Sarah Vollbracht

Depression and Anxiety in Episodic and Chronic Cluster Headache: A Pilot Study

Background.— In contrast to migraine and tension‐type headache, the psychiatric comorbidities of cluster headache (CH) have not been well‐studied.

The pipeline in headache therapy.

Migraine is a common, disabling, neurovascular disorder characterized by episodic attacks of head pain and associated disability plus systemic autonomic and neurologic symptoms. The advent of the triptan class of medication in the 1990s revolutionized the acute treatment of migraine, but many migraineurs do not respond optimally or at all to triptans, have intolerable adverse effects, or have contraindications to their use. Preventive pharmacotherapy has advanced mostly through serendipity, with new drugs being found effective while being used for other indications. There remains a significant need for new medications and devices that can provide effective, rapid, and sustained pain relief without adverse effects or recurrence. Several new acute and preventive therapies for the treatment of migraine and cluster headaches have shown promise and are currently under investigation. This article covers innovative delivery mechanisms, calcitonin gene-related peptide receptor antagonists, antibodies to calcitonin gene-related peptide and its receptor, 5-HT1F receptor agonists, transient receptor potential vanilloid receptor modulators, orexin receptor antagonists, glial cell modulators, and neurostimulation.

Emerging treatments for the primary headache disorders

Migraine and cluster headache are common, episodic, often chronic and disabling disorders of the brain. Although there are many standard treatment techniques, none are ideal. This article reviews various novel pharmacologic and device-related treatments for migraine and cluster headache. Emphasis is given to recent advances in the development of monoclonal antibodies (mAbs) targeting calcitonin gene-related peptide (CGRP) and its receptor, including promising results from phase 2 trials studying the safety and efficacy of LY2951742, ALD403 and TEV-48125, three anti-CGRP mAbs. Other new pharmacologic treatments discussed include the 5-HT1F receptor agonist lasmiditan and glial cell modulator ibudilast. Also reviewed is neuromodulation for migraine and cluster headache, including promising recent results of randomized controlled trials studying sphenopalatine ganglion stimulation, trigeminal nerve stimulation, transcutaneous vagus nerve stimulation, and transcranial magnetic stimulation. Finally, we discuss patch, inhaled, and intranasal methods of triptan and dihydroergotamine delivery.

Peripheral nerve blocks in the treatment of migraine in pregnancy.

OBJECTIVE: To describe the use of peripheral nerve blocks in a case series of pregnant women with migraine. METHODS: A retrospective chart review of all pregnant patients treated with peripheral nerve blocks for migraine over a 5-year period was performed. Injections targeted greater occipital, auriculotemporal, supraorbital, and supratrochlear nerves using local anesthetics. RESULTS: Peripheral nerve blocks were performed 27 times in 13 pregnant women either in a single (n=6) or multiple (n=7) injection series. Mean patient age was 28 years and gestational age was 23.5 weeks, and all women had migraine, including 38.5% who had chronic migraine. Peripheral nerve blocks were performed for status migrainosus (51.8%) or short-term prophylaxis of frequent headache attacks (48.1%). Before peripheral nerve blocks were performed, oral medications failed for all patients and intravenous medications failed for most. In patients with status migrainosus, average pain reduction was 4.0 (±2.6 standard deviation) (P<.001) immediately postprocedure and 4.0 (±4.4 standard deviation) (P=.007) 24 hours postprocedure in comparison to preprocedure pain. For patients receiving peripheral nerve blocks for short-term prophylaxis, immediate mean pain score reduction was 3.0 (±2.1 standard deviation). No patients had any serious immediate, procedurally related adverse events, and the two patients who had no acute pain reduction ultimately developed preeclampsia and had postpartum headache resolution. CONCLUSION: Peripheral nerve blocks for treatment-refractory migraine may be an effective therapeutic option in pregnancy. LEVEL OF EVIDENCE: III

New treatments for headache

Abstract Migraine and cluster headache are primary headache disorders commonly encountered in clinical practice. Despite the profound disability caused by these primary headache disorders, available acute and preventive treatment options are limited. Recent understanding of headache pathophysiology has led to the development of new drug formulations and novel drug targets that are extremely promising. This article will highlight several of the new treatments that are currently under investigation including novel delivery mechanisms of already existing medications, calcitonin gene-related peptide (CGRP) receptor antagonists, antibodies to CGRP and its receptor, serotonin receptor agonists, transient receptor potential vanilloid receptor modulators, orexin receptor antagonists, glial cell modulators, and neuromodulation. If data is supportive, these therapies will be welcome additions to the headache specialist’s armamentarium.

Psychological Factors Associated With Chronic Migraine and Severe Migraine-Related Disability: An Observational Study in a Tertiary Headache Center

To evaluate the relationships among modifiable psychological factors and chronic migraine and severe migraine‐related disability in a clinic‐based sample of persons with migraine.

