Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence.

In joint initiatives, the European Headache Federation and Lifting The Burden have described a model of structured headache services (with their basis in primary care), defined service quality in this context, and developed practical methods for its evaluation.Here, in a continuation of the service quality evaluation programme, we set out ten suggested role- and performance-defining standards for specialized headache centres operating as an integral component of these services. Verifiable criteria for evaluation accompany each standard. The purposes are five-fold: (i) to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence; (ii) to define the role of such centres within optimally structured and organized national headache services; (iii) to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role; (iv) to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally; (v) ultimately to improve the delivery and quality of health care for headache.

[Healthcare behavior of migraine and headache patients when treatment is accompanied by the digital migraine app]. / Gesundheitsverhalten von Migräne- und Kopfschmerzpatienten bei digitaler Therapiebegleitung mit der Migräne-App.

BACKGROUND: Tension-type headache and migraine are the second and third most prevalent disorders of mankind worldwide, after dental caries. The widespread implementation of smartphones enables the use of specific software applications (apps) for digital treatment accompaniment. In this study, the use of the migraine app (Migräne-App) for iOS and Android was examined in the practical treatment of migraine and headache patients in an extensive population sample. METHODS: An online survey was developed for the analysis of experiences as part of the treatment accompaniment and app usage. It contains questions concerning sociodemographic variables, the course of headache disorders and the previous treatment as well as the usage of the migraine app. The survey establishes compliance to the recommended treatment, the treatment plan, and treatment rules devised by the treating physician. The data collected were compared to traditional pen and paper documentation, prior to using the migraine app. RESULTS: A total of 1464 users participated in the standardized survey. The average age was 47.19 ± 11.37 years (87.4% female, 12.5% male). On average, users suffered from headaches for 27.28 ± 13.6 years. The majority (76.5%) were cared for by a general practitioner. Of the users 70.9% reported that they presented the aggregated data from the app to their physician on consultation, 76.4% reported that the migraine app helped them to adhere to the treatment plan designed together with their physician and the rules about headache therapy. It showed both a highly significant reduction of headache days per months prior to usage (13.30 ± 7.45 days) in comparison to at the time of conducting the survey (10.03 ± 7.30 days) as well as a highly significant reduction of intake of acute medication (before 7.61 ± 5.58 vs. ongoing 6.78 ± 4.72 days). CONCLUSION: The data show that the digital treatment control for therapy decisions made by the physician is highly relevant and established. Therapy compliance is improved and possible complications such as headache due to medication overuse are reduced. At the same time, a significant improvement of headache parameters and a marked overall improvement of treatment quality, amongst other things due to more easily available information and self-help tools can be observed.

Therapy susceptible germline-related BRCA 1-mutation in a case of metastasized mixed adeno-neuroendocrine carcinoma (MANEC) of the small bowel.

BACKGROUND: Adenocarcinomas or combined adeno-neuroendocrine carcinomas (MANEC) of small bowel usually have a dismal prognosis with limited systemic therapy options. This is the first description of a patient showing a germline-related BRCA1 mutated MANEC of his ileum. The tumor presented a susceptibility to a combined chemotherapy and the PARP1-inhibitor olaparib. CASE PRESENTATION: A 74-year old male patient presented with a metastasized MANEC of his ileum. Due to clinical symptoms his ileum-tumor and the single brain metastasis were removed. We verified the same pathogenic (class 5) BRCA1 mutation in different tumor locations. There was no known personal history of a previous malignant tumor. Nevertheless we identified his BRCA1 mutation as germline-related. A systemic treatment was started including Gemcitabine followed by selective internal radiotherapy (SIRT) to treat liver metastases and in the further course Capecitabine but this treatment finally failed after 9 months and all liver metastases showed progression. The treatment failure was the reason to induce an individualized therapeutic approach using combined chemotherapy of carboplatin, paclitaxel and the Poly (ADP-ribose) polymerase- (PARP)-inhibitor olaparib analogous to the treatment protocol of Oza et al. All liver metastases demonstrated with significant tumor regression after 3 months and could be removed. In his most current follow up from December 2017 (25 months after his primary diagnosis) the patient is in a very good general condition without evidence for further metastases. CONCLUSION: We present first evidence of a therapy susceptible germline-related BRCA1 mutation in small bowel adeno-neuroendocrine carcinoma (MANEC). Our findings offer a personalized treatment option. The germline background was unexpected in a 74-year old man with no previously known tumor burden. We should be aware of the familiar background in tumors of older patients as well.

