Increased MRI-based Brain Age in chronic migraine patients.

INTRODUCTION: Neuroimaging has revealed that migraine is linked to alterations in both the structure and function of the brain. However, the relationship of these changes with aging has not been studied in detail. Here we employ the Brain Age framework to analyze migraine, by building a machine-learning model that predicts age from neuroimaging data. We hypothesize that migraine patients will exhibit an increased Brain Age Gap (the difference between the predicted age and the chronological age) compared to healthy participants. METHODS: We trained a machine learning model to predict Brain Age from 2,771 T1-weighted magnetic resonance imaging scans of healthy subjects. The processing pipeline included the automatic segmentation of the images, the extraction of 1,479 imaging features (both morphological and intensity-based), harmonization, feature selection and training inside a 10-fold cross-validation scheme. Separate models based only on morphological and intensity features were also trained, and all the Brain Age models were later applied to a discovery cohort composed of 247 subjects, divided into healthy controls (HC, n=82), episodic migraine (EM, n=91), and chronic migraine patients (CM, n=74). RESULTS: CM patients showed an increased Brain Age Gap compared to HC (4.16 vs -0.56 years, P=0.01). A smaller Brain Age Gap was found for EM patients, not reaching statistical significance (1.21 vs -0.56 years, P=0.19). No associations were found between the Brain Age Gap and headache or migraine frequency, or duration of the disease. Brain imaging features that have previously been associated with migraine were among the main drivers of the differences in the predicted age. Also, the separate analysis using only morphological or intensity-based features revealed different patterns in the Brain Age biomarker in patients with migraine. CONCLUSION: The brain-predicted age has shown to be a sensitive biomarker of CM patients and can help reveal distinct aging patterns in migraine.

Epicrania Fugax as the presenting symptom of a cerebellar abscess.

BACKGROUND: Epicrania fugax is included in the appendix of the International Classification of Headache Disorders and is characterized as recurrent brief attacks of linear or zigzag pain moving across the cranial surface, commencing and terminating in the distribution of different nerves. We present a new case of epicrania fugax in which the headache was the presenting symptom of a cerebellar abscess. CASE REPORT: We present a 58-year-old woman with prior history of Chiari I malformation who underwent suboccipital craniectomy. Two weeks after surgery, she experienced paroxysmal pain episodes of 1-3 seconds, with constant linear trajectory from the right occipital surface to the right orbital region, remaining pain free between episodes. Cranial tomography showed a hypodense intraaxial lesion in the right cerebellar hemisphere. Magnetic Resonance Imaging exhibited intralesional bleeding and peripheral enhancement after gadolinium administration. Post-surgical cerebellar abscess was diagnosed and antibiotic therapy was started; the patient underwent urgent surgical drainage. Pain disappeared after the surgery and the patient remains pain free with 12 months of follow-up. CONCLUSION: Posterior fossa abnormalities have been described as a possible cause of secondary epicrania fugax. The presence of red flags should encourage conducting of paraclinical tests to rule out a symptomatic form.

Quality assurance in specialized headache units in Spain: an observational prospective study.

OBJECTIVE: To assess the quality of the therapeutic approach in Specialized Headache Units in Spain. METHODS: An observational (prospective) study was conducted. Anonymized data of 313 consecutive patients during a defined period of time were analyzed and a comparison of performance in 13 consensual quality indicators between Specialized Headache Units and neurology consultations was calculated. Specialized Units and neurology consultations represented the type of provision that Spaniards receive in hospitals. RESULTS: The consensus benchmark standard was reached for 8/13 (61%) indicators. Specialized Headache Units performed better in the indicators, specifically in relation to accessibility, equity, safety, and patient satisfaction. Patients attended in Specialized Headache Units had more complex conditions. CONCLUSION: Although there is variability among Specialized Headache Units, the overall quality was generally better than in traditional neurology consultations in Spain.

Roller pressure algometry as a new tool for assessing dynamic pressure sensitivity in migraine.

