Dynamic Stability, Symmetry, and Smoothness of Gait in People with Neurological Health Conditions.

Neurological disorders such as stroke, Parkinson's disease (PD), and severe traumatic brain injury (sTBI) are leading global causes of disability and mortality. This study aimed to assess the ability to walk of patients with sTBI, stroke, and PD, identifying the differences in dynamic postural stability, symmetry, and smoothness during various dynamic motor tasks. Sixty people with neurological disorders and 20 healthy participants were recruited. Inertial measurement unit (IMU) sensors were employed to measure spatiotemporal parameters and gait quality indices during different motor tasks. The Mini-BESTest, Berg Balance Scale, and Dynamic Gait Index Scoring were also used to evaluate balance and gait. People with stroke exhibited the most compromised biomechanical patterns, with lower walking speed, increased stride duration, and decreased stride frequency. They also showed higher upper body instability and greater variability in gait stability indices, as well as less gait symmetry and smoothness. PD and sTBI patients displayed significantly different temporal parameters and differences in stability parameters only at the pelvis level and in the smoothness index during both linear and curved paths. This study provides a biomechanical characterization of dynamic stability, symmetry, and smoothness in people with stroke, sTBI, and PD using an IMU-based ecological assessment.

FunctionaL Assessment Scale of Hemianopia (FLASH): A New Multidisciplinary Tool to Assess Hemianopia in Patients with Severe Acquired Brain Injury.

BACKGROUND: Severe acquired brain injury (sABI) encompasses a range of neurological impairments. Visual dysfunction, particularly homonymous visual field defects (HVFDs) and homonymous hemianopia (HH), commonly afflicts sABI survivors, affecting their cognitive and motor rehabilitation. This study presents the FunctionaL Assessment Scale of Hemianopia (FLASH), developed to analyze the most common postural behaviors exhibited by sABI patients with hemianopia during activities of daily living. A comparison to traditional static automated perimetry for diagnosing visual field deficits (VFDs) to determine the sensitivity and specificity of the FLASH was used. Additionally, this study also aimed to assess its reliability. METHODS: Fifty-six patients (25 F, 31 M, mean age 60.59 ± 14.53) with strokes in the sub-acute phase (<6 months from the onset) were assessed with both FLASH and a Humphrey Field Analyzer. RESULTS: After removing two items found to be less reliable than others, FLASH showed high sensitivity (81%) and specificity (77%) when compared to static automated perimetry. Inter-rater reliability was also high, with an intra-class correlation coefficient of 0.954, as well as the internal consistency computed by Cronbach's alpha, equal to 0.874. CONCLUSION: FLASH could offer a valuable and cost-effective screening tool for VFD in sABI patients during neurorehabilitation, with potential implications for healthcare cost reduction.

Vestibular Rehabilitation Improves Gait Quality and Activities of Daily Living in People with Severe Traumatic Brain Injury: A Randomized Clinical Trial.

Neurorehabilitation research in patients with traumatic brain injury (TBI) showed how vestibular rehabilitation (VR) treatments positively affect concussion-related symptoms, but no studies have been carried out in patients with severe TBI (sTBI) during post-acute intensive neurorehabilitation. We aimed at testing this effect by combining sensor-based gait analysis and clinical scales assessment. We hypothesized that integrating VR in post-acute neurorehabilitation training might improve gait quality and activity of daily living (ADL) in sTBI patients. A two-arm, single-blind randomized controlled trial with 8 weeks of follow-up was performed including thirty sTBI inpatients that underwent an 8-week rehabilitation program including either a VR or a conventional program. Gait quality parameters were obtained using body-mounted magneto-inertial sensors during instrumented linear and curvilinear walking tests. A 4X2 mixed model ANOVA was used to investigate session−group interactions and main effects. Patients undergoing VR exhibited improvements in ADL, showing early improvements in clinical scores. Sensor-based assessment of curvilinear pathways highlighted significant VR-related improvements in gait smoothness over time (p < 0.05), whereas both treatments exhibited distinct improvements in gait quality. Integrating VR in conventional neurorehabilitation is a suitable strategy to improve gait smoothness and ADL in sTBI patients. Instrumented protocols are further promoted as an additional measure to quantify the efficacy of neurorehabilitation treatments.

Experimental animal models of migraine.

