Manejo de la trombosis venosa cerebral en España: estudio descriptivo MOTIVATE / Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

Introducción: La trombosis venosa cerebral (TVC) es una causa poco común de ictus que afecta principalmente a adultos jóvenes. Un diagnóstico precoz y preciso puede reducir la tasa y gravedad de las complicaciones. Objetivo: Analizar las características clínicas, manejo y tratamiento de la TVC en diferentes centros de nuestro país. Métodos: Estudio descriptivo retrospectivo multicéntrico de pacientes hospitalizados por TVC entre 2008 y 2017 en 11 centros sanitarios en nuestro país. Resultados: Se incluyeron 256 pacientes, edad media 49,8 ± 18,7 años y el 51% fueron mujeres. Los síntomas más frecuentes fueron: cefalea (73%), déficits focales (50%), crisis epilépticas (33%) y encefalopatía (21%). Las localizaciones más frecuentes fueron: seno longitudinal superior (12,5%), transverso (10,9%) y afectación de dos o más senos o venas (66,4%). La etiología conocida más frecuente fue la trombofilia (24%), siendo la mutación de la protrombina G20210A la más común (19%). El 46% fue tratado con antitrombóticos durante 3-6 meses, el 21% durante un año y un 22,6% de los pacientes requirieron anticoagulación indefinida. En un 5% de los sujetos fue preciso terapia endovascular y un 33% requirió neurocirugía. En relación al pronóstico, el 75% fueron independientes a los 3 meses con una puntuación en la escala de Rankin modificada (mRS) ≤ 2 y la presencia de papiledema (p = 0,03), déficit focal (p = 0,001) y encefalopatía (p < 0,001) se relacionaron significativamente con mal pronóstico (mRS > 3). La tasa de mortalidad intrahospitalaria fue del 4,3% y el 6,3% de los pacientes fallecieron a los 3 meses. Conclusión:La diversidad de factores de riesgo y la presentación variable suponen un desafío en el diagnóstico y tratamiento de la TVC. Para mejorar el pronóstico y reducir la mortalidad es fundamental la instauración de protocolos en el manejo de esta patología.(AU)

Introduction: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. Objective: The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. Methods: We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 11 Spanish centres. Results: We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3-6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P = .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. Conclusion: The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.(AU)

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group.

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

[New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants]. / Nueva era terapéutica para el ataque de migraña con los recientemente aprobados anticuerpos monoclonales, ditanes y gepantes.

Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market.

TITLE: Nueva era terapéutica para el ataque de migraña con los recientemente aprobados anticuerpos monoclonales, ditanes y gepantes.El tratamiento de los ataques de migraña se aconseja en todos los pacientes, utilizando antiinflamatorios no esteroideos cuando el dolor es leve y triptanes cuando la intensidad del dolor es moderada-grave. Sin embargo, la efectividad de estos fármacos es modesta, un porcentaje elevado de pacientes presenta efectos secundarios y los triptanes están contraindicados en las personas con antecedentes de ictus, cardiopatía isquémica o hipertensión mal controlada. Por tanto, es imprescindible disponer de nuevas alternativas terapéuticas. En los últimos años han ido apareciendo nuevos fármacos para los ataques de migraña, entre los que destacan los ditanes (lasmiditán) y los gepantes (ubrogepant y rimegepant). Por otro lado, el eptinezumab, que ha sido aprobado para el tratamiento preventivo de la migraña en adultos, se ha utilizado también para los ataques de migraña. En este manuscrito se revisan los resultados de eficacia y seguridad de los nuevos fármacos para los ataques de migraña que se comercializarán próximamente.

Aplicación de la telemedicina en la asistencia a pacientes con cefaleas: situación actual y recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de / NeurologíaTelemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group

