Time delay from onset to diagnosis of migraine.

OBJECTIVE: To investigate the factors involved in the delayed diagnosis of migraine without aura among patients attending a tertiary center for headache diagnosis and management. METHODS: Two hundred consecutive patients were divided into 3 groups according to the time elapsed from the first clinical manifestations and the diagnosis of migraine at our center. RESULTS: The interval was <1 year in 16.5% of patients (n = 33); from 1 to 5 years in 30% (n = 60); and >5 years in 53.5% (n = 107). Younger age at migraine onset and a lower level of education were significantly associated with a longer time to diagnosis (P = .01 and P = .0001, respectively). Longer delays were significantly associated with a larger number of specialists consulted (P < .05). CONCLUSION: Our findings suggest an insufficient awareness of the diagnostic criteria of migraine by non-specialist physicians, who often prescribe expensive and unnecessary diagnostic investigations that do not alleviate patients' symptoms while wasting health care resources.

Efficacy of topiramate and valproate in chronic migraine.

OBJECTIVES: The aim of this study was to compare the efficacy of sodium valproate and topiramate in treating chronic migraine. METHODS: Forty-nine patients with chronic migraine were randomly assigned to 1 of 2 groups of treatment: 750 mg/day valproate or 75 mg/day topiramate. Efficacy variables were number of days with headache over a 30-day period and changes in Migraine Disability Assessment (MIDAS) scores at 3 months. RESULTS: At baseline the 2 groups had similar numbers of days with headache and mean MIDAS scores. At the end of the treatment period, a significant reduction in 30-day headache frequency with respect to baseline (P < 0.00001) and a significant reduction in MIDAS scores (P < 0.00001) were recorded in both groups. There were no significant differences in beneficial effects between the 2 drugs. DISCUSSION: Valproate and topiramate seem to be able to manage successfully chronic migraine without substantial differences in efficacy and tolerability. This affords clear practical advantages-in the event of failure of or intolerance for one treatment, the patient may be switched to the other.

Carotid wall thickness and stroke risk in patients with asymptomatic internal carotid stenosis.

OBJECTIVE: Aim of this study was to investigate if the risk of stroke and other vascular diseases can be predicted in subjects with severe asymptomatic carotid artery stenosis on the basis of carotid wall thickness evaluation. METHODS: We included 162 consecutive subjects with asymptomatic internal carotid artery stenosis of 60% or greater reduction in diameter. Demographic characteristics, vascular risk factors, therapy, degree of carotid stenosis and carotid intima-media thickness (IMT) were detailed for all subjects. Subjects were prospectively evaluated for a median period of 35 months (min=10, max=47). Outcome measures were: the occurrence of ischemic stroke ipsilateral to carotid stenosis and any other vascular event. RESULTS: Thirty subjects (18.5%) suffered a vascular event: 16 (53%) myocardial infarctions and 14 (47%) strokes. Older age and higher IMT values were the only factors significantly associated with the risk of vascular events. The hazard ratio (adjusted for age, sex and other risk factors) for each 0.1 mm of IMT increase resulted 1.30 (95% CI: 1.14, 1.18) for combined vascular events, 1.47 for cerebrovascular events (95% CI: 1.16, 1.87) and 1.24 (95% CI: 1.09, 1.42) for cardiovascular events. Values of IMT above 1.15 mm increased the risk of having a stroke 19 times and the risk of having a myocardial infarction two times. CONCLUSIONS: An increased carotid wall thickness can be considered as a marker of an increased risk of vascular events in asymptomatic subjects with internal carotid artery stenosis>60%. Highest IMT values are able to identify subjects with specific stroke risk. This information could be of interest to recognize subjects who might benefit most from surgical or revascularization procedures.

Carotid atherosclerosis and cognitive decline in patients with Alzheimer's disease.

Aim of the study was to explore the correlation between the progression of carotid atherosclerosis and the evolution of cognitive impairment in 66 patients with Alzheimer's disease (AD). They underwent cognitive status evaluation and ultrasonography (US) to investigate carotid arteries intima-media thickness (IMT) and plaque index (PI). After a 12-month follow-up period, neuropsychological and US examinations were repeated to assess the progression of carotid atherosclerosis and of cognitive decline [in terms of changes in Mini Mental State Examination (MMSE) scores]. MMSE score changes were related to baseline IMT (p=0.018), changes in IMT (p<0.001) and PI (p=0.006), and "antihypertensive drug intake" (p<0.001). While the first three variables correlated with increased cognitive impairment, the last one was associated with a reduced extent of MMSE score decline. Results show a link between progression of carotid wall changes and of cognitive decline, and suggest a possible protective role of antihypertensive therapy. Given the potential clinical implications, our preliminary findings could stimulate further investigations into the role of vascular impairment in patients with AD.

Basilar and middle cerebral artery reactivity in patients with migraine.

BACKGROUND: Migraine has been reported as a possible risk factor for ischemic stroke. The mechanisms underlying this association are unknown. OBJECTIVES: To evaluate cerebrovascular reactivity to hypercapnia in the anterior and posterior circulation of patients with migraine, as reduced cerebrovascular reactivity is associated with a predisposition to stroke in various clinical conditions. METHODS: Using transcranial Doppler ultrasonography, changes in flow velocity during apnea were measured in both middle cerebral arteries and in the basilar artery of 15 control subjects and 30 patients with migraine (15 with aura and 15 without aura) during an attack-free period. Cerebrovascular reactivity was evaluated using the breath-holding index, which is calculated by dividing the percent increase in mean flow velocity recorded during a breath-holding episode by its duration (in seconds) after a normal inspiration. RESULTS: Vascular reactivity in the middle cerebral arteries was similar in patients and controls and significantly lower in the basilar artery of patients with migraine with aura compared with the other 2 groups (P <.0001). CONCLUSIONS: These findings show that in patients with migraine with aura, there is an impairment in the adaptive cerebral hemodynamic mechanisms in the posterior circulation. This fact could have pathogenetic implications since the association between migraine and stroke frequently regards patients with migraine with aura, and cerebral infarcts occur more commonly in the vertebrobasilar district.