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Pro S.,Headache Center | Tarantino S.,Headache Center | Capuano A.,Headache Center | Vigevano F.,Headache Center | And 2 more authors.
Clinical Neurophysiology | Year: 2014

Although primary headaches are very prevalent also in pediatric age, most neurophysiologic studies in these diseases concerned only the adulthood. The neurophysiologic investigation of the pathophysiological mechanisms subtending migraine and tension-type headache in children and adolescents could be particularly interesting, since during the developmental age the migrainous phenotype is scarcely influenced by many environmental factors that can typically act on adult headache patients. The neurophysiologic abnormality most frequently found in adult migraineurs, that is the reduced habituation of evoked potentials, was confirmed also in migraine children, although it was shown to involve also children with tension-type headache. Some studies showed abnormalities in the maturation of brain functions in migraine children and adolescents. While the visual system maturation seems slowed in young migraineurs, the psychophysiological mechanisms subtending somatosensory spatial attention in migraine children are more similar to those of healthy adults than to those of age-matched controls. There are some still unexplored fields that will have to be subjects of future studies. The nociceptive modality, which has been investigated in adult patients with primary headaches, should be studied also in pediatric migraine. Moreover, the technique of transcranial magnetic stimulation, not yet used in young migraineurs, will possibly provide further elements about brain excitability in migraine children. © 2013 International Federation of Clinical Neurophysiology.

Vollono C.,Headache Center | Vigevano F.,Headache Center | Tarantino S.,Headache Center | Valeriani M.,Headache Center | Valeriani M.,University of Aalborg
Expert Review of Neurotherapeutics | Year: 2011

Abortive drugs used for migraine in children and adolescents are usually the same as those used in adults. Only a few studies have assessed the efficacy of triptans other than sumatriptan in pediatric migraine. This systematic review describes the evidence concerning the efficacy and tolerability of these triptans. The PubMed research produced 481 results and only seven studies were randomized controlled trials. A total of 11 articles were reviewed. Zolmitriptan and rizatriptan were superior to placebo in most studies. Almotriptan demonstrated a high profile of tolerability. A single study of eletriptan demonstrated no statistical difference between this drug and placebo in terms of both efficacy and tolerability. All studies have reported a good triptan safety profile. The conflicting data regarding triptan efficacy are probably due to differences in populations, methodologies and efficacy measures among the different studies. Triptans are an important option in the symptomatic treatment of childhood and adolescent migraine. © 2011 Expert Reviews Ltd.

News Article | October 27, 2016

CINCINNATI - Prescribed medications are no more effective than a sugar pill when used to prevent migraines in children and teens. A study to be published Oct. 27 in The New England Journal of Medicine shows no significant differences among amitriptyline, topiramate and placebo in reducing headache days or related disability. "The study was intended to demonstrate which of the commonly used preventive medications in migraine was the most effective. What we found is that we could prevent these headaches with either a medication or a placebo," says Andrew Hershey, MD, PhD, co-director of the Cincinnati Children's Headache Center and senior author of the study. "This study suggests that a multi-disciplinary approach and the expectation of response is the most important, not necessarily the prescription provided." Researchers conducted the Childhood and Adolescent Migraine Prevention (CHAMP) study at 31 sites in the United States. Cincinnati Children's served as the Clinical Coordinating Center (CCC) for the study, and was responsible for all clinical oversight activities. The Clinical Trials Statistical and Data Management Center (CTSDMC) at the University of Iowa served as the Data Coordinating Center for the study. It had primary responsibility for data management, implementing the electronic data capture system, and all statistical aspects of the study. The 24-week clinical trial included 328 eligible patients. The trial used a clinically meaningful endpoint of a 50 percent or greater reduction in headache days from the 28 days prior to randomization to the final four weeks of the 24-week study. Sixty-one percent of those on a placebo saw the days they had a headache reduced by 50 percent or more. For the two medication groups, 52 percent of those taking amitriptyline and 55 percent of those taking topiramate had this level of reduced headache days. The responder rates were not statistically different between the three groups. Compared to placebo, those on the two active drugs had a significantly higher rate of side effects, including fatigue, dry mouth and, in three cases, mood alteration. Thirty-one percent of those on topiramate had paresthesia - a "pins and needles" tingling in the hands, arms, legs or feet. The results raise questions about the best way to prevent migraines, particularly given that it's unethical to prescribe a placebo without the patient's knowledge, according to the authors. They add it's likely the expectation of responding to a medication may override the actual biochemical and pharmacological changes that are thought to occur with pharmacotherapy. Major pediatric headache centers, such as Cincinnati Children's, incorporate a multi-disciplinary approach that includes acute therapy, preventive therapy and behavioral treatment in a systematic approach, says Hershey. The CHAMP study incorporated this approach across all 31 study sites to ensure uniformity. The study authors stress that further studies need to be done to identify the optimal way to incorporate multi-disciplinary strategies. One of the preventive therapies often used is cognitive behavior therapy (CBT). CBT refers to a group of psychological treatments that are based on scientific evidence. While CBT has not been directly compared to a pill placebo for pediatric migraines, neurologists and psychologists view it as a helpful and critical component in a treatment plan. "Our national team was hoping to develop evidence to drive the choice by medical providers of the first line prevention medication for helping youth with migraine, but the data showed otherwise, says Scott Powers, PhD, pediatric psychologist, co-director of the headache center at Cincinnati Children's, and first author of the paper. "We see this as an important opportunity for health care providers, scientists, children, and families because our findings suggest a paradigm shift. First line prevention treatment will involve a multidisciplinary team approach and focus on non-pharmacological aspects of care. The good news is we can help children with migraines get better." Powers says the study also underscores the importance of conducting more research with a developmental focus on children and young adults. This will allow innovations that can be applied directly to a chronic illness of childhood. "The interpretation of these results is very challenging. In most situations, trials that fail to show benefit of an intervention do so because study participants do not improve. That was not the situation here. A majority of all study participants improved, regardless of their assigned treatment group," says Chris Coffey, PhD, director of the CTSDMC and professor of biostatistics in the University of Iowa's College of Public Health, and lead statistician for the study. "Further research is needed to better understand the results and to determine what future strategies might optimize the treatment of headaches in these childhood and adolescent populations." The study was supported by the National Institute of Neurological Disorders and Stroke and the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health through grants U01NS076788 and U01NS077108.

