Cephalalgia

Occipital nerve stimulation (ONS) has been shown to be effective for selected patients with intractable headache disorders. We performed a prospective critical evaluation of complications and direct treatment costs.

Twenty-seven patients with chronic cluster headache (CCH, n = 24) or chronic migraine (CM, n = 3) underwent a trial phase with bilateral ONS and subsequent implantation of a permanent generator (IPG), if responsive to treatment according to predefined criteria. Procedural and long-term complications as well as direct treatment costs of neuromodulation therapy of ONS were recorded over a mean follow-up period of 20 months (range 5–47 months).

Twenty-five of 27 patients (93%) responded to treatment. Twenty-one complications in 14 patients were identified, necessitating reoperation in 13 cases. Overall treatment costs were €761,043, including hardware-related costs of €506,019, costs for primary hospital care of €210,496, and complications related to hospitalization costs of €44,528. This results in a per case-based cost of €9445 for hospitalization and €18,741 for hardware costs, totaling €28,186.

ONS for treatment of refractory CCH and CM is a cost-intensive treatment option with a significant complication rate. Nevertheless, patients with refractory primary headache disorders may experience substantial relief of pain attacks, and headache days, respectively.

The objective of this article is to assess the effects of sumatriptan monotherapy, telcagepant monotherapy, and their combination on blood pressure (BP) in migraine patients during a headache-free period.

A double-blind, placebo-controlled, four-period, single-dose, randomized crossover study in 24 migraine patients was conducted. In each period, patients received a single oral dose of sumatriptan 100 mg alone, telcagepant 600 mg alone, sumatriptan 100 mg coadministered with telcagepant 600 mg, or placebo. Semi-recumbent BP was measured pre-dose and at seven post-dose timepoints over a period of six hours. Individual time-weighted averages in mean arterial pressure (MAP) were evaluated using a linear mixed-effects model. The pharmacokinetics of sumatriptan alone and in the presence of telcagepant were also evaluated using limited sampling times.

The mean difference in time-weighted (0–2.5 h) MAP (90% confidence interval) was 1.2 mmHg (−0.2, 2.7) between telcagepant and placebo, 4.0 mmHg (2.5, 5.5) between sumatriptan and placebo, and 1.5 mmHg (0.0, 3.0) between telcagepant with sumatriptan vs sumatriptan alone. When coadministered with telcagepant, the AUC_0–6h and C_max of sumatriptan were increased by 23% and 24%, respectively. The small MAP increases observed after coadministration could possibly be associated with the slight elevations in sumatriptan levels.

Telcagepant does not elevate mean MAP, and coadministration of telcagepant with sumatriptan results in elevations in MAP similar to those observed following administration of sumatriptan alone in migraineurs during the interictal period. When coadministered, telcagepant slightly increases the plasma levels of sumatriptan, but without an apparent clinically meaningful effect.

We describe a four-generation Italian family with familial hemiplegic migraine (FHM) and epilepsy due to a novel ATP1A2 missense mutation (R1007W).

Mutational analysis revealed a heterozygous nucleotide substitution c.3019C>T resulting in the missense substitution p.Arg1007Trp (p.R1007W) in seven subjects: Three individuals had hemiplegic migraine, two exhibited a clinical overlap between migraine and epilepsy, one had migraine and one was unaffected. The identified ATP1A2 mutation was not found in an ethnically matched control population of 190 individuals and was not reported in a polymorphisms database.

In two-electrode voltage-clamp experiments on Xenopus oocytes, the ATP1A2 R1007W mutant showed (i) reduced ion pumping activity due to a more profound voltage dependence and (ii) decreased apparent affinity for extracellular K⁺ at voltages around the cellular resting potential. This distinct type of loss of function has not been reported for other FHM2 mutations and can lead to impaired K+ clearance and elevated K⁺ levels in the CNS.

The functional data and clinical evidence suggest that in FHM2 migraine and epilepsy may originate from the same pathogenic mechanisms associated with genetically determined alterations of ion channels and pumps. Our data also support the hypothesis that the new mutation R1007W in our family may be a susceptibility factor for epilepsy.

Recurrent headache is common in childhood, but there is not a great amount of data on the associations between headaches and psychopathology in children.