Objectives To explore the validity of the roller pressure algometer as a new tool for evaluating dynamic pressure sensitivity by assessing its association with pain features and widespread pressure pain sensitivity in migraine women, and also to determine whether dynamic pressure algometry differentiates between episodic and chronic migraine. Methods One hundred and twenty women with migraine (42% chronic, 58% episodic) participated. Dynamic pressure sensitivity was assessed with a set of roller pressure algometers (Aalborg University, Denmark®) consisting of 11 rollers with fixed pressure levels from 500 to 5300 g. Each roller was moved at a speed of 0.5 cm/sec over a 60 mm horizontal line covering the temporalis muscle. The dynamic pain threshold (the pressure level of the first painful roller) and pain elicited during the pain threshold (roller evoked pain) were determined. Static pressure pain thresholds were assessed over the temporalis muscle, C5/C6 joint, second metacarpal, and tibialis anterior. Results Side-to-side consistency between dynamic pain threshold (rs = 0.769, p < 0.001) and roller evoked pain (rs = 0.597; p < 0.001) were found. Women with chronic migraine exhibited bilateral lower dynamic pain thresholds ( p < 0.01), but similar widespread pressure pain thresholds (all, p > 0.284) than those with episodic migraine. Dynamic pain threshold was moderately positively associated with widespread pressure pain thresholds (0.358 > rs > 0.700, all p < 0.001). This association was slightly stronger in chronic migraine. Pain during dynamic pain threshold was negatively associated with widespread pressure pain thresholds (-0.336 < rs < -0.235, all p < 0.01). Conclusions Roller pressure algometry was valid for assessing dynamic pressure sensitivity in migraine in the trigeminal area and is consistent with widespread static pressure pain sensitivity. Roller, but not static, pressure algometry differentiated between episodic and chronic migraine. Assessing static and dynamic deep somatic tissue sensitivity may provide new opportunities for evaluating treatment outcomes.

Acute and Preventive Treatment of COVID-19-Related Headache: A Series of 100 Patients.

To describe the need and effectiveness of acute and preventive medications in a series of 100 consecutive patients referred due to COVID-19-related headaches. Patients were aged 48.0 (standard deviation (SD): 12.4), 84% were female, and 56% had a prior history of headache. The most common headache phenotype was holocranial (63%), frontal (48%), pressing (75%), of moderate intensity (7 out of 10), and accompanied by photophobia (58%). Acute medication was required by 93%, with paracetamol (46%) being the most frequently used drug, followed by ibuprofen (44%). The drugs with the highest proportion of a 2 h pain-freedom response were dexketoprofen (58.8%), triptans (57.7%), and ibuprofen (54.3%). Preventive treatment was required by 75% of patients. The most frequently used drugs were amitriptyline (66%), anesthetic blockades (18%), and onabotulinumtoxinA (11%). The drugs with the highest 50% responder rate were amitriptyline (45.5%), mirtazapine (50%), and anesthetic blockades (38.9%). The highest 75% responder rate was experienced following onabotulinumtoxinA (18.2%). In conclusion, most patients required acute medication, with triptans and non-steroidal anti-inflammatory drugs achieving the best responses. Three-quarters of patients required preventive medication. The most frequently used drug was amitriptyline, which obtained the best results. In some treatment-resistant patients, anesthetic blockades and onabotulinumtoxinA were also beneficial.

Migraña crónica con cefalea diaria. Revisión de la bibliografía / Chronic migraine with daily headache. Literature review

INTRODUCCIÓN: A pesar de suponer un número no desdeñable de casos, los pacientes con migraña crónica y cefalea diaria son frecuentemente excluidos de los grandes ensayos clínicos terapéuticos. Estos individuos apenas han sido estudiados en la bibliografía y podrían presentar características específicas. DESARROLLO: Un tercio de los pacientes con migraña crónica podría sufrir cefalea todos los días del mes, lo que supone hasta un 1,7-3,3% de los pacientes atendidos en una consulta de neurología general. Al ser excluidos de la mayor parte de los estudios, apenas hay información sobre sus características clínicas y respuesta al tratamiento, y pueden tener una historia de migraña más prolongada y una diferente respuesta al tratamiento. Los pacientes con migraña crónica y cefalea diaria podrían presentar mecanismos fisiopatológicos complejos que favorezcan la manifestación diaria de la migraña. El manejo de estos pacientes es un reto terapéutico, y se ha propuesto la utilidad de la onabotulinumtoxinA. CONCLUSIONES: Los pacientes con migraña crónica y cefalea diaria pueden presentar características clínicas y terapéuticas específicas. Nuevos estudios podrían llevar a plantear su consideración diferenciada de la migraña crónica