Animal models of migraine have been widely used during the last decades to provide clues for understanding mechanisms underlying pathophysiology of migraine attacks and for developing specific therapeutic agents. They can be grouped into two main types: vascular and neurovascular. Trigemino-vascular system (TVS) is the most relevant efferent component and the mediators of its activity have been thoroughly studied along with some of the receptors involved to characterize anatomical and functional aspects of the system and to test efficacy and mechanisms of therapeutic agents. Neurovascular models are numerous. Plasma protein extravasation (PPE) model consists of measuring the amount of proteins leaking from vessels when TVS is either electrically or chemically stimulated and evaluating its blockade by systemically administered therapeutic agents of which specific receptors have also been identified. Activation of trigeminal nucleus caudalis (TNC) through meningeal stimulation of the superior sagittal sinus served to better understand the mechanisms of central nociceptive pathway. The cortical spreading depression (CSD) model has been used to activate the TVS through application of potassium chloride and evaluate Fos expression in the trigeminal nucleus caudalis (TNC). Finally, neurochemical, cerebrovascular, and nociceptive response to systemic or central administration of nitric oxide (NO) donors served to study central nociceptive pathway and autonomic response interaction. Transgenic mouse expressing human migraine mutations has been genetically engineered to provide an understanding of familial hemiplegic migraine (FHM). Animal models of migraine also served to better understand the role of hormones, genes, and environmental factors on migraine pathophysiology.

Physical Therapy Exercises for Sleep Disorders in a Rehabilitation Setting for Neurological Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Sleep occupies one-third of human life and is essential for health and for emotional, physical, and cognitive well-being. Poor or insufficient sleep is associated with a wide range of dysfunctions that involve different body systems, such as the endocrine, metabolic, and immune systems, thus compromising the higher cortical functions, cognitive performance, mood, and post-physical activity recovery. The present systematic review and meta-analysis aimed to explore the effectiveness of physical therapy exercises on sleep disorders in patients with neurological disorders. Our systematic review identified 10 articles that investigated the effects of physical therapy on sleep disorders in patients with neurological disorders, 6 of which were included in the meta-analysis. Results suggest that physical therapy exercises are a safe and useful strategy for managing sleep disorders in neurorehabilitation.

Does Curved Walking Sharpen the Assessment of Gait Disorders? An Instrumented Approach Based on Wearable Inertial Sensors.

Gait and balance assessment in the clinical context mainly focuses on straight walking. Despite that curved trajectories and turning are commonly faced in our everyday life and represent a challenge for people with gait disorders. The adoption of curvilinear trajectories in the rehabilitation practice could have important implications for the definition of protocols tailored on individual's needs. The aim of this study was to contribute toward the quantitative characterization of straight versus curved walking using an ecological approach and focusing on healthy and neurological populations. Twenty healthy adults (control group (CG)) and 20 patients with Traumatic Brain Injury (TBI) (9 severe, sTBI-S, and 11 very severe, sTBI-VS) performed a 10 m and a Figure-of-8 Walk Test while wearing four inertial sensors that were located on both tibiae, sternum and pelvis. Spatiotemporal and gait quality indices that were related to locomotion stability, symmetry, and smoothness were obtained. The results show that spatiotemporal, stability, and symmetry-related gait patterns are challenged by curved walking both in healthy subjects and sTBI-S, whereas no difference was displayed for sTBI-VS. The use of straight walking alone to assess gait disorders is thus discouraged, particularly in patients with good walking abilities, in favor of the adoption of complementary tests that were also based on curved paths.

Pain and Evil: From Local Nociception to Misery Following Social Harm.

Experiencing pain, especially when chronic, is an excruciating condition that should be regarded as a syndrome, if not a disease. People suffering from chronic pain tend to develop psychological discomfort mostly due to lack of acceptance, disbelief, blame. The complexity of pain pathophysiology, plus a wide range of negative psychosocial factors, leads to a more complex suffering that deserves attention and multidisciplinary treatments. The possibility that chronic pain may occur following physical aggression, torture, or persecution raises the issue of evil as a major contributor to pain in its worst representation - when individuals or groups are attacked based on racial, social, gender, religious, political, or other grounds. To explore the complex issue of chronic pain following physical or psychological harm, and to underscore the need for a multidisciplinary approach to reduce the burden of chronic pain, we discuss the biological mechanisms underlying pain state. We seek to clarify those factors leading to pain chronification, as well as personal and social attitudes that confound patients with chronic pain. The importance of family and social environment is also investigated, as well as personality traits of chronic pain patients that may further hamper successful treatment. The presence of chronic pain, modulated by, for example, acceptance of being a victim of premeditated physical and social violence, makes the issue more difficult to comprehend.