The aim of this study is to examine the relationships between primary headaches and psychopathology in children, using both the categorical and dimensional assessment.

The sample consisted of 70 patients with primary headache compared to a matched sample of 50 healthy children. Psychiatric comorbidity was defined according to the diagnostic criteria of the Diagnostic and Statistical Manual of Disorders. Child psychopathology outcomes were assessed using child- and parent-reported standardized instruments.

Internalizing and externalizing problems were significantly represented among children with headaches compared to the control group, respectively 63% and 27%, without significant differences between migraine and tension-type headache children. Moreover, a total of 26% of the children with a headache reported psychiatric comorbidity such as anxiety and mood disorders.

The dimensional approach improves accuracy in the recognition of emotional and behavioral problems compared to the categorical approach; however, the use of both of these approaches could be useful for clinical practice, treatment and research.

Individuals with tension-type headache (TTH), in addition to headache pain, typically suffer from pericranial muscle tenderness and increased cervical muscle tone. Physical and physiological outcomes related to musculoskeletal function, however, are not commonly assessed in clinical studies and not systematically proposed as outcome measures in headache-related practice guidelines.

To review which musculoskeletal outcomes are used in the clinical assessment of patients with TTH and which are associated with headache pain and related dysfunction.

Methods: Literature searches were performed in MEDLINE, PubMed, the Cochrane databases and EMBASE using terms relating to musculoskeletal physical outcomes in TTH.

Twenty-six studies met selection criteria. Physiological outcomes typically reported in laboratory studies were trigger points, pressure pain threshold, range of motion and tenderness. A greater number of trigger points and lower pressure pain threshold were reported in patients with episodic TTH in comparison with healthy subjects. Individuals with chronic TTH, when compared with non-headache controls, consistently showed a greater number of trigger points, a lower value of pressure pain threshold and a more severe forward head posture.

Musculoskeletal outcomes, such as trigger points, pressure pain threshold and forward head posture should inform TTH pathophysiology, diagnosis and interdisciplinary patient care.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with cranial autonomic symptoms (SUNA) are primary headache syndromes. A growing body of literature has focused on brain magnetic resonance imaging (MRI) evidence of neurovascular compression in these syndromes.

The objective of this article is to assess whether SUNCT is a subset of SUNA or whether the two are separate syndromes and clarify the role of neurovascular compression.

We describe three new SUNCT cases with MRI findings of neurovascular compression and critically review published SUNCT/SUNA cases.

We identified 222 published SUNCT/SUNA cases. Our three patients with neurovascular compression added to the 34 cases previously described (16.9%). SUNCT and SUNA share the same clinical features and therapeutic options. At present, there is no available abortive treatment for attacks. Lamotrigine was effective in 64% of patients; topiramate and gabapentin in about one-third of cases. Of the 34 cases with neurovascular compression, seven responded to drug therapies, 16 patients underwent microvascular decompression of the trigeminal nerve (MVD) with effectiveness in 75%.

We suggest that SUNCT and SUNA should be considered clinical phenotypes of the same syndrome. Brain MRI should always be performed with a dedicated view to exclude neurovascular compression. The high percentage of remission after MVD supports the pathogenetic role of neurovascular compression.

Hypnic headache (HH) is a rare primary headache disorder that is characterised by strictly sleep-related headache attacks.

Because of the low prevalence of this headache disorder, disease information is mainly based on case reports and small case series. This review summarises current knowledge on HH in regard to clinical presentation, pathophysiology, symptomatic causes and therapeutic options.

We review all reported HH cases since its first description in 1988 by Raskin. Broadened diagnostic criteria were applied for patient selection that slightly deviate from the current ICHD-II criteria. Patients were allowed to describe the headache character to be other than dull. Additionally, accompanying mild trigemino-autonomic symptoms were permitted.

Mainly elderly patients are affected, but younger patients and even children might also suffer from HH. Headache attacks usually last between 15 and 180 minutes, but some patients report headache attacks up to 10 hours. Almost all patients report motor activity during headache attacks. Cerebral MRI and 24-hour blood pressure monitoring should be performed in the diagnostic work-up of HH. Other primary headache disorders such as migraine and cluster headache may also present with sleep-related headache attacks and should be considered first. Caffeine taken as a cup of strong coffee seems to be the best acute and prophylactic treatment option.