Introducción: La pandemia COVID-19 ha provocado un inusitado impulso a la telemedicina(TM). Analizamos el impacto de la pandemia en la TM aplicada en las consultas de cefaleasespañolas, revisamos la literatura y lanzamos unas recomendaciones para implantar la TM enlas consultas. Método: Tres fases: 1) Revisión de la base Medline desde el año 1958 (primera experienciade TM); 2) Formulario Google Forms enviado a todos los neurólogos del Grupo de Estudio de Cefaleas de la Sociedad Espa˜nola de Neurología (GECSEN), y 3) Consenso on-line de expertosGECSEN para emitir recomendaciones para implantar la TM en España. Resultados: La pandemia por COVID-19 ha empeorado los tiempos de espera presenciales,incrementando el uso de todas las modalidades de TM antes y después de abril de 2020: teléfonofijo (del 75% al 97%), teléfono móvil (del 9% al 27%), correo electrónico (del 30% al 36%) yvideoconsulta (del 3% al 21%). Los neurólogos son conscientes de la necesidad de ampliar laoferta con videoconsultas, claramente in crescendo, y otras herramientas de e-health y m-health. Conclusiones: Desde el GECSEN recomendamos y animamos a todos los neurólogos que asis-ten a pacientes con cefaleas a implantar recursos de TM, teniendo como objetivo óptimo lavideoconsulta en menores de 60-65 a˜nos y la llamada telefónica en mayores, si bien cada casodebe individualizarse. Se deberá contar previamente con la aprobación y asesoramiento de losservicios jurídicos e informáticos y de la dirección del centro. La mayoría de los pacientes concefalea y/o neuralgia estable son candidatos a seguimiento mediante TM, tras una primeravisita que tiene que ser siempre presencial.(AU)

Introduction: The COVID-19 pandemic has caused an unexpected boost to telemedicine. Weanalyse the impact of the pandemic on telemedicine applied in Spanish headache consultations,review the literature, and issue recommendations for the implementation of telemedicine inconsultations. Method: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (firstreported experience with telemedicine); 2) Google Forms survey sent to all members of theSpanish Society of Neurology’s Headache Study Group (GECSEN); and 3) online consensus ofGECSEN experts to issue recommendations for the implementation of telemedicine in Spain.Results: COVID-19 has increased waiting times for face-to-face consultations, increasing theuse of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after),mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3%to 21%). Neurologists are aware of the need to expand the availability of video consultations,which are clearly growing, and other e-health and m-health tools. Conclusions: The GECSEN recommends and encourages all neurologists who assist patients withheadaches to implement telemedicine resources, with the optimal objective of offering videoconsultation to patients under 60-65 years of age and telephone calls to older patients, althougheach case must be considered on an individual basis. Prior approval and advice must be soughtfrom legal and IT services and the centre’s management. Most patients with stable headacheand/or neuralgia are eligible for telemedicine follow-up, after a first consultation that mustalways be held in person.(AU)

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group.

INTRODUCTION: The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations. METHOD: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain. RESULTS: COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools. CONCLUSIONS: The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study.

INTRODUCTION: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. OBJECTIVE: The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. METHODS: We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 10 Spanish centres. RESULTS: We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3 to 6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P =  .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. CONCLUSION: The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

[Prognosis of patients assisted in the emergency unit by the 'TIA protocol' in a third-level hospital at 90 days]. / Pronóstico de pacientes atendidos en urgencias mediante 'protocolo AIT' en un hospital de tercer nivel a los 90 días.

INTRODUCTION: Care models developed for the rapid management of patients with transient ischaemic attack (TIA) are safe, effective and reduce recurrence rates. The aim is to determine the prevalence of cardiovascular events at 90 days. PATIENTS AND METHODS: An observational, analytical, cross-sectional study was conducted. Adult male and female patients seen in the emergency department using the 'TIA protocol' between January 2016 and December 2019 were analysed. Data were collected on clinical variables, complementary tests, treatment and cardiovascular events (stroke/TIA, acute coronary syndrome or death due to cardiovascular causes) at 90 days. The study was approved by the Research Ethics Committee of Aragon. RESULTS: The TIA protocol was performed on 163 out of 591 patients diagnosed with TIA in the emergency department. Brain CT and neurosonology scans were performed in 100% and a 24-hour Holter-electrocardiogram was carried out in 52.1%; atrial fibrillation (AF) was detected in 3.6% of them. An MRI brain scan was performed in 78.4% and acute ischaemic injury was seen in diffusion sequences (DWI+) in 13.5%. The prevalence of cardiovascular events at 90 days was 4.9% (8): stroke, 3.1% (five TIAs); acute coronary syndrome, 0.6% (one); and death from cardiovascular causes, 1.2% (two). Major adverse cardiovascular events were significantly associated with a history of ischaemic heart disease (p = 0.014). Cardiovascular death was associated with a history of AF (p = 0.008), anticoagulants at discharge (p = 0.007) and no antiplatelet therapy at discharge (p = 0.012), and there was a tendency towards an association with a history of type 2 diabetes mellitus (p = 0.05). CONCLUSIONS: Rapid TIA protocols allow early care and avoid hospital admissions, without increasing the incidence of cardiovascular events or recurrence of stroke or TIA at 90 days.

