Comorbidity of migraine and headache associated with sexual activity

In order to investigate the comorbidity of migraine and headache associated with sexual activity (HSA), we performed a case-control study based on migraine patients. By means of a questionnaire and a personal interview, 100 migraine patients and 100 control subjects were examined regarding a diagnosis of HSA. In five subjects from the migraine group vs. none from the control group, a diagnosis of HSA could be established (P = 0.021). Previous studies that have demonstrated comorbidity of migraine and HSA were all based on HSA patients. Thus, it can now be concluded that the association between the two headache disorders is bilateral. In addition, the prevalence of HSA in the general population can be estimated to average around at least 0.9%, which concurs with previously published data.     

Patients with acenocoumarol treatment and migraine

OBJECTIVE: The aim of our study was to investigate the possible effect of acenocoumarol, which is indicated for nonneurological disease, on headache. BACKGROUND: It has been suggested that anticoagulation can have beneficial effects in the control of migraine attacks. METHODS: Four hundred randomized patients on oral anticoagulant therapy were asked to complete a questionnaire regarding their headaches. RESULTS: Headache was present before or during oral anticoagulation in 166 (66 migraineurs and 100 nonmigraineurs) of 326 respondents. The major finding was that oral anticoagulation produced improvement in 63% of patients with migraine versus 38% of patients with nonmigranous headache. Improvement was related to the severity of migraine but not to age. CONCLUSIONS: Oral anticoagulant therapy can improve migraine. The way in which anticoagulant therapy acts on migraine is unknown, but potential mechanisms include its effect on platelet aggregability and pharmacological effects such as suppression of enhanced nitric oxide.     

Clonazepam for Refractory Headache: Three Cases Illustrative of Benefit and Risk

Many patients with migraine are poorly responsive to conventional preventive therapies. Comorbid anxiety and depression may contribute to headache refractoriness, but studies of headache preventives have not typically addressed the patient with psychiatric comorbidity. The author has used clonazepam empirically to treat a subgroup of headache patients with associated anxiety, who were poorly responsive to conventional preventives. The use of a benzodiazepine as a headache preventive raises concerns regarding tolerance and addiction. The author presents 3 cases that illustrate different outcomes associated with this therapy, and suggests guidelines for its use. (Headache 2010;50:650‐656)     

Botulinum Neurotoxin for the Treatment of Migraine and Other Primary Headache Disorders: From Bench to Bedside

Botulinum toxin type A, a neurotoxin, is effective for treating a variety of disorders of involuntary muscle contraction including cervical dystonia, blepharospasm, and hemifacial spasm. It inhibits neuromuscular signaling by blocking the release of acetylcholine at the neuromuscular junction. The biological effects of the toxin are transient, with normal neuronal signaling returning within approximately 3 to 6 months postinjection.
Recent clinical findings suggest that botulinum toxin type A may inhibit pain associated with migraine and other types of headache. However, the mechanism by which this toxin inhibits pain is not fully understood and is under investigation. Research findings suggest that botulinum toxin type A inhibits the release of neurotransmitters from nociceptive nerve terminals and, in this way, may possess an analgesic effect. A number of retrospective open-label chart reviews and 3 double-blind, placebo-controlled trials have demonstrated that localized injections of botulinum toxin type A significantly reduce the frequency, severity, and disability associated with migraine headaches. Although the majority of patients in these studies experienced no botulinum toxin type A-mediated side effects, a small percentage of patients did report transient minor side effects including blepharoptosis, diplopia, and injection-site weakness. Currently, 4 randomized, placebo-controlled, clinical trials are being conducted to evaluate the efficacy, optimal dosing, and side-effect profile of botulinum toxin type A as a novel treatment for migraine and other types of headache. These studies may provide further evidence that botulinum toxin type A is an effective option for the preventive treatment of migraine.     