Gait Quality Assessment in Survivors from Severe Traumatic Brain Injury: An Instrumented Approach Based on Inertial Sensors.

Despite existing evidence that gait disorders are a common consequence of severe traumatic brain injury (sTBI), the literature describing gait instability in sTBI survivors is scant. Thus, the present study aims at quantifying gait patterns in sTBI through wearable inertial sensors and investigating the association of sensor-based gait quality indices with the scores of commonly administered clinical scales. Twenty healthy adults (control group, CG) and 20 people who suffered from a sTBI were recruited. The Berg balance scale, community balance and mobility scale, and dynamic gait index (DGI) were administered to sTBI participants, who were further divided into two subgroups, severe and very severe, according to their score in the DGI. Participants performed the 10 m walk, the Figure-of-8 walk, and the Fukuda stepping tests, while wearing five inertial sensors. Significant differences were found among the three groups, discriminating not only between CG and sTBI, but also for walking ability levels. Several indices displayed a significant correlation with clinical scales scores, especially in the 10 m walking and Figure-of-8 walk tests. Results show that the use of wearable sensors allows the obtainment of quantitative information about a patient's gait disorders and discrimination between different levels of walking abilities, supporting the rehabilitative staff in designing tailored therapeutic interventions.

Late recovery of responsiveness after intra-thecal baclofen pump implantation and the role of diffuse pain and severe spasticity: a case report.

Patients with a prolonged disorder of consciousness (DoC) may present with severe spasticity and diffuse pain, which might impair motor output, thus preventing any possible behavioral responsiveness. A 26-year-old man affected by frontoparietal hemorrhage was operated by hematoma evacuation and decompressive craniectomy; coma persisted for 1 month; cranioplasty and ventriculo-peritoneal shunting was performed after 4 months. At admission in rehabilitation, he was diagnosed as vegetative state/unresponsive wakefulness syndrome (VS/UWS). The implantation of intrathecal baclofen (ITB) pump (Medtronic SynchroMed™ II), 14 months after, (60 µg/daily), dramatically improved behavioral responsiveness according to Coma Recovery Scale-Revised (CRS-R) from 6 to 12 (1 month after ITB). Nociception Coma Scale-Revised (NCS-R) also changed from 4 to 8 at the same time points. This case report may be an example of covert cognition that should have been diagnosed as a functional locked-in syndrome or motor-cognitive dissociation, rather than as VS/UWS.

Understanding Spreading Depression from Headache to Sudden Unexpected Death.

Spreading depression (SD) is a neurophysiological phenomenon characterized by abrupt changes in intracellular ion gradients and sustained depolarization of neurons. It leads to loss of electrical activity, changes in the synaptic architecture, and an altered vascular response. Although SD is often described as a unique phenomenon with homogeneous characteristics, it may be strongly affected by the particular triggering event and by genetic background. Furthermore, SD may contribute differently to the pathogenesis of widely heterogeneous clinical conditions. Indeed, clinical disorders related to SD vary in their presentation and severity, ranging from benign headache conditions (migraine syndromes) to severely disabling events, such as cerebral ischemia, or even death in people with epilepsy. Although the characteristics and mechanisms of SD have been dissected using a variety of approaches, ranging from cells to human models, this phenomenon remains only partially understood because of its complexity and the difficulty of obtaining direct experimental data. Currently, clinical monitoring of SD is limited to patients who require neurosurgical interventions and the placement of subdural electrode strips. Significantly, SD events recorded in humans display electrophysiological features that are essentially the same as those observed in animal models. Further research using existing and new experimental models of SD may allow a better understanding of its core mechanisms, and of their differences in different clinical conditions, fostering opportunities to identify and develop targeted therapies for SD-related disorders and their worst consequences.

Improvement rate of patients with severe brain injury during post-acute intensive rehabilitation.