TITLE: Pronóstico de pacientes atendidos en urgencias mediante 'protocolo AIT' en un hospital de tercer nivel a los 90 días.Introducción. Los modelos asistenciales desarrollados para el manejo rápido de pacientes con accidente isquémico transitorio (AIT) son seguros, eficaces y disminuyen las tasas de recurrencia. El objetivo es conocer la prevalencia de eventos cardiovasculares a 90 días. Pacientes y métodos. Estudio observacional, analítico y transversal. Se analiza a pacientes adultos de ambos sexos atendidos en urgencias mediante el 'protocolo AIT' entre enero de 2016 y diciembre de 2019. Se recogen variables clínicas, pruebas complementarias, tratamiento y eventos cardiovasculares (ictus/AIT, síndrome coronario agudo o muerte por causa cardiovascular) a los 90 días. El estudio fue aprobado por el Comité Ético de Investigación de Aragón. Resultados. Se realizó el protocolo AIT a 163 de 591 pacientes diagnosticados de AIT en urgencias. Se realizó una tomografía computarizada cerebral y una neurosonología al 100%, y un Holter-electrocardiograma de 24 horas al 52,1%, y se detectó fibrilación auricular (FA) en el 3,6%. Se hizo una resonancia magnética cerebral al 78,4%, y se demostró lesión isquémica aguda en secuencias de difusión (DWI+) en un 13,5%. La prevalencia de eventos cardiovasculares a los 90 días fue del 4,9% (8): ictus, el 3,1% (cinco AIT); síndrome coronario agudo, el 0,6% (uno), y muerte por causa cardiovascular, el 1,2% (dos). Los eventos adversos cardiovasculares mayores se asociaron de forma significativa al antecedente de cardiopatía isquémica (p = 0,014). La muerte por causa cardiovascular se asoció al antecedente de FA (p = 0,008), anticoagulación al alta (p = 0,007) y no antiagregación al alta (p = 0,012), y hubo una tendencia a la asociación con antecedente de diabetes mellitus de tipo 2 (p = 0,05). Conclusiones. Los protocolos AIT de actuación rápida permiten una atención precoz y evitan ingresos hospitalarios, sin implicar un incremento en la incidencia de eventos cardiovasculares o recurrencia de ictus o AIT a los 90 días.

Pronóstico de pacientes atendidos en urgencias mediante protocolo AIT en un hospital de tercer nivel a los 90 días / Prognosis of patients assisted in the emergency unit by the ‘TIA protocol’ in a third-level hospital at 90 days

Introducción: Los modelos asistenciales desarrollados para el manejo rápido de pacientes con accidente isquémico transitorio (AIT) son seguros, eficaces y disminuyen las tasas de recurrencia. El objetivo es conocer la prevalencia de eventos cardiovasculares a 90 días. Pacientes y métodos: Estudio observacional, analítico y transversal. Se analiza a pacientes adultos de ambos sexos atendidos en urgencias mediante el ‘protocolo AIT’ entre enero de 2016 y diciembre de 2019. Se recogen variables clínicas, pruebas complementarias, tratamiento y eventos cardiovasculares (ictus/AIT, síndrome coronario agudo o muerte por causa cardiovascular) a los 90 días. El estudio fue aprobado por el Comité Ético de Investigación de Aragón. Resultados: Se realizó el protocolo AIT a 163 de 591 pacientes diagnosticados de AIT en urgencias. Se realizó una tomografía computarizada cerebral y una neurosonología al 100%, y un Holter-electrocardiograma de 24 horas al 52,1%, y se detectó fibrilación auricular (FA) en el 3,6%. Se hizo una resonancia magnética cerebral al 78,4%, y se demostró lesión isquémica aguda en secuencias de difusión (DWI+) en un 13,5%. La prevalencia de eventos cardiovasculares a los 90 días fue del 4,9% (8): ictus, el 3,1% (cinco AIT); síndrome coronario agudo, el 0,6% (uno), y muerte por causa cardiovascular, el 1,2% (dos). Los eventos adversos cardiovasculares mayores se asociaron de forma significativa al antecedente de cardiopatía isquémica (p = 0,014). La muerte por causa cardiovascular se asoció al antecedente de FA (p = 0,008), anticoagulación al alta (p = 0,007) y no antiagregación al alta (p = 0,012), y hubo una tendencia a la asociación con antecedente de diabetes mellitus de tipo 2 (p = 0,05). Conclusiones: Los protocolos AIT de actuación rápida permiten una atención precoz y evitan ingresos hospitalarios, sin implicar un incremento en la incidencia de eventos cardiovasculares o recurrencia de ictus o AIT a los 90 días.(AU)

