Post-traumatic headache: from classification challenges to biological underpinnings.

The ICHD-II criteria for post-traumatic headache (PTH) are strictly outlined. PTH can be subdivided into an acute and a chronic forms, the former likely nociceptive in nature, the latter likely neuropathic. The time of transition between the acute and the chronic forms is artificial and in the future should be better based on clear clinical or rather biological data. Chronic PTH often presents as one of the primary headache syndromes, e.g. migraine or tension-type headache. Its biology is poorly understood and whether it merely represents the expression of the primary headache or it has a distinct pathogenesis remains unclear. The frontal lobe is often affected in traumatic head injury. Its dysfunction can cause an array of clinical consequences that have an impact on the patient's symptomatology and therapeutic outcome. Its recognition is likely to improve patient management quality.

Medication overuse headache.

Medication overuse headache is a common feature underlying chronic headache, especially migraine. It also represents a major therapeutic challenge, especially in headache specialty clinics where it can represent the majority of patients. The syndrome remains under-diagnosed and the role of symptomatic medication overuse underestimated. Physicians should be properly educated in this area of pain, for prevention of this too often intractable syndrome could be improved. The basis of therapy is discontinuance of the abused medication. Additional treatment relies on a multifaceted approach that embraces management of psychiatric comorbidities and emphasizes patient education. Various pharmacological regimens, abortive and prophylactic, are available. Further scientific study is warranted to elucidate the ultimate mechanisms of this syndrome and define more effective treatments. This article gives detailed clinical description, tentative pathophysiologic explanation and therapeutic suggestions.

Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial.

A deficit of mitochondrial energy metabolism may play a role in migraine pathogenesis. We found in a previous open study that high-dose riboflavin was effective in migraine prophylaxis. We now compared riboflavin (400 mg) and placebo in 55 patients with migraine in a randomized trial of 3 months duration. Using an intention-to-treat analysis, riboflavin was superior to placebo in reducing attack frequency (p = 0.005) and headache days (p = 0.012). Regarding the latter, the proportion of patients who improved by at least 50%, i.e. "responders," was 15% for placebo and 59% for riboflavin (p = 0.002) and the number-needed-to-treat for effectiveness was 2.3. Three minor adverse events occurred, two in the riboflavin group (diarrhea and polyuria) and one in the placebo group (abdominal cramps). None was serious. Because of its high efficacy, excellent tolerability, and low cost, riboflavin is an interesting option for migraine prophylaxis and a candidate for a comparative trial with an established prophylactic drug.

[Late form with psychiatric presentation of Wilson's disease, with pseudo-compulsive stereotyped movements. Neuro-radiological correlations]. / Forme tardive à présentation psychiatrique de la maladie de Wilson, avec mouvements stéréotypés pseudo-compulsifs. Corrélations neuro-radiologiques.

Wilson's disease rarely starts after the third decade and may present with misleading psychiatric signs. We observed a 39-year-old white male who developed hysterical behaviour followed by frank delusional psychosis. Secondary neurological symptoms like astasia and dyarthria were misinterpreted as drug-induced. Despite a treatment with D-penicillamine and zinc sulfate there was further deterioration with anarthria and pseudo-compulsive stereotypies. These latter signs cleared after five months, whereas astasia and abasia remained the same and MRI imaging showed further deterioration characterized by marked bilateral putaminal cavitation. SPECT imaging could not predict the clinical evolution. Our case emphasizes that Wilson's disease can have variable initial presentations, and confirms the relationship between pseudo-compulsive stereotypies and bilateral lenticular lesions, as already described in other diseases of the basal ganglia.

Sodium valproate in severe migraine and tension-type headache: an open study of long-term efficacy and correlation with blood levels.

We performed an open prospective study of the prophylactic efficacy of sodium valproate in 56 patients among which 35 migraineurs, 7 chronic tension-type headache patients and 14 patients with combined headaches. We compared the mean number of headache days per month during a one-month-baseline period without prophylactic treatment and during the last month of a 6-month-treatment course. Among secondary parameters, we assessed headache intensity, adverse experiences and we measured valproate blood levels after one and after six months of treatment. Sixty percent of migraineurs had a 75% or more improvement in the number of headache days under sodium valproate, most of the remaining attacks being less severe. There was no significant improvement in chronic tension-type headache patients and only a mild effect in patients with combined headaches, almost exclusively on the migraine component. Thirty percent of patients reported adverse effects of which none was serious: there were 3 drop-outs. We found a moderate, but statistically significant, correlation between efficacy and blood levels of sodium valproate.

High-dose riboflavin as a prophylactic treatment of migraine: results of an open pilot study.

If the brain of migraineurs is characterized between attacks by a reduction of mitochondrial phosphorylation potential, riboflavin, which has the potential of increasing mitochondrial energy efficiency, might have prophylactic effects in migraine. In this preliminary open pilot study, 49 patients suffering from migraine (45 without aura, 4 with aura) were treated with 400 mg of riboflavin as a single oral dose for at least 3 months. Twenty-three patients received in addition 75 mg of aspirin. Mean global improvement after therapy was 68.2% and there was no difference between the two groups of patients. With the exception of one patient in the riboflavin plus aspirin group who withdrew because of gastric intolerance, no drug-related side effects were reported. High-dose riboflavin could thus be an effective, low-cost prophylactic treatment of migraine devoid of short-term side effects. A placebo-controlled trial of its efficacy seems worthwhile.

No significant effect of an "atraumatic" needle on incidence of post-lumbar puncture headache or traumatic tap.

We compared the incidence of post-lumbar puncture headache and of red blood cells in the first CSF sample (traumatic tap) in 35 inpatients punctured with a standard 20 G Yale needle and in 26 patients punctured with Sprotte's "atraumatic" needle. No significant difference was found between the two groups in incidence of headache or in frequency of traumatic taps.

Blood magnesium levels in migraine.

Serum and erythrocyte magnesium levels were screened between attacks in patients with migraine without aura (n = 38) and with aura (n = 6), and for comparison in a group of patients suffering from chronic tension-type headache (n = 25) as well as a group of neurological, non-headache patients (n = 19). Serum magnesium levels were not significantly different between the four groups of patients. In contrast, magnesium in erythrocytes was on average significantly reduced in patients with migraine without aura compared to the other groups. It is hypothesized that this reduction might be due to an abnormal regulation of intracellular magnesium possibly reflecting at the periphery changes observed in the brain of migraineurs.

[Cholinergic and adrenergic innervation of the bladder obstructed by urethral stenosis in the rat]. / L'innervation cholinergique et adrénergique de la vessie obstruée par sténose de l'urètre chez le rat.

In the obstructed bladder by urethral stenosis the morphometry studies show a decrease of the cholinergic and adrenergic intrinsic innervation in a different way according the tissue layer and the experimental delay. Adrenergic nerves are more affected than cholinergic ones but they recover more quickly. In the adventitia and the sub-mucosa first affected by the high pressures inside the bladder the density of the autonomous nerves decreases from the first week. The perivascular and muscular nervous fibers are less sensitive and the similar shape of their innervation histogram gives evidence of a tight bond between their adrenergic network. Beside their motor participation the adrenergic terminal fibers may play a role in the cellular trophicity of the muscle.