Herbal therapy in migraine.

The use of herbal therapies is ancient and increasing worldwide. There is a growing body of evidence supporting the efficacy of various "complementary" and alternative medicine approaches in the management of headache disorders. Promising tools to treat migraine patients are herbal products. In particular constituents of Petasites hybridus, Tanacetum Parthenium and Ginkgo Biloba have shown antimigraine action in clinical studies. A miscellaneous of recreational drugs and other herbal remedies have been supposed to have a role in headache treatment but quality of clinical studies in this field is low and inconclusive. Further research is warranted in this area.

Basilar-type migraine patients responsive to lamotrigine: a 5-year follow-up.

Five years ago we reported the case of three patients affected by basilar-type migraine (BM) responsive to lamotrigine. At that time, proven treatment options for BM are rather limited and lamotrigine has been tested in BM patients because it was a widely tested treatment for migraine with aura. That positive 1-year experience leaded us to suggest that lamotrigine could be a preventive therapeutic option for BM patients, with and without menstruation association. We now report the five-year follow-up of the same patients to confirm and underlie the possible role of lamotrigine to induce BM attacks remission.

Migraine and movement disorders.

A large series of clinical and experimental observations on the interactions between migraine and the extrapyramidal system are available. Some previous studies reported high frequency of migraine in some basal ganglia (BG) disorders, such as essential tremor (ET), Tourette's syndrome (TS), Sydenham's chorea and more recently restless legs syndrome (RLS). For example, the frequency of migraine headache in a clinic sample of TS patients was found nearly fourfold more than that reported in the general population. To the best of our knowledge, no controlled studies have been conducted to determine a real association. ET and migraine headache have been considered comorbid diseases on the basis of uncontrolled studies for many years. In a recent Italian study, this comorbid association has been excluded, reporting no significant differences in the frequency of lifetime and current migraine between patients with ET and controls. Among mostly common movement disorders, RLS has been recently considered as possibly comorbid with migraine. Studies in selected patient groups strongly suggest that RLS is more common in migraine patients than in control populations, although no population-based study of the coincidence of migraine and RLS has yet been identified. The exact mechanisms and contributing factors for a positive association between migraine and RLS remain unclear. A number of possible explanations have been offered for the association of RLS and primary headache, but the three most attractive ones are a hypothetical dopaminergic dysfunction and dysfunctional brain iron metabolism, a possible genetic linkage and a sleep disturbance. More recently, the role of BG in pain processing has been confirmed by functional imaging data in the caudate, putamen and pallidum in migraine patients. A critical appraisal of all these clinical and experimental data suggests that the extrapyramidal system is somehow related to migraine. Although the primary involvement of extrapyramidal system in the pathophysiology of migraine cannot as yet be proven, a more general role in the processing of nociceptive information and/or maybe part of the complex behavioral adaptive response that characterizes migraine may be suggested.

Migraine and metabolism.

Migraine is a chronic disorder with complex pathophysiology involving both neuronal and vascular mechanisms. Migraine is associated with an increased risk of vascular disorders, such as stroke and coronary heart disease. Obesity and diabetes are metabolic disorders with a complex association with migraine. Insulin resistance, which represents the main causal factor of diseases involved in metabolic syndrome, is more common in patients with migraine. A better understanding of the relationship between metabolic syndrome and migraine may be of great clinical interest for migraine management.

Polytherapy for migraine prophylaxis.

Migraine is a chronic neurological disorder with episodic manifestations, progressive in some individuals. Preventive treatment is recommended for patients with frequent or disabling attacks. A sizeable proportion of migraineurs in need of preventive treatment does not significantly benefit from monotherapy. This short review evaluates the role of pharmacological polytherapy in migraine prevention.

Triptans: over the migraine.