Topiramate prophylaxis and response to triptan treatment for acute migraine

OBJECTIVE: To evaluate the effect of topiramate migraine prophylaxis on subject responsiveness to triptans used for acute symptomatic migraine treatment. BACKGROUND: Clinical experience suggests that prophylactic migraine treatment may enhance the efficacy of symptomatic medications used to treat acute migraine attacks. METHODS: This open-label, single-arm multicenter study consisted of a 6-week baseline period followed by a 16-week topiramate treatment period. Subjects meeting International Headache Society (IHS) criteria for migraine with and without aura signed consent and entered the baseline period. Those with 3 to 12 migraine periods per month during baseline received topiramate prophylactic treatment. Only patients who completed at least 12 weeks of topiramate treatment were included in the data analysis. RESULTS: Of 55 patients screened, 40 subjects entered the topiramate treatment period and 21 subjects received at least 12 weeks of treatment. Mean final dose of topiramate was 124 mg per day (range 50 to 200 mg per day). During the baseline period, the mean percentage of attacks rendered pain-free at 2 hours for the 21 subjects was 46.9% (SD = 31.9), while during the topiramate treatment period it was 44.6% (SD = 32.2) (P= .8). On topiramate, after the first 8 weeks of dosage titration, patients experienced a mean of 3.68 migraine attacks/month, compared to 4.31 during the baseline period (P < .03). Thirteen subjects discontinued because of adverse events. The most commonly reported adverse events were paresthesia, fatigue, anxiety, and dizziness. CONCLUSION: Although topiramate prophylaxis did reduce migraine attack frequency, in this pilot study topiramate prophylactic migraine treatment did not increase the proportion of patients pain-free 2 hours after symptomatic triptan therapy.     

Cervicogenic Headache: The Neck Is a Generator: Con

Cervicogenic headache (CeH) is a well‐recognized headache syndrome, distinguishable from other primary and secondary headaches. Although in some cases a cervical lesion may be detected in connection with the headache, many CeH patients have no demonstrable lesion. Besides, most of the frequent cervical diseases, such as spondylosis and disc herniations, do not present with headache of the cervicogenic type. This suggests that the neck is not an independent headache generator. CeH may depend in addition on a central predisposition counterpart, leading to the activation of the trigeminovascular system and pain generation.     

Exteroceptive Suppression of Temporalis Muscle Activity: A Blind Study of Tension-Type Headache, Migraine, and Cervicogenic Headache

Exteroceptive suppression of temporalis muscle activity (ES2 duration) has been reported to be reduced in chronic tension-type headache in previous open studies (with varying stimulus and analysis methods). We studied ES2 duration and latency in 11 patients with chronic tension-type headache, 10 patients with cervicogenic headache, 11 migraine patients, and 9 headache-free control subjects. The investigator was blinded as to the diagnostic category. Electrical stimuli of 0.5 ms duration and at least three times sensory threshold (median 9.6 mA) were used. ES2 was obtained in all but one (control) subject and the control ES2 duration mean was 33.5 (SD 8.5) ms (80% EMG amplitude reduction criterion). Mean ES2 duration differences were not found between the four groups. None of the headache patients had ES2 durations below the control group range. ES2 duration tended to decrease with increasing duration of headache history. Consistent asymmetries of ES2 latency and duration were not found among patients with (unilateral) cervicogenic headache. Thus, the role of ES2 in headache diagnosis still seems to be unsettled.     