Introduction: Care models developed for the rapid management of patients with transient ischaemic attack (TIA) are safe, effective and reduce recurrence rates. The aim is to determine the prevalence of cardiovascular events at 90 days. Patients and methods: An observational, analytical, cross-sectional study was conducted. Adult male and female patients seen in the emergency department using the ‘TIA protocol’ between January 2016 and December 2019 were analysed. Data were collected on clinical variables, complementary tests, treatment and cardiovascular events (stroke/TIA, acute coronary syndrome or death due to cardiovascular causes) at 90 days. The study was approved by the Research Ethics Committee of Aragón. Results: The TIA protocol was performed on 163 out of 591 patients diagnosed with TIA in the emergency department. Brain CT and neurosonology scans were performed in 100% and a 24-hour Holter-electrocardiogram was carried out in 52.1%; atrial fibrillation (AF) was detected in 3.6% of them. An MRI brain scan was performed in 78.4% and acute ischaemic injury was seen in diffusion sequences (DWI+) in 13.5%. The prevalence of cardiovascular events at 90 days was 4.9% (8): stroke, 3.1% (five TIAs); acute coronary syndrome, 0.6% (one); and death from cardiovascular causes, 1.2% (two). Major adverse cardiovascular events were significantly associated with a history of ischaemic heart disease (p = 0.014). Cardiovascular death was associated with a history of AF (p = 0.008), anticoagulants at discharge (p = 0.007) and no antiplatelet therapy at discharge (p = 0.012), and there was a tendency towards an association with a history of type 2 diabetes mellitus (p = 0.05). Conclusions: Rapid TIA protocols allow early care and avoid hospital admissions, without increasing the incidence of cardiovascular events or recurrence of stroke or TIA at 90 days.(AU)

Headache as a reason for consultation: the primary care perspective.

INTRODUCTION: Headache is a frequent reason for consultation with primary care (PC) physicians. However, the condition is underdiagnosed and undertreated. One reason for this may be the lack of specific training on headache in PC. METHODS: We conducted a descriptive cross-sectional study of data gathered with a self-administered survey that was completed by PC physicians from our health district. We collected sociodemographic data and information on previous training in neurology and headache, and training needs. RESULTS: The survey was completed by 104 PC physicians, 53% of whom were women; mean age was 49 years. Most respondents worked in urban settings (42.3%) and had been trained via residency (77.9%). Although 65.4% spent more time with patients with headache than with other patients, only 32.7% used the International Classification of Headache Disorders. In our sample, 68.3% of respondents reported a high or very high interest in headache, and 75.9% wished to receive further training on the condition; theoretical and practical courses and update lectures were regarded as the most useful tools. In clinical practice, 90% used triptans and 78% used preventive treatments. The most frequently used drug was amitriptyline; only 22.1% choose topiramate. CONCLUSIONS: PC physicians are in frequent contact with patients with headache and show interest in receiving training on this condition. This could be helpful in designing training programmes aimed at improving quality of care in this area.

Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications.

BACKGROUND AND OBJECTIVE: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus. METHODS: This is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms. RESULTS: We recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P=.320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment. CONCLUSION: Anti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19.