Zidverc-Trajkovic J.,University of Belgrade | Zidverc-Trajkovic J.,Headache Center
Headache | Year: 2013

Background According to the International Classification of Headache Disorders diagnostic criteria, the differences between migraine and cluster headache (CH) are clear. In addition to headache attack duration and pain characteristics, the symptoms accompanying headache represent the key features in a differential diagnosis of these 2 primary headache disorders. Just a few studies of patients with CH exist examining the presence of nausea, vomiting, photophobia, phonophobia, and aura, the features commonly accompanying migraine headache. The aim of this study was to determine the presence of migraine-like features (MF) in patients with CH and establish the significance of these phenomena related to other clinical features and response to treatment. Methods One hundred and fifty-five patients with CH were studied, and 24.5% of them experienced at least one of MF during every CH attack. Nausea and vomiting were the most frequently reported MF. The clinical presentation between CH patients with and without MF was not significantly different with the exception of aggravation of pain by effort (20.6% vs 4.1%) and facial sweating (13.2% vs 0.85%), both more frequent in CH patients with MF. Conclusion Inferred from the results of our study, the presence of MF in CH patients had no important influence on the diagnosis and treatment of CH patients. The major differences of these 2 primary headache disorders, attack duration, lateralization, and the nature of associated symptoms, as delineated in the International Classification of Headache Disorders, are still useful tools for effective diagnosis. © 2013 American Headache Society.

Blumenfeld A.,Headache Center | Silberstein S.D.,Thomas Jefferson University | Dodick D.W.,Mayo Clinic Arizona | Aurora S.K.,University of Washington | And 2 more authors.
Headache | Year: 2010

Chronic migraine (CM) is a prevalent and disabling neurological disorder. Few prophylactic treatments for CM have been investigated. OnabotulinumtoxinA, which inhibits the release of nociceptive mediators, such as glutamate, substance P, and calcitonin gene-related peptide, has been evaluated in randomized, placebo-controlled studies for the preventive treatment of a variety of headache disorders, including CM. These studies have yielded insight into appropriate patient selection, injection sites, dosages, and technique. Initial approaches used a set of fixed sites for the pericranial injections. However, the treatment approach evolved to include other sites that corresponded to the location of pain and tenderness in the individual patient in addition to the fixed sites. The Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) injection paradigm uses both fixed and follow-the-pain sites, with additional specific follow-the-pain sites considered depending on individual symptoms. The PREEMPT paradigm for injecting onabotulinumtoxinA has been shown to be safe, well-tolerated, and effective in well-designed, controlled clinical trials and is the evidence-based approach recommended to optimize clinical outcomes for patients with CM. © 2010 American Headache Society.

