Michel D. Ferrari

Occipital nerve stimulation in medically intractable, chronic cluster headache. The ICON study: rationale and protocol of a randomised trial.

Background About 10% of cluster headache patients have the chronic form. At least 10% of this chronic group is intractable to or cannot tolerate medical treatment. Open pilot studies suggest that occipital nerve stimulation (ONS) might offer effective prevention in these patients. Controlled neuromodulation studies in treatments inducing paraesthesias have a general problem in blinding. We have introduced a new design in pain neuromodulation by which we think we can overcome this problem. Methods/design We propose a prospective, randomised, double-blind, parallel-group international clinical study in medically intractable, chronic cluster headache patients of high- versus low-amplitude ONS. Primary outcome measure is the mean number of attacks over the last four weeks. After a study period of six months there is an open extension phase of six months. Alongside the randomised trial an economic evaluation study is performed. Discussion The ICON study will show if ONS is an effective preventive therapy for patients suffering medically intractable chronic cluster headache and if there is a difference between high- and low-amplitude stimulation. The innovative design of the study will, for the first time, assess efficacy of ONS in a blinded way.

Prophylactic treatment of migraine; the patient's view, a qualitative study

BackgroundProphylactic treatment is an important but under-utilised option for the management of migraine. Patients and physicians appear to have reservations about initiating this treatment option. This paper explores the opinions, motives and expectations of patients regarding prophylactic migraine therapy.MethodsA qualitative focus group study in general practice in the Netherlands with twenty patients recruited from urban and rural general practices. Three focus group meetings were held with 6-7 migraine patients per group (2 female and 1 male group). All participants were migraine patients according to the IHS (International Headache Society); 9 had experience with prophylactic medication. The focus group meetings were analysed using a general thematic analysis.ResultsFor patients several distinguished factors count when making a decision on prophylactic treatment. The decision of a patient on prophylactic medication is depending on experience and perspectives, grouped into five categories, namely the context of being active or passive in taking the initiative to start prophylaxis; assessing the advantages and disadvantages of prophylaxis; satisfaction with current migraine treatment; the relationship with the physician and the feeling to be heard; and previous steps taken to prevent migraine.ConclusionIn addition to the functional impact of migraine, the decision to start prophylaxis is based on a complex of considerations from the patients perspective (e.g. perceived burden of migraine, expected benefits or disadvantages, interaction with relatives, colleagues and physician). Therefore, when advising migraine patients about prophylaxis, their opinions should be taken into account. Patients need to be open to advice and information and intervention have to be offered at an appropriate moment in the course of migraine.

Proactieve benadering van migraine

Samenvattingxa0Smelt AFH, Blom JW, Dekker F, Van den Akker ME, Knuistingh Neven A,Zitman FG, Ferrari MD, Assendelft WJJ. Proactieve benadering van migraine.Huisarts Wet 2012;55(8):336-40.DoelBepalen of een proactieve benadering van migrainepatiënten leidt tot minder hoofdpijnklachten en kosten.MethodeEen pragmatisch, clustergerandomiseerd onderzoek in 64 Nederlandse huisartsenpraktijken onder patiënten die minstens twee triptanen per maand voorgeschreven kregen. Onze primaire uitkomstmaat was de score op de Headache Impact Test (HIT-6) na zes maanden (klinisch relevante verbetering van 2,3 punten). Daarnaast maten wij psychische klachten met behulp van de K10-vragenlijst. Interventiehuisartsen kregen nascholing over diagnostiek en behandeling van migraine. Zij nodigden patiënten uit voor een evaluatieconsult om te beoordelen of de migrainebehandeling kon worden verbeterd. Controlehuisartsen continueerden hun gebruikelijke zorg.ResultatenNa zes maanden was de score van de interventiegroep (n = 233) op de HIT-6 0,81 punten meer verbeterd dan die van de controlegroep (n = 258; p =0,07). In de subgroep van patiënten die geen profylaxe gebruikten en twee of meer aanvallen per maand rapporteerden, was het verschil 1,37 punten (p = 0,04). De verbetering was groter bij patiënten met weinig psychische klachten (–1,51; p = 0,008) dan bij patiënten met veel psychische klachten (0,16; p = 0,494).ConclusieEen proactief beleid had bij onze onderzoekspopulatie geen klinisch relevant effect. Toekomstig onderzoek moet zich richten op patiënten die geen profylaxe gebruiken en twee of meer migraineaanvallen per maand rapporteren. De interventie had meer effect bij patiënten met weinig psychische klachten.

Migraine as a Cerebral Ionopathy with Abnormal Central Sensory Processing**Some portions of the pathophysiology have appeared fully referenced [1].

Migraine is a highly prevalent, multifactorial, episodic disorder of the brain, with high impact on the patient and society. Changes within the trigeminocervical complex and trigeminovascular system, mainly leading to abnormal central sensory processing, are crucial pathophysiological mechanisms of the migraine attack. Interference with these neurovascular mechanisms offers new avenues for novel, specific, acute treatments of the migraine attack, which are hopefully not associated with potential cardiovascular complications Migraine is in essence a familial episodic disorder whose marker is headache, although the key to recognition is in the associated features of the attack and the biology of the triggering of exacerbations. Migraine patients also have an increased risk (comorbidity) of epilepsy, depression, anxiety disorders, and stroke. Effective and well-tolerated treatments to prevent attacks, rather than abort them after they begin, are dearly needed. New insights into the genetics and molecular biology of the migraine trigger threshold suggest that migraine might be a cerebral ionopathy resulting in enhanced propensity for cortical spreading depression, as a triggering mechanism for attacks. Similar mechanisms might be involved in changing the modulatory role of the trigeminocervical complex on central trigeminal pain and other sensory signal transmission. Pharmacological interferences aimed at normalizing the disturbed ion homeostasis might offer new avenues for the development of specific migraine prophylactic treatments.