Virtual neuromuscular ultrasound courses during COVID-19 pandemic: Leveraging technology to enhance learning opportunities.

INTRODUCTION/AIMS: Hands-on supervised training is essential for learning diagnostic ultrasound. Unfortunately, the coronavirus disease 2019 (COVID-19) pandemic led to suspension of in-person training courses. As a result, many hands-on training courses were converted into virtual courses during the pandemic. Several reports regarding virtual ultrasound courses exist, but none has addressed virtual neuromuscular ultrasound courses, their design, or participants' views of this form of training. Therefore, the aims of this study were: (1) to determine the feasibility of conducting virtual neuromuscular ultrasound courses during the COVID-19 pandemic; and (2) to report the positive and negative aspects of the courses through the analyses of the responses of post-course surveys. METHODS: Two virtual neuromuscular ultrasound courses, basic and intermediate level, were conducted by the Egyptian Neuromuscular Ultrasound society during August 2020. Post-course, the attendees were directed to an electronic survey that consisted of eight questions. Ninety-three responses (23.8%) were obtained from the survey of the basic course and 156 responses (44.4%) were obtained from the survey of the intermediate course. RESULTS: Ninety-eight percent of the respondents to basic course surveys, and 100% of the respondents to the intermediate course survey found the courses useful or very useful. DISCUSSION: This report demonstrates the utility of virtual neuromuscular ultrasound courses for those participants willing to respond to a survey and describes a proposed design for such courses. Although hands-on supervised ultrasound training is ideal, virtual courses can be useful alternatives to in-person training when in-person interaction is restricted.

Prognostic value of nerve ultrasonography: A prospective multicenter study on the natural history of chronic inflammatory neuropathies.

BACKGROUND AND OBJECTIVE: Nerve ultrasound is a promising new tool in chronic inflammatory neuropathies. The aim of this study was to determine its prognostic value in a prospective multicenter cohort study including incident and prevalent patients with CIDP and MMN. METHODS: We enrolled 126 patients with CIDP, and 72 with MMN; 71 were treatment-naive. Patients with chronic idiopathic axonal polyneuropathy (CIAP; n = 35) were considered as disease controls. Standardized neurological examination, questionnaires, and nerve ultrasonography were obtained at time of inclusion and 1-year follow-up. Nerve size development over time and correlation between nerve size and clinical outcome measures were determined using linear mixed effects models. RESULTS: Nerve size development over time was heterogeneous. Only in MMN was there a correlation between C5 nerve root size and deterioration of grip strength (-1.3 kPa/mm2 (95% confidence interval [CI] -2.3 to -0.2). No other significant correlations between nerve size and clinical outcome measures were found. In MMN, presence of nerve enlargement at inclusion predicted deterioration of grip strength, and MMN patients with enlargement confined to the brachial plexus seemed to have more favorable outcomes. No other predictive effects of sonographic nerve size were found. CONCLUSIONS: The present study indicates that the natural course of nerve size development in CIDP and MMN is heterogeneous, and that the prognostic value of sonographic nerve enlargement is limited. It had some predictive effect in patients with MMN. Further research in specific subgroups of chronic inflammatory neuropathy is necessary to determine the usefulness of nerve ultrasonography after the diagnostic phase.

Ultrasound of peripheral nerves in neuralgic amyotrophy.

INTRODUCTION: Neuralgic amyotrophy (NA) can often be difficult to diagnose. Nerve ultrasound (US) is potentially useful, but it is operator-dependent, especially for small nerves. METHODS: Fifty-one consecutive patients with NA (mean duration 16 months) and 50 control subjects underwent US of the brachial plexus and major nerves of the upper extremity at predefined sites. We compared cross-sectional areas (CSAs) of affected and unaffected sides with controls and sides within patients. RESULTS: The median nerve and radial nerve at the level of the upper arm were enlarged on the affected sides compared with controls and the unaffected sides of patients. Enlargement was most pronounced for affected sides vs. controls (median 44%, radial 67%). DISCUSSION: NA patients showed increased CSAs, especially in the major nerves of the upper limb, even after longer disease duration. This could make US a useful adjunct in diagnosing NA. Muscle Nerve 59:55-59, 2019.

Field testing of ICHD-3 beta criteria of periictal headaches in patients with focal epilepsy - a prospective diary study.

