IL-6 Levels in Migraine Patients Receiving Topiramate

There is considerable evidence suggesting that cytokines play important roles in pain and in mediating neurovascular inflammation associated with migraine headaches. Although consensus exists to recommend topiramate (TPM) for migraine prevention, the mechanism of action in this regard is unknown. We measured serum interleukin-6 (IL-6) levels in 66 migraine patients. Of these patients, 23 (34.9%) were taking TPM for migraine, and 43 (65.1%) were not. The IL-6 levels were compared with those of healthy controls without migraine, from the population living in the same region. The mean IL-6 levels in migraine patients taking TPM and patients who did not were 67.06 ± 92.09 pg/mL and 44.09 ± 59.19 pg/mL, respectively ( P  > 0.05). The IL-6 levels were higher in the patients taking TPM. The IL-6 level in the controls was 8.60 ± 7.36 pg/mL, which was significantly lower than the patient group using TPM ( P  = 0.001). Our results show that, although IL-6 may be involved in pain induction or inflammatory mechanisms of migraine attacks, the serum IL-6 level was not reduced in migraine patients receiving TPM therapy. In conclusion, we found high IL-6 levels in migraine patients both with and without TPM therapy, suggesting that high IL-6 levels during pain-free periods could be a conditioning factor, making patients more vulnerable to pain attacks in chronic migraine. Further studies investigating the possible mechanism of TPM in migraine are needed.     

Cervical mobility in women with migraine

Objective.— To contrast the cervical range of motion (CROM) in women with episodic migraine (EM), transformed migraine (TM), and controls without migraine headaches.
Background.— Migraineurs often complain about neck pain. Furthermore, neck problems can worsen the headaches in individuals with migraine. Individuals with neck pain usually have reduced CROM. Nonetheless, studies assessing the CROM in migraineurs are scarce.
Methods.— Our sample was selected in an outpatient headache clinic, and consisted of 45 women aged 20-54 years old, 15 per group. Cervical mobility was evaluated in movements of flexion, extension, right lateral flexion, left lateral flexion, right rotation, and left rotation using the CROM technique, and was contrasted among the groups. Migraine clinical patterns were also evaluated (frequency, duration of migraine, pain in the moment of evaluation, pain in movement, and pain localization) as a function of CROM.
Results.— Compared with controls, individuals with TM had numerically inferior CROM in all parameters, and significant reduction in 3 of them: extension (59.3 vs 68.1, P  = .02), left lateral flexion (44.5 vs 49.1, P  = .03), and right rotation (62.2 vs 69.6, P  = .02). Compared with individuals with migraine, the TM group presented significantly reduced mobility only for extension (59.3 vs 68.4, P  = .02). Migraineurs also had numerically inferior ROM, contrasted to controls, in 5 of the 6 parameters, although significance was seen just for right rotation (60.8 vs 68.6 P  < .01). There was no correlation between cervical mobility and migraine parameters. The CROM was not reduced for the symptomatic side of migraine, in cases of unilateral pain.
Conclusion.— Contrasted to controls, individuals with episodic and TM have decreased cervical range of motion.     

Low leptin levels in migraine: a case control study

Background.— Obesity has been shown to be a risk factor for transformation of episodic migraine to chronic form, and adipocytokines have been implicated to modulate some of the cytokins such as interleukin-6 and tumor necrosis factor, which also act in the neurogenic inflammation in migraine. The aim of the study was to assess leptin levels, one of the adipocytokines, in headache-free period of migraine patients and investigate its relation to vascular risk factors.
Material and Methods.— Sixty-one patients with episodic migraine headaches and 64 control subjects were enrolled in the study. Demographic data and anthropometric measurements were obtained from all participants; body mass index and fat mass values were calculated. Glucose and lipid parameters were measured by oxidase technique and cholesterol esterase enzymatic assays, and leptin levels were measured by ELISA in serum samples obtained after an overnight fasting.
Results.— Leptin levels were found significantly lower in migraineurs than controls (40.1 ± 21.2 ng/mL, 48.5 ± 24.5 ng/mL; P  < .05). Although body mass index did not differ between 2 groups, fat mass, and fat percentages were significantly lower in migraine patients (19.4 ± 8.8 kg, 26.0 ± 8.7 kg; P  < .001 and 28 ± 9%, 34 ± 5%; P  < .001, respectively).
Conclusion.— Migraine patients have low leptin levels and fat mass which may be related to the pathogenesis of migraine. The importance and impact of our findings on the prevalence, characteristics, and treatment of migraine needs to be investigated in further detailed studies.     