INTRODUCTION: Despite representing a significant number of cases, patients with chronic migraine and daily headache are frequently excluded from large therapeutic clinical trials. These individuals have hardly been studied and could have specific properties. Body. A third of patients with chronic migraine may suffer from headaches every day, representing up to 1.7 - 3.3% of patients in a general neurology consultation. These patients are excluded from most studies, so little information is available. They may have a longer lasting migraine and different response to treatment. Patients with chronic migraine and daily headache may have complex pathophysiological mechanisms that favor the daily manifestation of migraine. The management of these patients is a therapeutic challenge, and OnabotulinumtoxinA may be useful. CONCLUSION: Patients with chronic migraine and daily headache may have specific clinical and therapeutic characteristics. New studies could lead to differentiate it from chronic migraine

[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.

[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.

Predicción de la respuesta al tratamiento preventivo en migraña crónica mediante la medición de la sustancia gris en resonancia magnética: estudio piloto / Response prediction for chronic migraine preventive treatment by gray matter morphometry in magnetic resonance imaging: a pilot study

INTRODUCCIÓN: El topiramato es el único tratamiento preventivo oral con nivel de evidencia I para la migraña crónica. OBJETIVO: Evaluar los parámetros de la sustancia gris, obtenidos mediante resonancia magnética, como marcadores de respuesta al tratamiento con topiramato en pacientes con migraña crónica. PACIENTES Y MÉTODOS: La muestra se compuso de 57 pacientes con migraña crónica atendidos por primera vez en una unidad de cefaleas como consecuencia de migraña crónica, a los que se realizó una resonancia magnética de 3 T. Posteriormente, se inició el tratamiento preventivo con topiramato. Se evaluaron la respuesta y la tolerancia a los tres meses y se definió respuesta como disminución de al menos un 50% en el número de días de cefalea al mes. Mediante procesamiento de imágenes de resonancia magnética ponderadas en T1 y difusión, se obtuvieron los parámetros de la sustancia gris (68 estructuras corticales y 16 subcorticales). Se obtuvo un modelo de regresión logística para la valoración predictiva. RESULTADOS: Se analizó a 42 pacientes que toleraron el tratamiento, con respuesta terapéutica en 23 de ellos (54,7%). El modelo final de predicción se construyó con parámetros de la sustancia gris con resultados significativos. En dicho modelo, a mayor curvatura del cúneo izquierdo y área de la ínsula derecha, mayor probabilidad de respuesta, y menor probabilidad a mayor volumen de la corteza inferior parietal derecha y área del giro temporal superior izquierdo. La precisión del modelo predictivo fue del 95%. CONCLUSIÓN: Los parámetros de la sustancia gris pueden ser marcadores útiles de respuesta al tratamiento preventivo con topiramato en la migraña crónica Historia y Humanidades Origen y evolución histórica del término «prefrontal»

INTRODUCTION. Topiramate is the only oral preventative with level of evidence I for the treatment of chronic migraine. AIM. To evaluate gray matter parameters, obtained with magnetic resonance imaging (MRI), as biomarkers of the response to topiramate in chronic migraine patients. PATIENTS AND METHODS. The sample was composed by 57 chronic migraine patients, screened for first time in a Headache Unit due to chronic migraine. MRI acquisitions were performed at a 3 T unit. Afterwards, topiramate preventive treatment began. Response and tolerability were evaluated after three months, defining response as at least 50% reduction in headache days per month. We included patients that tolerated topiramate. T1- and diffusion-weighted MRI were processed to obtain gray matter (68 cortical and 16 subcortical regions) descriptive parameters. A logistic regression model was employed for the predictive assessment. RESULTS. Forty-two patients tolerated the treatment and were analyzed, responding 23 of them (54.7%). The final prediction model was built with gray matter parameters with significant results. In this model, higher left cuneus curvature and right insula area values were associated with a higher probability of response, while higher right inferior parietal cortex volume and left superior temporal gyrus area values were associated with a lower probability. The accuracy of the predictive model was 95%. CONCLUSION. The gray matter parameters may be useful biomarkers of preventive treatment response with topiramate in chronic migraine

Unidades especializadas de cefalea, una alternativa viable en España / Specialised headache units, a feasible alternative in Spain

