Werner J. Becker

Comorbidity of migraine and psychiatric disorders--a national population-based study.

Background.— Migraine is common, with an estimated lifetime prevalence of 7‐17%. Population‐based studies have reported an association between various psychiatric conditions and migraine. This is a population‐based study exploring the association between migraine and psychiatric disorders in a large cohort and assessing various health‐related outcomes.

Opiate Use to Control Bowel Motility May Induce Chronic Daily Headache in Patients With Migraine

Objectives.—To investigate whether opiate overuse might cause chronic daily headache in those with migraine, we studied patients who were taking codeine (or other opiates) for control of bowel motility after colectomy for ulcerative colitis.

Cost of health care among patients with chronic and episodic migraine in Canada and the USA: results from the International Burden of Migraine Study (IBMS).

(Headache 2011;51:1058‐1077)

The Stress and Migraine Interaction

There are several ways in which stress may interact with migraine in those predisposed to migraine attacks. These interactions may result from biochemical changes related to the physiological stress response, as, for example, the release of corticotrophin releasing hormone, or from changes induced by the psychological response to stressors. Stress is the factor listed most often by migraine sufferers as a trigger for their attacks, but in addition there is evidence that stress can help initiate migraine in those predisposed to the disorder, and may also contribute to migraine chronification. Migraine attacks themselves can act as a stressor, thereby potentially leading to a vicious circle of increasing migraine frequency. Since the important factor in the stress–migraine interaction is likely the individuals responses to stressors, rather than the stressors themselves, the acquisition of effective stress management skills has the potential to reduce the impact of stressors on those with migraine.

Coordination of a multi-joint movement in normal humans and in patients with cerebellar dysfunction.

The contribution of the cerebellar cortex to coordination of a multi-joint throwing movement was studied by measuring various movement and EMG parameters while normal control subjects and patients with cerebellar cortical atrophy threw a ball at a target. Although patients did not throw as accurately as controls, several coordination measurements were normal in the patients. These included parameters used by us to assess elbow-wrist coordination and the coordination of hand opening with activation of more proximal arm muscles. Postural support for the movement at the shoulder was also normal in that the shoulder was not pushed backwards by the reaction forces resulting from the rapid forward acceleration of the forearm and hand. In contrast, however, patients were unable to coordinate the muscles so as to produce the same hand direction from trial to trial when throwing at the same target. In addition, EMG onset times were abnormal in the antagonist muscles relative to agonist EMG bursts and kinematic parameters of the movement. In conclusion, our patients with cerebellar cortical atrophy showed abnormalities in visual-motor coordination, in that they were unable to consistently produce the appropriate hand direction in response to a visual target. Agonist-antagonist relationships were also impaired. Other aspects of coordination, such as the relative timing of EMG onsets of agonist muscles, even when these were active at different joints, were normal.

Speed of Onset and Efficacy of Zolmitriptan Nasal Spray in the Acute Treatment of Migraine A Randomised, Double-Blind, Placebo-Controlled, Dose-Ranging Study versus Zolmitriptan Tablet