Leone M.,Headache Center | Franzini A.,Fondazione Irccs Instituto Neurologico Carlo Besta | Proietti Cecchini A.,Headache Center | Mea E.,Headache Center | And 2 more authors.
Neurotherapeutics | Year: 2010

Cluster headache (CH), paroxysmal hemicrania (PH), and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome) are primary headaches grouped together as trigeminal autonomic cephalalgias (TACs). All are characterized by short-lived unilateral head pain attacks associated with oculofacial autonomic phenomena. Neuroimaging studies have demonstrated that the posterior hypothalamus is activated during attacks, implicating hypothalamic hyperactivity in TAC pathophysiology and suggesting stimulation of the ipsilateral posterior hypothalamus as a means of preventing intractable CH. After almost 10 years of experience, hypothalamic stimulation has proved successful in preventing pain attacks in approximately 60% of the 58 documented chronic drug-resistant CH patients implanted at various centers. Positive results have also been reported in drug-resistant SUNCT and PH. Microrecording studies on hypothalamic neurons are increasingly being performed and promise to make it possible to more precisely identify the target site. The implantation procedure has generally proved safe, although it carries a small risk of brain hemorrhage. Long-term stimulation is proving to be safe: studies on patients under continuous hypothalamic stimulation have identified nonsymptomatic impairment of orthostatic adaptation as the only noteworthy change. Studies on pain threshold in chronically stimulated patients show increased threshold for cold pain in the distribution of the first trigeminal branch ipsilateral to stimulation. When the stimulator is switched off, changes in sensory and pain thresholds do not occur immediately, indicating that long-term hypothalamic stimulation is necessary to produce sensory and nociceptive changes, as also indicated by clinical experience that CH attacks are brought under control only after weeks of stimulation. Infection, transient loss of consciousness, and micturition syncope have been reported, but treatment interruption usually is not required. © 2010 The American Society for Experimental NeuroTherapeutics, Inc.

News Article | September 1, 2016

When the twinkle of pain behind your eye turns into a crippling migraine, you’re left with two options: riding it out, or taking drugs with side-effects that could make you even more sick. For many of us dealing with the chronic pain of migraines, navigating treatments can feel like stomping through a minefield. Anyone who has ever been prescribed migraine medication knows that it’s a crapshoot. Often, doctors will use trial-and-error to land on a treatment that works best for you. But this imperfect system leaves many patients dissatisfied with their pain regimen, as a new national survey from Health Union reveals. According to the study, which polled 3,900 individuals who experience migraines, only 40 percent of patients are happy with their medication. While the results suggest that no two migraine sufferers are alike, they also highlight a pharmaceutical industry that has ignored the demand for better, safer drugs. Currently, three categories of migraine medication exist. They are abortive, preventative, and rescue. The most popular of these, as reported by the study, are abortive treatment options, which are used by 66 percent of migraineurs who depend on prescription pain relief. Drugs like Imitrex and certain nasal sprays are popular because they can stop a migraine from progressing if you’ve already started to feel its effects. But even the most preferred and well-studied migraine treatments aren’t always perfect. Triptans, which are a class of abortive drugs, and have received the most scientific evaluation, work by binding to serotonin receptors in the brain. They constrict the swelling of blood vessels, which can prevent the painful evolution of a migraine. In 2014, a comparative study of triptans found that when most effective, they provide two-hour pain relief 68 percent of the time, and 24-hour pain relief 54 percent of the time. And the side-effects of triptans are myriad, leaving many patients feeling dizzy, nauseous, numb, or weak; and not everyone can use them. When taken by people who are also on antidepressants, a life-threatening reaction called “serotonin syndrome” could occur, causing toxic levels of the chemical to flood the body. One of the reasons why migraine drugs are so unpredictable has to do with the disease’s variability. According to the Health Union survey, migraine triggers range from barometric pressure changes to overpowering smells to stress, and even sunshine. Symptoms run the gamut, too, including pain, sensitivity to light, fatigue, and irritability. While 97 percent of people are aware of their triggers, the study notes, most admit that avoiding them is next to impossible. Earlier this year, a paper published in the journal Headache accused pharmaceutical researchers of failing to study the impact of migraine drugs on a wide array of sufferers. As the authors pointed out, clinical trials for certain treatments can exclude some categories of migraineurs—either assuming that all types of migraines are the same, or failing to investigate the different effects that a drug might have on different subsets of migraines. “There are not enough medicines out there to appropriately manage migraine headaches,” author Brad Klein, a doctor and medical director of the Headache Center at Abington Hospital-Jefferson Health, said in a statement. “At a time in history when an unprecedented number of people are getting hooked on narcotic opiates by way of prescribed medications—as is the case with migraine sufferers as well—we owe it to ourselves as physicians to try medications that could work without the risk of addiction.” As a result of poor migraine treatments, as well as a general misunderstanding of what migraines actually are, patients can become overwhelmed by more than just pain. When asked how migraines affect their personal lives, 64 percent of respondents were constantly worried about disappointing people in the struggle to manage their symptoms. Approximately 46 percent were embarrassed about their disease, and 41 percent of participants confessed to hiding their migraines from others. In the past couple of years, there has been more of an effort to destigmatize migraines, though some campaigns are more eager to promote drugs than awareness. Researchers are now looking at experimental medications to stop migraines before they start, however, it could be years until newer, safer treatment options reach market. “No one took my symptoms seriously until I was in my 20s. I have had chronic migraine since I was age 11, but was not diagnosed until I was 25. When I was kid, most people thought I was making excuses to skip school,” said Kerrie Smyres, a patient advocate for the community website “In all those years that my symptoms were dismissed, I internalized the stigma of migraine. I'm nearly 40 and, after three years of intense therapy, have finally stopped questioning if my symptoms were as severe as I believe them to be.” Want more Motherboard in your life? Then sign up for our daily newsletter.