Patients with severe acquired brain injury (SABI) may evolve towards different outcomes. The primary aim was to evaluate the clinical evolution of a large population of patients with SABI admitted to post-acute rehabilitation from 2001 to 2016, diagnosed with severe brain injury (GCS ≤ 8) in the acute phase and a coma duration of at least 24 h. The possible changes between the admission time to a post-acute rehabilitation hospital and the discharge time were measured by means of Glasgow Outcome Scale (GOS), Level of Cognitive Functioning (LCF), and Disability Rating Scale (DRS). We also correlated the improvement rate with some sociodemographic and clinical features of the individuals with SABI enrolled. Data of 890 patients were analyzed (54% TBI, length of stay = 162 ± 186 days, GCS = 7.46 ± 1.28); time interval from the SABI (OR = 0.246, CI 95% = 0.181 - 0.333), scores at admission of LCF (OR = 2.243, CI 95% = 1.492 - 3.73), GOS (OR = 0.138, CI 95% = 0.071 - 0.266), DRS (OR = 0.457, CI 95% = 0.330 - 0.632), and etiology (OR = 2.273, CI 95% = 1.676 - 3.084) played a significant role (p < 0.001, explained variance 69.9%) for improving GOS score. Time interval from the SABI to admission in our post-acute rehabilitation ward (OR = 0.300, CI 95% = 0.179 - 0.501, p < 0.001), length of rehabilitation stay (OR = 2.808, CI 95% = 1.694 - 4.653, p < 0.001), and etiology (OR = 1.769, CI 95% = 1.095 - 2.857, p = 0.020) led to a statistically significant improvement in DRS (explained variance 91%). The most significant predictive factors for the outcome of patients with SABI were etiology, time interval from SABI to admission in rehabilitation, and length of rehabilitation stay.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases.

BACKGROUND: Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery. METHODS: In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases. RESULTS AND CONCLUSION: In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Possible Involvement of the CACNA1E Gene in Migraine: A Search for Single Nucleotide Polymorphism in Different Clinical Phenotypes.

OBJECTIVE: To search for differences in prevalence of a CACNA1E variant between migraine without aura, various phenotypes of migraine with aura, and healthy controls. BACKGROUND: Familial hemiplegic migraine type 1 (FHM1) is associated with mutations in the CACNA1A gene coding for the alpha 1A (Cav 2.1) pore-forming subunit of P/Q voltage-dependent Ca2+ channels. These mutations are not found in the common forms of migraine with or without aura. The alpha 1E subunit (Cav 2.3) is the counterpart of Cav 2.1 in R-type Ca2+ channels, has different functional properties, and is encoded by the CACNA1E gene. METHODS: First, we performed a total exon sequencing of the CACNA1E gene in three probands selected because they had no abnormalities in the three FHM genes. In a patient suffering from basilar-type migraine, we identified a single nucleotide polymorphism (SNP) in exon 20 of the CACNA1E gene (Asp859Glu - rs35737760; Minor Allele Frequency 0.2241) hitherto not studied in migraine. In a second step, we determined its occurrence in four groups by direct sequencing on blood genomic DNA: migraine patients without aura (N = 24), with typical aura (N = 55), complex neurological auras (N = 19; hemiplegic aura: N = 15; brain stem aura: N = 4), and healthy controls (N = 102). RESULTS: The Asp859Glu - rs35737760 SNP of the CACNA1E gene was present in 12.7% of control subjects and in 20.4% of the total migraine group. In the migraine group it was significantly over-represented in patients with complex neurological auras (42.1%), OR 4.98 (95% CI: 1.69-14.67, uncorrected P = .005, Bonferroni P = .030, 2-tailed Fisher's exact test). There was no significant difference between migraine with typical aura (10.9%) and controls. CONCLUSIONS: We identified a polymorphism in exon 20 of the CACNA1E gene (Asp859Glu - rs35737760) that is more prevalent in hemiplegic and brain stem aura migraine. This missense variant causes a change from aspartate to glutamate at position 859 of the Cav 2.3 protein and might modulate the function of R-type Ca2+ channels. It could thus be relevant for migraine with complex neurological aura, although this remains to be proven.

Effects of Osteopathic Manipulative Therapy on Pain and Mood Disorders in Patients With High-Frequency Migraine.

