"Growing pains" in children and adolescents as an early symptom of migraine: A prospective study.

BACKGROUND: Children and adolescents may experience pain in the lower limbs, predominantly at the end of the day or during the night, without any relation to organic disease. These pains are often called "growing pains" (GP) by pediatricians and orthopedists. They are commonly attributed to rapid growth. OBJECTIVE: The aim of this study was to review and characterize GP in children and adolescents as a precursor/comorbidity with migraine. METHODS: The study was of a cross-sectional, prospective, longitudinal cohort, with group comparison. A sample of 100 children/adolescents born to mothers with migraine seen at a headache clinic was recruited in a random order chosen by lot, maintaining the ratio of 1:1 for the group with GP and the controls. Both groups were followed for a period of 5 years. RESULTS: After 5 years of follow-up, 78 patients completed the study, of which 42 were from the GP group and 36 were from the control group. Headache fulfilling the International Classification of Headache Disorders, 3rd edition diagnostic criteria for migraine without aura or probable migraine occurred in 32/42 (76%) of patients with GP and in 8/36 (22%) of controls (p < 0.001). In the sample that initially had "growing pains," these pains persisted in 6/42 (14%) and appeared in 14/36 (39%) of those who were previously asymptomatic (p = 0.026). CONCLUSIONS: Pain in the lower limbs of children and adolescents, commonly referred to as GP by pediatricians and orthopedists, may reflect a precursor or comorbidity with migraine.

Migraine Attacks Triggered by Ingestion of Watermelon.

INTRODUCTION: Ingesting some foods can trigger headache attacks in migraine patients. Diet-sourced citrulline activates the l-arginine-nitric oxide pathway, acting on the pathophysiology of migraine. METHODS: The study was a clinical trial, interventional, controlled, and with group comparison. The sample was non-random, composed of 38 volunteers with migraine and 38 without headache (control). Both groups ingested a portion of watermelon to determine the onset of headache attacks. Before and after ingesting watermelon, they underwent blood collections to determine serum nitrite levels. RESULTS: There were 38 volunteers diagnosed with migraine without aura and 38 controls, whose mean age was, respectively, 22.4 ± 1.5 and 22.9 ± 3.1 years (p = 0.791). Headache was triggered by watermelon ingestion after 124.3 ± 20.5 min of ingestion in 23.7% (9/38) of the migraine volunteers and in none of the controls (p = 0.002). There was an increase in serum nitrite levels, both in migraine volunteers (23.4%) and in the control group (24.3%), after watermelon ingestion. This difference was significant (p < 0.001). DISCUSSION: Watermelon ingestion triggered headache attacks in migraine patients and increased serum nitrite levels, attesting to a possible activation of the l-arginine-nitric oxide pathway.

Circadian rhythmicity on red ear syndrome in a patient with migraine: A case report.

BACKGROUND: Red ear syndrome (RES) was first described by Lance in 1994. It is characterized by recurrent attacks of redness of the ear, accompanied by burning pain, increased temperature, dysesthesia, and nosological relationship with headache. CASE: We report the case of a 43-year-old woman with migraine who developed RES. Redness episodes occurred at the same time of the day. She had a good therapeutic response to gabapentin. CONCLUSIONS: To the best of our knowledge, this is the first case of RES in which redness episodes occurred at the same time of the day.

Tolosa-Hunt Syndrome in Childhood and Adolescence: A Literature Review in the Last 10 Years.

OBJECTIVES: The aim of the study is to review the articles published in the last 10 years on Tolosa-Hunt syndrome (THS) in childhood and adolescence to learn about its clinical and epidemiological characteristics and its therapeutic management. METHODS: Based on the literature search in the major medical databases and using the descriptors "Tolosa-Hunt syndrome and children" and "Tolosa-Hunt syndrome and adolescent" we included articles published between 2009 and 2019. We found 51 articles, but only 11 met the inclusion criteria. RESULTS: There were eight women and four men with THS, whose average age was 12.0 ± 4.3 years, ranging from 4 to 17 years. Magnetic resonance imaging showed inflammation in the cavernous sinus (100%), orbit (25%), and superior orbital fissure (8.3%), unilateral in all patients. The internal carotid artery (58.3%), third (66.7%), sixth (33.3%), and fourth (25%) cranial nerves were injured. Headache was located in the orbital region, ipsilaterally to nerve involvement and had mild to severe intensity. Corticosteroid was the treatment used in 91.7% of the patients. They were followed for an average of 13.4 ± 12.4 months. Only two patients had recurrence of the disease. CONCLUSION: THS is infrequent in childhood and adolescence and knowledge of its clinical and epidemiological characteristics and its therapeutic management is necessary for pediatricians.

Cefaleia em Salvas em Crianças e Adolescentes: Uma revisão sistemática de relatos de casos.