Mainardi F.,Headache Center
Current neurology and neuroscience reports | Year: 2013

The headache attributed to airplane travel, also named "airplane headache", is characterized by the sudden onset of a severe head pain exclusively in relation to airplane flights, mainly during the landing phase. Secondary causes, such as upper respiratory tract infections or acute sinusitis, must be ruled out. Although its cause is not thoroughly understood, sinus barotrauma should be reasonably involved in the pathophysiological mechanisms. Furthermore, in the current International Classification of Headache Disorders, rapid descent from high altitude is not considered as a possible cause of headache, although the onset of such pain in airplane travellers or aviators has been well known since the beginning of the aviation era. On the basis of a survey we conducted with the courteous cooperation of people who had experienced this type of headache, we proposed diagnostic criteria to be added to the forthcoming revision of the International Classification of Headache Disorders. Their formal validation would favour further studies aimed at improving knowledge of the pathophysiological mechanisms involved and at implementing preventative measures.

Frediani F.,S Carlo Borromeo Hospital | Bussone G.,C Besta Neurological Institute | Bussone G.,Headache Center
Neurological Sciences | Year: 2015

HaNDL (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) syndrome is an infrequent condition included at group 7 “headache attributed to non-vascular intracranial disorder” in the recent International Classification of Headache Disorders (ICHD-3), code 7.3.5. The description states “migraine-like headache episodes (typically 1–12) accompanied by neurological deficits including hemiparaesthesia, hemiparesis and/or dysphasia, but positive visual symptoms only uncommonly, lasting several hours. There is lymphocytic pleocytosis. The disorder resolves spontaneously within 3 months”. In this description confusional state is not considered as a main symptom, even if in the literature this aspect is frequently reported. Here, we report the cases of two young boys presenting with confusional state as the main complaint. The possible pathogenesis of the different clinical presentation is discussed. © 2015, Springer-Verlag Italia.

Buzzi M.G.,Headache Center | Tassorelli C.,University of Pavia
Handbook of Clinical Neurology | Year: 2010

In vitro studies on animal and human cephalic vessels allow the measurement of second messengers or intracellular calcium concentrations and the evaluation of the role of endogenous neuropeptides in perivascular nerve endings involved in migraine pathophysiology. In addition, in vitro human models allow the assessment of receptorial cranial selectivity and the collection of reliable information regarding the behavior of these vessels in migraine headache. The availability of animal models of migraine has favoured impressive advances in understanding the mechanisms and mediators underlying migraine attacks, as well as the development of new and more specific therapeutic agents. The trigeminovascular system (TVS) has emerged as a critical efferent component, and the mediators of its activity have been identified and characterized, as have some of the receptors involved. The similarity of the trigeminal innervation across species has made it possible to draw conclusions on the neurophysiological responses to electrical or chemical stimulation of the trigeminal fibers. Studies involving substances known to induce migraine-like attacks, i.e., nitric oxide (NO) donors, have provided interesting insights into the central nuclei probably involved in the initiation and repetition of migraine attacks. The neuronal and vascular effects of such substances might yield an increasing body of evidence for a better understanding of the pathophysiology of migraine attacks. © 2011 Elsevier B.V.

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