Maurice Borges Vincent

Migraine aura and related phenomena: beyond scotomata and scintillations.

Migraine affects the cortical physiology and may induce dysfunction both ictally and interictally Although visual symptoms predominate during aura, other contiguous cortical areas related to less impressive symptoms are also impaired in migraine. Answers from 72.2% migraine with aura and 48.6% of migraine without aura patients on human faces and objects recognition, colour perception, proper names recalling and memory in general showed dysfunctions suggestive of prosopagnosia, dyschromatopsia, ideational apraxia, alien hand syndrome, proper name anomia or aphasia, varying in duration and severity. Symptoms frequently occurred in a successively building-up pattern fitting with the geographical distribution of the various cortical functions. When specifically inquired, migraineurs reveal less evident symptoms that are not usually considered during routine examination. Spreading depression most likely underlies the aura symptoms progression. Interictal involvement indicates that MWA and MWoA are not completely silent outside attacks, and that both subforms of migraine may share common mechanisms.

The hemicrania continua diagnosis.

More than 16 years after the first description of hemicrania continua (HC), its aetiology and pathogenesis remain obscure. Clinically, HC is considered a syndrome with two pivotal characteristics: (i) strictly unilateral (moderate, fluctuating, relatively long-lasting) headache; and (ii) absolute response to indomethacin. HC is further characterized by some ancillary, but mostly ‘negative’, features such as: (iii) relative paucity of accompaniments; and (iv) lack of precipitating factors. The female preponderance is also remarkable, although not diagnostic in the solitary case. Finally, a non-specific, but remarkable feature is the temporal pattern. HC may present as a remitting or chronic (continuous) headache. In HC, unilaterality and absolute response to indomethacin are considered crucial diagnostically. Existing controversy, such as regarding atypical features, particularly the so-called ‘HC resistant to indomethacin’, is discussed. The nature of hemicrania with negative indomethacin response remains most unclear; it may not belong to the HC cycle at all. Accordingly, we propose that the typical clinical picture of HC, including an absolute response to indomethacin, be termed Hemicrania continua vera. More or less analogous, but indomethacin-resistant, clinical pictures can provisionally be termed Hemicrania generis incerti (of undetermined nature), provided other diagnostic possibilities have been ruled out. The differential diagnosis of HC vs. other unilateral headaches is commented on. Previous attempts at classification of HC into the group chronic daily headache (CDH) are discussed. The only acceptable ‘link’ of HC with the other headaches classified as CDH is the temporal pattern (which is a non-specific feature). HC is probably pathophysiologically different from the others disorders classified under CDH. Conversely, HC and chronic paroxysmal hemicrania share many common features, including the absolute response to indomethacin. HC should probably be included in the IHS group 3.

Enhanced interictal responsiveness of the migraineous visual cortex to incongruent bar stimulation: a functional MRI visual activation study.

Since visual aura is usually described as expanding zigzag lines, neurones involved with the perception of line orientation may initiate this phenomenon. A visual incongruent line stimulation protocol was developed to obtain functional magnetic resonance images (fMRI) interictally in 5 female migraine patients with typical fortification spectra and in 5 normal matched controls. Activation in the visual cortex was present contralateral to the side of stimulation in 4 of 5 patients, notably in the extrastriate visual cortex. In 4 of 5 controls activation was observed in the medial and anterior orbitofrontal cortex. In one of them additional activation at the right nucleus accumbens/ventral striatum and right ventral pallidum was present. In the remaining control subject activation was present in the left primary visual cortex. The enhanced interictal reactivity of the visual cortex in migraineurs supports the hypothesis of abnormal cortical excitability as an important pathophysiological mechanism in migraine aura, though the role of specific regions of the visual cortex remains to be explored.

Cervicogenic Headache: A Comparison with Migraine and Tension-Type Headache

Cervicogenic headache (CEH) is a neck-generated headache syndrome. Attacks may be similar to migraine (M) or tension-type headache (TTH). In order to test the accuracy of the IHS diagnostic criteria for M and episodic TTH and of the criteria for CEH of Sjaastad et al., 33 CEH, 65 M, and 29 TTH were evaluated according to the CEH criteria, and CEH patients were tested for M and TTH according to the IHS criteria. Only 30% of the CEH patients met the criteria for M, 3% met the criteria for TTH, and 66% were neither M nor TTH. The mean number of criteria met, sex, age, and age of onset were also analysed, and the results indicate an inequality among these three headache types. The most important differentiating aspects were the site and radiation of the pain, the temporal pattern, and the induction of attacks from neck posture, movements, and/or digital pressure. CEH clearly differs from M and TTH. Existing criteria adequately distinguish the three headaches.