INTRODUCCIÓN: Las consultas por cefalea son el motivo más frecuente de demanda de atención de causa neurológica en la atención primaria y en los servicios de neurología. Las unidades de cefalea mejoran la calidad asistencial, reducen las listas de espera, facilitan el acceso a nuevos tratamientos de eficacia contrastada y optimizan el gasto sanitario. No obstante, la implantación de estas unidades no está extendida en España debido a la relativa importancia atribuida a la patología y a la suposición de que su coste es elevado. OBJETIVO: Definir la estructura y los requerimientos mínimos de una unidad de cefalea con la intención de contribuir a su extensión en los hospitales de España. SUJETOS Y MÉTODOS: Estudio de consenso entre profesionales tras la revisión de la bibliografía sobre la estructura, las funciones y los recursos de una unidad de cefalea para un área de 350.000 habitantes. RESULTADOS: Se tomaron como referencia ocho publicaciones para la identificación de recursos mínimos necesarios de una unidad de cefalea. El panel de expertos estuvo integrado por 12 profesionales de diferentes especialidades. El principal recurso para la implementación de estas unidades son profesionales (superiores y técnicos), lo que puede suponer un coste adicional para el primer año de alrededor de 107.287,19 euros. CONCLUSIONES: Si consideramos los costes directos e indirectos debidos a las pérdidas por productividad laboral por paciente y los comparamos con los costes estimados de implantación de estas unidades y su expectativa de resultados, todo apunta a que es necesaria la generalización de unidades de cefalea en España

INTRODUCTION: Visits due to headaches are the most frequent cause of demand for neurological treatment in primary care and neurology services. Headache units improve the quality of care, reduce waiting lists, facilitate access to new treatments of proven efficacy and optimise healthcare expenditure. However, these units have not been implemented on a widespread basis in Spain due to the relatively low importance attributed to the condition and also the assumption that such units have a high cost. AIM: To define the structure and minimum requirements of a headache unit with the intention of contributing to their expansion in hospitals in Spain. SUBJECTS AND METHODS: We conducted a consensus study among professionals after reviewing the literature on the structure, functions and resources required by a headache unit designed to serve an area with 350,000 inhabitants. RESULTS: Eight publications were taken as a reference for identifying the minimum resources needed for a headache unit. The panel of experts was made up of 12 professionals from different specialties. The main resource required to be able to implement these units is the professional staff (both supervisory and technical), which can mean an additional cost for the first year of around 107,287.19 euros. CONCLUSIONS: If we bear in mind the direct and indirect costs due to losses in labour productivity per patient and compare them with the estimated costs involved in implementing these units and their expected results, everything points to the need for headache units to become generalised in Spain

[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.

[Migraine with prolonged eyelid edema: a series of 10 cases]. / Migraña con edema palpebral prolongado: serie de 10 casos.

INTRODUCTION: Migraine may present with cranial autonomic symptoms typical of trigeminal-autonomic cephalalgias, thus posing diagnostic difficulties. AIM. To report a series of patients with prominent eyelid oedema associated with migraine. PATIENTS AND METHODS: Ten patients attending the headache offices in three hospitals (nine women, one man; age: 26-53 years-old) with recurrent eyelid oedema as a migraine accompaniment. RESULTS: According to the diagnostic criteria of the International Classification of Headache Disorders (ICHD-III, beta version), eight patients had migraine without aura, one had migraine with aura, and one had chronic migraine. Eyelid oedema appeared during the most severe headache attacks, and had longer duration than the pain. Pharmacological or systemic causes of the oedema were ruled out in all cases. Other associated autonomic symptoms were conjunctival injection (n = 3), lacrimation (n = 2) and rhinorrhoea (n = 1). Both the pain and the oedema improved with symptomatic and preventive therapies for migraine. CONCLUSIONS: Eyelid oedema may occasionally be a migraine accompaniment. It appears in some patients during their most severe migraine attacks, and may improve with the acute and preventive treatment for migraine.