CONTEXT: The substantial functional impairment associated with migraine has both physical and emotional ramifications. Mood disorders are often comorbid in patients with migraine and are known to adversely affect migraine activity. OBJECTIVES: To explore the effects of osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) on pain and mood disorders in patients with high-frequency migraine. METHODS: Retrospective review of the medical records of patients with high-frequency migraine who were treated with OMTh at the Headache Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia from 2011 to 2015. Clinical assessments were made using the Headache Disability Inventory (HDI), the Headache Impact Test (HIT-6), the Hamilton Depression Rating Scale (HDRS), and the State-Trait Anxiety Inventory (STAI) forms X-1 and X-2. RESULTS: Medical records of 11 patients (6 women; mean age, 47.5 [7.8] years) with a diagnosis of high-frequency migraine who participated in an OMTh program met the inclusion criteria and were included in the study. When the questionnaire scores obtained at the first visit (T0) and after 4 OMTh sessions (T1) were compared, significant improvement in scores were observed on STAI X-2 (T0: 43.18 [2.47]; T1: 39.45 [2.52]; P<.05), HIT-6 (T0: 63 [2.20]; T1: 56.27 [2.24]; P<.05), and HDI (T0: 58.72 [6.75]; T1: 45.09 [7.01]; P<.05). CONCLUSION: This preliminary study revealed that patients with high-frequency migraine and comorbid mood disorders showed significant improvement after four 45-minute OMTh sessions. Further investigation into the effects of OMTh on pain and mood disorders in patients with high-frequency migraine is needed.

Effect of ethylic alcohol on attentive functions involved in driving abilities.

The burden of injuries due to drunk drivers has been estimated only indirectly. Indeed, alcohol is considered one of the most important contributing cause of car crash injuries and its effect on cognitive functions needs to be better elucidated. Aims of the study were i) to examine the effect of alcohol on attentive abilities involved while driving, and ii) to investigate whether Italian law limits for safe driving are sufficiently accurate to prevent risky behaviours and car crash risk while driving. We conducted a cross-over study at IRCCS Fondazione Santa Lucia Rehabilitation Hospital in Rome. Thirty-two healthy subjects were enrolled in this experiment. Participants were submitted to an attentive test battery assessing attention before taking Ethylic Alcohol (EA-) and after taking EA (EA+). In the EA+ condition subjects drank enough wine until the blood alcohol concentration, measured by means of Breath Analyzer, was equal to or higher than 0.5 g/l. Data analysis revealed that after alcohol assumption, tonic and phasic alertness, selective, divided attention and vigilance were significantly impaired when BAC level was at least 0.5 g/l. These data reveal that alcohol has a negative effect on attentive functions which are primarily involved in driving skills and that Italian law limits are adequate to prevent risky driving behaviour.

Vegetative state, minimally conscious state, akinetic mutism and Parkinsonism as a continuum of recovery from disorders of consciousness: an exploratory and preliminary study.

The aim of this study was to review the usefulness of clinical and instrumental evaluation in individuals with disorders of consciousness (DOC). Thirteen subjects with severe acquired brain injury (ABI) and a diagnosis of DOC were evaluated using the Coma Recovery Scale in its revised version (CRS-R) and a new global disability index, the Post-Coma Scale (PCS). These instruments were administered both by a neutral examiner (professional) and by a professional in the presence of a caregiver. All patients were also scored using the International Classification of Functioning, Disability and Health (ICF). A statistically significant correlation between CRS-R and PCS was demonstrated. However, there also emerged significant differences in responsiveness between professional versus caregiver+professional assessment using the two scales. The emotional stimulation provided by significant others (caregivers) during administration of DOC evaluation scales may improve the assessment of responsiveness.

The interplay of two single nucleotide polymorphisms in the CACNA1A gene may contribute to migraine susceptibility.