Cytokines and Chemokines in Idiopathic Intracranial Hypertension

Background.— The pathogenesis of idiopathic intracranial hypertension (IIH) remains unclear and as such it remains a diagnosis of exclusion.
Objectives.— To identify cerebrospinal fluid (CSF) and serum cytokine and chemokine profiles associated with IIH.
Method.— Semiquantitative assessment with cytokine antibody arrays was used to detect the relative expression of 42 different cytokines and chemokines in the CSF and serum of 8 IIH patients and 8 controls. Subsequently, quantitative assay with enzyme linked immunosorbent assay was performed for chemokine CCL2, interleukin-1 alpha (IL-1α), and leptin.
Results.— Cytokine antibody array showed elevated levels of CCL2 in the CSF and CCL7, CCL8, IL-1α, and leptin levels in serum in IIH patients compared with controls. Subsequent quantitative assessment with enzyme linked immunosorbent assay showed significantly elevated CSF CCL2 in IIH patients compared with controls ( P  < .01) but there was no significant difference in leptin and IL-1α levels between the groups.
Conclusion.— This is the first report demonstrating differences in cytokine expression in the serum and CSF in IIH patients compared with controls. Since the pathogenesis of IIH is unclear, the heterogeneity of the cytokine expression reported here may help understand the pathogenesis of this condition.     

Obsessive-Compulsive Disorder and Migraine With Medication-Overuse Headache

Objective.— A strong association has been demonstrated between migraine, particularly in the chronic form and with medication overuse, and either major depression or various anxiety disorders. However, there has been less systematic research on the links between migraine with medication-overuse headache (MOH) and obsessive-compulsive disorder (OCD). A drug-seeking behavior shares with OCD the compulsive quality of the behavior. We investigated the relationship between OCD and MOH in migraineurs.
Methods.— A structured questionnaire was administered to subjects with: episodic migraine (EM) (n = 30), chronic migraine (CM) (n = 24), and MOH with a previous history of EM (n = 33) and 29 control subjects. Psychiatric diagnoses were made by a senior psychiatrist blinded to the diagnosis of migraine. Psychiatric assessment of OCD illness was evaluated by means of The Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Results.— In the subgroup of patients with MOH, psychiatric comorbidity (anxiety and mood disorders) was prevalent compared with CM, EM, and controls ( P  < .0001). Subclinical OCD was significantly prevalent in MOH patients with respect to other groups ( P  < .0002). Higher scores in Y-BOCS, as a measure of severity of obsessive-compulsive symptoms, were found in both MOH and CM compared with controls and EM.
Conclusions.— The excess of psychiatric comorbidity in patients with MOH can be related either to medication overuse or to chronification of headache. Among anxiety disorders, we observed a high rate of subclinical OCD. However, a direct link between compulsive behavior and medication overuse cannot be established yet. OCD in MOH might be underdiagnosed and undertreated.     

Bilateral pressure pain sensitivity mapping of the temporalis muscle in chronic tension-type headache

Purpose.— To analyze pressure pain sensitivity maps in chronic tension-type headache (CTTH) and healthy controls over nine locations covering the temporalis muscle.
Background.— Lower pressure pain thresholds (PPT) have been found in craniofacial muscles in patients with CTTH. Since the temporalis muscle can play a relevant role in the genesis or maintenance of headache, the determination of pressure pain sensitivity maps of this muscle is needed.
Methods.— A pressure algometer was used to measure PPT over 9 points of the temporalis muscle (3 points in the anterior part of the muscle, another 3 in the middle of the muscle, and the remaining 3 in the posterior part) in 15 females suffering from CTTH and 10 healthy women. A pressure pain sensitivity map of both dominant and nondominant sides in patients and controls was calculated.
Results.— Chronic tension-type headache patients showed lower PPT as compared with healthy subjects ( P  < .01). Further, PPT levels of the nondominant side were lower than those on the dominant side for controls ( P  < .01). Within the CTTH group, more bilaterally homogeneous pressure pain sensitivity maps with PPT decreased from the posterior to anterior column were found, whereas among controls, PPT distribution maps were inhomogeneous with side-to-side differences.
Conclusions.— Our data may provide preliminary new key information about muscle sensitivity, since it seems that pressure pain sensitivity maps could be different between CTTH patients and healthy subjects. Further studies with greater sample sizes and other headache populations are now required to confirm our results.     