Background To date we are lacking prospective data for field testing of ICHD-3 beta criteria for periictal headache (PIH). Methods Patients with focal epilepsy diagnosed by means of prolonged video-EEG monitoring completed a paper-pencil diary for three months and recorded seizures and headaches on a daily basis. According to ICHD-3 beta, we classified PIH, defined as headache present on a day with at least one seizure, as "7.6 headache related to epileptic seizure", "7.6.1 hemicrania epileptica" or "7.6.2 postictal headache". In addition, we compared the ICHD-3 beta diagnoses to the diagnoses according to ICHD-2. Results Thirty two patients completed the diary. Data analysis included 2,668 patient days, 300 seizures and 37 episodes of PIH. Two of these episodes (5.4%) were classified as headache related to seizure, three (8.1%) fulfilled both the criteria of headache related to seizure and hemicrania epileptica and four (10.8%) were postictal headaches. Twenty eight episodes (75.7%) did not fulfil any of the ICHD-3 beta criteria of seizure-related headaches, mostly because headache onset was before seizure onset. Applying ICHD-2 criteria allowed only one single episode of PIH to be classified as postictal headache. Discussion Our study is the first to present prospective field testing data of the ICHD-3 beta criteria for three types of seizure-related headaches. The majority of PIH episodes do not fulfil any of these criteria. One quarter can be classified according to ICHD-3 beta, whereas purely clinical diagnosis of PIH is markedly restricted in ICHD-2 because of mandatory electroencephalographic evidence.

Extremely Painful Multifocal Acquired Predominant Axonal Sensorimotor Neuropathy of the Upper Limb.

The differential diagnosis of upper extremity mononeuritis multiplex includes neuralgic amyotrophy, vasculitic neuropathy, and Lewis-Sumner syndrome. We describe 3 patients initially suspected of neuralgic amyotrophy, who had an extremely painful, protracted, progressive disease course, not fitting one of these established diagnoses. Nerve ultrasonography showed focal caliber changes of the roots, plexus, and limb nerves. Electromyography showed predominant multifocal axonopathy. Ongoing autoimmune neuropathy was suspected. Steroid treatment provided temporary relief, and intravenous immunoglobulin A sustained pain decrease and functional improvement. These patients appear to have extremely painful axonal inflammatory neuropathy, with a good response to immune-modulating treatment.

High-resolution ultrasound visualization of the deep branch of the ulnar nerve.

INTRODUCTION: The value of imaging the deep branch of the ulnar nerve (DBUN) over its entire course has not been clarified. Therefore, this study evaluates the feasibility of visualizing the DBUN from its origin to the most distal point. METHODS: We performed high-resolution ultrasound (HRUS) with high-frequency probes (18-22 MHZ), HRUS-guided ink marking, and consecutive dissection in 8 fresh cadaver hands. In both hands of 10 healthy volunteers (n = 20), the cross-sectional area (CSA) was measured at 2 different locations (R1 and R2). RESULTS: The DBUN was clearly visible in all anatomical specimens and in healthy volunteers. Dissection confirmed HRUS findings in all anatomical specimens. The mean CSA was 1.8 ± 0.5 mm2 at R1 and 1.6 ± 0.4 mm2 at R2. DISCUSSION: This study confirms that the DBUN can be reliably visualized over its entire course with HRUS in anatomical specimens and in healthy volunteers. Muscle Nerve 56: 1101-1107, 2017.

High-resolution ultrasound visualization of the recurrent motor branch of the median nerve: normal and first pathological findings.

PURPOSE: To evaluate in a prospective study the possibility of visualization and diagnostic assessment of the recurrent motor branch (RMB) of the median nerve with high-resolution ultrasound (HRUS). MATERIALS AND METHODS: HRUS with high-frequency probes (18-22 MhZ) was used to locate the RMB in eight fresh cadaveric hands. To verify correct identification, ink-marking and consecutive dissection were performed. Measurement of the RMB maximum transverse-diameter, an evaluation of the origin from the median nerve and its course in relation to the transverse carpal ligament, was performed in both hands of ten healthy volunteers (n = 20). Cases referred for HRUS examinations for suspected RMB lesions were also assessed. RESULTS: The RMB was clearly visible in all anatomical specimens and all volunteers. Dissection confirmed HRUS findings in all anatomical specimens. Mean RMB diameter in volunteers was 0.7 mm ± 0.1 (range, 0.6-1). The RMB originated from the radial aspect in 11 (55%), central aspect in eight (40%) and ulnar aspect in one (5%) hand. Nineteen (95%) extraligamentous courses and one (5%) subligamentous course were detected. Three patients with visible RMB abnormalities on HRUS were identified. CONCLUSION: HRUS is able to reliably visualize the RMB, its variations and pathologies. KEY POINTS: • Ultrasound allows visualization of the recurrent motor branch of the median nerve. • Ultrasound may help clinicians to assess patients with recurrent motor branch pathologies. • Patient management may become more appropriate and targeted therapy could be improved.