Migraine is a chronic, recurrent, disabling condition that affects millions of people worldwide. Proper acute care treatment for migraineurs is based on triptans, a class of specific medications approved over 20 years ago. Triptans are serotonin (5-HT1B/1D) receptor agonists that are generally effective, well tolerated and safe. Seven triptans are available worldwide, although not all are available in every country, with multiple routes of administration, giving to doctors and patients a wide choice. Despite the similarities of the available triptans, pharmacological heterogeneity offers slightly different efficacy profiles. Triptans are not pain medications, they are abortive migraine medications which cannot prevent migraines. In addition to migraine attacks, triptans are also helpful for cluster headaches. If they are useful in other primary headaches rather than migraine and cluster headache it is yet to be addressed. In the literature there are only limited controlled clinical data to support a migraine-selective activity for triptans. Reports are available about efficacy of triptans to stop attacks of other types of primary headache, such as tension type headache, hypnic headache and other rare forms of primary headaches. On the other hand, sumatriptan failed to treat the indomethacin-responsive primary headache disorders like chronic paroxysmal hemicrania and hemicrania continua, nor was it effective in the myofascial temporal muscle pain or in atypical facial pain. Why triptans are effective in so different types of primary headaches remain unclear. Up to date, it is not clear whether the antimigrainous activity of the triptans involves an action only in the periphery or in the CNS as well. Probably we should consider triptans as "pain killers" and not only as "migraine killers". We clearly need additional studies on triptans as putative analgesics in well-accepted animal and clinical models of acute and chronic somatic pain.

Restless legs syndrome is not associated with migraine with aura: a clinical study.

Based on recent data about the association between restless legs syndrome (RLS) and migraine, we performed an observational study on the occurrence of RLS in patients affected by "pure" migraine with aura (pMA). We recruited 63 patients (33 females and 30 males) affected by MA without other types of primary headache among all patients referred in five Italian headache centers in a 1-year period. The prevalence of RLS in pMA patients (9.5%) is similar to that observed in Italian headache-free subjects (8.3%). No significant differences were found between pMA patients with and without RLS about clinical features of MA attacks and systemic and psychiatric diseases were investigated. Moreover, no association appeared between RLS and familial cases of MA. Differently from migraine without aura, our data do not confirm the existence of an association between RLS and MA, not even when a genetic factor is involved.

Basilar-type migraine responsive to lamotrigine: three case reports.

Basilar-type migraine (BM) has been recognised in the revised International Classification of Headache Disorders as a distinct clinical entity (subtype of migraine with aura), characterised by disturbing migraine aura clearly originating from the brainstem or from both hemispheres simultaneously affected. It differs from familial and sporadic hemiplegic migraines by the absence of motor deficit. Lamotrigine has been shown to be effective in preventing migraine aura symptoms in typical aura and in some cases of BM. We tried lamotrigine in three female cases of BM.

Adult abdominal migraine: a new syndrome or sporadic feature of migraine headache? A case report.

Abdominal migraine is one of the variants of migraine headache typically occurring in children and coded as 1.3.2 in the revised edition of IHS classification within the group 'Childhood periodic syndromes that are commonly precursors of migraine'. The affected children frequently develop typical migraine later in their life. We report a case of a 23 years old woman affected by attacks of recurrent abdominal pain accompanied by migraine. Abdominal pain attacks started in the adolescence and persisted without headache until the patient was 21. At this time, she experienced migraine pain accompanied by nausea, photophobia and phonophobia and associated to acute abdominal pain. Neuroimaging investigations and laboratory testing excluded any underlying organic disease. Complete remission of abdominal attacks was obtained during 4-month treatment period with pizotifen. Attacks fulfil IHS diagnostic criteria for 'abdominal migraine', although of late onset. This case report suggests that 'abdominal migraine' is a migraineous disorder to be hypothesized in adult patients after having disclosed any organic disease. As reported in the literature, 'adult abdominal migraine' is a sporadic migraine subtype in adult patients and it is not to be considered as a new migraineous syndrome.

Idiopathic intracranial hypertension (pseudotumor cerebri): descriptive epidemiology, clinical features, and visual outcome in Parma, Italy, 1990 to 1999.