Rizatriptan 10-mg ODT for Early Treatment of Migraine and Impact of Migraine Education on Treatment Response

Objective.— To examine the efficacy of rizatriptan 10-mg orally disintegrating tablet (ODT) for treating migraines of mild intensity soon after onset, with or without patient-specific migraine education.
Background.— Studies have shown rizatriptan tablet efficacy in early migraine treatment.
Methods.— In this randomized, placebo-controlled, double-blind, factorial design study, adults with a history of migraine were assigned to rizatriptan 10-mg ODT ± patient education (personalized summary of early migraine signs and symptoms) or placebo ± patient education in a 1 : 1 : 1 : 1 ratio. Patients were instructed to treat 1 attack at the earliest time they knew that their headache was a migraine, while pain was mild. During the next 24 hours, patients assessed pain severity, associated symptoms, functional disability, use of rescue medication, and treatment satisfaction. The primary endpoint was pain freedom at 2 hours; a key secondary endpoint was 24-hour sustained pain freedom.
Results.— Of 207 patients randomized to treatment, 188 (91%) treated a study migraine. Significantly more patients taking rizatriptan reported pain freedom at 2 hours compared with placebo (66.3% vs 28.1%, P  < .001). Similarly, significantly more patients taking rizatriptan reported 24-hour sustained pain freedom (52.2% vs 17.7%, P  < .001). A greater proportion of patients in the rizatriptan + education group reported pain freedom at 2 hours compared with those in the rizatriptan + no education group (71.7% vs 60.9%, P  = .430). Few adverse events were reported.
Conclusion.— Rizatriptan 10-mg ODT, when taken early, while headache pain is mild, was superior to placebo at providing pain freedom at 2 hours and 24-hour sustained pain freedom (NCT00516737).     

Headache Prophylaxis With BoNTA: Patient Characteristics

( Headache 2010;50:63-70)
Objective.— To assess the characteristics of patients receiving botulinum toxin type A (BoNTA; BOTOX^®) in the treatment of headache (HA) disorders.
Methods.— The following observational epidemiologic data and baseline patient characteristics were prospectively collected from eligible patients treated with BoNTA at 10 US HA specialty centers: demographics; HA diagnoses and characteristics (frequency, severity, and disability); prior and current HA treatments and response; clinical response to BoNTA; Migraine Disability Assessment (MIDAS) questionnaire; and adverse events. Patients maintained a daily HA diary and were evaluated at each follow-up visit.
Results.— Of 703 patients enrolled (mean age 43.1 years, 78.5% females, 95.4% white), nearly 66% had a diagnosis of chronic migraine (CM), with or without medication overuse. Approximately 75% had severe disability (MIDAS grade IV), and the mean pain rating was 6.5 (where 0 = no pain, 10 = pain as bad as it can be). More than 90% of patients had ≥1 prophylactic HA treatment failure; median number of failures was 4. Significant association was observed between HA frequency and MIDAS grade ( P  < .001). Approximately 80% of patients with CM had severe (grade IV) disability. The median number of monthly medication days was higher in the group with MIDAS grade IV ( P  < .001). HA frequency and severity, failed prophylactic therapies, and greater number of coexisting medical conditions were all negatively associated with measures of health-related quality of life.
Conclusions.— Majority of patients treated with BoNTA in a specialty HA center presented with a CM diagnosis. HA disability was correlated with measures of frequency and treatment utilization.     

