Real-World Evaluation of the Tolerability to Onabotulinum Toxin A: The RETO Study.

Onabotulinumtoxin A (onabotA) has shown efficacy in chronic migraine (CM), with good tolerability and a low rate of adverse effects, most of them not severe. The aim of this study is to evaluate tolerability and adverse effects of onabotA in clinical practice and to analyze if there is a relationship between tolerability to treatment administration, adverse effects' (AEs) occurrence and clinical response. We included patients with CM that received treatment with onabotA for the first time. Tolerability to treatment was evaluated by a 0-10 numeric rating scale (0: worst possible, 10: optimal tolerability). We assessed the presence of AEs by using a standardized questionnaire. Treatment response was based on the 50 and 75% responder rate between weeks 20 and 24, compared with the baseline, according to headache diaries. We analyzed whether the tolerability was associated with a higher frequency of AEs or a higher probability of clinical response. We included 105 patients, 87.7% female, with an age of 43.9 ± 10.7 years. Mean tolerability was 7.8/10 and 7.2/10 in the first and second onabotA administration, respectively. AEs were reported by (first-second) 71.4-68.6% patients. The percentage of patients with a 50% response was 56.3%. There was no association between tolerability and AEs' occurrence or clinical response.

Epicrania fugax combining forward and backward paroxysms in the same patient: the first four cases.

BACKGROUND: The first description of epicrania fugax (EF) reported brief painful paroxysms that start in posterior regions of the scalp and move forward to reach the ipsilateral forehead, eye, or nose. A backward variation, wherein pain stems from frontal areas and radiates to the posterior scalp, has also been acknowledged. We report four patients with features reminiscent of EF and the coexistence of forward and backward pain paroxysms. METHODS: We considered all patients attending the headache outpatient office at two tertiary hospitals from March 2008 to March 2016. We enrolled four patients with paroxysms fulfilling criteria for EF and a combination of forward and backward radiations. RESULTS: In all cases, pain paroxysms moved both in forward and backward directions with either a zigzag (n=2) or linear (n=2) trajectory. Three patients presented two stemming points, in the occipital scalp and forehead (n=2) or in the parietal area and eye (n=1), whereas the fourth patient only had a stemming point located in the parietal region. Pain quality was mainly stabbing, and its intensity was moderate (n=1) or severe (n=3). The duration of the paroxysms was highly variable (3-30 seconds), and two patients reported autonomic symptoms. CONCLUSION: The clinical picture presented by our patients does not fit with other types of known headache or neuralgia syndromes; we propose it corresponds to a bidirectional variant of EF.

[Personality traits in patients with chronic migraine: a categorial and dimensional study in a series of 30 patients]. / Rasgos de personalidad en migraña crónica: estudio categorial y dimensional en una serie de 30 pacientes.

INTRODUCTION: The pathogenic role of personality in migraine has not yet been defined. It can be studied by means of dimensional or categorial measurement instruments, although there is no agreement as to the most suitable approach in this respect either. AIM: To analyse the personality of patients with chronic migraine from the dimensional and categorial point of view. PATIENTS AND METHODS: We used the Salamanca questionnaire as our categorial test and, as the dimensional test, we employed the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Mood disorders were evaluated with the hospital anxiety and depression scale and the impact of migraine was determined by means of the Headache Impact Test-6 (HIT-6). RESULTS: We included 30 patients (26 females), with a mean age of 40.7 ± 9.6 years. One case (3.3%) presented criteria for depression and four (13.3%) for anxiety. In the Salamanca test, the most common personality traits were those included within cluster C: anankastic (n = 28; 93.3%), anxious (n = 18; 60%) and dependent (n = 7; 23.3%). On the MMPI-2, 16 patients (53.3%) fulfilled criteria for hypochondria; 7 (23.3%) for depression; and 10 (33.3%) for hysteria, which are traits included within the neurotic triad. A pattern called 'conversion V' was observed. No correlation was found between the personality traits and the length of time with chronic migraine, the intensity measured by HIT-6 or the excessive use of symptomatic medication. CONCLUSIONS: In the analysis of the personality in chronic migraine, what stood out from the dimensional point of view was neuroticism and as regards the categorial perspective, the obsessive-compulsive or anankastic trait was the most salient. More extensive series need to be conducted, together with comparisons with episodic migraine and population control.