[Peppermint oil in the acute treatment of tension-type headache]. / Oleum menthae piperitae (Pfefferminzöl) in der Akuttherapie des Kopfschmerzes vom Spannungstyp.

Tension-type headache is the most frequent form of headache. The local topical treatment with peppermint oil (oleum menthae piperitae) has proven to be significantly more effective than placebo in controlled studies. Peppermint oil targets headache pathophysiology in multiple ways. The efficacy is comparable to that of acetylsalicylic acid or paracetamol. Solutions of 10 % peppermint oil in ethanol are licensed for the treatment of tension-type headache in adults and children above 6 years. It is included in treatment recommendations and guidelines by the respective professional societies and is regarded as a standard treatment for the acute therapy of tension-type headaches.

[Spiradenocarcinoma of the forehead : A rare skin tumor in the head and neck region]. / Spiradenokarzinom der Stirn : Ein seltener Hauttumor im Kopf-Hals-Bereich.

Spiradenocarcinomas are rare malignant tumors that originate from the sweat glands of the skin and demonstrate aggressive growth. We report the case of an 86-year-old female patient presenting with a growth on the forehead which had been apparent for 2 years. After surgical removal of the tumor, histological workup culminated in the diagnosis of a spiradenocarcinoma. Surgical margins were free of tumor on pathological examination. Metastasis was excluded by positron-emission tomography-computed tomography (PET-CT). Due to the advanced age of the patient and the absence of metastatic disease, no adjuvant therapy was performed. Six months postoperatively there is no evidence of relapse.

Early identification of renal transplant recipients with high risk of polyomavirus-associated nephropathy.

Polyomavirus BK (BKPyV) is ubiquitous among humans. Following primary infection, the virus remains latent predominantly in the hosts' uroepithelial cells. Up to 10 % of renal transplant recipients show a viral reactivation that can lead to polyomavirus-associated nephropathy (PyVAN). In the absence of early treatments, the risk of graft loss is up to 80 %. Monitoring viral load in urine and plasma by real-time PCR after transplantation is the most common diagnostic tool to detect viral reactivation. In the present retrospective study, BKPyV-DNA loads in urine and plasma by quantitative real-time PCR were associated with clinical data, including HLA haplotype, blood parameters and viral genotype, of 40 renal transplant recipients at the University Clinics of Cologne. Seventeen out of 329 patients screened for BKPyV from January 2009 to October 2013 were detected BKPyV positive in urine only, whereas in 23 patients the virus became additionally detectable in plasma. Among these, ten patients progressed to PyVAN. Overall, the present study showed that the detection from the third month onwards after transplantation of a first viruric episode with a median viral load of 1 × 10(8) copies/mL, followed after few days by a first viremic episode with a median viral load of >1 × 10(4) copies/mL, was strongly associated with the development of PyVAN. In conclusion, the viral load and the temporal profile of the first viruric and viremic episode post-transplantation, in combination with specific features of the host immune response, should be considered as relevant clinical determinants of the risk of renal transplant recipients to progress to PyVAN.

[Classification and therapy of medication-overuse headache: impact of the third edition of the International Classification of Headache Disorders]. / Klassifikation und Therapie des Medikamenten-Übergebrauch-Kopfschmerzes (MÜK) : Auswirkungen der 3. Auflage der internationalen Kopfschmerzklassifikation auf die Praxis.

The diagnosis of medication-overuse headache (MOH) is of central importance because this secondary headache disorder can be treated very effectively and patients do not usually respond to headache prophylaxis as long as MOH persists. The article describes important changes in the diagnostic criteria of different MOH subtypes after publication of the International Classification of Headache Disorders (ICHD-3beta) in 2013. The new classification has a crucial and direct impact on prevention and treatment of MOH. In addition interactions exist with the new criteria of chronic migraine. With a controlled medication intake scheme according to the 10-20 rule and using a medication break, MOH usually remits in most patients. If patient education and advice does not lead to remission of MOH, a specialized managed medication break or withdrawal treatment becomes necessary. This can be done on an outpatient, day clinic or inpatient basis. In uncomplicated cases, the results of these three treatment settings do not differ. From a cost-effectiveness standpoint, the outpatient treatment should be given priority. In complicated cases, a fully inpatient withdrawal treatment using a multimodal treatment concept is significantly superior.