Occipital Nerve Blocks: Effect of Symptomatic Medication

Objective.— To explore the effect of symptomatic medication overuse (SMO) and headache type on occipital nerve block (ONB) efficacy.
Methods.— We conducted a chart review of all of the ONBs performed in our clinic over a 2-year period.
Results.— Of 108 ONBs with follow-up data, ONB failed in 22% of injections overall. Of the other 78%, the mean decrease in head pain was 83%, and the benefit lasted a mean of 6.6 weeks. Failure rate without SMO was 16% overall, and with SMO was 44% overall ( P  < .000). In those who did respond, overall magnitude and duration of response did not differ between those with and those without SMO. Without SMO, ONB failure rate was 0% for postconcussive syndrome, 14% for occipital neuralgia, 11% for non-intractable migraine, and 39% for intractable migraine. With SMO, failure rate increased by 24% ( P  = .14) in occipital neuralgia, by 36% ( P  = .08) for all migraine, and by 52% ( P  = .04) for non-intractable migraine.
Conclusions.— SMO tripled the risk of ONB failure, possibly because medication overuse headache does not respond to ONB. SMO increased ONB failure rate more in migraineurs than in those with occipital neuralgia, possibly because migraineurs are particularly susceptible to medication overuse headache. This effect was much more pronounced in non-intractable migraineurs than in intractable migraineurs.     

Incomplete Posterior Circle of Willis: A Risk Factor for Migraine?

Background.— Migraine is associated with vascular risk factors and white matter abnormalities (WMA). Cerebral hypoperfusion is known to be one mechanism underlying WMA and a few studies have shown that an incomplete circle of Willis (CW) may predispose to cerebral hypoperfusion. This study assessed the relationship between the morphologic characteristics of the CW and migraine.
Methods.— This case–control study was carried out in the Amiens University Hospital. Patients undergoing 3-dimensional time of flight magnetic resonance angiography of the CW from January 1 to June 30, 2006 were included (n = 124). A definitive diagnosis of migraine was established in 47 patients: 23 (48.9%) experienced migraine without aura and 24 (51.1%) migraine with aura. The remaining 77 patients with other neurologic disorders constituted the control group. The posterior CW was graded as complete when both posterior communicating arteries and the P1 segments of the posterior cerebral artery were present on visual examination and incomplete when one of these vessels was missing (interobserver agreement: K_total = 0.746).
Results.— Incomplete posterior CW was significantly more common in migraineurs than in the control group (49% vs 18%; P  < .001). On multivariate analysis, incomplete posterior CW was the sole independent factor associated with migraine (OR: 6.5; 95% CI: 2.6-16.2; P  < .001). No difference was found between migraineurs with and without aura.
Conclusions.— Despite some methodological limitations, our results showed that incomplete posterior CW was associated with migraine.     

Clinical Significance of Brush Allodynia in Emergency Patients With Migraine

Background.— Cutaneous brush allodynia may be a practical and readily assessable marker of progression of an acute migraine attack. We determined the relative frequency of this finding in emergency department (ED) patients with acute migraine and tested the hypothesis that the presence of cutaneous brush allodynia prior to initial treatment in the ED could predict poor 2-hour and 24-hour pain intensity outcomes.
Methods.— As part of a multicenter ED-based clinical trial testing the benefit of dexamethasone vs placebo for the adjuvant parenteral treatment of acute migraine, cutaneous brush allodynia was assessed prior to treatment using an established methodology. In addition to dexamethasone or placebo, all patients received intravenous metoclopramide + diphenhydramine as primary treatment for their migraine. Pain intensity outcomes were assessed in the ED 2 hours after medication administration and again by telephone 24 hours after medication administration.
Results.— An assessment of cutaneous brush allodynia was performed in 182 migraineurs from 3 different EDs, of whom 26 (14%, 95% CI: 10-20%) had cutaneous brush allodynia. A pain-free state within 2 hours of medication administration was achieved by 46% of the allodynic patients and by 47% of the nonallodynic patients ( P  = .91). Median headache intensity over the 24 hours after ED discharge, as measured on a pain intensity scale from zero to 10, was 3 in the allodynic patients and 3 in the nonallodynic patients ( P  = .23).
Conclusions.— Cutaneous brush allodynia is an uncommon finding in the ED, occurring in fewer than 1 in 5 migraineurs. It does not seem to have prognostic relevance for the ED-based management of the acute migraine attack.     