Giant Cell Arteritis Associated With Orbital Pseudotumor

CASE SUMMARY An 83-year-old woman with a past medical history of hypertension, dyslipidemia, diabetes mellitus, congestive heart failure, chronic kidney disease, hypothyroidism, bilateral cataracts, retinitis pigmentosa, alpha-1-antitrypsin deficiency, and liver transplantation on oral immunosuppressive therapy presented to the emergency department (ED) with a 5-day history of right-sided headache and facial pain. The pain was located in the right frontotemporal and periorbital regions, was gradual in onset, severe in intensity, and throbbing and constant in quality.Associated symptoms included ipsilateral lacrimation, decreased vision, and jaw claudication. Review of systems was positive for a 20-pound weight loss over a 2-week period, myalgias, and generalized fatigue. General physical and neurologic examination was significant for normal vital signs. There was allodynia to light touch over the right V1-V3 dermatomes without associated sensory loss. The right temporal artery was prominent with significant tenderness to palpation. Visual acuity was 20/70 and 20/50 in the right and left eye, respectively. Fundoscopic examination was unremarkable bilaterally. The remainder of the general physical and neurologic examination was unremarkable. Serologic evaluation revealed an erythrocyte sedimentation rate (ESR) of 127, C-reactive protein (CRP) of 3.7, platelets of 419, rheumatoid factor of 865, and a positive anti-neutrophil cytoplasmic antibody. Basic metabolic panel, liver function tests, and angiotension converting enzyme were unremarkable. A right-sided temporal artery biopsy was consistent with occlusive calcified atherosclerosis with no evidence of giant cell arteritis (GCA). Magnetic resonance imaging (MRI) of the brain and orbits with and without the administration of intravenous gadolinium demonstrated enhancement of the right optic nerve sheath and surrounding retrobulbar fat (Fig. 1), findings that are consistent with inflammatory orbital pseudotumor. Based on the high clinical suspicion and supporting serologic evaluation, the patient was started on prednisone 60 mg once daily for the treatment of presumptive GCA. She experienced a rapid resolution of symptoms and was discharged pain free on prednisone 60 mg daily. One month later, the patient returned to the ED with sudden bilateral vision loss after stopping prednisone for 1 week. General physical and neurologic examination was unchanged with the exception of bilateral visual acuity to hand motion only. ESR and CRP remained elevated at 50 and 13.2, respectively. MRI of the brain and orbits without gadolinium revealed improvement of the previously seen increased signal in the right retrobulbar region (Fig. 2). The patient was treated with intravenous solumedrol 1 g daily for 3 days with some improvement of visual function and was discharged on prednisone 60 mg once daily. Repeat sedimentation rate on prednisone several months later was 31. The patient has since been lost to follow up.

Acute postpartum headache.

PRESENTATION OF CASE – ROBERT L. GLOVER, MD, ADULT NEUROLOGY RESIDENT, MONTEFIORE MEDICAL CENTER, ALBERT EINSTEIN COLLEGE OF MEDICINE, BRONX, NY A 22-year-old woman 6 days postpartum originally presented to the emergency room in 2007 with headache.The patient underwent an elective cesarean section 6 days prior to presentation with use of epidural anesthesia after an uncomplicated pregnancy. Vaginal delivery was deferred because of her history of multiple previous cesarean sections. She began experiencing a bilateral frontal headache the day prior to arrival in the emergency room. She described the headache as 9/10 in intensity,of sudden onset,and with associated photophobia but no nausea or vomiting. Review of systems was otherwise negative.The patient reported no significant medical history and no history of headaches. She had undergone uncomplicated cesarean section deliveries in 2001,2003,and 2005.She could not recall any family history of neurological symptoms or conditions, and denied the use of any alcohol, tobacco, or any illicit drugs. Query by discussant Matthew S. Robbins, MD, Montefiore Headache Center,Albert Einstein College of Medicine, Bronx, NY: Were there any additional details offered regarding exacerbating or alleviating factors? Response by Dr. Glover: Yes, the headache did not change with position or straining. Additionally, the patient did not feel nauseous or have any episodes of vomiting. Her blood pressure and pulse were normal, and she was afebrile. Neurological examination was notable for diffuse hyperreflexia, including bilateral Hoffman’s reflexes but no Babinski signs and otherwise demonstrated no neurological focality. Query by discussant Matthew S. Robbins, MD: It was mentioned that the headache was sudden onset, were there any meningeal signs on examination? Response by Dr. Glover: No, on examination the neck was supple. She underwent computerized tomography (CT) scan of the head without intravenous contrast (Fig. 1). Multiple hypodensities in the frontal white matter were visualized. Based on imaging results, the patient was admitted to the neurology inpatient service. Results from human immunodeficiency virus testing, copper levels, antinuclear antibody, antineutrophil cytoplasmic antibody, as well as antibodies to Ro, La, and DNA, and were all negative or within normal limits. A comprehensive antiphospholipid battery was unremarkable. Rheumatoid factor was measured at 22.3 IU/mL (normal 0.0-20.0 IU/mL). Plasma From the Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA (R.L. Glover, S. Vollbracht, M.S. Robbins); Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA (S. Vollbracht, M.S. Robbins).

New and emerging treatments for headache.

Migraine is a common, disabling, episodic, neurovascular disorder. The introduction of the triptans in the 1990s revolutionized the acute treatment of migraine and improved the lives of millions of sufferers. Many patients, however, either do not respond, have an incomplete response, do not attain sustained relief or have contraindications to their use. Advances in preventive pharmacotherapy have occurred largely serendipitously, with new drugs being discovered through their use for other indications. Despite the advances of the last 20 years, many patients continue to suffer. Novel approaches are needed to deliver pain and associated symptom relief to the millions of patients who are inadequately treated with the currently available options.

Cluster headache associated with a sixth nerve palsy: A case report

Background: Cluster headache is a rare primary headache disorder characterized by recurrent, stereotyped short-lasting attacks of severe, unilateral head pain accompanied by autonomic symptoms. Methods/results: Ophthalmic features such as conjunctival injection, lacrimation, ptosis and miosis occur in the vast majority of patients with cluster headache, whereas co-existent ocular movement disorders are rare. Conclusions: To the best of our knowledge, only two documented cases of cluster headache with external ocular movement disorders have been reported. We describe herein an additional case with this unusual finding and discuss the putative pathophysiology of cluster headache associated with ophthalmoparesis.