The Cerebellum and Migraine

Clinical and pathophysiological evidences connect migraine and the cerebellum. Literature on documented cerebellar abnormalities in migraine, however, is relatively sparse. Cerebellar involvement may be observed in 4 types of migraines: in the widespread migraine with aura (MWA) and migraine without aura (MWoA) forms; in particular subtypes of migraine such as basilar‐type migraine (BTM); and in the genetically driven autosomal dominant familial hemiplegic migraine (FHM) forms. Cerebellar dysfunction in migraineurs varies largely in severity, and may be subclinical. Purkinje cells express calcium channels that are related to the pathophysiology of both inherited forms of migraine and primary ataxias, mostly spinal cerebellar ataxia type 6 (SCA‐6) and episodic ataxia type 2 (EA‐2). Genetically driven ion channels dysfunction leads to hyperexcitability in the brain and cerebellum, possibly facilitating spreading depression waves in both locations. This review focuses on the cerebellar involvement in migraine, the relevant ataxias and their association with this primary headache, and discusses some of the pathophysiological processes putatively underlying these diseases.

Supraorbital neuralgia. On the clinical manifestations and a possible therapeutic approach

The clinical manifestations of supraorbital neuralgia are apparently only incompletely known. The lack of awareness of this head pain may possibly be due to its rarity and problems with making the diagnosis. In the present work, the long‐term result of minor, decompressive surgery of the supraorbital nerve in five patients is reported. The immediate improvement was good and, after a mean observation time of more than 6 years, an improvement of 50% to 100% was observed (mean, circa 85%). In the two patients with the longest postoperative observation time, approximately 8 years, pain has not recurred.

The Global Campaign (GC) to Reduce the Burden of Headache Worldwide. The International Team for Specialist Education (ITSE)

The social perception of headache, everywhere at low levels in industrialised countries, becomes totally absent in developing ones. Headache disorders came into the World Health Organization’s strategic priorities after publication of the 2001 World Health Report. Among the leading causes of disability, migraine was ranked 19th for adults of both sexes together and 12th for females. The Global Campaign (GC) to Reduce the Burden of Headache Worldwide was planned by the major international headache organizations together with WHO in order to identify and remove those cultural, social and educational barriers recognised as responsible factors for the inadequate treatment of headache disorders worldwide. Within the GC activities, the education of the medical body will represents a central pillar. An International Team for Specialist Education (ITSE) has been created to train physicians from all over the world through the acquisition of a university level Master Degree in Headache Medicine. Once trained as headache specialists, physicians will become trainers, offering education in this field to other health care providers in their own countries. In this way they will give life to a cultural chain raising awareness locally of headache, its burden and its medical control.

Depression in Parkinson's disease: diagnosis and treatment

The prevalence of non-motor symptoms in Parkinsons disease (PD) is high. Depression varies from 20 to 50% of the PD patients, and is associated with increasing disability. The key characteristics of depression are anhedonia and low mood. The recommended scales for screening purposes are: HAM-D, BDI, HADS, MADRS and GDS. As for measurement of severity: HAM-D, MADRS, BDI and SDS. In cases with mild depression, non-pharmacological intervention is the treatment of choice. In moderate depression, antidepressants are required. The choice of an antidepressant should be based mainly on the comorbidities and unique features of the patient. Evidence for antidepressant effectiveness is seen mostly with amitriptyline and nortriptyline, but one should be cautious in elderly patients. Other antidepressants that can be prescribed are: citalopram, escitalopram, sertraline, bupropion, trazodone, venlafaxine, mirtazapine and duloxetin. The dopaminergic agonist pramipexole is a treatment option.

Persistence of isolated flow in the internal carotid artery in brain death

The criteria for the confirmation of brain death (BD) using transcranial Doppler ultrasonography (TCD) state that flow should not be observed in the internal carotid artery (ICA). In 94 brain-dead patients examined by TCD, 19 (20%) had flow in the ICA despite cerebral circulatory arrest. There was no difference in the clinical characteristics of patients with or without isolated flow in the ICA. Shunting of blood from the ICA into the external carotid system or the arrest of blood flow at a higher level than the carotid siphon may explain our findings. Our results show that the current TCD criteria can result in a high rate of false negatives. We suggest that the TCD criteria for the diagnosis of brain death should be reviewed.

SUMATRIPTAN BLOCKS SPREADING DEPRESSION IN ISOLATED CHICK RETINA

Spreading depression is a neurohumoral phenomenon that has been related to the pathophysiology of migraine. The recently introduced 5HTID agonist anti-migraine compound sumatriptan blocks neurogenic extravasation and induces cerebral vasoconstriction, but the actual mechanism of action against migraine remains obscure. Retinal spreading depression (RSD) velocity has been measured in isolated chick retinas in the presence of 0.05-2.00:nM sumatriptan. This drug reversibly blocks RSD in a concentration-dependent manner. Since the preparation is blood-vessel free, this effect must be related to the nervous tissue.