TITLE: Rasgos de personalidad en migraña cronica: estudio categorial y dimensional en una serie de 30 pacientes.Introduccion. El papel patogenico de la personalidad en la migraña no esta definido. Para su estudio se pueden utilizar instrumentos de medida dimensional o categorial, sin que haya tampoco acuerdo acerca del abordaje mas adecuado. Objetivo. Analizar la personalidad de pacientes con migraña cronica desde el punto de vista dimensional y categorial. Pacientes y metodos. Como test categorial utilizamos el cuestionario Salamanca, y, como dimensional, el Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Evaluamos trastornos del animo con la escala de ansiedad y depresion hospitalaria y el impacto de la migraña mediante el Headache Impact Test-6 (HIT-6). Resultados. Incluimos 30 pacientes (26 mujeres), con una edad media de 40,7 ± 9,6 años. Un caso (3,3%) presentaba criterios de depresion, y 4 (13,3%), de ansiedad. En el test Salamanca, los rasgos de personalidad mas frecuentes fueron los integrados en el cluster C: anancastico (n = 28; 93,3%), ansioso (n = 18; 60%) y dependiente (n = 7; 23,3%). En el MMPI-2, 16 pacientes (53,3%) cumplian criterios de hipocondria; 7 (23,3%), de depresion, y 10 (33,3%), de histeria, rasgos integrados en la triada neurotica. Se objetivo una configuracion denominada 'conversiva V'. No hallamos correlacion entre los rasgos de personalidad y el tiempo de migraña cronica, la intensidad medida por el HIT-6 o el uso excesivo de medicacion sintomatica. Conclusiones. En el analisis de la personalidad en la migraña cronica destaca, desde el punto de vista dimensional, el neuroticismo, y respecto al categorial, el rasgo obsesivo-compulsivo o anancastico. Es necesario el estudio de series mas extensas y la comparacion con pacientes con migraña episodica y poblacion control.

[Email in a dedicated headache clinic: experience gained over a five-year period]. / Correo electronico de una consulta monografica de cefaleas: experiencia durante cinco años.

INTRODUCTION: The use of email can facilitate communication between the different levels of an organisation. Our primary care physicians have had an email service in the dedicated headache clinic (DHC) since November 2009, and our aim is therefore to analyse the use of email over that five-year period. PATIENTS AND METHODS: Data concerning the emails sent up until October 2014 were collected prospectively. The questions were classified as need for referral to the DHC (group 1), progress made by the cases seen in the DHC (group 2), training in headaches (group 3) or the treatment of the headaches suffered by primary care physicians themselves as patients (group 4). RESULTS: A total of 274 email messages were analysed. Monthly consultations have increased (from 1.5 per month during the first year to 7.5 per month during the fifth). Findings showed that 10.2% of the email messages came from rural health centres and 89.8% were sent from urban health centres. Replies were sent within 2 ± 2.8 days (range: 0-24 days). Altogether 130 consultations were classified as belonging to group 1 (47.4%), in which referral through the normal channel was recommended in 60 cases (46.2%), via the preferential channel in 47 (36.2%) and non-referral was suggested in 23 cases (17.6%). Group 2 included 125 emails (45.7%) and in 80 cases there was no need to make a new appointment or to bring forward the existing one (64%). Thirteen visits (4.7%) were classified into group 3 and six (2.2%) in group 4. CONCLUSIONS: Our primary care physicians are using the email of the DHC on an increasingly more frequent basis. Its use makes it possible to detect patients whose appointment -whether the first or a follow-up- needs to be brought forward, as well as allowing issues to be solved without the need for referral. It is effective for the treatment of physicians who themselves have headaches and as a tool for continuing education.