TITLE: Migraña con edema palpebral prolongado: serie de 10 casos.Introduccion. La migraña puede cursar con sintomas autonomicos craneales propios de las cefaleas trigeminoautonomicas, lo que plantea dificultades en el diagnostico. Objetivo. Describir una serie de diez pacientes con edema palpebral asociado a la migraña. Pacientes y metodos. Diez pacientes atendidos en la consulta de cefaleas de tres hospitales (nueve mujeres, un varon; edad: 26-53 años), con edema palpebral recurrente asociado a la migraña. Resultados. Segun los criterios diagnosticos de la Clasificacion Internacional de las Cefaleas (ICHD-III, version beta), ocho pacientes presentaban migraña sin aura, una tenia migraña con aura y otra, migraña cronica. El edema palpebral aparecia durante las crisis de migraña mas intensas, y tenia mayor duracion que la cefalea. Se descartaron causas farmacologicas o sistemicas del edema en todos los casos. Otros sintomas autonomicos asociados fueron la inyeccion conjuntival (n = 3), el lagrimeo (n = 2) y la rinorrea (n = 1). Tanto el dolor como el edema asociado respondieron a los tratamientos sintomaticos y preventivos de la migraña. Conclusiones. El edema palpebral es un posible acompañante de la migraña. Aparece en algunos pacientes con los episodios de mayor intensidad, y responde al tratamiento sintomatico y preventivo de la migraña.

[Occipital neuralgia: clinical and therapeutic characteristics of a series of 14 patients]. / Neuralgia occipital: características clinicas y terapéuticas de una serie de 14 pacientes.

INTRODUCTION. Occipital neuralgia is a pain in the distribution of the occipital nerves, accompanied by hypersensitivity to touch in the corresponding territory. AIMS. We present the occipital neuralgia series from the specialised headache unit at a tertiary hospital and analyse its clinical characteristics and its response to therapy. PATIENTS AND METHODS. Variables were collected from the cases of occipital neuralgia diagnosed in the above-mentioned headache unit between January 2008 and April 2013. RESULTS. A series of 14 patients (10 females, 4 males) with occipital neuralgia was obtained out of a total of 2338 (0.59%). Age at onset of the clinical signs and symptoms: 53.4 ± 20.3 years (range: 17-81 years) and time elapsed to diagnosis was 35.5 ± 58.8 months (range: 1-230 months). An intracranial or cervical pathology was ruled out by suitable means in each case. Baseline pain of a generally oppressive nature and an intensity of 5.3 ± 1.3 (4-8) on the verbal analogue scale was observed in 13 of them (92.8%). Eleven (78.5%) presented exacerbations, generally stabbing pains, a variable frequency (4.6 ± 7 a day) and an intensity of 7.8 ± 1.7 (range: 4-10) on the verbal analogue scale. Anaesthetic blockade was not performed in four of them (two due to a remitting pattern and two following the patient's wishes); in the others, blockade was carried out and was completely effective for between two and seven months. Four cases had previously received preventive treatment (amitriptyline in three and gabapentin in one), with no response. CONCLUSIONS. In this series from a specialised headache unit, occipital neuralgia is an infrequent condition that mainly affects patients over 50 years of age. Given its poor response to preventive treatment, the full prolonged response to anaesthetic blockades must be taken into account.

TITLE: Neuralgia occipital: caracteristicas clinicas y terapeuticas de una serie de 14 pacientes.Introduccion. La neuralgia occipital es un dolor en la distribucion de los nervios occipitales, acompañado de hipersensibilidad al tacto en el territorio correspondiente. Objetivos. Presentamos la serie de neuralgia occipital de la consulta monografica de cefaleas de un hospital terciario y analizamos sus caracteristicas clinicas y su respuesta terapeutica. Pacientes y metodos. Se recogen variables de los casos de neuralgia occipital diagnosticados en dicha consulta entre enero de 2008 y abril de 2013. Resultados. Serie de 14 pacientes (10 mujeres, 4 varones) con neuralgia occipital sobre un total de 2.338 (0,59%). Edad al inicio del cuadro: 53,4 ± 20,3 años (rango: 17-81 años), y tiempo hasta el diagnostico de 35,5 ± 58,8 meses (rango: 1-230 meses). Se descarto apropiadamente en cada caso patologia intracraneal o cervical. En 13 de ellos (92,8%) se observo dolor basal de caracter generalmente opresivo e intensidad 5,3 ± 1,3 (4-8) en la escala analogica verbal. Once (78,5%) presentaban exacerbaciones, generalmente de caracter punzante, frecuencia variable (4,6 ± 7 al dia) e intensidad 7,8 ± 1,7 (rango: 4-10) en la escala analogica verbal. En cuatro no se llevo a cabo bloqueo anestesico (dos por patron remitente y dos por deseo del paciente); en los restantes, se realizo bloqueo con eficacia completa de duracion entre dos y siete meses. Cuatro casos habian recibido anteriormente tratamiento preventivo (amitriptilina en tres y gabapentina en uno), sin respuesta. Conclusiones. En esta serie de una consulta monografica de cefaleas, la neuralgia occipital es una entidad infrecuente y que afecta principalmente a pacientes mayores de 50 años. Ha de tenerse en cuenta, dada su respuesta escasa a preventivos, y completa y prolongada a bloqueos anestesicos.