AbstractObjective: Zolmitriptan oral tablet is highly effective and well tolerated in the acute treatment of migraine with and without aura in adults. A nasal spray formulation has now been developed. The objective of this study was to compare the efficacy and tolerability of fixed doses of zolmitriptan administered via a nasal spray with placebo and zolmitriptan oral tablet in the acute treatment of migraine. Patients and study design: This was a randomised, double-blind, double-dummy, placebo-controlled, parallel-group, multicentre, dose-ranging study. 1547 patients aged 18–65 years with an established diagnosis of migraine with or without aura (as defined by International Headache Society criteria) who had at least a 1-year history of migraine and an age of onset <50 years were included. Patients were able to distinguish typical migraine from nonmigraine headaches and had experienced an average of one to six migraine headaches per month during the 2 months preceding the study. Patients were randomised to zolmitriptan (Zomig®1) nasal spray (5.0, 2.5, 1.0 or 0.5mg), zolmitriptan oral tablet (2.5mg) or placebo for the treatment of three moderate or severe migraine attacks. The primary outcome measure was headache response at 2 hours following treatment, defined as reduced intensity of migraine pain (using a scale of none, mild, moderate or severe) from severe or moderate at baseline to mild or no pain at 2 hours after treatment. Secondary outcome measures included early headache response at 15, 30 and 45 minutes and headache response at 1 and 4 hours postdose, as well as pain-free rates at 15, 30 and 45 minutes and 1, 2 and 4 hours postdose. Laboratory assessments, vital signs, 12-lead ECGs and nose and throat examinations were performed at screening and follow-up visits. Adverse events were recorded throughout the study using Coding Symbols for Thesaurus of Adverse Reaction Terms (COSTART) terminology. Results: Each dose of zolmitriptan nasal spray produced a greater 2-hour headache response rate than placebo (70.3%, 58.6%, 54.8% and 41.5% for zolmitriptan nasal spray 5.0, 2.5, 1.0 and 0.5mg, compared with 30.6% for placebo [all p < 0.001 vs placebo]). The 2-hour headache response rate for zolmitriptan nasal spray 5.0mg was significantly higher than that of the zolmitriptan 2.5mg oral tablet (61.3%; p < 0.05), while comparisons of nasal spray 0.5, 1.0 and 2.5mg with zolmitriptan 2.5mg oral tablet were not statistically significant. The nasal spray 5.0 and 2.5mg showed a rapid onset of action, with a significant difference in headache response compared with placebo from 15 minutes through 4 hours after administration and a significant difference between the nasal spray 5.0mg and 2.5mg oral tablet from 15 minutes through to 2 hours (the other nasal spray doses were not statistically significant compared with 2.5mg oral tablet). Zolmitriptan nasal spray resulted in pain-free rates that were dose dependent. While all doses from l.0mg upwards produced significant pain-free outcomes from 30 minutes versus placebo, only the 5.0mg dose produced pain-free rates significantly superior to both placebo and the 2.5mg oral tablet. Zolmitriptan nasal spray was well tolerated, with the most common adverse events being unusual taste and paresthesia. The majority of adverse events were of short duration and mild or moderate intensity. Only ten patients were withdrawn from the trial because of adverse events. Serious adverse events were reported by nine patients after taking study medication, but none was considered to be causally related to study medication. Zolmitriptan was not associated with any clinically significant changes in laboratory test values or vital signs. Conclusion: All doses of zolmitriptan nasal spray produced significant 2-hour headache response rates compared with placebo. The 5.0 and 2.5mg doses were also significantly more effective than placebo for the majority of secondary efficacy measures. Zolmitriptan nasal spray 5.0mg provided a headache response statistically superior to both placebo and the 2.5mg tablet as early as 15 minutes after administration, while demonstrating pain-free outcomes significantly superior to placebo and the 2.5mg tablet as early as 30 minutes after administration. All doses of zolmitriptan nasal spray were well tolerated, resulting in an optimal therapeutic index and clinical recommendation for the 5.0mg dose.