Postangiography Headache

In order to study the frequency and characteristics of post-angiography headache, we interviewed 45 consecutive patients (mean age ± SD= 57 ± 15 years; M/F=15/30) who underwent transfemoral cerebral angiography for: ischemic cerebrovascular disease (n=33); suspected arteriovenous malformations (n=4; one confirmed); suspected cerebral aneurysm (n=5; two confirmed); and arterial dissection (n=3; one confirmed and one was a follow-up study of a previously demonstrated dissection). Postangiography headache developed in 15 (33%) patients, 125 ± 99 min after the completion of the study. It was unilateral in nine (60%) patients, homolateral to the usual side of migraine headache in two of three migraineurs, and pulsating in six (40%). Nausea, vomiting, photophobia, and phonophobia accompanied postangiography headache in 20%, 7%, 33%, and 20% respectively. Postangiography headache fulfilled the International Headache Society criteria for migraine without aura (except for the number of attacks) in 27% of patients. Patients with and those without postangiography headache were comparable in mean age, sex, and indication for angiography. Fifty-three percent (8/15) of patients with postangiography headache and 23% (7/30) of the non postangiography headache group reported prior recurrent headaches (P =0.047, likelihood ratio chi-square). Postangiography headache has the characteristics of delayed arterial pain which may be related to a catheter-induced or contrast dye-induced release of vasoactive substances, notably nitric oxide and serotonin.     

Headaches precipitated by cough,prolonged exercise or sexual activity: a prospective etiological and clinical study

Headaches provoked by cough, prolonged physical exercise and sexual activity have not been studied prospectively, clinically and neuroradiologically. Our aim was to delimitate characteristics, etiology, response to treatment and neuroradiological diagnostic protocol of those patients who consult to a general Neurological Department because of provoked headache. Those patients who consulted due to provoked headaches between 1996 and 2006 were interviewed in depth and followed-up for at least 1 year. Neuroradiological protocol included cranio-cervical MRI for all patients with cough headache and dynamic cerebrospinal functional MRI in secondary cough headache cases. In patients with headache provoked by prolonged physical exercise or/and sexual activity cranial neuroimaging (CT and/or MRI) was performed and, in case of suspicion of subarachnoid bleeding, angioMRI and/or lumbar tap were carried out. A total of 6,412 patients consulted due to headache during the 10 years of the study. The number of patients who had consulted due to any of these headaches is 97 (1.5% of all headaches). Diagnostic distribution was as follows: 68 patients (70.1%) consulted due to cough headache, 11 (11.3%) due to exertional headache and 18 (18.6%) due to sexual headache. A total of 28 patients (41.2%) out of 68 were diagnosed of primary cough headache, while the remaining 40 (58.8%) had secondary cough headache, always due to structural lesions in the posterior fossa, which in most cases was a Chiari type I malformation. In seven patients, cough headache was precipitated by treatment with angiotensin-converting enzyme inhibitors. As compared to the primary variety, secondary cough headache began earlier (average 40 vs. 60 years old), was located posteriorly, lasted longer (5 years vs. 11 months), was associated with posterior fossa symptoms/signs and did not respond to indomethacin. All those patients showed difficulties in the cerebrospinal fluid circulation in the foramen magnum region in the dynamic MRI study and preoperative plateau waves, which disappeared after posterior fossa reconstruction. The mean age at onset for primary headaches provoked by physical exercise and sexual activity began at the same age (40 years old), shared clinical characteristics (bilateral, pulsating) and responded to beta-blockers. Contrary to cough headache, secondary cases are rare and the most frequent etiology was subarachnoid bleeding. In conclusion, these conditions account for a low proportion of headache consultations. These data show the total separation between cough headache versus headache due to physical exercise and sexual activity, confirm that these two latter headaches are clinical variants of the same entity and illustrate the clinical differences between the primary and secondary provoked headaches.     

Contraception and Headache

Most women have used at least 1 method of contraception during their reproductive years, with the majority favoring combined oral contraceptives. Women are often concerned about the safety of their method of choice and also ask about likely effects on their pre‐existing headache or migraine and restrictions on using their headache medication. While there should be no restriction to the use of combined hormonal contraceptives by women with migraine without aura, the balance of risks vs benefits for women with aura are debatable. Migraine with aura, but not migraine without aura, is associated with a twofold increased risk of ischemic stroke, although the absolute risk is very low in healthy, nonsmoking women. Although ethinylestradiol has been associated with increased risk of ischemic stroke, the risk is dose‐dependent. Low‐dose pills currently used are considerably safer than pills containing higher doses of ethinylestradiol but they are not risk‐free. This review examines the evidence available regarding the effect that different methods of contraception have on headache and migraine and identifies strategies available to minimize risk and to manage specific triggers such as estrogen “withdrawal” headache and migraine associated with combined hormonal contraceptives. The independent risks of ischemic stroke associated with migraine and with hormonal contraceptives are reviewed, and guidelines for use of contraception by women with migraine are discussed in light of the current evidence.     

Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study

We performed a long-term follow-up examination in children and adolescents with migraine and tension-type headache (TTH) in order to investigate the evolution of clinical features and headache diagnoses, to compare International Classification of Headache Disorders (ICHD)-I and ICHD-II criteria and to identify prognostic factors. We re-examined 227 patients (52.4% female, age 17.6 +/- 3.1 years) 6.6 +/- 1.6 years after their first presentation to a headache centre using identical semistructured questionnaires. Of 140 patients initially diagnosed with migraine, 25.7% were headache free, 48.6% still had migraine and 25.7% had TTH at follow-up. Of 87 patients with TTH, 37.9% were headache free, 41.4% still had TTH and 20.7% had migraine. The number of subjects with definite migraine was higher in ICHD-II than in ICHD-I at baseline and at follow-up. The likelihood of a decrease in headache frequency decreased with a changing headache location at baseline (P < 0.0001), with the time between baseline and follow-up (P = 0.0019), and with an initial diagnosis of migraine (P = 0.014). Female gender and a longer time between headache onset and first examination tended to have an unfavourable impact. In conclusion, 30% of the children and adolescents presenting to a headache centre because of migraine or TTH become headache-free in the long-term. Another 20-25% shift from migraine to TTH or vice versa. ICHD-II criteria are superior to those of ICHD-I in identifying definite migraine in children and adolescents presenting to a headache centre. The prognosis is adversely affected by an initial diagnosis of migraine and by changing headache location, and it tends to be affected by an increasing time between headache onset and first presentation.     

Headache Disability Inventory (HDI): Short-term Test-Retest Reliability and Spouse Perceptions

We have reported previously that the 25-item Headache Disability Inventory has good internal consistency reliability, robust long-term (2 month) test-retest stability, and good construct validity. We conducted further investigations to evaluate the short-term (1 week) test-retest reliability and spouse perceptions of patients' self-perceived headache disability. The short-term test-retest reliability of the Headache Disability Inventory was excellent. Additionally, the spouse and patients' perceptions of the patient's headache disability generally were congruent, although we observed instances where the differences were marked.     

Posttraumatic Headache: Basic Mechanisms and Therapeutic Targets

Frequent or continuous headache, often refractory to medical therapy, is a common occurrence after head trauma. In addition to being the most common acute symptom after traumatic brain injury (TBI), headache is also one of the most persistent and disabling symptoms. Different studies indicate that 18‐58% of those suffering a TBI will have significant headache at 1 year following the trauma. In addition to being disabling on its own, posttraumatic headache (PTH) is a predictor of overall outcome after concussion. Despite its remarkable prevalence and associated social and economic costs, many fundamental and important questions about PTH remain unanswered. The purpose of this review is to identify key questions regarding the clinical characteristics of posttraumatic headache, its basic mechanisms, and its optimal management. We discuss phenotypic features of PTH, pathophysiological mechanisms of TBI including potential overlaps with those of migraine and other primary headache disorders, and potential novel targets for treatment. We suggest different strategies to finding answers to the questions regarding PTH in order to advance the understanding of the disorder and develop more effective therapies.     

Sexual Headache in Young Adolescence: A Case Report

We present the case of a boy who first experienced typical primary headache associated with sexual activity, orgasmic type, at age 12. Neurological examination and brain imaging were normal. A family history of migraine existed. The case shows the broad age spectrum of this primary headache disorder.