Congestión nasal como síntoma autonómico acompañante de crisis migrañosas / Nasal congestion as an autonomic symptom accompanying migraine attacks

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[Personality traits in patients with migraine: a multi-centre study using the Salamanca screening questionnaire]. / Rasgos de personalidad en pacientes migrañosos: estudio multicentrico utilizando el cuestionario de cribado Salamanca.

INTRODUCTION: Psychiatric comorbidity is frequent in cases of migraine and research has focused more on that related to affective disorders and anxiety than to personality traits. AIMS: To study the presence of personality traits in persons with migraine and how they are related with the presence of chronic migraine or medication abuse. PATIENTS AND METHODS: Patients attended consecutively in five centres were evaluated. The 22 questions in the Salamanca screening questionnaire were used to explore 11 personality traits classified in three groups. Data were obtained concerning demographic characteristics and the impact of migraine. RESULTS: The sample used in the study included 164 patients (134 females and 30 males), with a mean age of 36.6 ± 12.5 years (range: 18-78 years). In most patients, the impact of migraine was high. The personality traits that appeared most frequently were: anxious (53.7%), anankastic (44.5%), histrionic (40.9%) and dependent (32.9%). The risk of chronic migraine was higher in patients with the anankastic trait (relative risk = 2.06; confidence interval at 95% = 1.07-3.94; p = 0.027). CONCLUSIONS: Some of the personality traits that can be detected with the Salamanca questionnaire are very common in patients with migraine. In our series, the anankastic trait is related with the presence of chronic migraine.

TITLE: Rasgos de personalidad en pacientes migrañosos: estudio multicentrico utilizando el cuestionario de cribado Salamanca.Introduccion. La comorbilidad psiquiatrica en migraña es frecuente, y se ha estudiado mas la relacionada con trastornos afectivos y ansiedad que los rasgos de personalidad. Objetivo. Estudiar la presencia de rasgos de personalidad en personas con migraña y su relacion con la presencia de migraña cronica o abuso de medicacion. Pacientes y metodos. Se evaluan pacientes atendidos consecutivamente en cinco centros. Se exploran, mediante las 22 preguntas del cuestionario de cribado Salamanca, 11 rasgos de personalidad agrupados en tres grupos. Se obtuvieron datos referentes a las caracteristicas demograficas e impacto de la migraña. Resultados. Se incluyeron en el estudio 164 pacientes (134 mujeres, 30 varones), con una edad media de 36,6 ± 12,5 años (rango: 18-78 años). En la mayoria de los pacientes, el impacto de la migraña fue elevado. Los rasgos de personalidad que aparecieron mas frecuentemente fueron: ansioso (53,7%), anancastico (44,5%), histrionico (40,9%) y dependiente (32,9%). El riesgo de migraña cronica fue superior en pacientes con el rasgo anancastico (riesgo relativo = 2,06; intervalo de confianza al 95% = 1,07-3,94; p = 0,027). Conclusiones. Hay rasgos de personalidad detectables con el cuestionario Salamanca muy frecuentes en pacientes migrañosos. En nuestra serie, el rasgo anancastico se relaciona con la presencia de migraña cronica.

[Chronic migraine: clinical manifestations and differential diagnosis]. / Migraña crónica: manifestaciones clínicas y diagnóstico diferencial.