Posttraumatic Stress Disorder in Migraine

Objective.— To evaluate the relative frequency of posttraumatic stress disorder (PTSD) in episodic migraine (EM) and chronic daily headache (CDH) sufferers and the impact on headache-related disability.
Background.— Approximately 8% of the population is estimated to have PTSD. Recent studies suggest a higher frequency of PTSD in headache disorders. The association of PTSD and headache-related disability has not been examined.
Methods.— A prospective study was conducted at 6 headache centers. PTSD was assessed using the life events checklist and PTSD checklist, civilian version (PCL-C). We compared data from EM to CDH, and migraine with PTSD to migraine without PTSD. The PHQ-9 was used to assess depression, and headache impact test (HIT-6) to assess disability.
Results.— Of 767 participants, 593 fulfilled criteria for EM or CDH and were used in this analysis. The mean age was 42.2 years and 92% were women. The frequency of PTSD was greater in CDH than in EM (30.3% vs 22.4%, P  = .043), but not after adjusting for demographics and depression ( P  = .87). However, participants with major depression and PTSD were more likely to have CDH than EM (24.6% vs 15.79%, P  < .002). Disability was greater in migraineurs with PTSD, even after adjustments (65.2 vs 61.7, P  = .002).
Conclusion.— The frequency of PTSD in migraineurs, whether episodic or chronic, is higher than the historically reported prevalence of PTSD in the general population. In addition, in the subset of migraineurs with depression, PTSD frequency is greater in CDH sufferers than in episodic migraineurs. Finally, the presence of PTSD is independently associated with greater headache-related disability in migraineurs.     

Clinical Assessment of Topiramate Therapy in Patients With Migrainous Vertigo

( Headache 2010;50:77-84)
Objective.— To assess the efficacy of topiramate in reducing both the frequency and the severity of vertigo and headache attacks in patients with migrainous vertigo and to compare 50 and 100 mg/day doses of the drug.
Methods.— Thirty patients diagnosed as definite migrainous vertigo were recruited in the study. Vertigo and headache frequency was determined as the monthly number of attacks whereas severity was determined by visual analog scales measured in millimeters from 0 to 100. Patients were randomized to either 50 or 100 mg/day topiramate for 6 months. Vertigo and headache frequency and severity were evaluated at the end of the study period.
Results.— Number of mothly vertigo attacks decreased significantly in the overall group after treatment (median from 5.5 to 1; P  < .01). The same was true for monthly headache attacks (median from 4 to 1; P  < .01). A statically significant improvement in vertigo severity was noted (median from 80 to 20 mm; P  < .01). Headache severity showed significant improvement as well (median from 60 to 30 mm; P  < .01). No statistically significant difference between high- and low-dose groups was present regarding efficacy ( P  > .05). Four patients in the high-dose group discontinued treatment at the end of the first month because of adverse effects.
Conclusions.— In the overall group, topiramate was found to be effective in reducing the frequency and the severity of vertigo and headache attacks. Both doses of the drug were equally efficacious. The 50 mg/day dose seems to be appropriate as higher adverse effects were noted when 100 mg/day was used.     

Expanding Access to Triptans: Assessment of Clinical Outcome

Objective.— To evaluate whether access to more liberal quantities of rizatriptan improves clinical outcome in patients with episodic migraine.
Background.— Currently many pharmacy benefit programs limit the number of triptan tablets/injections per month based on perceived cost savings and the belief that too-frequent use of triptans may lead to medication overuse headache and headache chronification.
Methods.— This observer-blind, randomized, parallel-group study enrolled 197 subjects with migraine with or without aura. Subjects completed a 3-month baseline period to establish migraine frequency and then were randomly assigned to receive 9 (formulary limit [FL]) or 27 (clinical limit [CL]) tablets of 10 mg rizatriptan orally disintegrating tablet (ODT) per month for 3 months. The primary endpoint was change in the mean number of migraine days from the baseline to treatment period.
Results.— There was no statistically significant difference between the FL and CL groups in mean number of migraine days (FL-CL LS mean: −0.08 [−0.39, 0.23]; P  = .613). Subjects in the CL group treated attacks at lower headache severity. No CL subjects were reported to have developed chronic migraine despite utilization of greater than 10 rizatriptan ODT tablets per month. Rizatriptan was generally well tolerated by both groups.
Conclusion.— Providing a greater quantity of rizatriptan ODT 10 mg did not reduce the number of migraine days compared with providing 9 tablets per month for this population with episodic migraine with a frequency of 3-8 migraines per month. Regardless of quantity provided, rizatriptan was generally well tolerated.     