TITLE: Correo electronico de una consulta monografica de cefaleas: experiencia durante cinco años.Introduccion. El correo electronico puede facilitar la comunicacion entre niveles. Nuestros medicos de atencion primaria disponen del correo de la consulta monografica de cefaleas (CMC) desde noviembre de 2009, por lo que se pretende analizar la utilizacion del correo electronico durante cinco años. Pacientes y metodos. Recogimos prospectivamente datos de los correos enviados hasta octubre de 2014. Las preguntas se clasificaron en necesidad de derivacion a la CMC (grupo 1), evolucion de casos atendidos en la CMC (grupo 2), formacion en cefaleas (grupo 3) o tratamiento de la cefalea padecida por el propio medico de atencion primaria como paciente (grupo 4). Resultados. Analizamos 274 correos. Las consultas mensuales se han incrementado (de 1,5 al mes durante el primer año a 7,5 al mes durante el quinto). El 10,2% de los correos provenia de centros de salud rurales y el 89,8% de centros de salud urbanos. Se contestaron en 2 ± 2,8 dias (rango: 0-24 dias). En el grupo 1 se encuadraron 130 consultas (47,4%), y en 60 se recomendo (46,2%) la derivacion por via normal, en 47 (36,2%) la preferente y en 23 (17,6%) la no derivacion. En el grupo 2 se incluyeron 125 correos (45,7%), y en 80 no fue necesaria nueva cita o adelanto de la prevista (64%). Trece consultas (4,7%) se clasificaron en el grupo 3 y seis (2,2%) en el grupo 4. Conclusiones. Nuestros medicos de atencion primaria manejan cada vez mas el correo electronico de la CMC. Permite detectar pacientes en los que procede un adelanto de cita, bien primera visita o revision, o resolver cuestiones sin necesidad de derivacion. Es eficaz para la atencion del medico con cefalea y como herramienta de formacion continuada.

[Sexual dysfunction in migraine patients who receive preventive treatment: identification by means of two screening tests]. / Disfuncion sexual en pacientes migrañosos que reciben tratamiento preventivo: identificacion mediante dos tests de cribado.

INTRODUCTION: Sexual dysfunctions are one of the most important problems affecting sexual health and are associated with low levels of quality of life. AIM: To assess the sexual functioning in migraine patients and the sexual dysfunction that can be attributed to its preventive treatment. PATIENTS AND METHODS: The patients attended in the headache units of two general hospitals who visited for the first time after being prescribed preventive treatment. They answered the Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ) and the Psychotropic-Related Sexual Dysfunction Questionnaire (SALSEX). RESULTS: The sample used in the study consisted of 79 patients (17 males, 62 females) aged 37.6 ± 9.1 years (range: 19-57 years), 31 (39.2%) of them with chronic migraine. As preventive treatment, 23 (29.1%) received beta blockers; 42 (53.2%) neuromodulators; 8 (10.1%), calcium antagonists; and 6 (7.6%), antidepressants. The MGH-SFQ detected diminished overall sexual satisfaction that was at least moderate in 24 patients (30.4%). SALSEX showed changes in sexual functioning that was attributable to the preventive treatment in 36 cases (45.5%), which only exceptionally appeared spontaneously. In patients with at least moderate dysfunction on the MGH-SFQ, the mean ages at the time of testing, the number of days with pain per month and the excessive use of medication for their symptoms were all higher (53.3% versus 46.7%; p = 0.03). CONCLUSIONS: Simple sexual dysfunction screening tests often detect sexual dysfunctions in patients with migraine on preventive treatment and changes in their sex life that can be attributed to these drugs.

