Headache attributed to intracranial pressure alterations: applicability of the International Classification of Headache Disorders ICHD-3 beta version versus ICHD-2.

The association between headache and changes in intracranial pressure is strong in clinical practice. Syndromes associated with abnormalities of cerebrospinal fluid (CSF) pressure include spontaneous intracranial hypotension (SIH) and idiopathic intracranial hypertension (IIH). In 2013, the Headache Classification Committee of the International Headache Society (IHS) published the third International Classification of Headache Disorders (ICHD-3 beta version). The aim of this study was to investigate applicability of the new ICHD-3 versus ICHD-2 criteria in a clinical sample of patients with intracranial pressure (ICP) alterations. Patients admitted at our Headache Center for headache evaluation in whom a diagnosis of ICP alterations was performed were reviewed. 71 consecutive patients were studied. 40 patients (Group A) were diagnosed as IIH, 22 (Group B) as SIH, 7 (Group C) and 2 (Group D), respectively, as symptomatic intracranial hypertension and symptomatic intracranial hypotension. Main headache features were: in Group A, daily or nearly-daily headache (100 %) with diffuse/non-pulsating pain (73 %), aggravated by coughing/straining (54 %) and migrainous-associated symptoms (43 %). In Group B, an orthostatic headache (100 %) with nausea (29 %), vomiting (24 %), hearing disturbance (33 %), neck pain (48 %), hypacusia (24 %), photophobia (22 %) was reported. In Group C, a diffuse non-pulsating headache was present in 95 % with vomiting (25 %), sixth nerve palsy (14 %) and tinnitus (29 %). In Group D, an orthostatic headache with neck stiffness was reported by 100 %. Regarding applicability of ICHD-2 criteria in Group A, 73 % of the patients fitted criterion A; 100 %, criterion B; 100 %, criterion C; and 75 %, criterion D; while applying ICHD-3 beta version criteria, 100 % fitted criterion A; 97.5 %, criterion B; 100 %, criterion C; and 100 %, criterion D. In Group B, application of ICHD-2 showed 91 % patients fitting criterion A; 100 %, criterion B; 100 %, criterion C; and 68 %, criterion D; while applying ICHD-3 beta version all patients, 100 % fitted criterion A, B, C, D. 73 % patients of Group A fitted all ICHD-2 criteria and 97.5 % all ICHD-3 beta version criteria for headache attributed to IIH. 68 % patients of Group B fitted all ICHD-2 criteria and 100 % all ICHD-3 beta version criteria for headache attributed to SIH. In Group C and Group D, although patients fitted some clinical criteria, the underlying disorder caused exclusion of both ICHD-2 and ICHD-3 beta version applicability for headache attributed to IIH and SIH; they were coded in criteria for the secondary headaches. In summary, ICHD-3 beta version seems to have better applicability but worse reliability in defining headache features in CSF alterations.

Study of parafunctions in patients with chronic migraine.

The purpose of this paper is to present the results of a questionnaire investigating parafunctions (particularly clenching and grinding) in patients with chronic migraine presenting sign of temporomandibular disorder. The questionnaire was elaborated by the Dental Clinic of the University of Milano and completed by 125 patients experiencing chronic migraine and attending the Neurological Institute Carlo Besta for an inpatient withdrawal protocol to treat medication overuse. Our results showed high percentages of parafunctions, which were present in 80 % of patients. We note that patient information on possible behaviours and coexisting conditions which may be involved in the mechanisms of chronic headaches, as well as education about these factors, are crucial aspects in the management of chronic headache patients. We suggest that patients suffering from chronic migraine with medication overuse headache should be evaluated in relation to the possible presence of parafunctions, and as far as the need for interocclusal devices, in order to limit the role of temporomandibular dysfunctions as trigger factors or coexisting conditions favouring the development/maintaining of headache chronification.

Efficacy of frovatriptan and other triptans in the treatment of acute migraine of hypertensive and normotensive subjects: a review of randomized studies.