Cefalea como motivo de consulta: la visión desde atención primaria / Headache as a reason for consultation: the primary care perspective

Introducción: La cefalea es un motivo de consulta frecuente en atención primaria (AP), sin embargo, se trata de una patología infradiagnosticada e infratratada. Uno de los posibles factores es la falta de formación de los profesionales de AP en cefaleas.MétodosEstudio descriptivo transversal mediante encuesta autoadministrada a los médicos de AP de nuestro sector sanitario. Se recogieron variables sociodemográficas, variables relacionadas con la formación previa en neurología y cefaleas y variables en relación con sus necesidades formativas.ResultadosCompletaron la encuesta 104 médicos de AP, de los cuales el 53% fueron mujeres y la edad media fue 49 años. La mayoría de los encuestados trabajan en un centro de salud urbano (42,3%) y se han formado vía MIR (77,9%). El 65,4% dedica más tiempo a una consulta de cefaleas que a otras consultas y solo un 32,7% utiliza la Clasificación Internacional de Cefaleas. El 68,3% declara tener un interés alto o muy alto en cefaleas y al 75,9% le gustaría mejorar su formación, eligiendo cursos teórico-prácticos y ponencias de actualización como la herramienta más útil. Un 90% utiliza triptanes en su práctica clínica diaria y el 78% emplea tratamientos preventivos. El fármaco más utilizado es amitriptilina y solo un 22,1% elige topiramato.ConclusionesLos profesionales de AP están en contacto constante con pacientes con cefaleas y muestran interés en la formación en esta patología, lo que podría ayudarnos a diseñar programas docentes dirigidos a mejorar la calidad asistencial en este ámbito. (AU)

Introduction: Headache is a frequent reason for consultation with primary care (PC) physicians. However, the condition is underdiagnosed and undertreated. One reason for this may be the lack of specific training on headache in PC.MethodsWe conducted a descriptive cross-sectional study of data gathered with a self-administered survey that was completed by PC physicians from our health district. We collected sociodemographic data and information on previous training in neurology and headache, and training needs.ResultsThe survey was completed by 104 PC physicians, 53% of whom were women; mean age was 49 years. Most respondents worked in urban settings (42.3%) and had been trained via residency (77.9%). Although 65.4% spent more time with patients with headache than with other patients, only 32.7% used the International Classification of Headache Disorders. In our sample, 68.3% of respondents reported a high or very high interest in headache, and 75.9% wished to receive further training on the condition; theoretical and practical courses and update lectures were regarded as the most useful tools. In clinical practice, 90% used triptans and 78% used preventive treatments. The most frequently used drug was amitriptyline; only 22.1% choose topiramate.ConclusionsPC physicians are in frequent contact with patients with headache and show interest in receiving training on this condition. This could be helpful in designing training programmes aimed at improving quality of care in this area. (AU)

Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications / Seguridad de los anticuerpos monoclonales anti-CGRP en pacientes con migraña durante la pandemia de COVID-19: implicaciones actuales y futuras

Background and objective: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus.MethodsThis is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms.ResultsWe recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P = .320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment.ConclusionAnti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19. (AU)

Antecedentes y objetivo: El péptido relacionado con el gen de la calcitonina (CGRP, por sus siglas en inglés), es un neuropéptido involucrado en la fisiopatología de la migraña, que también es conocido por participar en la regulación del sistema respiratorio y en algunas enfermedades inmunológicas como la sepsis. Hemos analizado el impacto del uso de los antagonistas de CGRP en pacientes con migraña durante la pandemia de COVID-19, causada por el coronavirus SARS-CoV-2.MétodosEstudio transversal multicéntrico desarrollado entre mayo y noviembre de 2020, en el que la Sociedad Española de Neurología distribuyó a nivel nacional una encuesta de la que recogimos datos sobre la presencia, las características y la gravedad de síntomas de COVID-19, entre los que se encontraba la cefalea, en pacientes con migraña tratados con anticuerpos monoclonales (AcM) anti-CGRP, y los comparamos con los de pacientes con migraña que no recibían dicho tratamiento. También realizamos un subanálisis de los pacientes con síntomas de COVID-19.ResultadosIdentificamos 300 pacientes con migraña: 51,7% (155/300) recibían AcM anti-CGRP; el 87,3% eran mujeres (262/300) y la edad media (desviación estándar) de la muestra fue de 47,1 (11,6) años. Un total de 41 pacientes (13,7%) cumplían los criterios diagnósticos de COVID-19, sin diferencias estadísticamente significativas entre los pacientes que recibían tratamiento con AcM anti-CGRP y los que no (16,1% y 11,0%, respectivamente; p = 0,320). De los pacientes con COVID-19, el 48,8% (20/41) acudieron a urgencias y el 12,2% (5/41) fueron hospitalizados. Igualmente, no se detectaron diferencias clínicas entre los pacientes que recibían dicho tratamiento y los que no.ConclusiónEl tratamiento con AcM anti-CGRP parece un recurso seguro en la práctica clínica, y no se asocia a un mayor riesgo de COVID-19. (AU)

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study. / Manejo de la trombosis venosa cerebral en España: estudio descriptivo MOTIVATE.