TITLE: Disfuncion sexual en pacientes migrañosos que reciben tratamiento preventivo: identificacion mediante dos tests de cribado.Introduccion. Las disfunciones sexuales constituyen uno de los problemas mas importantes que afectan a la salud sexual y se asocian a bajos niveles de calidad de vida. Objetivo. Evaluar la funcion sexual en pacientes migrañosos y la disfuncion sexual atribuible al tratamiento preventivo. Pacientes y metodos. Pacientes atendidos en las consultas de cefaleas de dos hospitales generales que acudian a la primera visita tras prescripcion de un preventivo. Respondieron al cuestionario de funcionamiento sexual del Hospital General de Massachusetts (MGH-SFQ) y al cuestionario de disfuncion sexual secundaria a psicofarmacos (SALSEX). Resultados. Muestra de 79 pacientes (17 varones, 62 mujeres), de 37,6 ± 9,1 años (rango: 19-57 años), 31 (39,2%) de ellos con migraña cronica. Como tratamiento preventivo, 23 (29,1%) recibian betabloqueantes; 42 (53,2%), neuromoduladores; 8 (10,1%), antagonistas del calcio, y 6 (7,6%), antidepresivos. El MGH-SFQ detecto en 24 pacientes (30,4%) disminucion al menos moderada de satisfaccion sexual global. El SALSEX mostro cambio de la funcion sexual atribuible al tratamiento preventivo en 36 casos (45,5%), solo excepcionalmente manifestada de forma espontanea. En pacientes con disfuncion al menos moderada en el MGH-SFQ, eran significativamente mayores la edad media en el momento de la inclusion, el numero de dias de dolor al mes y el uso excesivo de medicacion sintomatica (53,3% frente a 46,7%; p = 0,03). Conclusion. La disfuncion sexual evaluada con sencillos test de cribado detecta con frecuencia disfuncion sexual en pacientes migrañosos en tratamiento preventivo y cambios en su vida sexual atribuibles a estos farmacos.

[Endovascular treatment of critical basilar stenosis with a Solitaire® stent device: a first experience in our centre]. / Tratamiento endovascular de una estenosis crítica basilar con dispositivo stent Solitaire®: primera experiencia en nuestro centro.

INTRODUCTION: Although intracranial arteriosclerosis is an important cause of stroke, the therapeutic attitude has still not been clearly established. Hence, the SAMMPRIS study compared intensive medical treatment with angioplasty and stent placement, with outcomes favouring the pharmacological treatment. These results could be partly due to the device used (Wingspan® stent). CASE REPORT: A 71-year-old male with a severe stenosis of the basilar artery, who suffered repeated episodes of transient neurological focus despite being treated with antiplatelet therapy and statins. Given the circumstances, the decision was made to perform a therapeutic arteriography with angioplasty and placement of a Solitaire® stent in order to optimise results, a residual stenosis of 40% being achieved. Subsequent progress was favourable and the control tests carried out showed a minimum progression. CONCLUSIONS: As far as we know, this is the first case of critical stenosis of the basilar artery being treated by placement of a Solitaire® stent to be reported in the literature.

TITLE: Tratamiento endovascular de una estenosis critica basilar con dispositivo stent Solitaire ®: primera experiencia en nuestro centro.Introduccion. Aunque la arterioesclerosis intracraneal es una causa importante de ictus, la actitud terapeutica no esta claramente establecida. En este sentido, el estudio SAMMPRIS comparo el tratamiento medico intensivo con la angioplastia y colocacion de stent, con resultados favorables al tratamiento farmacologico. Estos resultados podrian, en parte, deberse al dispositivo utilizado (stent Wingspan ®). Caso clinico. Varon de 71 años con una estenosis grave de la arteria basilar, en quien se repetian episodios de focalidad neurologica transitoria a pesar del tratamiento con doble antiagregacion y estatinas. En estas circunstancias se decidio realizar una arteriografia terapeutica con angioplastia y colocacion de un stent Solitaire ® para optimizar resultados y se logro una estenosis residual del 40%. La evolucion fue favorable y los controles posteriores muestran una minima progresion. Conclusion. Segun nuestro conocimiento, este es el primer caso publicado de tratamiento de una estenosis critica de la arteria basilar mediante la colocacion de un stent Solitaire ®.

[Referrals from primary care to a dedicated headache clinic: analysis of the first 1,000 patients]. / Derivaciones de atencion primaria a una consulta monografica de cefaleas: analisis de los 1.000 primeros pacientes.