Migraine might be associated with high blood pressure (BP), which can cause more severe and more difficult to treat forms of headache. To evaluate the efficacy of frovatriptan and other triptans in the acute treatment of migraine, in patients classified according to a history of arterial hypertension, enrolled in three randomized, double-blind, crossover, Italian studies. Migraineurs with or without aura were randomized to frovatriptan 2.5 mg or rizatriptan 10 mg (study 1), frovatriptan 2.5 mg or zolmitriptan 2.5 mg (study 2), frovatriptan 2.5 mg or almotriptan 12.5 mg (study 3). After treating up to three episodes of migraine in 3 months with the first treatment, patients switched to the alternate treatment for the next 3 months. The present analysis assessed triptan efficacy in 60 subjects with a history of treated or untreated essential arterial hypertension (HT) and in 286 normotensive (NT) subjects. During the study, migraine attacks with aura were significantly more prevalent in HT subjects (21 vs. 13 % NT, p < 0.001). The proportion of pain free at 2 h did not significantly differ between HTs and NTs for either frovatriptan (25 vs. 26 %) or the comparators (33 vs. 32 %). Pain relief was achieved in significantly (p < 0.05) fewer episodes in HT subjects for both frovatriptan (41 vs. 52 % NT) and the comparators (48 vs. 58 %). Relapses at 48 h were similarly low in HTs and NTs with frovatriptan (29 vs. 31 %), while they were significantly (p < 0.05) larger in HTs (62 %) than in NTs (44 %) with comparators. No BP or heart rate increment was observed during the study in HT subjects. No difference in tolerability was reported between HTs and NTs. In conclusion, HT individuals tend to be less responsive than NT migraineurs to triptan therapy. However, frovatriptan, in contrast to other triptans, seems to have a sustained antimigraine effect in both HT and NT patients.

Headache as presenting symptom of neurosarcoidosis.

Headache may occur in neurosarcoidosis and diagnostic criteria are given in the International Classification of Headache Disorders (ICHD-II). We present a case series of patients suffering from neurosarcoidosis in whom headache was the presenting symptom. The aim of the present study was to analyze the possible clinical presentations and the corresponding cerebral lesions in a retrospective chart review of patients suffering from neurosarcoidosis in whom headache was the presenting symptom. Medical records and data of six patients were analyzed. The possible diagnoses of headache forms included in ICDH-II, and in particular the correspondence with the criteria for "headache attributed to neurosarcoidosis", as well as neuroimaging findings were evaluated in each patient. The ICHD-II criteria were fulfilled in all the six patients. As for as clinical presentation, in three patients (50 %), headache had the clinical characteristics of Tolosa-Hunt syndrome, with evidence of a lesion into the cavernous sinus. In the remaining three cases headache was the only neurological symptom found in association with systemic features of sarcoidosis, and had the clinical features of tension-type headache. Our findings confirm that the clinical features of headache in patients with this disorder may have different presentations, which depend on neuropathologic involvement. Thus, a detailed neuroimaging study and CSF evaluation are needed to confirm diagnosis, particularly in patients with no sign of systemic sarcoidosis or in those in whom head pain may mimic a primary headache syndrome.

Psychopathological profile of patients with chronic migraine and medication overuse: study and findings in 50 cases.

Patients with chronic migraine (CM) have high frequence of psychiatric comorbidity or psychological distress. The presence of depression, anxiety, panic or obsessive disorders in these patients contributes to poor quality of life and can influence prognosis and treatment. A systematic investigation of psychiatric comorbidity is needed in patients with CM especially in those with medication overuse (MO), in order to reach a more comprehensive clinical management. We assessed the psychological profile of 50 patients, 40 women and 10 men suffering from CM with MO. The Spectrum Project, a complementary way of describing and assessing psychopathology with structured clinical interviews, was used for the psychological evaluation of the patients to explore personality traits. Spectrum instruments mood disorders (MOODS), panic agoraphobic disorders (PAS) and obsessive-compulsive disorder (OBS) were applied to study patients. OBS-questionnaire was positive in 28% of the patients, MOODS-questionnaire in 44%, PAS-questionnaire in 46%. 19 on 50 patients (38%) presented positivity to 2 or to all questionnaires in variable associations. None of the patients of the studied group had complete normal findings in the questionnaires. Clinical records of patients with OBS-questionnaire positivity showed a worse clinical course and tendency to relapse. These results suggest that psychological assessment is an essential step in the evaluation and treatment of patients with CM and MO. The remarkable percentage of OBS-questionnaire positivity in this group indicates that obsessive-compulsive trait represents besides depression and anxiety, a major risk of chronification and overusing.