OBJETIVO: Descrever as características clínicas e as melhores opções terapêuticas para cefaleia em salvas na idade pediátrica. MÉTODO: Com base em pesquisa bibliográfica nas bases de dados médicos PubMed, LiLacs e WoS e usando descritores selecionados, analisamos todos os relatos de casos de cefaleia em salvas em idade pediátrica publicados de 1990 a 2020. RESULTADOS: Cinquenta e um pacientes (29 meninos e 22 meninas) com idade média (DP) de 9 anos e 7 meses (3 anos e 10 meses), variando de 2 a 16 anos, foram diagnosticados com cefaleia em salvas. O diagnóstico médio (DP) foi feito 27,8 meses (26,2 meses) após o início da cefaleia em salvas. A dor ocorreu à noite ou ao despertar (76,5%), uma a três crises por dia (62,7%), com duração de 30-120 minutos (68,6%), localizada unilateralmente (90,2%), de caráter pulsátil (64,7%) e intensidade severa (100%). Houve manifestações autonômicas (90,2%), predominantemente ipsilaterais à dor, nesta ordem: lacrimejamento, injeção conjuntival, congestão nasal, ptose, edema palpebral e rinorreia. Sumatriptano e inalação de oxigênio foram os tratamentos agudos mais eficazes. Na profilaxia, corticosteroides, verapamil e gabapentina foram os medicamentos mais eficazes. INTERPRETAÇÃO: Devido ao pequeno número de estudos publicados, esta revisão não foi capaz de fornecer dados confiáveis, mas parece que a cefaleia em salvas em crianças e adolescentes é semelhante à do adulto, tanto nas características clínicas quanto no tratamento.

Migraine Treatment in Emergency Departments of Brazil: A Retrospective Study of 2 Regions.

OBJECTIVE: This study describes the approaches, medications used, and time of care for migraineurs, who have been in emergency departments (ED) from 2 different regions of Brazil. METHODS: Retrospective, cross-sectional, observational, non-randomized study of migraine patients seen at 2 headache centers in Brazil. RESULTS: Eighty-four migraine patients (15 men and 69 women) were divided into 2 groups: chronic (19%, n = 16) and episodic migraineurs (81%, n = 68). In the ED, medications were used in the following order of frequency: dipyrone or metamizole (89.3%, 75/84), nonsteroidal anti-inflammatory drugs (57.1%; 48/84) opioids (51.1%; 43/84), metoclopramide (29.8%; 25/84), dexamethasone (28.6%; 24/84), chlorpromazine (13.1%; 11/84), and subcutaneous sumatriptan (7.1%; 6/84). The average time in the care center was 8.2 hours, but only 23 patients (27.4%) left the hospital with greater than 50% relief in headache severity. CONCLUSIONS: Dipyrone and nonsteroidal anti-inflammatories were the most used drugs, but nearly half received opioids. More efficient drugs were poorly used. Considering the number of patients leaving the hospital with headache relief, a changing treatment paradigm should be carried out in Brazil.

A Historical Review of Headaches: Who First Described Them and When did This Occur?

BACKGROUND: Headache is as old as human history and has been able to report, and the first descriptions were found in Greece and Mesopotamia. OBJECTIVE: Our objective was to know the date of the first description of ICHD-3 headaches, with their respective author. METHODS: We searched for articles that addressed the historical aspects of primary and secondary headaches and painful cranial neuropathies. RESULTS: Twenty-seven different headaches were analyzed according to the occurrence of their first description, with the respective author and country of origin. CONCLUSIONS: The knowledge of the first description of ICHD-3 headaches, with their respective author, showed us how and when the different headaches appeared over the years.

Prevalence of Headache Attributed to Airplane Travel Among Medical Students in Brazil.

BACKGROUND: Headache attributed to airplane travel is a rare form of headache that develops exclusively during airplane travel. It is characterized by occurring during takeoff, landing, or both, and improves spontaneously within 30 minutes after the ascent or descent of the airplane is completed. OBJECTIVES: Our objectives were to determine the prevalence of headache attributed to airplane travel among medical students who traveled by plane, the time of flight when it occurred, and the emotional state of passengers on new trips. METHODS: The study was prospective, cross-sectional, using a non-random sample of medical students who traveled by plane. In total, 155 passengers who traveled by plane on at least 3 flights, regardless of duration were interviewed. RESULTS: Headache during flight occurred 3 or more times in 7.5% (80/1070) of the trips and 14.2% (22/155) of the passengers, especially during takeoff or landing (17/22; 77.3%), having a stabbing character and lasting less than 30 minutes. The headache improved spontaneously at the end of the landing phase (17/22; 77.3%). When traveling again, 68.2% (15/22) of passengers traveled normally, despite previous painful experience. CONCLUSIONS: This study demonstrated that headache attributed to airplane travel is not as rare as previously thought, being predominant during takeoff or landing. In addition, despite the bothersome feeling, most passengers who experienced this headache traveled normally, despite previous painful experience.