Neuroimaging of classic neuralgic amyotrophy.

INTRODUCTION: Neuralgic amyotrophy (NA) often imposes diagnostic problems. Recently, MRI and high-resolution ultrasound (HRUS) have proven useful in diagnosing peripheral nerve disorders. METHODS: We performed a chart and imaging review of patients who were examined using neuroimaging and who were referred because of clinically diagnosed NA between March 1, 2014 and May 1, 2015. RESULTS: Six patients were included. All underwent HRUS, and 5 underwent MRI. Time from onset to evaluation ranged from 2 weeks to 6 months. HRUS showed segmental swelling of all clinically affected nerves/trunks. Atrophy of muscles was detected in those assessed >1 month after onset. MRI showed T2-weighted hyperintensity in all clinically affected nerves, except for the long thoracic nerve, and denervation edema of muscles. CONCLUSIONS: HRUS and MRI are valuable diagnostic tools in NA. This could change the diagnostic approach from one now focused on excluding other disorders to confirming NA through imaging markers. Muscle Nerve 54: 1079-1085, 2016.

The lesser occipital nerve visualized by high-resolution sonography--normal and initial suspect findings.

BACKGROUND: The lesser occipital nerve (LON) supplies the lateral part of the occiput and is-together with the greater occipital nerve (GON)-involved in headache pathogenesis. While the GON was described in high-resolution ultrasound (HRUS), the same does not apply to the LON. We aimed at characterizing the LON in HRUS, and present cases of suspect findings in the course of the LON identified by HRUS. METHODS: The LON was examined bilaterally in eight anatomical specimens with HRUS (n = 16). HRUS-guided ink marking and consecutive dissection was performed. Further, measurements of the LON diameter were performed in 10 healthy volunteers (n = 20), and patient charts were reviewed to identify patients who were considered to have possible pathology of the LON. RESULTS: The LON was identified correctly in all cadavers on both sides and all volunteers except for one side (n = 19). The average diameter was 1.08 ± 0.30 mm. Four patients with pain within the LON territory and presumed peripheral origin of headache (defined as resolution of headache after diagnostic HRUS-guided selective blockade) were identified, and three of these showed interference of the LON with lymph nodes or an accessory muscle belly. DISCUSSION: We confirm the possibility of visualization of the LON using HRUS. HRUS may be a helpful adjunct tool in the assessment of patients with atypical headache.

High-resolution ultrasound of the posterior femoral cutaneous nerve: visualization and initial experience with patients.

OBJECTIVE: The posterior femoral cutaneous nerve (PFCN) is a sensory nerve originating from the sacral plexus. PFCN neuropathy leads to pain within the inferior gluteal region and the posterior aspect of the thigh. As electrophysiological assessment is challenging, diagnosis of PFCN neuropathy has been, thus far, primarily based on clinical findings, which can result in misdiagnosis. Therefore, alternative confirmatory assessments such as an imaging modality that could aid in the diagnosis of PFCN neuropathy would be desirable. The purpose of this study was to determine the feasibility of visualization of the PFCN with high-resolution ultrasound (HRUS) and to test this technique in our clinical routine. MATERIALS AND METHODS: The study consisted of two parts. In the first part, HRUS-guided perineural ink injections along the course of the PFCN were performed at the posterior aspect of the thigh in 26 lower limbs of 14 fresh non-embalmed cadavers. Subsequent dissection confirmed correct identification of the nerve. In the second part, patients with a suspected PFCN neuropathy were examined and a selective HRUS-guided nerve block was performed to verify the suspected diagnosis. RESULTS: The PFCN was correctly identified with HRUS in 96.2% (25/26) of cadavers. Further, six patients with a suspected lesion of the PFCN were examined, and the diagnosis was proven by successful HRUS-guided block in all cases. CONCLUSION: We confirmed the reliable visualization of the PFCN using HRUS. This offers a new technique for the assessment of the PFCN, which could also be demonstrated with the case series presented.

Do nocturnal headaches matter? A prospective diary study on subjective sleep parameters in snorers and their bed partners.