INTRODUCTION: It is commonplace practice in dedicated clinics or headache units to deal with complex patients referred from general neurology clinics. In our centre, part of the schedule of the dedicated headache clinic (DHC) is reserved for patients referred from primary care (PC) in the form of one-stop clinics. AIMS: To analyse both the characteristics of the patients referred by PC to DHC and the suitability of the agreed referral criteria, and to compare them with the first visits due to headache in a general neurology clinic. PATIENTS AND METHODS: The study was conducted on a sample of 1,000 patients (741 females and 259 males) in the DHC and 290 (203 females and 87 males) in the general clinic. Data were collected retrospectively and included demographic variables, previous use of symptomatic or preventive treatments, need for complementary examinations and adjustment to referral criteria. Headaches were coded in accordance with the second edition of the International Headache Classification (IHC-2). RESULTS: A total of 1,562 headaches were coded in the DHC group and 444 in the general clinic group; their distribution over the groups of the IHC-2 was similar, and most of them fell into group 1 (migraine). The percentage of patients who had received preventive treatment was higher in the DHC. The percentage of appropriate referrals was high and a little higher still in the general clinic. CONCLUSIONS: The characteristics of the patients referred from PC to a DHC in our milieu were similar to those reported in previous studies. These patients have received treatment more frequently than those who were seen in a general neurology clinic.

TITLE: Derivaciones de atencion primaria a una consulta monografica de cefaleas: analisis de los 1.000 primeros pacientes.Introduccion. Es habitual en las consultas monograficas o unidades de cefaleas que atiendan a pacientes complejos derivados desde consultas generales de neurologia. En nuestro centro, parte de la agenda de la consulta monografica de cefaleas (CMC) se reserva a pacientes remitidos desde atencion primaria (AP) con formato de alta resolucion. Objetivos. Analizar las caracteristicas de los pacientes derivados por AP a la CMC y la adecuacion a los criterios de derivacion consensuados, y compararlos con las primeras visitas por cefalea en una consulta general de neurologia. Pacientes y metodos. Muestra de 1.000 pacientes (741 mujeres y 259 varones) en la CMC y 290 (203 mujeres y 87 varones) en la consulta general. Recogemos prospectivamente variables demograficas, uso previo de tratamientos sintomaticos o preventivos, necesidad de exploraciones complementarias y adecuacion a los criterios de derivacion. Codificamos las cefaleas de acuerdo con la segunda edicion de la Clasificacion Internacional de Cefaleas (CIC-2). Resultados. En el grupo de la CMC se codificaron 1.562 cefaleas, y en la consulta general, 444; su distribucion en los grupos de la CIC-2 era similar, y la mayoria se encuadraba en el grupo 1 (migraña). El porcentaje de pacientes que habian recibido tratamiento preventivo era mayor en la CMC. El porcentaje de derivaciones adecuadas fue alto y algo mayor en la consulta general. Conclusiones. Las caracteristicas de los pacientes derivados desde AP a una CMC en nuestro medio son similares a las previamente descritas. Estos pacientes han recibido tratamiento con mas frecuencia que los atendidos en una consulta general de neurologia.

[Encephalitis due to the Epstein-Barr virus: a description of a clinical case and review of the literature]. / Encefalitis por el virus de Epstein-Barr: descripción de un caso clínico y revisión de la bibliografía.

INTRODUCTION. Infection by the Epstein-Barr virus (EBV) -either as a primary infection, a reactivation or an active chronic infection- can give rise to several clinical forms of involvement of the central nervous system. We report a case of encephalitis due to EBV produced by viral reactivation in an immunocompetent patient which initially mimicked, from the clinical and electroencephalographic point of view, encephalitis due to type 1 herpes simplex virus (HSV-1). CASE REPORT. A 51-year-old male who had reported the presence of dorsal herpes zoster some days earlier. The patient visited the emergency department after suffering a holocranial oppressive headache and febricula for seven days; 24 hours before admission to hospital, he was suffering from drowsiness and language disorder. The neurological examination revealed stiffness in the back of the neck and dysphasia. An analysis of the cerebrospinal fluid revealed pleocytosis (422 cells/mm(3)) with 98% of mononuclear cells and normal protein and glucose concentration levels in cerebrospinal fluid. Magnetic resonance imaging of the brain and electroencephalogram readings were normal with periodic lateralised epileptiform discharges in the left temporal region. Intravenous acyclovir treatment was initiated, but renal failure meant it had to be changed to oral valaciclovir with clinical resolution and improvement of the liquoral parameters. Polymerase chain reaction in the cerebrospinal fluid was positive for EBV and negative for the other neurotropic viruses. In blood, the serology test for EBV with IgG was positive, while IgM and heterophile antibody tests were negative. CONCLUSIONS. EBV infection can give rise to acute disseminated encephalomyelitis or affect several locations in the central nervous system, especially the cerebellum. Clinical pictures mimicking HSV-1 are less frequent. When encephalitis is related to viral reactivation, precipitating factors can be detected, as in our case.