Efficacy and tolerability of coadministration of rizatriptan and acetaminophen vs rizatriptan or acetaminophen alone for acute migraine treatment

Objective.— To evaluate the efficacy and tolerability of coadministration of rizatriptan and acetaminophen in the acute treatment of migraine.
Background.— Rizatriptan is a selective 5-HT_1B/1D agonist approved for the acute treatment of migraine. Acetaminophen has been studied for acute migraine treatment. In consideration of the prominent central and peripheral mechanisms in migraine, the use of "multi-mechanism therapy" is gaining momentum in the treatment of acute migraine attacks.
Study Design.— This was a randomized, double-blind, placebo-controlled trial conducted at 10 centers. Eligible patients with migraine according to International Headache Society criteria treated a single migraine attack of moderate or severe intensity within 4 h from pain onset. Patients were randomized into 1 of 4 groups (rizatriptan 10 mg + acetaminophen 1000 mg [RA], rizatriptan alone [R], acetaminophen alone [A], and placebo [P]). There were 3 co-primary hypotheses tested sequentially for 2-h pain relief: (1) RA would be superior to P; (2) if the first was fulfilled, RA would be superior to A; and (3) if the first 2 were fulfilled, RA would be superior to R.
Results.— Of 173 patients who treated a migraine, 123 patients (71.5%) achieved pain relief within 2 h. RA (90%) was significantly better than P (46%) and A (70%), but only numerically better than R (77%) for 2-h pain relief. No significant differences were seen between the active treatment groups in adverse events.
Conclusion.— Rizatriptan coadministered with acetaminophen achieved 2 of the 3 primary hypotheses, proving superior to both acetaminophen and placebo for 2-h pain relief, but failing to achieve superiority to rizatriptan alone. RA was as well tolerated as each of the individual agents.     

高血压病人高尿酸血症与冠心病发生的关系

目的　探讨原发性高血压病人高尿酸血症与冠心病发生的关系。方法　经临床诊断的病人 6 8例 ,6 2例献血员及健康查体者设为对照。测定以上两组人员血中尿酸、肌酐、总胆固醇、低密度脂蛋白胆固醇。结果　冠心病组与高血压组比较血清尿酸、肌酐间有非常显著性差异 (P <0 0 1) ,低密度脂蛋白胆固醇亦有显著差异 (P <0 0 5 )。高血压患者血尿酸低密度脂蛋白胆固醇水平显著高于对照组 (P <0 0 5 )。结论　合并冠心病高血压患者血尿酸显著增高 ,高尿酸血症的高血压病人与冠心病的发生有很直接的关系 ,可能是致冠心病的危险因素之一。     

A study to evaluate the feasibility of an aerobic exercise program in patients with migraine

Objectives.— The aim of this study was to develop and evaluate an exercise program to improve maximum oxygen uptake (VO_{2 max}) in untrained patients with migraine without making their migraines worse.
Patients and methods.— Twenty-six patients were studied at a headache clinic in Sweden. The exercise program, based on indoor cycling, was performed 3 times per week during 12 weeks. VO_{2 max}, migraine status, side effects, and quality of life were evaluated.
Results.— VO_{2 max} increased from 32.9 mL/kg/minute to 36.2 mL/kg/minute ( P  = .044). Quality of life increased and significant improvements in migraine status (attack frequency, symptom intensity, and intake of medicine) were seen. During the 12 weeks of exercise, on one occasion one patient had a migraine attack, which started immediately after training. No other side effects were reported.
Conclusions.— The evaluated exercise program was well tolerated by the patients and improved their VO_{2 max} with no deterioration of migraine status.     

Ophthalmoplegia With Migraine in Adults: Is It Ophthalmoplegic Migraine?