PURPOSE: To ascertain the annual incidence rate and the clinical features, other than visual outcome, of idiopathic intracranial hypertension (IIH) in Parma, northern Italy. METHODS: Neurologic care of people living in the Parma area is entirely provided by one private and two public hospitals. Medical records related to IIH were retrospectively reviewed for all Parma residents from 1990 through 1999. RESULTS: Ten patients (8 women and 2 men) were identified as having IIH according to modified Dandy criteria. Their age ranged from 16 to 53 years with a mean of 36 years at diagnosis. The annual age-adjusted rate per 100,000 is 0.28 for the total population. For women in reproductive age, the annual incidence rate is 0.65/100,000. For overweight women in reproductive age, the annual incidence rate is 2.7/100,000. CONCLUSIONS: The incidence rate found in this study is lower than the incidence reported in previous US and Libyan studies. A significant difference in overweight distribution is observed comparing percentage of body weight between US and Parma populations. As overweight and obesity are important factors contributing to IIH development, it is possible that their low percentage in the Parma population may, at least partially, explain the low IIH incidence observed.

Familial occurrence of migraine with aura in a population-based study.

OBJECTIVE: To better define a possible genetic basis for migraine with aura (MWA). METHODS: We investigated the familial occurrence of migraine with aura in a sample of (MWA) subjects recruited from an epidemiologic study of migraine with aura involving the general population. The sample with migraine with aura (n = 26) was selected out of a total of 1392 subjects (842 women and 550 men) representative of the general population aged 18 to 65 years in the southern Italian town of San Severo. A family history of migraine with aura was determined via direct interviews with all living first-degree relatives of the 26 subjects who could be reached by investigators, 119 people: 71 women and 48 men. The diagnosis of migraine with aura was made according to the 1988 International Headache Society (IHS) criteria. RESULTS: Of the 26 subjects with migraine with aura, 7 (6 women and 1 man) had a positive family history, with a total of 7 first-degree relatives affected by the disease (1 mother, 2 fathers, 1 brother, 1 sister, and 2 children). Based on the lifetime prevalence rate of migraine with aura (1.6%) in the San Severo general population, the relative risk of migraine with aura in the first-degree relatives of the subjects was 3.68 (4.16 for women and 2.77 for men). CONCLUSION: Our subjects' relative risk rate for familial occurrence of migraine with aura was similar to that reported by one investigator, but markedly lower than that reported by another group.

A prospective study of the headache phase in 32 migraine with aura patients.

For an accurate description of the clinical features of the headache phase in migraine with aura (MA) attacks, we thought it useful to conduct a prospective study of consecutively referred MA patients seeking treatment at the Headache Centre of the University of Parma Institute of Neurology. The case series included 32 patients (22 women and 10 men). At the time of the first visit, each patient was given a questionnaire to be filled in at the next MA attack. Six patients (four women and two men) had attacks of migraine aura without headache. Among the remaining 26 patients (18 women and eight men), the duration of the headache phase was <24 h in 23 (88.5%); pain location was bilateral in 14 (53.8%) and unilateral in 12, but occurring on the opposite side to aura only in one patient; pain intensity was mild or moderate in 13 (50.0%). The headache phase of MA appeared to have clinical features that differed widely from patient to patient and was consistent with the International Headache Society diagnostic criteria for migraine without aura in 26.9% of patients and for tension-type headache (TTH) in 23.1%.

Application of the International Headache Society classification criteria in 652 cluster headache patients.

We applied the International Headache Society (IHS) classification coding parameters to a study population of 652 cluster headache (CH) patients, in order to determine how many patients did not fulfil the diagnostic criteria for group 3.1 and to find out any diagnostic elements that could be changed in the upcoming revision of the classification to make it more relevant to current clinical practice. Ninety-nine patients were found to have cluster-like disorder (3.3), including 74 (74.7%) who did not fulfil the diagnostic criteria for CH, because either pain was not associated with any of the accompanying autonomic phenomena listed in the classification or it was not located orbitally, supraorbitally and/or temporally. A review of our total sample showed that 72.0% of patients reported frontal and occipital pain location; in 61.8%, 33.4% and 39.1% of cases, attacks were also accompanied by restlessness/agitation, nausea and photophobia, respectively. In a coding system that took into account the diagnostic elements that we considered in our study, group 3.1 of the existing IHS classification would actually include 51 of the 99 patients currently coded as 3.3.

