Modar Khalil

EHMTI-0102. Prospective analysis of the use of onabotulinumtoxina (botox®) In the treatment of chronic migraine; real-life data in 299 patients from hull, UK

BackgroundChronic migraine affects 2% of the population. It results in substantial disability and reduced quality of life. Medications used for prophylaxis in episodic migraine may also work in chronic migraine. The efficacy and safety of OnabotulinumtoxinA (BOTOX) in adults with chronic migraine was confirmed in the PREEMPT programme. However, there are few real-life data of its use.Method254 adults with chronic migraine were injected with OnabotulinumtoxinA BOTOX as per PREEMPT Protocol between July 2010 and May 2013, their headache data were collected using the Hull headache diary and analysed to look for headache, migraine days decrements, crystal clear days increment in the month post treatment, we looked at the 50% responder rate as well.ResultsOur prospective analysis shows that OnabotulinumtoxinA, significantly, reduced the number of headache and migraine days, and increased the number of headache free days. OnabotulinumtoxinA Botox also improved patients’ quality of life. We believe that these results represent the largest post-marketing cohort of patients treated with OnabotulinumtoxinA in the real-life clinical setting.ConclusionOnabotulinumtoxinA is a valuable addition to current treatment options in patients with chronic migraine. Our results support findings of PREEMPT study in a large cohort of patients, we believe, is representative of the patients seen in an average tertiary headache centre. While it can be used as a first line prophylaxis its cost may restrict its use to more refractory patients who failed three oral preventive treatments.

Hemicrania Continua Responsive to Botulinum Toxin Type A: A Case Report

Hemicrania continua (HC) is a primary headache disorder with full response to indomethacin as one of its diagnostic criteria; however, indomethacins side effects could limit its use in HC.

Chronic daily headaches.

Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.

An Unusual Case of Episodic SUNCT Responding to High Doses of Topiramate

Trigeminal autonomic cephalalgias (TAC) are rare. Cluster headaches comprise the majority, with short‐lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) being the rarest and shortest in duration. The majority of SUNCT are primary with a few cases occurring secondary to posterior fossa or pituitary lesions. Although activities like exercise or blowing of the nose can trigger SUNCT, onset during orgasm has not been described. Short‐lasting aura has been described in TACs including SUNCT, but persistence of focal symptoms and signs without an underlying structural lesion have not been described. Lastly, treatment of SUNCT is difficult, with lamotrigine being the most common effective reported. We report a case of episodic SUNCT with symptoms suggestive of brainstem stroke that completely resolved spontaneously for which no underlying structural cause was found. The onset of first attack occurred during orgasm, and the patient responded to a high dose of topiramate.

How to do it: bedside ultrasound to assist lumbar puncture

For many neurologists, lumbar puncture is the only practical procedure that they undertake on a regular basis. Although anaesthetists and emergency physicians routinely employ ultrasound to assist lumbar puncture, neurologists do not. In this article, we outline the technique that we use for an ultrasound-assisted lumbar puncture, together with the evidence base that suggests that ultrasound has significant benefits. We aim to raise awareness of a method that can make lumbar puncture more likely to succeed and to be more comfortable for the patient.

Cluster-like headache responsive to phlebotomy.

We report the first case of cluster-like headache secondary to polycythaemia vera (PV) that responded to phlebotomy as part of PV treatment.

Iatrogenic visual aura: a case report and a brief review of the literature

Iatrogenic migraine aura following transseptal catheterization has only rarely been reported in the literature. We report the case of a 60-year-old female who presented with new onset of migraine with visual aura 1 day after transseptal cryoballoon catheter ablation for atrial fibrillation. The patient had a 5-year history of typical migraine without aura and had never experienced visual aura before the cardiac intervention. The neurological examination, fundoscopy, and blood tests were normal. The magnetic resonance imaging of the brain showed small vessel ischemia without evidence of vessel ischemic changes in the occipital lobes and large blood vessel disease. A change in the characteristics of existing migraine could occur following an iatrogenic episode, which in this case was catheter ablation for atrial fibrillation. A new onset of aura is considered an indication for a brain scan as it may signify underlying new pathology.

A COMPARISON OF LUMBAR PUNCTURE WITH AND WITHOUT BEDSIDE ULTRASOUND

Background There is evidence that ultrasound-assisted lumbar puncture (LP) is more effective, and has fewer side effects, than the traditional, palpation based technique. However, neurologists have never published a trial of the method, and the use of ultrasound is not common practice in UK neurology departments. The aim of this study was to compare the efficacy and adverse effects of using ultrasound-assisted versus traditional LP, in a neurology department setting. Methods Consecutive patients undergoing day case LP were randomly assigned to ultrasound-assisted (n=20), or traditional (n=19) LP. Two neurology registrars, previously trained in ultrasound, performed the procedures. We measured success in obtaining CSF, time to mark, patient-rated discomfort, and side effects, including patient-reported post-LP headache. Results Ultrasound-assisted lumbar punctures showed a higher rate of success in obtaining CSF (90% vs 74%), and a lower rate of post-LP headache (20% vs 55%), although neither reached statistical significance. Time to mark was longer with ultrasound (166 s vs 30 s, p=0.0001). Discomfort scores were similar between groups. Conclusion Our experience of bedside ultrasound assisted lumbar puncture is one of a higher success rate and lower post-LP headache rate compared with the traditional technique (although numbers did not reach statistical significance in this small trial).

EHMTI-0133. Does medication overuse matter? Response to botulinum toxin type A in chronic migraine in patients with or without medication overuse

Chronic migraine (CM) affects 2% of the general population with substantial impact on quality of life. Chronic headache with medication overuse prevalence is about 65% in specialised-headache-centres based studies . Medication overuse (MO), by the International Headache Study definition, is different to Medication overuse headache (MOH) . There is no consensus as to whether pharmacological prophylaxis should be initiated once MO has been treated or both could be done simultaneously . Topiramate efficacy was found to be not affected by medication overuse, moreover the PREEMPT data also indicated a similar response between the two groups.

EHMTI-0090. Botox in the prevention of chronic migraine; comparing NICE criteria versus hull criteria for evaluating responder rate

Background Chronic migraine (CM) affects 2% of the population and Botox is the only licensed treatment for prevention of adult patients with CM. In the UK, National Institute for Clinical Excellence (NICE) approved its use on the National Health Service (NHS) provided patients had failed three preventive medications and appropriately addressed for medication overuse. NICE defines responder with 30% reduction in headache days without emphasis on severity of headache or number of migraine days. We developed Hull Criteria that defines responder as one with either: 50% reduction in either Headache days Or migraine days An increment in crystal clear days twice that of baseline