Massimo Alessandri

Increase in plasma calcitonin gene-related peptide from the extracerebral circulation during nitroglycerin-induced cluster headache attack.

&NA; In this study, changes in plasma levels of calcitonin gene‐related peptide (CGRP) and substance P (SP) during a spontaneous‐like cluster headache attack provoked by nitroglycerin were evaluated. Peptide variations after spontaneous or sumatriptan‐induced remission were also assessed. Blood was collected from the external jugular vein homolateral to the pain side of 30 male cluster headache patients; 18 men were in an active and 12 in a remission one. Plasma levels of CGRP and SP were determined using sensitive radioimmunoassays for each peptide. CGRP‐like immunoreactivity (CGRP‐LI) was found to be augmented in patients in an active period and became elevated further at the peak of the provoked attack. A complete reversal occurred both after spontaneous and sumatriptan‐induced remission. On the contrary, nitroglycerin neither provoked a cluster headache attack nor altered CGRP‐LI in the patients in a remission period. The augmented levels of CGRP‐LI measured before and after nitroglycerin administration, when the provoked attack reached the maximum intensity, suggest an activation of the trigeminovascular system during the active period of cluster headache. Moreover, the clinical and biochemical actions showed by sumatriptan stress the involvement of serotonin in cluster headache mechanisms.

The contribution of capsaicin-sensitive sensory nerves to xylene-induced visceral pain in conscious, freely moving rats

Summary1.Intravesical instillation of xylene (10–100%, dissolved in silicone oil) through a catheter implanted into the bladder of conscious, freely-moving rats produced behavioural effects (licking of lower abdomen or perineal region) suggestive of intense visceral pain, not mimicked by topical application of the irritant on the urethral outlet.2.The xylene-induced visceral pain was prevented, to the same extent, by systemic desensitization to capsaicin (50 mg/kg s.c.) performed in either adult or newborn rats, as well as by extrinsic bladder denervation (pelvic ganglionectomy), thus indicating the involvement of primary afferents in the bladder wall.3.Other behavioural responses induced by xylene instillation into the bladder (hind limb hyperextension, grooming) were not affected by systemic capsaicin desensitization in either adult or newborn rats, but were abolished by bladder denervation.4.Systemic capsaicin desensitization produced an almost complete depletion of substance P-, neurokinin A-like and calcitonin gene-related peptide-like immunoreactivity in the rat urinary bladder.5.These findings indicate that, in addition to their role in activating reflex micturition, the neuropeptides-containing capsaicin-sensitive sensory nerves of the rat bladder are involved in chemogenic visceral pain.

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

Analgesic effect of capsaicin in idiopathic trigeminal neuralgia.

Twelve informed and consenting patients were studied to determine the influence of capsaicin, the pungent component of the red pepper, on trigeminal neuralgia. All of these patients had idiopathic trigeminal neuralgia. These patients were followed up for 1 yr after the topical application over the painful area of 1.0 g of capsaicin three times a day for several days. Six patients had complete and four patients had partial relief of pain; the remaining two patients had no relief of pain. Of the 10 patients who were responsive to therapy, four had relapses of pain in 95-149 days. There were no relapses following the second therapy for the remainder of the year. We conclude that the topical application of capsaicin is frequently successful in relieving the pain from trigeminal neuralgia.

Substance P Theory: A Unique Focus on the Painful and Painless Phenomena of Cluster Headache

SYNOPSIS

Capsaicin-sensitive tachykinin-like immunoreactivity in the thymus of rats and guinea-pigs

Capsaicin-sensitive, substance P-like immunoreactivity (SP-LI) has been detected recently in rat thymus. Other tachykinins are frequently present with SP. In the present study, tachykinin-like immunoreactivity (TK-LI) was measured in guinea-pig, rat, mouse and hamster thymus with the amount detectable being greatest in guinea-pig, less in rat and least in mouse; it was not detectable in hamsters. In guinea-pig and rat thymus, but not in mouse, TK-LI was markedly reduced by pretreatment with capsaicin. TK-LI levels correlated significantly with those of SP-LI in both guinea-pig and rat thymus. High-performance liquid chromatography (HPLC) fractions considered to represent neurokinin A, eledoisin and neuropeptide K were present in guinea-pig thymus but only the first two were present in rat thymus.