Painful ophthalmoplegia: a retrospective study of 23 cases.

Painful ophthalmoplegia is a rare pathologic condition caused by non-specific inflammation of the cavernous sinus, but other causes such as tumours, vasculitis, basal meningitis, neurosarcoidosis, diabetes can be responsible for the syndrome. Aim of this study is a review of the cases of painful ophthalmoplegia admitted to our Institute in the last 20 years in order to verify the incidence of symptomatic versus benign forms in a clinical case series, with particular focus on the cases in which a long term (at least 4 years) and detailed follow-up did not revealed spread of any systemic disease or other presumed causes for painful ophthalmoplegia. Twenty-three patients were retrospectively studied, 12 patients (52%) were classified as benign forms and their disease course was again evaluated and 11 cases (48%) were designated as symptomatic. The present study suggests that in the clinical practice the incidence of benign forms among the painful ophthalmoplegias is more elevate than the symptomatic ones and underlines the need of a specific nosography for benign forms.

The patient with medication overuse: clinical management problems.

Patients with chronic headache arise many problems in clinical management, often strictly related to medication overuse. IHS classification did not clear the different clinical presentation and a chapter dedicated to this problem is lacking. This condition is very frequently associated with psychiatric illness, so that the clinical features become more complex over the years. Most of patients share a past clinical condition of episodic migraine; this aspect is very important facing the therapeutical phase, because after discontinuing medication overuse, if present, the treatment must be direct toward this disease. To treat a patient with analgesic, or ergotamine, or triptan abuse, require much caution because stopping the drug may arise new problems, such as different headache, abstinence syndrome, epileptic seizures etc. We review the different possibility that we have to manage the overuser patient.

Double blind comparison of lithium and verapamil in cluster headache prophylaxis.

Chronic Cluster Headache (CCH) treatment is troublesome; since there are no pain-free periods, it must be continuous. The most effective CCH prophylactic drug today is lithium carbonate but long-term use of this drug is limited by the possibility of side effects. Recently, calcium antagonists have been successfully employed to prevent migraine, and preliminary studies also indicate that verapamil in particular is an efficacious treatment for CCH. We have conducted a multicenter trial employing a double-dummy, double blind, cross-over protocol, comparing verapamil with the established efficacy of lithium carbonate, in preventing CCH attacks. Both lithium carbonate and verapamil were effective in preventing CCH but verapamil caused fewer side effects and had a shorter latency period. We did not observe any correlation between plasma levels of the two drugs and their clinical efficacy. Both the drugs tested here may exert their effect by restoring a normal inhibitory tone to the pain modulating pathways from the trigemino-vascular system, a circuit putatively implicated in CCH.

Calcium entry blocker: treatment in acute pain in cluster headache patients.

15 chronic cluster headache patients in whom pain was induced by nitroglycerin received acute intravenous treatment with a calcium entry blocker. At the time of peak pain we noted a sudden decrease after the Verapamil injection. The mechanism by which the calcium entry blocker afforded relief is unlikely to have been vasodilatation in patients whose blood vessels had just been dilated by nitroglycerin. A more probable mechanism is blockade of the release of the pain-inducing neurotransmitters. The vasodilatation phase is not a primary factor in the onset of pain.

Cryptococcal meningoencephalitis. Case report and review of Italian literature.

A case of cryptococcal meningoencephalitis, as presented by a hypertensive hydrocephalus, is described. To our knowledge, this is the 24th case described in Italy since 1953. The diagnosis was made with ventricular fluid examination: the patient was successfully treated with amphotericin B and 5-fluorocytosine, thus avoiding the risks of surgical treatment of hydrocephalus. Early diagnosis and proper therapy are necessary in order to decrease the high lethality of cryptococcosis.

Clinical usefulness of a dopaminergic agonist in headache diagnosis.

The dopaminergic system seems to be involved in pain modulation. In a 1983 publication, the administration of a dopaminergic agonist has been proposed as a test able to distinguish migraine from other cephalalgia. In the present study, 123 people were tested, 102 of them being migraine patients and the others being normal subjects. The test showed highly specificity for headache patients when compared to normal subjects, and was highly specific for migraine patients when compared to headache patients. Data are discussed considering the clinical diagnostic value, pathophysiological and therapeutic aspects.