Migraine is a common disorder with a significant genetic component. Mutations in the CACNA1A gene are found in hemiplegic migraine (HM). Basilar-type (BM), another subtype of migraine with aura, differs from HM only by the absence of motor deficits. BM and HM may thus share common genetic features. In the present study, two single nucleotide polymorphisms (SNPs) of the CACNA1A gene were characterized in a population of migraine patients and healthy controls. The polymorphisms, E918D, predicting a glutamic acid-to-aspartic acid substitution at codon 918 and E993V, predicting a glutamic acid-to-valine substitution at codon 993, were frequently detected among patients and controls. Seven BM, 10 SHM, 5 FHM, 57 migraine with typical aura, 32 migraine without aura patients and 107 healthy controls were screened. The E918D and E993V SNPs were found in 30/117 (25.6%) and 32/117 (27.3%) migraine patients, respectively. The prevalence of these SNPs taken separately was not significantly different from that of control subjects (n=28/107, 26.2% for E918D; n=29/107 for E993V, 27.1%) neither for the total migraine population nor for the various migraine subtypes. By contrast, coexistence of both SNPs was more frequent in migraineurs (25/117, 21%) than in healthy controls (12/107, 11%; p=0.048), a difference that was significant for every migraine subtype. This result suggests that the interplay of minor genetic variants such as single nucleotide polymorphisms may influence the P/Q-type calcium channel function in several subtypes of migraine.

Blink reflex changes in parkinsonism following severe traumatic brain injury correlates with diffuse axonal injury.

BACKGROUND: Survivors of severe traumatic brain injury (TBI) may show transient or persistent extrapyramidal symptoms such as rigidity, akinesia and parkinsonian posture, associated with hypomimia, not estinguishable glabellar tap reflex, seborrhea and hypersalivation. The Blink Reflex (BR), an electrically-induced reflex, is abnormal in Parkinson's disease (PD) and in some parkinsonisms. The aim of the study was to investigate BR habituation and its recovery cycle in survivors of severe TBI suffering from parkinsonian syndrome and the possible correlation with neuroimaging findings. MATERIAL/METHODS: Twenty-three patients (18 males, 5 females; mean age 23.7 years, range 13-35), who sustained a severe TBI, (Glasgow Coma Scale or GCS, lower than 8 in the first 48 hours), and followed by coma for a duration equal or longer than 15 days, were studied during the post-acute or chronic phase. Enrollement criteria include the presence of at least 3 extrapyramidal symptoms. BR was elicited by electrical stimulation of the supraorbital nerve and responses were recorded with surface electrodes from the orbicularis oculi muscle ipsilateral to the stimulation. A repeated series of 10 electrical stimuli was applied at the frequencies of stimulation of 0.3, 0.5, 0.7, 1.0, 1.5, 2.0 and 3.0 Hz, respectively. Values between 0.5 and 1 Hz were considered as normal, according to the international literature, Cerebral Magnetic Resonance (C-MRI), with fast sequences was performed within 3 months after brain injury. Ten healthy subjects, age and sex matched, served as controls and underwent the same procedure. RESULTS: Nineteen of the twenty-three patients (82.6%) showed a significantly reduced BR habituation in comparison with controls. This findings highly correlated with C-MRI diagnosis of Diffuse Axonal Injury (DAI). A normal BR habituation was found in only 4 out of 23 patients (17%). In these subjects, C-MRI revealed focal lesions rather than DAI. CONCLUSIONS: BR changes correlate with parkinsonian signs and neuroimaging findings. BR may have a role as a diagnostic tool in post-traumatic parkinsonism and as a prognostic tool to evaluate the effect of therapeutic options.

Symptomatic cluster-like headache triggered by forehead lipoma: a case report and review of the literature.

We describe the case of a patient with symptomatic strictly unilateral paroxysmal headache mimicking cluster headache related to an ipsilateral forehead lipoma. Interestingly, immediately after the surgical excision of the lipoma pain attacks disappeared with no recurrence during a follow-up period of 18 months. Like other descriptions of cluster-like headaches secondary to extracranial lesions, this case report focuses on the hypothetical role of a peripheral trigger factor for trigeminal autonomic cephalgias (TACs). To our knowledge, this is the first well-described cluster-like headache case secondary to an extracerebral lipoma. This case offered the opportunity to discuss the possible pathophysiological mechanisms underlying probable TACs and the relationship with peripheral extracerebral activation of the trigeminal-autonomic reflex.

ATP1A2 gene mutations are not present in two sisters with basilar-type migraine associated with menses.

Basilar-type migraine (BM) and hemiplegic migraine are clinically distinct subtypes of migraine with aura, however they do share clinical features and it is possible they may share genetic bases. In recent years, ATP1A2 and other gene mutations have been discovered in familial and sporadic hemiplegic migraine. More recently, an ATP1A2 mutation has been identified in an Italian family with BM. In this study we document the absence of ATP1A2 mutations in two Italian sisters with menstrual BM, suggesting that other genes are involved in the condition.