Plasma changes of calcitonin gene‐related peptide and substance P in patients with dialysis headache

Little is known of mechanism of dialysis headache (DH). As suggested for migraine, a role for neuropeptides has been investigated. Twenty-four patients under haemodialysis were studied. Twelve of them suffered from DH. The remaining patients were headache free. Blood samples for radioimmunoassay of calcitonin gene-related peptide (CGRP) and substance P (SP) were collected from the arteriovenous fistula before and after dialysis treatment. Basal plasma concentrations of CGRP were found to be higher in headache patients. Dialysis significantly decreased CGRP concentrations in both groups. No difference in basal plasma concentrations of SP was observed between groups. At the end of the treatment plasma SP concentrations were reduced in headache-free patients but increased in headache patients. Elevated plasma concentrations of CGRP in patients with DH could represent a biochemical factor contributing to susceptibility to headache. Because of the disputable role of SP in migraine, the significance of the increase of the peptide in plasma during DH remains to be elucidated.

Hypertonic media produce Ca2+-dependent release of calcitonin gene-related peptide from capsaicin-sensitive nerve fibres in the rat urinary bladder

Superfusion of slices of the rat urinary bladder with hypertonic NaCl produced a remarkable and concentration-dependent (150-280 mM) increase in the outflow of calcitonin gene-related peptide-like immunoreactivity (CGRP-LI). This effect was completely abolished by pre-exposure of the tissue to capsaicin (10 microM for 20 min) or by superfusion with a Ca(2+)-free medium. Capsaicin (10 microM) was still able to release a consistent amount of CGRP-LI from tissue pre-exposed (20 min) to 280 mM NaCl. Similarly, hypertonic sucrose (160 mM added to the physiological salt solution) induced a consistent release of CGRP-LI that was abolished by capsaicin-pretreatment or in a Ca(2+)-free medium. The experiments demonstrate that hypertonic solutions activate the efferent function of capsaicin-sensitive neurons and suggest that this event may have some relevance in pathophysiological conditions of the lower urinary tract in which hypertonic urine may diffuse to submucosal layers.

Unilateral impairment of pupillary response to trigeminal nerve stimulation in cluster headache

&NA; The pupillary constriction induced ipsilaterally by transcutaneous electrical nerve stimulation (TENS) of the infratrochlear nerve was measured, using an electronic pupillometer, in 26 episodic cluster headache (CH) and 15 migraine sufferers tested during an attack‐free period and in 16 healthy controls. In controls, TENS gave rise to a miosis which was slow in onset and long‐lasting in duration, and which was comparable to that mediated by tachykinins in animals. A similar miotic response was bilaterally observed in migraine patients and in CH patients examined during the inactive phase. In CH sufferers during the cluster period, TENS only elicited a normal pupillary constriction in the asymptomatic eye, whereas the resulting response in the symptomatic eye was markedly decreased. Although the exact mechanism underlying the dysfunction remains to be clarified, these results seem to indicate that ocular trigeminal pathways are involved in CH.

The pressor hyperresponsiveness to phenylephrine unmasks sympathetic hypofunction in migraine

The pressor responsiveness to phenylephrine, an almost pure agonist of peripheral alpha-1-adrenoceptors, was studied in 32 migraine patients in headache-free intervals. Eighteen healthy volunteers served as a control group. Fourteen patients and 14 controls also underwent the tilt test. The following observations were made: (1) the pressor response to phenylephrine was significantly greater and longer lasting in patients than in controls; (2) the reflex decrease of heart rate did not differ in the two groups; (3) a normal orthostatic increase of blood pressure and heart rate occurred in migraineurs with hyperresponsiveness to phenylephrine. These findings suggest a supersensitivity of vascular adrenoceptors which is compatible with a chronic adrenergic deficiency in migraineurs. Since patients did not show an orthostatic hypotension in attack-free periods, the compensatory character of receptoral supersensitivity and the possible mechanisms of cardiovascular dysautonomia, which may occur during migraineous attack, were discussed.