Chinook winds and migraine headache

Objective: To determine the effects of chinook weather conditions on probability of migraine headache onset. Background: Many migraineurs believe weather to be a trigger factor for their headaches; however, there is little supportive evidence in the literature. Migraineurs in the southern part of the Canadian province of Alberta frequently report that chinooks, warm westerly winds specific to the region, trigger their headaches. Methods: Weather data from Environment Canada were used to designate each calendar day during the study period as a chinook, prechinook, or nonchinook day. Headache data were collected from 75 patient diaries from the University of Calgary Headache Research Clinic. Individual and multiple logistic regression models were used to determine if the weather conditions affected the probability of migraine onset. Results: The probability of migraine onset was increased on both prechinook days (odds ratio 1.24; 95% CI 1.08 to 1.42) and on days with chinook winds (1.19; 1.02 to 1.39) compared with nonchinook days. Analysis of chinook wind velocities revealed that for chinook days, the relative risk of migraine onset was increased only on high-wind chinook days (velocity > 38 km/h) (odds ratio 1.41; 95% CI 1.06 to 1.88). A subset of individuals was sensitive to high-wind chinook days, and another subset was only sensitive to prechinook days. Only two patients were sensitive to both weather conditions, and the majority of patients was not sensitive to either. Neither weather condition had a protective effect. Increasing age was associated with high-wind chinook sensitivity (p = 0.009) but not prechinook sensitivity (p = 0.389). Conclusions: Both prechinook and high-wind chinook days increase the probability of migraine onset in a subset of migraineurs. Because few subjects were found to be sensitive to both weather types, the mechanisms for these weather effects may be independent. This is supported by the presence of an age interaction for high-wind chinook days but not for prechinooks day.

Cutaneous allodynia in transformed migraine patients.

Background.—There is growing evidence that central sensitization plays a role in migraine pathogenesis, and that cutaneous allodynia is its clinical correlate. In headache research, allodynia has largely been studied in episodic migraine. The purpose of this investigation was to determine whether cutaneous allodynia occurs in transformed migraine, using individuals without headaches as controls.

Multi-Joint Reaching Movements and Eye-Hand Tracking in Cerebellar Incoordination: Investigation of a Patient with Complete Loss of Purkinje Cells

Performance on an eye-hand tracking task and a multi-joint reaching movement to a visual target was studied in a patient with stable cerebellar ataxia and in control subjects. The patient subsequently died and a full neuropathological examination was performed. The neuropathological findings were similar to those seen in patients with paraneoplastic cerebellar degeneration, but no tumor was found at autopsy eight years after onset of the patients cerebellar syndrome. A severe cerebellar cortical degeneration with complete Purkinje cell loss was demonstrated, whereas cerebellar nuclei and brainstem structures showed no neuronal loss. Tracking performance by the patient was characterized by abnormally large numbers of high velocity movements and hand direction reversals, and by excessive lagging of the hand behind the target in time. In the multi-joint reaching movement, the patient showed a delay in movement onset at the elbow joint compared to movement onset at the shoulder joint. The velocity profile of the movement at the shoulder joint was abnormal. The duration of the acceleration phase was poorly correlated with both peak angular velocity and the duration of the deceleration phase. One of the most striking findings was the inability of the patient to consistently produce the same movement direction from trial to trial while reaching to the same target. Our data suggests that the cerebellar cortex is involved in multiple aspects of motor control including visuomotor integration mechanisms.

Acute and preventive pharmacologic treatment of cluster headache

Cluster headache (CH) is a rare and disabling primary headache disorder. CH attacks are unilateral, short, severe headaches associated with ipsilateral autonomic symptoms that occur in a periodic fashion. We provide a systematic review and meta-analysis of existing trials of pharmacotherapy for CH and evidence-based suggestions for acute abortive treatment and preventive therapy for cluster headache. Prospective, double-blind, randomized controlled trials of any pharmacologic agent for the symptomatic relief or prevention of CH were included in this evidence-based review. The main outcomes considered were headache response and pain-free response at 15 and 30 minutes for acute treatment trials, and the cessation of CH attacks within a specific time period or the number of days on which CH attacks occurred for preventive trials. Twenty-seven trials were included in the analysis. The American Academy of Neurology quality criteria were used to assess trial quality and to grade advisements. Based on the evidence, for acute treatment of CH, Level A advice can be given for subcutaneous sumatriptan 6 mg, zolmitriptan nasal spray 5 mg and 10 mg, and 100% oxygen 6–12 L/min. Level B advice can be given for sumatriptan nasal spray 20 mg and oral zolmitriptan 5 mg and 10 mg. For the prevention of CH, Level B advice can be given for intranasal civamide 100 μg daily and suboccipital steroid injections, and Level C advice can be given for verapamil 360 mg, lithium 900 mg, and melatonin 10 mg.