Objective.— Ophthalmoplegic migraine (OM) is a rare disorder characterized by recurrent oculomotor nerve palsy in children, following migraine headaches. We report 62 adults, seen consecutively, who developed acute ophthalmoplegia with severe attacks of migraine over a 10-year (1996-2005) period. An overwhelming majority of these patients had an antecedent worsening in severity of migraine headaches, before the ophthalmoplegic attack.
Methods.— Sixty-two patients, aged 15-68 years, with an acute attack of OM underwent detailed clinical, biochemical, and neuroradiological evaluation.
Results.— There were 62 patients with 86 attacks of OM. Whereas 48 patients had a single attack, 14 had 2 or more attacks, fulfilling the International Headache Society criteria for probable and definite OM, respectively. At presentation, isolated abducens, oculomotor, and trochlear nerve involvements were seen in 35 (56.5%), 21 (33.9%), and 5 (8.1%) patients, respectively. One patient had simultaneous involvement of 3rd and 6th nerves. Fifty-one (82.3%) patients exhibited an antecedent worsening in severity of migraine, before developing ophthalmoplegia during (59/95.2%) or within 24 hours (3/4.8%) of a severe migraine attack, respectively. Detailed biochemistry and cranial neuroimaging were normal. No case had any nerve enhancement. Use of steroids hastened recovery ( P  < .05).
Conclusion.— We conclude: (1) OM in adults is characterized by single attacks of ophthalmoplegia in a great majority of patients; and (2) 6th nerve involvement occurs commonly. Our results indicate that moving OM to the chapter on cranial neuralgias in the second edition of the International Headache Classification may be premature, since nerve palsy occurred during a severe migraine attack in all patients.     

Proton Spectroscopy in Patients With Post-Traumatic Headache Attributed to Mild Head Injury

Background.— Post traumatic headaches (PTH) following mild head injury (MHI) impose important diagnostic challenges to clinicians, and are often the scope of litigation.
Objective.— To investigate whether spectroscopy magnetic resonance imaging (MRS) demonstrates markers of PTH following MHI.
Methods.— We imaged individuals with PTH following MHI (n = 17), as well as controls (n = 12), using Proton MRS (1-HS MRI). We estimated the metabolic ratios of N-acetylaspartate (NAA) and choline (Cho), relative to creatine (Cr). Compared with controls, individuals with PTH following MHI had reduced values of NAA in the right (1.64 ppm vs 2.05 ppm, P  = .012) and left anterior regions of the frontal lobe white matter (1.52 ppm vs 2.10 ppm; P  = .024); anterior (1.52 ppm vs 1.78 ppm; P  = .0155) and posterior medial region of the frontal lobes (1.6 ppm vs 2.07 ppm; P  = .0045), and medial region of parietal lobes (1.76 ppm vs 2.23 ppm; P  = .0065). Contrasted to controls, Cho measures were statistically increased in the posterior region of the white matter of the right side fontal lobe (1.18 ppm vs 0.99 ppm; P  = .0095), anterior medial region of the frontal lobe (1.20 ppm; vs 1.07 ppm; P  = .0265), and medial region of the parietal lobes (0.92 ppm vs 0.65 ppm; P  = .0005).
Conclusions.— Proton MRS may be useful as an imaging marker for PTH following mild injury. Future studies should contrast PTH following mild vs severe trauma, as well as PTH with other forms of headache, to clarify if the findings are specific of the disease, may be correlated with disease severity, or if they are unspecific headache markers.     

The Prevalence of Headache and Its Association With Socioeconomic Status Among Schoolchildren in Istanbul, Turkey

Objective.— The etiology and pathogenesis of migraine and other types of headache are still under discussion. An interaction of organic, psychological, and psychosocial factors is operative. In this study, we aimed to determine the prevalence of headache and its association with socioeconomic status among schoolchildren.
Study Design.— A cross-sectional study was performed on 2669 schoolchildren via a parental questionnaire. Socioeconomic status was determined according to the Turkish socioeconomic status scale.
Results.— The mean age of the students was 8.2 ± 2.4 years. The headache prevalence was 46.2% (95% CI: 44.3-48.1). The prevalence of migraine was 3.4% (95% CI: 2.8-4.1), the prevalence of probable migraine was 8.7% (95% CI: 7.6-9.8), and that of non-migraine headache was 34.1% (95% CI: 32.3-35.9). Multivariate analysis revealed that older age, being a girl, having a family history of headache, and exposure to passive smoking at home were independently associated with headache. There was an inverse association between socioeconomic status and all 3 types of headaches after adjusting for age, sex, family history of headache, and presence of passive smoking. When the group with the lowest socioeconomic status was taken as the reference category, the odds ratios for the highest socioeconomic group were 0.33 (95% CI: 0.16-0.69, P  = .003) for the migraine, 0.30 (95% CI: 0.11-0.89, P  = .029) for the probable migraine, and 0.34 (95% CI: 0.16-0.72, P  = 0.005) for the non-migraine headache.
Conclusion.— Headache is more common among children with lower socioeconomic groups. Social causation can play a role in the pathogenesis of headache.