BACKGROUND: The objective of this study was to assess the influence of nocturnal headaches (NH) on subjective sleep parameters prospectively in habitual snorers and their bed partners. METHODS: We recruited habitual snorers and their bed partners via newspaper articles. The participants completed a semistructured interview, filled in questionnaires about quality of sleep (PSQI), daytime sleepiness (ESS), depression (SDS) and anxiety (SAS) and they kept a 90-day headache and sleep diary. RESULTS: Seventy-six snorers (25 female) and 41 bed partners (31 female) completed the study recording a total of 6690 and 3497 diary days, respectively. NH were recorded on 222 (3.3%) and 79 (2.2%) days in 32 (42%) snorers and 17 (41%) bed partners, respectively. Snorers with NH showed significantly higher PSQI (5 ± 3 vs. 4 ± 2, p = 0.004), SAS (38 ± 11 vs. 31 ± 10, p = 0.011) and SDS scores (39 ± 12 vs. 34 ± 10, p = 0.048) than snorers without NH. For bed partners with NH we found a significant female predominance (sex ratio f:m = 16:1 vs. 12:12, p = 0.005) and significantly higher SAS scores (38 ± 6 vs. 33 ± 8, p = 0.030) compared with bed partners without NH. The subjective quality of sleep in habitual snorers (p < 0.001) as well as their bed partners (p = 0.017) was negatively influenced by NH, but not total sleep time. DISCUSSION: NH occurred in around 40% of snorers and their bed partners at least once during the 90-day observation period. Our results confirmed a negative impact on the subjective quality of sleep in both groups.

Characteristics of acute posttraumatic headache following mild head injury.

BACKGROUND: To examine the prevalence and characteristics of acute posttraumatic headache (APTH) attributed to mild head injury within a prospective, observational study design. METHODS: We recruited 100 patients with acute mild head injury as defined in the International Classification of Headache Disorders, 2nd Edition (ICHD-2) presenting to the department of trauma surgery at the Medical University of Vienna. Patients underwent a detailed telephone interview between days 7 and 10 and between days 90 and 100 after the injury. RESULTS: The prevalence of APTH was 66%. APTH had occurred within 24 hours after the trauma in 78% and lasted for a median of 3.0 days. Headache was unilateral in 45%. Aggravation by physical activity, nausea and photo-/phonophobia was present in 49%, 42% and 55%, respectively. The prevalence of APTH was related to conditions of chronic pain (excluding headache), pre-existing episodic headache, number of posttraumatic symptoms, anxiety and depression. At follow-up at 90-100 days, posttraumatic headache had abated in all patients. CONCLUSIONS: APTH attributed to mild head injury is a common but self-limiting condition frequently showing migrainous features. Participants with chronic pain other than headache, pre-existing headache and affective disorders are at higher risk of developing APTH. None of the patients developed chronic posttraumatic headache.

Sex hormones and primary headaches other than migraine.

The relation between sex hormones and migraine has been examined in a series of studies, leading to the definitions of pure menstrual migraine and menstrually-related migraine. The relation between sex hormones and other types of primary headache has been studied less extensively, but there is at least some evidence that hormones in general, and menstruation, pregnancy, or menopause in particular, also impact these disorders. This article reviews the available literature on changes of tension-type headache, cluster headache, other trigeminal autonomic cephalalgias, and hemicrania continua during women's reproductive periods.

Migraine and vertigo--a prospective diary study.

The objective of the study was to examine migrainous vertigo prospectively by means of a diary. We included 146 patients with at least one migraine attack per month. All patients underwent a semistructured interview, completed questionnaires on depression, anxiety and quality of sleep and kept a diary covering detailed information on headache, vertigo and dizziness over a period of 30 days. A completed diary was returned by 116 patients (79.5%). Based on the diary migrainous vertigo (MV) was diagnosed in 18 patients (15.5%) and non-migrainous vertigo or dizziness (non-MV) in 35 patients (30.2%). MV was present on 65 of 3477 patient days (1.9%) and non-MV on 145 days (4.2%). MV occurred more often on days with headache (P < 0.001). Its median duration was 3 h and it lasted longer on days with headache than on days without headache (P < 0.001). The most prominent specific feature of MV was head motion intolerance. Patients with MV showed anxiety more often (P < 0.001) and tended to have worse quality of sleep and higher depression scores. In conclusion, vertigo and dizziness are frequent symptoms in migraineurs. The 1-month prevalence of MV is 16% and that of non-MV 30% in patients with at least one migraine attack per month. Frequency of MV is higher and duration longer on days with headache. MV is a risk factor for co-morbid anxiety.