INTRODUCTION: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. OBJECTIVE: The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. METHODS: We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 11 Spanish centres. RESULTS: We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3-6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P=.03), focal deficits (P=.001), and encephalopathy (P <.001) showing a statistically significant association with poor prognosis (mRS> 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. CONCLUSION: The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Grado de cumplimiento terapéutico a los tres meses en pacientes con migraña / Degree of compliance with treatment at three months in migraine patients

Introducción: La adhesión al tratamiento preventivo oral (TPO) en la migraña se ve frecuentemente comprometida. El objetivo fue conocer el grado de adhesión al TPO en pacientes con migraña a los tres meses. Pacientes y métodos: Estudio multicéntrico observacional de pacientes diagnosticados de migraña episódica o crónica (criterios de la Clasificación Internacional de Cefaleas, tercera edición) en los que se iniciaba TPO. Se recogieron datos demográficos (edad, género, nivel estudios, estado civil) y de enfermedad (número de ataques, puntuación en las escalas Headache Impact Test-6 y Migraine Disability Assessment Scale). A los tres meses se pasó la escala de Morisky Green, que diferencia niveles de adhesión: excelente (0), moderada (1-2) y baja (3-4). Resultados: Participaron 100 pacientes, un 87% mujeres de 42 ± 13 años, el 14% con migraña crónica. El 53,2% comenzaba su primer TPO. Se iniciaron betabloqueantes en el 23,2%, antidepresivos tricíclicos en el 35,4%, flunaricina en el 21,2%, neuromoduladores en el 19,2% y antihipertensivos en el 1%. El 56% presentaba discapacidad grave y el 79,5%, impacto muy grave. La adhesión a los tres meses fue excelente en el 41,8%, moderada en el 28,6% y baja en el 29,6%. El motivo más frecuente de discontinuación fueron los efectos adversos (44%). Se encontró una relación significativa entre adhesión excelente y estado civil soltero (p = 0,046), y entre adhesión baja y efectos adversos (p = 0,009). No se encontraron diferencias significativas entre los TPO empleados y el grado de adhesión ni con el resto de variables estudiadas. Conclusiones: Aunque nuestros resultados son mejores que los publicados en la bibliografía, consideramos que la adhesión terapéutica en nuestro medio es baja y es prioritario educar a nuestros pacientes en este sentido.(AU)

Introduction: Adherence to oral preventive treatment (OPT) in migraine is often compromised. The aim was to determine the degree of adherence to OPT in migraine patients at three months. Patients and methods: We conducted a multicentre observational study of patients diagnosed with episodic or chronic migraine (criteria of the International Headache Classification, third edition) in whom OPT was initiated. Demographic data (age, gender, educational level, marital status) and disease data (number of attacks, Headache Impact Test-6 and Migraine Disability Assessment Scale scores) were collected. At three months, the Morisky-Green scale was administered, which differentiates levels of adherence: excellent (0), moderate (1-2) and low (3-4). Results: Altogether 100 patients participated in the study: 87% women aged 42 ± 13 years, 14% with chronic migraine; 53.2% of them were beginning their first OPT. Beta-blockers were initiated in 23.2%, tricyclic antidepressants in 35.4%, flunarizine in 21.2%, neuromodulators in 19.2% and antihypertensives in 1%. Severe disability was observed in 56%, and the impact was very severe in 79.5%. Adhesion at three months was excellent in 41.8%, moderate in 28.6% and low in 29.6%. The most frequent reason for discontinuing was the occurrence of adverse effects (44%). A significant relationship was found between excellent adherence and being single (p = 0.046), and between low adherence and adverse effects (p = 0.009). No significant differences were found between the OPT used and the degree of adherence or the other variables studied. Conclusions: Although our results are better than those published in the literature, we consider that therapeutic adherence in our setting is low and educating our patients in this regard is a priority.(AU)

[Degree of compliance with treatment at three months in migraine patients]. / Grado de cumplimiento terapéutico a los tres meses en pacientes con migraña.