TITLE: Encefalitis por el virus de Epstein-Barr: descripcion de un caso clinico y revision de la bibliografia.Introduccion. La infeccion por el virus de Epstein-Barr (VEB) puede dar lugar ­tanto como primoinfeccion, reactivacion o infeccion cronica activa­ a varias formas clinicas de afectacion del sistema nervioso central. Presentamos un caso de encefalitis por VEB producido por reactivacion virica en un paciente inmunocompetente, que inicialmente simulaba, desde el punto de vista clinico y electroencefalografico, una encefalitis por virus herpes simple tipo 1 (VHS-1). Caso clinico. Varon de 51 años con antecedente de herpes zoster dorsal en los dias previos. Acudio a urgencias por un cuadro de siete dias de duracion de cefalea opresiva holocraneal y febricula; 24 horas antes de su ingreso, padecia somnolencia y alteracion del lenguaje. En la exploracion neurologica presentaba rigidez nucal y disfasia. En el liquido cefalorraquideo se evidencio pleocitosis (422 celulas/mm3) con un 98% de mononucleares, y proteinorraquia y glucorraquia normales. Resonancia magnetica cerebral normal y electroencefalograma con descargas epileptiformes lateralizadas periodicas en la region temporal izquierda. Se trato con aciclovir intravenoso; una insuficiencia renal motivo su cambio a valaciclovir oral con resolucion clinica y mejoria de los parametros licuorales. La reaccion en cadena de la polimerasa en el liquido cefalorraquideo fue positiva para VEB y negativa para el resto de virus neurotropos. En sangre, la serologia para VEB con IgG resulto positiva, y negativa con IgM y anticuerpos heterofilos. Conclusiones. La infeccion por VEB puede dar lugar a una encefalitis aguda diseminada o afectar a varias localizaciones del sistema nervioso central, principalmente el cerebelo. Menos frecuentes son los cuadros imitadores de VHS-1. Cuando la encefalitis se relaciona con reactivacion viral pueden detectarse, como en nuestro caso, factores precipitantes.

[High performance of an implantable Holter monitor in the detection of concealed paroxysmal atrial fibrillation in patients with cryptogenic stroke and a suspected embolic mechanism]. / Altorendimiento del holter implantable en la detecciónde fibrilación auricular paroxística oculta en pacientescon ictus criptogénico y sospecha de mecanismo embólico.

INTRODUCTION: Implantable loop recorders (ILR) may allow detection of occult paroxysmal atrial fibrillation (PAF) in patients with cryptogenic ischemic stroke. However, optimal selection algorithm and ideal duration of monitoring remain unclear. AIM. To determine the incidence and time-profile of PAF in patients with cryptogenic ischemic stroke studied with Reveal XT ILR, who were selected based on a high suspicion of cerebral embolism. SELECTION CRITERIA: absence of stroke etiology after complete study including vascular imaging, transesophageal echocardiography and at least 24 hours of cardiac rhythm monitoring, and confirmation of acute embolic occlusion of intracranial artery by transcranial duplex or characteristics of acute ischemic lesion on neuroimaging suggesting embolic mechanism of ischemia. After implanting Reveal XT ILR, patients were trained to perform transmissions monthly or when symptoms occurred. We reviewed the information online each month and patients underwent clinical visits at 3rd and 6th month and then every six months. RESULTS: We included 101 patients with cryptogenic ischemic stroke and at least one month of follow-up after ILR implant. Mean age was 67 years, 54 women (53.5%). Mean follow-up after implantation was 281 ± 212 days. Occult PAF was detected in 34 patients (33.7%). Frequency of false positives: 22.8%. Median time from implant to arrhythmia detection was 102 days (range: 26-240 days). 24 (70%) patients with PAF had several arrhythmic episodes detected with ILR. The majority of events (75%) were detected during the first six months of monitoring. CONCLUSIONS: In our patients with probably embolic cryptogenic ischemic stroke, PAF was detected by Reveal XT ILR in 33.7%. One in four events occurred after the first six months of monitoring.

