Veronica Villani

Migraine and depression

Investigations of migraine comorbidity have confirmed its association with diverse psychiatric conditions. This association appears to be stronger for major depression and anxiety disorders, but comorbidity has also been reported with substance abuse and certain mood disorders. This literature also indicates that greater psychiatric comorbidity exists for migraine sufferers with aura than without. There is evidence that psychiatric comorbidity is higher in transformed migraine than in episodic migraine. However, research into the possible mechanisms underlying these associations remains limited. Subjects with migraine should be carefully screened for depression, which should be managed to prevent transformation of migraine, to increase quality of life and to gain more successful migraine therapies.

Primary headache and multiple sclerosis: preliminary results of a prospective study

The aim of this study was to explore the association between different types of headache (HA) and the clinical features of multiple sclerosis (MS). The relationship between HA and MS-specific therapies was also analysed. A total of 102 MS patients were recruited at the MS Centre of S. Andrea Hospital in Rome. According to International Headache Society criteria, the lifetime prevalence of primary HA was 61.8%. Migraine was observed more often in young relapsing-remitting MS patients, whilst tension-type HA was associated with older age, male gender and a secondary progressive course. Sixty-four patients had a history of ongoing or past interferon beta (IFNb) exposure. Of these, 17 subjects did not have a history of HA, while 24 complained of an increase in frequency of migraine attacks and 7 reported an IFNb-induced HA. Investigating and treating HA in MS patients starting IFNb therapy may improve MS-specific medication compliance.

Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence

Mood and anxiety disorders are comorbid with migraine. The coexistence of a psychiatric disorder alters the quality of life, the total disability, the course of migraine and the final prognosis; it increases the probability of central sensitization, other chronic pain conditions and the evolution to chronic migraine. All patients presenting with frequent episodic and chronic migraine should be screened for depression and anxiety. When these conditions are present, drugs for migraine prevention that may worsen the psychiatric comorbid disorder have to be avoided. When it is possible, both conditions should be treated with a single agent. Amitriptiline can be used both in mood disorders and migraine prevention. Flunarizine and beta-blockers may help if anxiety is present. Pregabalin has demonstrated efficacy in anxiety disorders and fibromyalgia. Divalproex sodium, topiramate and lamotrigine that have demonstrated efficacy in mood stabilization are also indicated in migraine without aura (divalproex sodium and topiramate) and with aura (lamotrigine). When a specific treatment for the comorbid psychiatric disorder is needed, the selective serotonin reuptake inhibitors or the serotonin norepinephrine reuptake inhibitors are the drugs of choice both in depression and anxiety, and the cognitive behavioural therapy has good evidence of efficacy in anxiety disorders. Vagal nerve stimulation may be an option in patients with refractory chronic migraine and depression.

Peripheral mechanism of action of antimigraine prophylactic drugs

The pathogenesis of migraine is obscure. A hyperexcitable brain state has been postulated. Cortical spreading depression (CSD) is the most suggestive argument for the brain hyperexcitability. It has been showed that valproate, topiramate, amitriptyline and propranolol inhibit CSD in rats, which suggests that most preventative treatments of migraine act by normalising neuronal firing and increasing a genetically lowered and environmentally modified threshold for neuronal discharge. It has also been suggested that some antimigraine prophylactic drugs (i.e., amitriptyline, candesartan and magnesium) may act by restoring central nociceptive dysmodulation.

Great occipital nerve blockade for cluster headache in the emergency department: case report

A 44-year-old man with a past medical history of episodic cluster headache presented in our ED with complaints of multiple daily cluster headache attacks, with cervico-occipital spreading of pain from May to September 2004. The neurological examination showed no abnormalities as well as brain and spine MRI. Great Occipital Nerve (GON) blockade, with Lidocaine 2% (5 ml) and betamethasone (2 mg), were performed in the right occipital region (ipsilaterally to cluster headache), during attack. GON blockade was effective immediately for the attack and the cluster period resolved after the injection. We suppose that the action of GON blockade may involve the trigemino-cervical complex and we moreover strongly suggest to use GON blockade in emergency departments for cluster headache with cervico-occipital spreading as attack abortive therapy, especially in oxygen and sumatriptan resistant cluster headache attacks, in patients who complaints sumatriptan side-effects or have contraindications to use triptans.

Zonisamide for Migraine Prophylaxis in Topiramate-Intolerant Patients: An Observational Study

(Headache 2011;51:287‐291)

Migraine and metabolism

Migraine is a chronic disorder with complex pathophysiology involving both neuronal and vascular mechanisms. Migraine is associated with an increased risk of vascular disorders, such as stroke and coronary heart disease. Obesity and diabetes are metabolic disorders with a complex association with migraine. Insulin resistance, which represents the main causal factor of diseases involved in metabolic syndrome, is more common in patients with migraine. A better understanding of the relationship between metabolic syndrome and migraine may be of great clinical interest for migraine management.

The Impact of Interferon Beta and Natalizumab on Comorbid Migraine in Multiple Sclerosis

Background.— Some multiple sclerosis (MS)‐specific therapies may exacerbate a comorbid migraine. Whereas data regarding the impact of interferon beta (IFNB) on this comorbidity have been reported, studies on the role of natalizumab (NTZ) are still lacking.

Primary headache in Emergency Department: prevalence, clinical features and therapeutical approach

Headache is one of the most common reported complaints in the general adult population and it accounts for between 1% and 3% of admissions to an Emergency Department (ED). The overwhelming majority of patients who present to an ED with acute primary headache (PH) have migraine and very few of them receive a specific diagnosis and then an appropriate treatment. This is due, in part, to a low likelihood of emergency physicians diagnosing the type of PH, in turn due to lack of knowledge of the IHS criteria, and also the clinical condition of the patients (pain, border type of headache, etc.) In agreement with the literature, another interesting aspect of data emerging from our experience is that few of the ED PH patients are referred to headache clinics for diagnosis and treatment, especially if they present with high levels of disability. This attitude promotes the high–cost phenomenon of repeater patients that have already been admitted to the ED for the same reason in the past. This is statistically important because it involves about 10% of the population with PH.

Therapeutic strategies in migraine patients with mood and anxiety disorders: physiopathological basis

Multiple epidemiologic studies have reported a strong comorbidity between migraine and various psychiatric disorders. Migraine, depression and anxiety could share neurobiological abnormalities in the same neuronal networks. Derangement in central monoaminergic systems is probably the major physiopathological event involved. Abnormalities of metabolism of glutamate and GABA, substances controlling the balance, respectively, between excitation and inhibition in the central nervous system, have also been suggested. A mitochondrial cellular energy failure in the brain of migraine sufferers and psychiatric patients has finally been hypothesized. An antidepressive action of triptans has been suggested. Several antidepressant drugs play a role in migraine prevention. Some antiepileptic drugs have shown to be effective in the treatment of migraine and psychiatric disorders. Nutritional supplements acting on mitochondrial metabolism could improve migraine and depression.