, clinical and epidemiological entity. Attacks are stereotypical. Episodes of severe unilateral headache are accompanied by symptoms of autonomic dysfunction. Both aetiology and pathophysiology of CH remain unknown (1). Some types of headache are considered neurovascular diseases. Selective inhibitors of phosphodiesterase (PDEi) have been included in the 2nd edition of the International Classification of Headaches (2) as headache triggers. PDE are enzymes involved in cAMP and cGMP degradation. When they are inhibited, nucleotide levels increase. This is the mechanism used by sildenafil, a highly selective inhibitor of intracellular cGMP degradation (3). Sildenafil and dipiridamol are the best studied PDE5i and both trigger headaches as a secondary effect (3, 4). We now report the first observation, to our knowledge, of isolated attacks of CH after sildenafil administration during the remission period in a patient with a personal history of this particular type of headache.

Opioid and Sympathetic Nervous System Activity in Cluster Headache Under Verapamil or Prednisone Treatment

SYNOPSIS

Changes in neutrophil met-enkephalin containing peptides in episodic cluster headache.

SYNOPSIS

Increase in plasma methionine‐enkephalin levels during the pain attack in episodic cluster headache

Since high levels of endogenous opioids (endorphins, enkephalins) were found in brain areas classically related to nociception, their peripheral levels in humans were studied in different pain syndromes yielding contradictory results. This study was undertaken to assess changes in plasma methionine-enkephalin (met-enkephalin) levels in patients with episodic cluster headache associated with the pain period. Twenty-nine patients, 24 in the cluster period (6 of them during an attack) and 3 in the remission period were studied. Two other patients were subjected to a longitudinal follow-up. Plasma met-enkephalin levels were determined by radioimmunoassay (RIA) with specific antibody. Plasma peptide concentration (pmol/ml) was higher (p < 0.001) in patients during the pain attack (3.97 ± 1.18) than in controls (0.25 ± 0.03). When measured 4 and 48 h after the pain attack lower levels were found (0.46 ± 0.06) which decreased to control values after 24 h. These results may suggest involvement of peripheral enkephalins in pain modulation in patients with episodic cluster headache.