High-Resolution Axonal Bundle (Fascicle) Assessment and Triple-Echo Steady-State T2 Mapping of the Median Nerve at 7 T: Preliminary Experience.

OBJECTIVES: The aims of this preliminary study were to determine the number of axonal bundles (fascicles) in the median nerve, using a high-resolution, proton density (PD)-turbo spin echo (TSE) fat suppression sequence, and to determine normative T2 values, measured by triple-echo steady state, of the median nerve in healthy volunteers and in patients with idiopathic carpal tunnel syndrome (CTS), at 7 T. MATERIALS AND METHODS: This prospective study was approved by the local ethics committee and conducted between March 2014 and January 2015. All study participants gave written informed consent. Six healthy volunteers (30 ± 12 years) and 5 patients with CTS (44 ± 16 years) were included. Measurements were performed on both wrists in all volunteers and on the affected wrist in patients (3 right, 2 left). Based on 5-point scales, 2 readers assessed image quality (1, very poor; 5, very good) and the presence of artifacts that might have a possible influence on fascicle determination (1, severe artifacts; 5, no artifacts) and counted the number of fascicles independently on the PD-TSE sequences. Furthermore, T2 values by region of interest analysis were assessed. Student t tests, a hierarchic linear model, and intraclass correlation coefficients (ICCs) were used for statistical analysis. RESULTS: Proton density-TSE image quality and artifacts revealed a median of 5 in healthy volunteers and 4 in patients with CTS for both readers. Fascicle count of the median nerve ranged from 13 to 23 in all subjects, with an ICC of 0.87 (95% confidence interval [CI], 0.67-0.95). T2 values were significantly higher (P = 0.023) in patients (24.27 ± 0.97 milliseconds [95% CI, 22.19-26.38]) compared with healthy volunteers (21.01 ± 0.65 milliseconds [95% CI, 19.61-22.41]). The ICC for all T2 values was 0.97 (95% CI, 0.96-0.98). CONCLUSIONS: This study shows the possibility of fascicle determination of the median nerve in healthy volunteers and patients with CTS (although probably less accurately) with high-resolution 7 T magnetic resonance imaging, as well as significantly higher T2 values in patients with CTS, which seems to be associated with pathophysiological nerve changes.

Successful Identification and Assessment of the Superior Cluneal Nerves with High-Resolution Sonography.

BACKGROUND: Low back pain is a disabling and common condition, whose etiology often remains unknown. A suggested, however rarely considered, cause is neuropathy of the medial branch of the superior cluneal nerves (mSCN)-either at the level of the originating roots or at the point where it crosses the iliac crest, where it is ensheathed by an osseo-ligamentous tunnel. Diagnosis and treatment have, to date, been restricted to clinical assessment and blind infiltration with local anesthetics. OBJECTIVE: To determine whether visualization and assessment of the mSCN with high-resolution ultrasound (HRUS) is feasible. STUDY DESIGN: Interventional cadaver study and case series. METHODS: Visualization of the mSCN was assessed in 7 anatomic specimens, and findings were confirmed by HRUS-guided ink marking of the nerve and consecutive dissection. Further, a patient chart and image review was performed of patients assessed at our department with the diagnosis of mSCN neuropathy. RESULTS: The mSCN could be visualized in 12 of 14 cases in anatomical specimens, as confirmed by dissection. Nine patients were diagnosed with mSCN syndrome of idiopathic or traumatic origin. Diagnosis was confirmed in all of them, with complete resolution of symptoms after HRUS-guided selective nerve block. LIMITATIONS: These findings are first results that need to be evaluated in a systematic, prospective and controlled manner. CONCLUSION: We hereby confirm that it is possible to visualize the mSCN in the majority of anatomical specimens. The patients described may indicate a higher incidence of mSCN syndrome than has been recognized. mSCN syndrome should be considered in patients with low back pain of unknown origin, and HRUS may be able to facilitate nerve detection and US-guided nerve block.

The pattern and time course of somatosensory changes in the human UVB sunburn model reveal the presence of peripheral and central sensitization.