Primary and secondary chronic cluster headache: two separate entities?

The International Headache Society (IHS) classification divides chronic cluster headache (CH) into two subtypes: chronic CH unremitting from onset (CCHU) and chronic CH evolved from episodic (CCHE). The purpose of our study was to point out any similarities and differences between the two chronic CH subtypes and to determine whether or not they can be considered as two separate clinical entities. We reviewed data about 31 CCHE patients and 38 CCHU patients referred to the Parma Headache Centre between 1975 and 1999. Clinically, CCHE patients exhibited statistically significant differences from CCHU patients, i.e. earlier CH onset and duration of attacks varying more frequently between 120 and 180 min. From the point of view of lifestyle, heavy alcohol and coffee drinkers prevailed among CCHU patients, while CCHE patients were more frequently heavy smokers. Based on clinical features, it seems reasonable to suppose that chronic CH may occur as two distinct entities.

Possible predictive factors in the evolution of episodic to chronic cluster headache.

The purpose of our study was to identify general factors and distinctive clinical features differentiating patients with chronic cluster headache (CH) evolved from episodic CH and patients with episodic CH. Our study sample included 28 patients suffering from chronic CH evolved from episodic CH and 258 patients with episodic CH; all were referred to the Headache Center of Parma between December 1975 and June 1998. Patients with episodic CH were selected from all episodic CH referrals (n = 485) and selection was based on the duration of the disorder, which was to exceed the average period needed for an episodic form to turn into a chronic form (4.5 years for females and 7.0 years for males). At CH onset, the mean age for patients with chronic CH evolved from episodic CH was older than for those with episodic CH. Among patients with chronic CH, more were smokers or heavy drinkers, and had suffered a head injury. Clinically, episodic CH evolving into chronic CH was characterized by a high frequency of cluster periods, a larger proportion of patients with attacks not occurring strictly within cluster periods, and remission periods lasting less than 6 months. Possible predictive factors in the development of chronic CH appear to be CH onset from the third decade of life onward, the occurrence of more than one cluster period a year, and the short-lived duration of remission periods. The role played by head injury and cigarette smoking in the evolution of the disorder still cannot be established with certainty.

A prospective study of migraine with aura attacks in a headache clinic population.

In order to investigate the prevalence of migraine with aura (MA) attacks according to the criteria set by the International Headache Society (IHS) for diagnosis down to the three-digit level of classification, and to determine the recurrence and possible variability of MA attacks over time, we conducted a 6-15-month-long prospective study on 64 MA patients (42 women and 22 men) consecutively referred for the first time to the University of Parma Headache Centre. At the end of the follow-up period, diagnosis was the same as at the first visit for 80.0% of patients, while it was changed for 20.0%. Throughout the duration of the study, the average number of attacks for each patient was 5.3 +/- 6.2 (range 0-30). Attacks of migraine with typical aura were the most frequent (69.1% of patients), but migraine aura without headache (29.1%) and migraine with prolonged aura (20.0%) were also common; by contrast, basilar migraine and migraine with acute onset aura were reported only by one patient in either case. Migraine aura without headache was statistically significantly more frequent in males than in females. Our study results suggest that in most cases the frequency of recurrent MA attacks is relatively low and provide interesting indications about the prevalence of the different MA subtypes listed in the IHS classification, albeit in a headache clinic population.

Possible predictive factors in the prognosis of migraine with aura.

