[Migraine during pregnancy and lactation: treatment of the acute attack and non-pharmacological prophylactic strategies]. / L'emicrania in corso di gravidanza e allattamento: trattamento dell'attacco acuto e strategie non farmacologiche di profilassi.

Migraine is a typical "women's disease": the fluctuations of sex hormones, in particular estrogens, during woman's reproductive life show a direct and major influence on migraine course. Even if during pregnancy a high percentage of migraineurs report an improvement of symptomatology, it is still controversial how to manage migraine crises occurring during pregnancy, considering that almost all drugs are partially or totally contraindicated during gestation. The most important drugs employed in acute attack management (triptans, non steroidal anti-inflammatory drugs, analgesics, antiemetics, ergot derivatives and combination products) are reviewed and the indications and contraindications of their use during the 3 trimesters of pregnancy and during lactation, taking into consideration the indications of the Food and Drug Administration and of the American Academy of Pediatrics, are analysed. Furthermore, the therapeutic effects of the 2 most important non pharmacological therapies used for migraine prophylaxis, biofeedback and acupuncture, are discussed. For this latter therapy, the personal preliminary positive experience using a predetermined formula of acupoints for the combined treatment of migraine and hyperemesis gravidarum is reported.

[Acupuncture in labor management]. / L'agopuntura nella gestione del travaglio di parto.

Acupuncture is being increasingly used in Western medical practice. The various applications of acupuncture during labor are reviewed in this paper. This ancient therapeutic technique can be employed with a significant percentage of positive results to induce labor in post-term pregnancies, to strengthen uterine contractility and to favour cervical maturation. The acupoints LI 4 Hegu e SP 6 Sanyinjiao electrostimulated are those more frequently used in labor induction and in increasing the frequency and duration of uterine contractions. Moreover, our experience indicates that the acupoint BL 67 Zhiyin can be helpful in accelerating the dilation of the cervix: the treatment is effective in about 75% of patients. The studies on the use of acupuncture to achieve pain relief and analgesia during labor show more controversial results, mainly due to the great heterogeneity of applied treatments and some methodological biases. Nevertheless, the general evidence seems to be positive also for this application.

Pathophysiological aspects of menstrual migraine.

We review the role of several biochemical and hormonal factors in menstrual migraine pathogenesis: ovarian hormones, aldosterone circadian rhythm, nocturnal urinary melatonin excretion, sympathetic autonomic system, prolactin levels and dopaminergic function, endogenous opioid tonus, platelet activity and arachidonic acid metabolites. In particular, we focus on certain aspects of platelet function and prostaglandin metabolism, taking into consideration the different behavior of platelet sensitivity to prostacyclin, intraplatelet 5HT, peripheral plasma concentrations of 6-keto-PGF1alpha and PGE2 in menstrual migraine sufferers and in control subjects during the menstrual cycle. A comprehensive view of the data suggests that a complex impairment of PG and 5HT metabolism, and of platelet function, may play a significant role in the pathogenesis of menstrual migraine. However, it is not yet clear whether these alterations are primary or secondary to neuroendocrine disorders.

Patterns of platelet aggregation in menstrual migraine.

We investigated the threshold of the platelet release reaction during the luteal phase of the cycle in 46 patients suffering from menstrual migraine (MM) and 27 healthy normal women. The distribution in both groups of the three types of aggregometric curves (types 1, 2 or 3) obtained in response to ADP 1 microM as aggregating agent was evaluated. Among MM sufferers, 19 (41%) showed a type 1 curve, while 14 (31%) had a type 2 curve and 13 (28%) showed an irreversible aggregation with a type 3 pattern. Curve distribution in controls was 18 (67%) for type 1, 8 (30%) for type 2 and 1 (3%) for type 3. A significantly (p < 0.05) different distribution of the three curve types between MM and controls was present, suggesting that a secondary wave of aggregation is more frequent in MM; the highest difference was due to the observed frequencies of type 3 curves.