Headache and Osmophobia in Gas Station Workers Exposed to Gasoline Odor.

INTRODUCTION: Headache attacks may be triggered by several factors, among them odors, especially in migraine patients. OBJECTIVES: The aim of this study wasto determine the association between gasoline odor and headache attacks in patients with migraine or tension-type headache (TTH). SUBJECTS AND METHODS: The study was prospective, cross-sectional, with comparison of groups, using nonrandom sample and convenience. Fifty-two gas station workers diagnosed with migraine or TTH according to ICHD-3 criteria were interviewed on the relationship between gasoline odor and headache. RESULTS: Of the 52 gas station workers with headaches, there were 39 (75%) with migraine without aura and 13 (25%) with TTH. The age ranged from 19 to 50 years, with a mean of 29.5 ± 7.2 years. Osmophobia during headache attacks predominated in workers with migraine (29/39; 74.4%). The onset of headache due to odor exposure occurred in 23/39 (60%) of the workers with migraine and in 2/13 (15.4%) in TTH. These differences were statistically significant (χ2 = 7.4; p = 0.016). Osmophobia in the absence of pain (period between attacks) predominated in workers with migraine (17/39, 43.6%), but with no statistical value. CONCLUSIONS: Gas station workers diagnosed with migraine or TTH may experience osmophobia and headache triggered by the odor of gasoline.

Hypnic Headache Due to Hypoglycemia: A Case Report.

Hypnic headache (HH) is a rare primary headache disorder and pathophysiology is still poorly understood. It is considered a chronobiological disorder in almost all published cases. Few secondary cases have been described so far. We report a case of a 64-year-old woman presenting headaches exclusively during sleep and fulfilling the diagnostic criteria for HH, but a 72-hour glucose monitoring showed hypoglycemia episodes related to the onset of headaches. To our knowledge, this is the first report of symptomatic HHs associated with hypoglycemia and it suggests direct evidence of HH due to a metabolic disorder.

Migraine patients' journey until a tertiary headache center: an observational study.

BACKGROUND: Migraine diagnosis is based on clinical aspects and is dependent on the experience of the attending physician. This study aimed to describe the patients journey profile until they start their experience in a tertiary headache center. METHODS: In a cross-sectional study, medical charts from migraine patients were reviewed to describe which treatments, procedures and follow-up strategies are performed until the first appointment with a headache specialist. Patients from both sexes, ≥18 years old, which came to their first visit from March to July 2017 were included. Sociodemographic information, headache characteristics, diagnostic methods previously used, clinical history, family history and the treatments previously used were assessed in the first appointment with a specialist. Patient Health Questionnaire-9 and General Anxiety Disorder-7 were also applied. Descriptive analyses were performed to describe the sample profile and statistical tests were used to evaluate factors associated with the type of migraine (chronic or episodic). RESULTS: The sample consisted of 465 patients. On average, the pain started 17.1 (SD = 11.4) years before the first appointment with a headache specialist. Most of patients were classified as having chronic migraine (51.7%), with an average frequency of 15.5 (SD = 9.9) days per month. Regarding patients' journey until a specialist, most patients were submitted to laboratory tests (74.0%), cranial tomography (66.8%) and magnetic resonance imaging (66.8%) as diagnostic methods, and preventive drugs (70.2%) and acupuncture (61.0%) as treatments. After stratification by migraine type as episodic or chronic, patients with chronic migraine were submitted to more magnetic resonance imaging test, acupuncture, psychotherapy, used preventive drugs, and reported to have used topiramate without beneficial effects. CONCLUSIONS: Brazilian patients with migraine experiment a long journey until getting to a headache specialist and are submitted to a great number of unnecessary exams, especially those with chronic migraine.

A double- blind, randomized, and placebo-controlled clinical trial with omega-3 polyunsaturated fatty acids (OPFA É·-3) for the prevention of migraine in chronic migraine patients using amitriptyline.

OBJECTIVE: To determine the prophylactic effect of OPFAϖ-3 in migraine. SUBJECTS AND METHODS: This was a prospective, experimental, controlled, double-blind, and with comparison groups study. Sixty patients diagnosed with chronic migraine, according to the criteria of the International Classification of Headache Disorders, Third Edition (beta version) (ICHD-3ß), were prophylactically treated with amitriptyline. They were divided into two equal groups: in group 1, prophylaxis was associated with OPFAϖ-3 and in group 2 with placebo. After 60 days, both groups were assessed by a second researcher. RESULTS: Of the 60 patients with chronic migraine, only 51 patients (15 men and 36 women) completed the treatment. The group that received OPFAϖ-3 consisted of 27 (52.9%) patients (six men and 21 women), while the control group was equal to 24 (47.1%) patients (nine men and 15 women). These differences were not significant (χ2 = 1.428; P = 0.375). In 66.7% (18/27) of the patients who used OPFAϖ-3, there was a reduction of more than 80.0% per month in the number of days of headache, while in the control group, the same improvement occurred in 33.3% (8/24) of patients. This difference was significant (χ2 = 5.649; P = 0.036). CONCLUSIONS: Polyunsaturated omega 3 fatty acids (OPFAϖ-3) are useful for prophylaxis of migraine attacks.