Chronic migraine is a condition that has been present since the dawn of medicine, although only recently has progress been made in characterising it nosologically. It is the result of the evolution of episodic migraine which, at one particular moment and in relation to certain risk factors, changes its characteristics. The diagnostic criteria of chronic migraine, which were initially very restrictive and based on the specific type of patient from the most important headache units, are gradually being adjusted to match the real situation experienced in most neurology departments. The consideration of medication abuse criteria has also evolved and this has made it possible to perform a prospective diagnosis of these cases, instead of requiring withdrawal from the abuse, which is not also feasible in practice. The influence of medication abuse in the development of chronic migraine remains a controversial issue. In our opinion, abuse is an important risk factor for the chronification of migraine, but it is not a necessary or a sufficient condition for it to become chronic. Like other authors, we recommend the use of the term 'chronic migraine' indistinctly for patients with or without abuse. The diagnosis of chronic migraine is not always a simple matter; the anamnesis is our best weapon, although in our patients with headache we must get used to taking into account not only the most striking bouts of pain but also the intercritical periods. The differential diagnosis has to be considered in cases of chronic headaches with prolonged episodes of pain. We draw special attention to its differentiation from tension-type headache and we recommend avoiding whenever possible the use of the term 'mixed headache'.

[Precipitating factors of migraine attacks in patients attended in neurology services. The FACTOR study]. / Factores precipitantes de crisis de migraña en pacientes atendidos en consultas de neurología. Estudio FACTOR.

INTRODUCTION: Patients with migraine often report factors or circumstances that precipitate or trigger their attacks. Yet few studies have been conducted to examine this matter. AIM: To explore the factors that precipitate migraine in our setting, as well is their possible relation with the intensity of the attacks or the overall repercussion of migraine. PATIENTS AND METHODS: An epidemiological, cross-sectional, multi-centre study was conducted in neurology consultation services. Sociodemographic and clinical data were collected and the precipitating factors were identified from a closed list. The specific migraine disability questionnaire -Headache Impact Test (HIT-6)- and the measurement of the number of lost workday equivalents were used in the study. RESULTS: Altogether 817 patients were recruited (72.5% females, mean age: 34.6 ± 10.3 years). A total of 70.5% of the patients had severe disability according to the HIT-6. The mean monthly number of lost workday equivalents was 2.1 ± 2.5. A total of 96.6% of the patients identified some precipitating factor for the attacks, the most commonly reported being hormonal (75.2%), stress (70.9%) and those related with disorders affecting sleep patterns (68.4%). CONCLUSIONS: The FACTOR study confirms that most patients with migraine identify some circumstance that precipitates their attacks. Controlling or avoiding these factors, whenever possible, must be part of the programme of education received by patients suffering from migraine.

[Hypnic headache: characteristics of a series of 13 new cases and proposal for modification of the diagnostic criteria]. / Cefalea hípnica: características de una serie de 13 nuevoscasos y propuesta de modificación de los criterios diagnósticos.

INTRODUCTION: Hypnic headache is a rare condition, since less than 150 cases have been reported to date. The second edition of the International Headache Classification (IHC2) has set out the diagnostic criteria of this condition, although some of them can be considered excessively strict. AIMS: To present a series of 13 new cases of hypnic headache that were dealt with in the headache unit of a tertiary hospital and to analyse how well they fit the diagnostic criteria of the IHC2. PATIENTS AND METHODS: Between January 2008 and January 2011, 13 patients (11 females and 2 males), out of a total of 1180 who visited the above-mentioned service (1.1%), were diagnosed with hypnic headache. The characteristics of the pain and the response to prophylactic treatment were evaluated. RESULTS: The age of onset of the clinical signs and symptoms was 56.7 ± 9.3 years (range: 40-76 years); in two patients (15.4%) it was prior to the age of 50. The number of symptomatic nights per month was 14.5 ± 7.6 (range: 5-25); in seven cases (53.8%) the number was less than 15 nights. All the patients presented one single episode per night, with a mean duration of 53.8 ± 24.6 minutes (range: 25-120 minutes). Thirty point seven per cent of the patients did not describe their pain as dull. Sixty-one point five per cent satisfied all the IHC2 diagnostic criteria. CONCLUSIONS: The characteristics of our series were similar to others that have recently been published. We propose that the next criteria in the IHC should include the possibility of the pain not being dull and that it occurs on fewer than 15 nights per month. The lower limit for the age of onset could be reduced to 40 years.