In order to identify possible predictive factors in the prognosis of migraine with aura (MA), we conducted a review at 10 to 20 years from referral on a sample of 77 MA patients (51 F, 26 M) consecutively seen for the first time at the University of Parma Headache Center. Based on the date of the last MA attack reported by these patients, we divided them into two study groups: a group of 22 patients "with remission of the disease," i.e. attack-free for at least 2 years at the end of the follow-up study; and a group of 55 patients "without remission of the disease," i.e. still having attacks in the last 2 years of the follow-up study. A comparative analysis of the MA clinical features observed in the two groups at the time of the patients' first visit to our Center enabled us to identify a number of favorable prognostic indicators, namely: a family history of parents with MA, the absence of other associated forms of primary headache, and the absence of both natural and artificial light stimulation as trigger factors.

Weekend headache: a possible role of work and life-style.

The purpose of our study was to determine whether or not patients reporting weekend headache exhibit distinctive features in their work habits, family life, and leisure on workdays and on weekends as compared to other headache sufferers, and whether or not they are inclined to change their living habits at the weekend. The study was done on an initial sample of 50 patients referred to the University of Parma Headache Centre between October 1996 and April 1997. These patients completed a specially designed questionnaire which, in addition to demographics, contained specific questions relevant to the subject matter being investigated. They were also given a diary which they had to complete for 8 consecutive weeks in order to determine the actual frequency of headache attacks over different days of the week. The questionnaire data were only analyzed for the 38 women in the sample, because there were too few male controls for an accurate comparison with weekend headache sufferers. Among the women with weekend headache, work habits, family life, and leisure were such as to suggest a possible increase in stress and frustration on weekends, which might have made them perceive the headaches occurring on Saturdays and Sundays as more severe. No changes were found in the intake of substances such as coffee and alcohol, nor in cigarette smoking over the different days of the week. Finally, analysis of the diaries showed an increased frequency of headache attacks on weekends only among the men, which seems to corroborate the hypothesis of weekend headache as a disorder typically affecting men.

Weekend headache: a retrospective study in migraine without aura and episodic tension-type headache.

Our retrospective study was aimed at determining the existence of weekend headache and, if so, whether it has the same clinical features as migraine without aura and episodic tension-type headache, or whether it occurs as a separate form of headache which could find its own place in the International Headache Society classification. For this study, we reviewed the clinical records of 120 patients with migraine without aura and 120 patients with episodic tension-type headache randomly selected among all those referred to the Headache Center of the University of Parma Institute of Neurology between 1985 and 1996. A review of these records suggests that weekend headache exists for both types of headache considered. Clinically, it is interesting to note that the male-to-female ratio for the weekend form of tension-type headache was 1:1, as opposed to 1:3 for general episodic tension-type headache. As regards classification, no evidence so far seems to suggest that weekend headache should be considered as an independent entity. Apart from certain features that appear to be peculiar to this form of headache-such as increased pain intensity-it thoroughly fulfills the diagnostic criteria of the primary headaches from which it evolves. Finally, a few clinical features suggest that the weekend may simply be a triggering factor in migraine without aura attacks, while playing a major role in episodic tension-type headache. However, weekend headache is a clinical entity that clearly needs further study.

Migraine with aura: a review of 81 patients at 10-20 years' follow-up.

We investigated the evolution over time of migraine with aura (MA) in a number of MA patients consecutively referred to the University of Parma Headache Center in the period 1976-86. The follow-up period chosen for our review of the clinical condition of patients varied from a minimum of 10 years to a maximum of 20 years. The study group comprised 81 patients (55F, 26M), 21 of them (14.2%) with at least one parent with MA. Migraine without aura (MO) was also present in 29.6% of the patients studied. Currently, 35% of patients (29.4% F, 46.1% M) have been free from attacks for at least 1 year and 19.4% (13.6% F, 30.8% M) for over 5 years. Moreover, the frequency of attacks has decreased considerably in 54.4% of cases (50% F, 63.7% M); it has increased in only 25% (26.1% F, 22.7% M). The headache has disappeared completely in 11.1% of patients (8.0% F, 18.2% M); it has become less severe in 36.2% and more severe in only 5.5%. The results of our investigation point to a favorable evolution of MA over time.