May headache triggered by odors be regarded as a differentiating factor between migraine and other primary headaches?

Objectives The objective of this article is to characterize olfactory stimulation as a trigger of headaches attacks and differentiation between migraine and other primary headaches. Participants and methods The study was prospective and experimental, with comparison of groups. A total of 158 volunteers (73 men and 85 women) were diagnosed with primary headaches, according to the criteria of the International Classification of Headache Disorders, Third Edition (beta version) (ICHD-3ß). The study was conducted by two examiners; one of them was assigned to diagnose the presence and type of primary headache, while the other was responsible for exposing the volunteers to odor and recording the effects of this exposure. Results Of the 158 volunteers with headache, there were 72 (45.6%) cases of migraine and 86 (54.4%) with other primary headaches. In both groups, there were differences in headache characteristics (χ2 = 4.132; p = 0.046). Headache attacks (25/72; 34.7%) and nausea (5/72; 6.9%) were triggered by odor only in patients with migraine, corresponding to 19.0% (30/158) of the sample, but in none with other primary headaches (χ2 = 43.78; p < 0.001). Headache occurred more often associated with nausea ( p = 0.146) and bilateral location ( p = 0.002) in migraineurs who had headache triggered by odor. Headache was triggered after 118 ± 24.6 min and nausea after 72.8 ± 84.7 min of exposure to odor. Conclusions The odor triggered headache attacks or nausea only in migraineurs. Therefore, headache triggered by odors may be considered a factor of differentiation between migraine and other primary headaches and this trigger seems very specific of migraine.

Monoclonal antibodies for chronic migraine and medication overuse headache: A real-world study.

Background: Medication-overuse headache is highly prevalent in tertiary care centers. It may be a cause or consequence of the overuse of symptomatic medications for migraine attacks. Objective: We aimed to compare the efficacy of anti-CGRP monoclonal antibodies (mAbs) added to conventional pharmacological treatments in patients with chronic migraine (CM) and medication overuse headache (MOH). Methods: A cross-sectional, prospective, randomized, open study with real-world comparison groups of patients was carried out. The sample consisted of 200 patients with CM and MOH, who received the same approach to withdraw overused medications, started preventative treatment, and either did or did not receive mAbs. Results: A total of 172 patients (126 women and 46 men) were included in the study and divided into two groups: group one consisting of 58 patients (control) and group two of 114 patients who used mAbs added to conventional pharmacological agents. The mean age was 44.1 ± 13.6 years, ranging from 18 to 78 years. In the 3 months follow-up after starting the treatment, both groups presented headache frequency reduction, but those with monoclonal antibodies had a significantly higher reduction in the number of headache days and symptomatic medication intake when compared to the control (p < 0.0001). Conclusions: The addition of an anti-CGRP monoclonal antibody to the treatment for medication overuse headaches in chronic migraineurs may result in decreasing headache frequency and symptomatic medication use when compared to conventional treatments with drugs.

Medication Overuse Headache, Chronic Migraine and Monoclonal Antibodies Anti-CGRP: A Real-World Study.

OBJECTIVE: Medication overuse headache (MOH) in chronic migraineurs may be a cause or consequence of the overuse of symptomatic medications for headache attacks. It is highly prevalent in tertiary centers. We compared the efficacy of 3 anti-CGRP monoclonal antibodies with traditional pharmacological agents in patients with chronic migraine (CM) and MOH. METHODS: A randomized, cross-sectional, prospective, and open trial with real-world comparison groups was carried out. The sample consisted of 100 consecutive patients having CM and MOH. RESULTS: Eighty-eight patients (65 women and 23 men) were included in the study and divided into 4 groups: those having used erenumab (19.3%), galcanezumab (29.6%), fremanezumab (25%) and conventional medications, and the control group (26.1%). Ages ranged from 18 to 78 years (mean, 44.1 ± 13.6 years). In the 6 months of follow-up, there was a significant reduction in the number of headache days in the 3 groups when compared with the control ( P < 0.0001). CONCLUSIONS: The small number of patients included in each group and the open design do not allow definitive conclusions, but the use of anti-CGRP monoclonal antibodies in patients with CM and MOH may result in lessening the number of headache days when compared with conventional treatment with drugs.

Medication-overuse headache-a review of different treatment strategies.

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.