The ultraviolet B (UVB) sunburn model was characterized with a comprehensive battery of quantitative sensory testing (QST). Primary hyperalgesia in UVB-irradiated skin and secondary hyperalgesia in adjacent nonirradiated skin were studied in 22 healthy subjects 24h after irradiation with UVB at 3-fold minimal erythema dose of a skin area 5 cm in diameter at the thigh and compared to mirror-image contralateral control areas. The time course of hyperalgesia over 96 h was studied in a subgroup of 12 subjects. Within the sunburn area, cold hyperesthesia (P=.01), profound generalized hyperalgesia to heat (P<.001), cold (P<.05), pinprick and pressure (P<.001), and mild dynamic mechanical allodynia (P<.001) were present. The finding of cold hyperalgesia and cold hyperesthesia is new in this model. The sunburn was surrounded by large areas of pinprick hyperalgesia (mean±SEM, 218±32 cm(2)) and a small rim of dynamic mechanical allodynia but no other sensory changes. Although of smaller magnitude, secondary hyperalgesia and dynamic mechanical allodynia adjacent to the UVB-irradiated area were statistically highly significant. Primary and secondary hyperalgesia developed in parallel within hours, peaked after 24-32 h, and lasted for more than 96 h. These data reveal that the UVB sunburn model activates a broad spectrum of peripheral and central sensitization mechanisms and hence is a useful human surrogate model to be used as a screening tool for target engagement in phases 1 and 2a of drug development.

Common anatomical variation in patients with idiopathic meralgia paresthetica: a high resolution ultrasound case-control study.

BACKGROUND: Meralgia paresthetica (MP) is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) characterized by pain, numbness or paresthesia on the anterolateral aspect of the thigh. Though several contributing factors have been identified, the cause of its idiopathic form still remains unclear. Anatomic and clinical studies have demonstrated a variable course for the LFCN and have suggested a contribution to the pathogenesis of MP. OBJECTIVE: It was the aim of the present case-control study to assess the anatomical course and compression site of the LFCN using high resolution ultrasound (HRUS) in patients suffering from idiopathic MP, and compare the anatomical course in these patients to an asymptomatic control group. STUDY DESIGN: Case-control study. SETTING: Nerve imaging center at a large university hospital in Austria. METHODS: Twenty-eight patients with a diagnosis of MP were included in this study (20 men, 8 women; mean age 54 years). The diagnosis was established by clinical history, physical examination, and diagnostic anesthetic block. Fifteen age- and gender-matched healthy volunteers served as the control group. Standardized HRUS examinations were performed by one experienced radiologist from June 2004 through April 2012. Two experienced radiologists reviewed the patients' standardized HRUS examinations and performed examinations in the control group to measure the minimal distance between the LFCN and the anterior superior iliac spine (ASIS). OUTCOMES: The minimal distance between the ASIS and the LFCN was measured using HRUS. RESULTS: The LFCN could be seen in all patients and volunteers. In MP patients, the mean distance between the LFCN and the ASIS was 0.52 cm (SD 0.46 cm), compared to a mean distance of 1.79 cm (SD 1.48 cm) in the control group (P < 0.001). LIMITATIONS: Limited sample size, retrospective design. CONCLUSIONS: The results of this study demonstrate a significantly different course of the LFCN, closer to the ASIS in patients with idiopathic MP.

Knowledge about and use of pharmacological and non-pharmacological headache therapies.

OBJECTIVE: To analyse knowledge and use of pharmacological and non-pharmacological therapies in headache patients referred to a tertiary headache centre. METHODS: We included 114 consecutive patients referred by a neurologist and asked them to fill out a comprehensive questionnaire immediately before their first appointment at our outpatient headache clinic. The questionnaire covered 23 compounds for acute treatment, 21 prophylactic drugs, and 30 complementary and alternative treatments. RESULTS: The proportion of patients who knew at least one acute therapy stood at 92 %; 62 % knew at least one pharmaco-prophylaxis and 80 % knew at least one non-pharmacological treatment. Even though 87 % of the patients with migraine had ³ 4 disabling headache days per month, only 41 % had used triptans and not more than 19 % had taken drugs of first choice for migraine prophylaxis for at least 3 months. In contrast, 75 % had used complementary or alternative treatments. Univariate analyses showed several predictors for the use of pharmaco-prophylaxis and non-pharmacological treatment, of which only knowledge about pharmaco-prophylaxis predicted use of alternative treatments in multivariate analysis. CONCLUSION: In Austria, a significant proportion of patients suffering from frequent recurrent headaches or migraines who are referred to a tertiary headache centre do not know and do not use triptans and pharmacological prophylaxis, while there is obviously broad acceptance and frequent use of mostly questionable alternative treatments. Improvement of primary and secondary care as well as patient education is desirable.