[Integrated headache care network. Kiel Migraine and Headache Center and German National Headache Treatment Network]. / Sektorenübergreifende schmerzmedizinische Versorgung. Schmerzklinik Kiel und bundesweites Kopfschmerzbehandlungsnetz.

Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors.

[Different headache forms of chapter 4 of the International Headache Classification]. / Verschiedenartige Kopfschmerzformen des Kapitels 4 der Internationalen Kopfschmerzklassifikation.

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.

[Therapy and care of patients with chronic migraine: expert recommendations of the German Migraine and Headache Society/German Society for Neurology as well as the Austrian Headache Society/Swiss Headache Society]. / Therapie und Versorgung bei chronischer Migräne : Expertenempfehlung der Deutschen Migräne- und Kopfschmerzgesellschaft/Deutsche Gesellschaft für Neurologie sowie der Österreichischen Kopfschmerzgesellschaft/Schweizerischen Kopfwehgesellschaft.

Chronic migraine (CM) was first defined in the second edition of the International Headache Society (IHS) classification in 2004. The definition currently used (IHS 2006) requires the patient to have headache on more than 15 days/month for longer than 3 months and a migraine headache on at least 8 of these monthly headache days and that there is no medication overuse. In daily practice the majority of the patients with CM also report medication overuse but it is difficult to determine whether the use is the cause or the consequence of CM. Most the patients also have other comorbidities, such as depression, anxiety and chronic pain at other locations. Therapy has to take this complexity into consideration and is generally multimodal with behavioral therapy, aerobic training and pharmacotherapy. The use of analgesics should be limited to fewer than 15 days per month and use of triptans to fewer than 10 days per month. Drug treatment should be started with topiramate, the drug with the best scientific evidence. If there is no benefit, onabotulinum toxin A (155-195 Units) should be used. There is also some limited evidence that valproic acid and amitriptyline might be beneficial. Neuromodulation by stimulation of the greater occipital nerve or vagal nerve is being tested in studies and is so far an experimental procedure only.

[Headache from increased cerebrospinal fluid pressure]. / Kopfschmerz durch Liquordrucksteigerung.

Increased cerebrospinal fluid (CSF) pressure is often accompanied by headache. The term idiopathic intracranial hypertension (pseudotumor cerebri) describes an increase in CSF pressure without a space-occupying intracranial lesion or hydrocephalus. After headaches, visual field defects are the second most common feature. Therapeutic measures include both drugs and surgical procedures. In high-pressure hydrocephalus, the volume of the CSF is increased, resulting either from increased production or reduced absorption. If an acquired or congenital obstruction of the ventricular system can be demonstrated, the term non-communicating hydrocephalus is used. In contrast, the CSF passage is blocked outside the ventricles in communicating hydrocephalus. Symptoms include diffuse headache worsening in the morning and with the Valsalva-like maneuver. Treatment is guided by etiology whenever possible; otherwise, drainage of CSF by ventriculostomy or shunt is necessary.

[Botulinum toxin type A for preventive treatment of chronic migraines]. / Prophylaxe der chronischen Migräne mit Botulinumtoxin Typ A.

The use of botulinum toxin type A for chronic migraines was studied systematically in the PREEMPT trials program. Superiority to placebo treatment was established. Thus, for the first time a prophylactic drug against chronic migraines is available that is both effective and well tolerated. Botox® was licensed in England for the prophylaxis of headaches in adults with chronic migraines (headaches on at least 15 days per month of which at least 8 days are with migraines) in 2010.

[Paroxysmal hemicrania and SUNCT]. / Paroxysmale Hemikranie und SUNCT.

