Michel Vandenheede

Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study.

&NA; Oral steroids can interrupt bouts of cluster headache (CH) attacks, but recurrence is frequent and may lead to steroid‐dependency. Suboccipital steroid injection may be an effective ‘single shot’ alternative, but no placebo‐controlled trial is available. The aim of our study was to assess in a double‐blind placebo‐controlled trial the preventative effect on CH attacks of an ipsilateral steroid injection in the region of the greater occipital nerve. Sixteen episodic (ECH) and seven chronic (CCH) CH outpatients were included. ECH patients were in a new bout since no more than 1 week. After a one‐week run‐in period, patients were allocated by randomization to the placebo or verum arms and received on the side of attacks a suboccipital injection of a mixture of long‐ and rapid‐acting betamethasone (n=13; Verum‐group) or physiological saline (n=10; Plac‐group). Acute treatment was allowed at any time, additional preventative therapy if attacks persisted after 1 week. Three investigators performed the injections, while four others, blinded to group allocation, followed the patients. Follow‐up visits were after 1 and 4 weeks, whereafter patients were followed routinely. Eleven Verum‐group patients (3 CCH) (85%) became attack‐free in the first week after the injection compared to none in the Plac‐group (P=0.0001). Among them eight remained attack‐free for 4 weeks (P=0.0026). Remission lasted between 4 and 26 months in five patients. A single suboccipital steroid injection completely suppresses attacks in more than 80% of CH patients. This effect is maintained for at least 4 weeks in the majority of them.

Induction of long‐lasting changes of visual cortex excitability by five daily sessions of repetitive transcranial magnetic stimulation (rTMS) in healthy volunteers and migraine patients

We have shown that in healthy volunteers (HV) one session of 1 Hz repetitive transcranial magnetic stimulation (rTMS) over the visual cortex induces dishabituation of visual evoked potentials (VEPs) on average for 30 min, while in migraineurs one session of 10 Hz rTMS replaces the abnormal VEP potentiation by a normal habituation for 9 min. In the present study, we investigated whether repeated rTMS sessions (1 Hz in eight HV; 10 Hz in eight migraineurs) on 5 consecutive days can modify VEPs for longer periods. In all eight HV, the 1 Hz rTMS-induced dishabituation increased in duration over consecutive sessions and persisted between several hours (n = 4) and several weeks (n = 4) after the fifth session. In six out eight migraineurs, the normalization of VEP habituation by 10 Hz rTMS lasted longer after each daily stimulation but did not exceed several hours after the last session, except in two patients, where it persisted for 2 days and 1 week. Daily rTMS can thus induce long-lasting changes in cortical excitability and VEP habituation pattern. Whether this effect may be useful in preventative migraine therapy remains to be determined.

Excitability of visual V1-V2 and motor cortices to single transcranial magnetic stimuli in migraine: a reappraisal using a figure-of-eight coil

We used transcranial magnetic stimulation (TMS) with a figure-of-eight coil to excite motor and visual V1-V2 cortices in patients suffering from migraine without (MO) (n = 24) or with aura (MA) (n = 13) and in healthy volunteers (HV) (n = 33). Patients who had a migraine attack within 3 days before or after the recordings were excluded. All females were recorded at mid-cycle. Single TMS pulses over the occipital cortex elicited phosphenes in 64% of HV, 63% of MO and 69% of MA patients. Compared with HV, the phosphene threshold was significantly increased in MO (P = 0.001) and in MA (P = 0.007), but there was no difference between the two groups of migraineurs. The motor threshold tended to be higher in both migraine groups than in HV, but the differences were not significant. In conclusion, this study shows that two-thirds (64.86%) of patients affected by either migraine type present an increased phosphene threshold in the interictal period, which suggests that their visual cortex is hypoexcitable.

The syndrome of transient headache with neurological deficits and CSF lymphocytosis (HaNDL): electrophysiological findings suggesting a migrainous pathophysiology

Episodes of headache with transient neurological deficits and cerebrospinal fluid (CSF) lymphocytosis are suggestive of a benign and self-limiting syndrome which was first delineated by Bartleson et al. (1) and given the acronym HaNDL in 1995 by Berg and Williams (2). Gómez-Aronda et al. (3), who reported the hitherto largest series of patients ( n = 50), preferred to call the syndrome pseudomigraine with temporary neurological symptoms and lymphocytic pleocytosis (PMP). The syndrome has been classified (code 7.8) in the 2nd edition of the International Headache Society classification of headache disorders (ICHD-II) (4) as a secondary headache attributed to a non-vascular intracranial disorder with the following diagnostic criteria: A, episodes of moderate or severe headache lasting hours before resolving fully and fulfilling criteria C and D; B, CSF pleocytosis with lymphocytic predominance ( > 15 cells/ m l) and normal neuroimaging, CSF culture and other tests for aetiology; C, episodes of headache are accompanied by or shortly follow transient neurological deficits and commence in close temporal relation to the development of CSF pleocytosis; D, episodes of headache and neurological deficits recur over < 3 months. The precise pathogenesis of HaNDL, however, is unknown and its phenotypic similarities with migraine with aura have been underlined by some authors (3, 5–8). Most migraineurs present interictally a deficit of the habituation of evoked cortical responses (9), for instance of pattern-reversal visual evoked potentials (PR-VEP) (10). Lack of habituation of the auditory evoked cortical potentials (11) leads in migraineurs to an increased intensity dependence (IDAP) of these potentials (12). Occipital high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS), which activates the underlying visual cortex in most subjects, is able to normalize PR-VEP habituation in migraine patients, which suggests that the habituation deficit is due to a reduced preactivation level (13). Mild subclinical abnormalities of neuromuscular transmission can be detected with single-fibre electromyography (SFEMG) in migraine patients with complex neurological (14) and/or prolonged auras (15). In HaNDL neurological symptoms are indeed complex in nature and of long duration. We have therefore examined whether the electrophysiological phenotype found in migraine with aura would be present in a patient presenting with a typical HaNDL syndrome.

Indomethacin-responsive hemicrania associated with an extracranial vascular malformation: report of two cases

Hemicrania continua (HC) was described in 1984 as a headache syndrome with absolute responsiveness to indomethacin (1). Since then a number of cases were reported in the literature (reviewed in 2, 3), but there is still uncertainty about its diagnostic clinical features. Symptomatic HC can occur, e.g. in mesenchymal tumours of the sphenoid bone (4), HIV (5) or malignant lung neoplasm (6). We report two patients with indomethacin-sensitive hemicrania associated with an extracranial vascular malformation.

Migraine prevention with a supraorbital transcutaneous stimulator: A randomized controlled trialAuthor Response

Schoenen et al.1 provided evidence that trigeminal neurostimulation with a supraorbital transcutaneous stimulator (STS) is effective for migraine. STS involves the application of electrodes and stimulator via an invasive surgical procedure that includes expensive medical consumables and possible complications. Only 70.6% of patients are very satisfied or moderately satisfied and approximately 1 out of 5 was not satisfied after STS effective neurostimulation.1 This means that 20%–30% of patients were dissatisfied with the procedure. Unfortunately, there is no way to preoperatively predict which patients will respond to the stimulation. STS has a sedative effect via a change in CNS activity.1 Acupuncture (e.g., somatic acupuncture, ear acupuncture, or electroacupuncture) has been successfully used for migraine2,3 and reduces sympathetic nerve activity.4 Based on those data, we propose that acupuncture can predict the efficacy of STS: if acupuncture is effective, STS will also be effective. For migraineurs, inexpensive and minimally invasive acupuncture can be performed before the STS. If acupuncture is efficient, STS may also be efficient and worth performing.