INTRODUCTION: Adherence to oral preventive treatment (OPT) in migraine is often compromised. The aim was to determine the degree of adherence to OPT in migraine patients at three months. PATIENTS AND METHODS: We conducted a multicentre observational study of patients diagnosed with episodic or chronic migraine (criteria of the International Headache Classification, third edition) in whom OPT was initiated. Demographic data (age, gender, educational level, marital status) and disease data (number of attacks, Headache Impact Test-6 and Migraine Disability Assessment Scale scores) were collected. At three months, the Morisky-Green scale was administered, which differentiates levels of adherence: excellent (0), moderate (1-2) and low (3-4). RESULTS: Altogether 100 patients participated in the study: 87% women aged 42 ± 13 years, 14% with chronic migraine; 53.2% of them were beginning their first OPT. Beta-blockers were initiated in 23.2%, tricyclic antidepressants in 35.4%, flunarizine in 21.2%, neuromodulators in 19.2% and antihypertensives in 1%. Severe disability was observed in 56%, and the impact was very severe in 79.5%. Adhesion at three months was excellent in 41.8%, moderate in 28.6% and low in 29.6%. The most frequent reason for discontinuing was the occurrence of adverse effects (44%). A significant relationship was found between excellent adherence and being single (p = 0.046), and between low adherence and adverse effects (p = 0.009). No significant differences were found between the OPT used and the degree of adherence or the other variables studied. CONCLUSIONS: Although our results are better than those published in the literature, we consider that therapeutic adherence in our setting is low and educating our patients in this regard is a priority.

TITLE: Grado de cumplimiento terapéutico a los tres meses en pacientes con migraña.Introducción. La adhesión al tratamiento preventivo oral (TPO) en la migraña se ve frecuentemente comprometida. El objetivo fue conocer el grado de adhesión al TPO en pacientes con migraña a los tres meses. Pacientes y métodos. Estudio multicéntrico observacional de pacientes diagnosticados de migraña episódica o crónica (criterios de la Clasificación Internacional de Cefaleas, tercera edición) en los que se iniciaba TPO. Se recogieron datos demográficos (edad, género, nivel estudios, estado civil) y de enfermedad (número de ataques, puntuación en las escalas Headache Impact Test-6 y Migraine Disability Assessment Scale). A los tres meses se pasó la escala de Morisky Green, que diferencia niveles de adhesión: excelente (0), moderada (1-2) y baja (3-4). Resultados. Participaron 100 pacientes, un 87% mujeres de 42 ± 13 años, el 14% con migraña crónica. El 53,2% comenzaba su primer TPO. Se iniciaron betabloqueantes en el 23,2%, antidepresivos tricíclicos en el 35,4%, flunaricina en el 21,2%, neuromoduladores en el 19,2% y antihipertensivos en el 1%. El 56% presentaba discapacidad grave y el 79,5%, impacto muy grave. La adhesión a los tres meses fue excelente en el 41,8%, moderada en el 28,6% y baja en el 29,6%. El motivo más frecuente de discontinuación fueron los efectos adversos (44%). Se encontró una relación significativa entre adhesión excelente y estado civil soltero (p = 0,046), y entre adhesión baja y efectos adversos (p = 0,009). No se encontraron diferencias significativas entre los TPO empleados y el grado de adhesión ni con el resto de variables estudiadas. Conclusiones. Aunque nuestros resultados son mejores que los publicados en la bibliografía, consideramos que la adhesión terapéutica en nuestro medio es baja y es prioritario educar a nuestros pacientes en este sentido.

Telemedicine in the management of patients with headache: current situation and recommendations of the Spanish Society of Neurology's Headache Study Group. / Aplicación de la telemedicina en la asistencia a pacientes con cefaleas: situación actual y recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología.

INTRODUCTION: The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations. METHOD: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain. RESULTS: COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools. CONCLUSIONS: The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications.

BACKGROUND AND OBJECTIVE: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus. METHODS: This is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms. RESULTS: We recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P=.320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment. CONCLUSION: Anti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19.