Paroxysmal hemicrania is experienced as headache attacks with pain and accompanying symptoms similar to those of cluster headaches. Attacks are, however of shorter duration, occur more frequently, affect predominantly women and respond reliably to indomethacin. Paroxysmal hemicrania can also occur secondary to an identifiable cause. To exclude symptomatic, paroxysmal hemicrania, especially with an atypical clinical picture and poor response to indomethacin, a careful diagnostic approach is necessary. The SUNCT syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) is characterized by one-sided pain attacks of short duration, much shorter than other trigeminal autonomic cephalgias. Classically, the pain is accompanied by ipsilateral lacrimation and conjunctival injection. Some patients have been described with both cluster headache and trigeminal neuralgia. These patients should receive both diagnoses. It is important to differentiate these headache entities as specific therapy is needed for each to achieve optimal pain relief.

[Chronic migraine and headache by medication overuse. Evolution and revision of classification]. / Chronische Migräne und Kopfschmerz bei Medikamentenübergebrauch. Evolution und Revision der Klassifikation.

The first International classification of headache disorders (ICHD-I) described migraine as a recurring headache disorder manifesting in attacks lasting 4-72 h. The headache frequency was not considered in these first diagnostic criteria of migraine. Thus, a chronic migraine with at least 15 migraine days per month was only included in the ICHD-II in 2004. Meanwhile, the diagnosis of chronic daily headache and transformed migraine had been established in the USA. The term transformed migraine describes the transformation of an episodic migraine into a chronic one, whether medication overuse had been present or not. Up till now a widely accepted definition of chronic migraine and medication overuse headache has not been established due to different views. An overview of the evolution of the diagnostic criteria for both headache disorders in recent years is provided.

[Botulinum toxin type A in the prophylactic treatment of chronic migraine]. / Prophylaxe der chronischen Migräne mit Botulinumtoxin Typ A.

Since the second edition of the International classification of headache disorders (ICDH-II 2004), chronic migraine has been listed amongst migraine complications. Compared to episodic migraine the prevalence of chronic migraine is low, its impact, however, significant. Until recently no prophylactic drug had been approved for chronic migraine prophylaxis. After case reports had stated an effect of botulinum toxin type A on migraine, several randomized placebo-controlled studies were conducted in episodic headache; the results, however, were disappointing. Only when botulinum toxin type A was used in chronic migraine in the PREEMPT (phase 3 research evaluating migraine prophylaxis therapy) trials, its superiority compared to placebo was established. Thus, for the first time a prophylactic drug against chronic migraine is available which is both effective and well tolerated. Botox® has been licensed in England for the prophylaxis of headaches in adults with chronic migraine in 2010. Approval for its use in Germany has been applied for.

The Migraine Intervention Score - a tool to improve efficacy of triptans in acute migraine therapy: the ALADIN study.

BACKGROUND: The 'Migraine Intervention Score' (MIS) is a new self-administered scale that can be used to quantify the severity of specific migraine symptoms. The objective of this study was to determine if MIS could be used to improve the efficacy of frovatriptan 2.5 mg in the early treatment of migraine attacks for clinical practice. METHODS: In this prospective observational study, patients suffering from migraines with or without aura were enrolled and permitted to choose the time of self-medication with frovatriptan 2.5 mg. At the time of intake of medication, patients evaluated the severity of individual migraine symptoms using MIS. The scores for each symptom were then totalled to provide an overall level of symptom severity. A total of 1620 patients completed the treatment of three migraine attacks with frovatriptan. A total of 1518 patients could be analysed with respect to the documented efficacy parameters of the third attack. Patients initiating treatment at low symptom severity levels were compared with those initiating treatment at high symptom severity levels. RESULTS: Time to the achievement of the primary endpoint (headache response) was significantly lower in patients who initiated treatment at low vs. high symptom severity levels (42.06 ± 32.33 vs. 49.25 ± 34.92 min; p = 0.0023). Likewise, patients who initiated treatment at low symptom severity levels achieved complete headache relief more rapidly (79.37 ± 65.33 vs. 96.05 ± 100.85 min; p = 0.0109) and required escape medication less frequently (3.88% vs. 13.73%; p < 0.0001). CONCLUSIONS: The initiation of attack treatment with frovatriptan at low severity of migraine symptoms is more effective than starting therapy at higher symptom levels. Together with the low recurrence headache rate, the decreased necessity for escape medication and the low number of tablets needed, these data demonstrate that operationalised intervention with frovatriptan 2.5 mg is a valuable method for improving the treatment of migraine attacks.