TITLE: Alto rendimiento del holter implantable en la deteccion de fibrilacion auricular paroxistica oculta en pacientes con ictus criptogenico y sospecha de mecanismo embolico.Introduccion. El holter implantable permite detectar fibrilacion auricular paroxistica (FAP) oculta en pacientes con ictus criptogenico, pero se desconoce que algoritmo de seleccion tiene un mayor rendimiento y la duracion optima de monitorizacion. Objetivo. Conocer la frecuencia y el tiempo hasta detectar la FAP mediante un holter implantable Reveal XT ® en pacientes con ictus criptogenico seleccionados por sospecha elevada de embolismo cerebral. Pacientes y metodos. Criterios de seleccion: ausencia de etiologia del ictus tras el estudio completo incluyendo un ecocardiograma transesofagico, monitorizacion ECG y holter de 24 horas, asi como confirmacion de oclusion aguda embolica de la arteria intracraneal por duplex transcraneal o bien alta sospecha de embolismo por caracteristicas de neuroimagen. Tras implantar el holter Reveal XT se formo a los pacientes para que emprendieran transmisiones todos los meses o ante sintomas. Se reviso la informacion online mensualmente y se realizaron visitas clinicas en las unidades de Neurologia y Cardiologia. Resultados. Se incluyeron 101 pacientes con ictus criptogenico y al menos un mes de seguimiento: edad media de 67 años, 54 mujeres (53,5%). Tiempo medio de seguimiento: 281 ± 212 dias. Se detecto FAP oculta en 34 pacientes (33,7%) y falsos positivos en 23 (22,8%). Mediana desde el implante hasta la deteccion de la arritmia: 102 dias (rango: 26-240 dias). En un 70% de los pacientes se registraron multiples episodios de FAP. El 75% de los eventos se detectaron durante los primeros seis meses de monitorizacion. Conclusiones. El algoritmo de seleccion de pacientes con ictus criptogenico segun sospecha de embolismo cerebral se asocio a una elevada frecuencia (33,7%) de FAP oculta con holter implantable. Uno de cada cuatro eventos sucedio tras los primeros seis meses de monitorizacion.

Nummular headache and epicrania fugax: possible association of epicranias in eight patients.

OBJECTIVES: Epicrania fugax (EF) is a novel syndrome presenting with brief pain paroxysms that always start in a particular area of the head to spread immediately either forward or backward. Paroxysms stem from a focal area, in which a well-shaped continuous pain reminiscent of the symptomatic area described in nummular headache (NH) can be present. We aimed to analyze the association of these two epicranial headaches in eight patients. METHODS: We prospectively assessed all patients with EF attending an outpatient headache office from March 2008, when EF was first described, to June 2012. Among them, we selected those patients with a well-circumscribed continuous pain at the stemming point fulfilling the research diagnostic criteria for NH of the International Classification of Headache Disorders II Edition (ICHD-II) appendix. We considered the demographic and clinical features of the selected patients. RESULTS: Eight patients (five females, three males) were diagnosed with both EF and NH. Mean age of onset was 44.2 ± 12 (range: 23-60). Regarding NH, the diameter of the painful area was 4.4 ± 1 centimeters (range: 3-6) and pain intensity was 4.2 ± 0.7 (range: 3-5) on a 10-point verbal analogical scale (VAS). As for the EF, the radiating paroxysms always started in the NH painful area and lasted 6.6 ± 4.5 seconds (range: 2-15), with a pain intensity of 7.9 ± 1.6 (range 5-10) on the VAS. Five cases had forward radiation, while three cases had backward EF. Four cases had ipsilateral autonomic accompaniments. Six patients required a preventive, and lamotrigine achieved complete response in three of them. CONCLUSION: Although the etiology of NH and EF remains uncertain, both syndromes seem to share a peripheral source. Their association in a number of patients is probably reflecting a pathophysiological connection. Lamotrigine might be a good therapeutic option for those patients presenting with both disorders.