Genomic expression patterns in medication overuse headaches.

BACKGROUND: Chronic daily headache (CDH) and chronic migraine (CM) are one of the most frequent problems encountered in neurology, are often difficult to treat, and frequently complicated by medication-overuse headache (MOH). Proper recognition of MOH may alter treatment outcome and prevent long term disability. OBJECTIVE: This study identifies the unique genomic expression pattern MOH that respond to cessation of the overused medication. METHODS: Baseline occurrence of MOH and typical pattern of response to medication cessation were measured from a large database. Whole blood samples from patients with CM with or without MOH were obtained and their genomic profile was assessed. Affymetrix human U133 plus2 arrays were used to examine the genomic expression patterns prior to treatment and 6-12 weeks later. Headache characterisation and response to treatment based on headache frequency and disability were compared. RESULTS: Of 1311 patients reporting daily or continuous headaches, 513 (39.1%) reported overusing analgesic medication. At follow-up, 44.5% had a 50% or greater reduction in headache frequency, while 41.6% had no change. Blood genomic expression patterns were obtained on 33 patients with 19 (57.6%) overusing analgesic medication with a unique genomic expression pattern in MOH that responded to cessation of analgesics. Gene ontology of these samples indicated a significant number were involved with brain and immunological tissues, including multiple signalling pathways and apoptosis. CONCLUSIONS: Blood genomic patterns can accurately identify MOH patients that respond to medication cessation. These results suggest that MOH involves a unique molecular biology pathway that can be identified with a specific biomarker.

Inpatient treatment of status migraine with dihydroergotamine in children and adolescents.

OBJECTIVE: To assess the effectiveness of aggressive therapy of status migraine in children and adolescents. BACKGROUND: Inpatient management of pediatric status migraine and intractable headache is limited because of a lack of studies and guidelines. Adult treatment is often based on anecdotal experience, although a few controlled studies have been reported. Added to that is the discomfort of general pediatricians and neurologists in using available effective treatments in pediatric patients (such as dihydroergotamine: DHE). METHODS: Charts of all patients admitted to the neurology service, at Cincinnati Children's Hospital Medical Center-Department of Neurology, for inpatient treatment for intractable headache/status migraine over a 6-week period were reviewed. Demographics, evaluation, diagnosis, and treatment used were tabulated. Data on the effectiveness of the treatments provided were evaluated. Thirty-two total consecutive charts were retrospectively reviewed during that period. RESULTS: Upon discharge, 74.4% of the patients were headache-free. The mean severity of the pain upon discharge was 1.02 +/- 2.22 (using the 0-10 pain scale). CONCLUSION: From our review, DHE is very effective in treating and aborting an episode of status migraine and should be offered to children and adolescent patients who have failed their usual abortive therapy to prevent further severe disability that mainly affects their schooling and social activities.

Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine.

BACKGROUND: Coenzyme Q10 (CoQ10) has been suggested to be effective in the prevention of migraine, and levels can be quantified with standardized reference ranges. OBJECTIVE: This study documents the prevalence of CoQ10 deficiency in migraine headache and examines the potential effectiveness of supplementation. METHODS: We assessed patients attending a tertiary care center with frequent headaches for CoQ10 deficiency. We recommended patients with low CoQ10 levels begin supplementation with CoQ10 as part of their multidisciplinary treatment plan. We assessed response to treatment including correction of CoQ10 deficiency, overall headache improvement, and headache disability. RESULTS: CoQ10 was measured in 1550 patients (mean age 13.3 +/- 3.5, range 3 to 22 years). The mean total CoQ10 level was 0.60 +/- 0.20 microg/mL (range 0.21 to 1.77 microg/mL). Of these patients, 32.9% were below the reference range. Patients with low CoQ10 were recommended to start 1 to 3 mg/kg per day of CoQ10 in liquid gel capsule formulation. In a subset of patients who returned for timely follow-up (mean, 97 days), the total CoQ10 level improved to 1.20 +/- 0.59 microg/mL (P < .0001), while the headache frequency improved from 19.2 +/- 10.0 to 12.5 +/- 10.8 (P < .001) and headache disability assessed with PedMIDAS improved from 47.4 +/- 50.6 to 22.8 +/- 30.6 (P < .001). CONCLUSIONS: Deficiency of CoQ10 may be common in pediatric and adolescent migraine. Determination of deficiency and consequent supplementation may result in clinical improvement. Further analysis involving more scientifically rigorous methodology will be required to confirm this observation.

Outcome of a multidisciplinary approach to pediatric migraine at 1, 2, and 5 years.

OBJECTIVE: To assess the long-term effectiveness and outcome of multidisciplinary treatment of childhood headaches 1, 2, and 5 years after initial treatment. BACKGROUND: Headaches are a common problem for children and adolescents and for many patients continue into adulthood. Outcome research for pediatric migraine headaches is limited, thus restricting knowledge of the effectiveness of long-term management and outcome. METHODS: Headache characteristics were assessed at the initial visit and were reevaluated 1, 2, and 5 years later in independent sub-groups of consecutive patients. These characteristics included headache frequency, severity, average duration, school absences, and overall perceived response to treatment. RESULTS: At 1 year, 96 patients were evaluated (mean age = 11.0 +/- 3.4, 59% females), 69 patients at 2 years (mean age = 10.6 +/- 3.4, 48% females), and 32 at 5 years (mean age = 10.5 +/- 3.9, 66% females). The headaches were reported as better in 94% at 1 year, 85% at 2 years, and 94% at 5 years. The initial frequency was at 13.4 +/- 10.8 headaches per month, 4.9 +/- 7.0 at 1 year (P < .001), 4.7 +/- 7.6 at 2 years (P < .001), and 4.5 +/- 7.5 at 5 years (P < .001). The severity decreased from 6.8 +/- 1.8 to 5.1 +/- 2.3 at 1 year (P < .001), to 5.0 +/- 2.4 at 2 years (P < .001), and to 4.6 +/- 2.5 at 5 years (P < .01). The school days missed per month showed a marked decrease from 4.5 +/- 9.5 at initial visit to 1.55 +/- 2.8 at 5 years (P < .001). Patients that were only seen at their initial visit and did not choose to return for follow-up had less frequent and shorter duration headaches on initial visit when compared with the rest of the sample and continued to be doing well at the 1-, 2-, and 5-year assessments. CONCLUSIONS: Multidisciplinary treatment was found to be effective for children and adolescents with improvement of multiple outcome variants of pediatric migraine care, including frequency, severity, and school days missed. Patients who did not return to follow-up evaluation were more likely to have less frequent and shorter duration headaches at initial presentation. Regular follow-up care is needed for those children with more severe initial headache presentation.