Refractory Migraine in a “Just World”

The “just world hypothesis” is the belief that a poor outcome to treatment always implies patient noncompliance. However, all disease states have a spectrum of severity, with the most severe end representing treatment failures despite compliant patients and excellent care. Some refractory headache patients represent this group of compliant patients, who had excellent care but who have bad disease.     

The “Ram's Horns Sign”: A Case Report of an Unusual Side Effect of OnabotulinumtoxinA in a Chronic Migraine Patient

OnabotulinumtoxinA (BoNT‐A) has been reported as an effective prophylactic treatment for chronic migraine to reduce disease severity improving health‐related quality of life. However, BoNT‐A, due to its activity on either the injected or adjacent muscles of the upper face, may induce well‐known side‐effects, such as the eyebrow or eyelid ptosis. However, unusual muscular side effects, related to the neurotoxic mechanism, may also arise. We describe the clinical case of a 55‐year‐old male patient who has been treated for chronic migraine by the injection of BoNT‐A, according to the PREEMPT protocol. Two weeks later, the patient developed two symmetrical bumps on the upper part of the forehead similar to the horns of a ram. We report, for the first time, this peculiar BoNT‐A side effect and suggest that the injection of additional BoNT‐A doses in the upper medial frontal fibers, for each side, can normalize the forehead shape over two weeks.     

The “Repeater” Phenomenon in Migraine Patients: A Clinical and Psychometric study

(Headache 2010;50:348‐356) Background.— Headache is one of the most common symptoms in an emergency department (ED), while migraine is the most frequently observed headache in this setting. The aim of our study was to evaluate the influence of clinical and psychometric variables on the repeater phenomenon, ie, patients who make at least 3 visits to the ED at least 1 week apart during a 6‐month period. Methods.— According to the International Classification of Headache Disorders, 2nd edition (ICHD‐II) criteria, we consecutively recruited Italian‐speaking migraine subjects who came to the ED or outpatient service. All the patients underwent the Migraine Disability Assessment Scale for the evaluation of migraine disability. We also administered the Beck Depression Inventory, State and Trait Anxiety Inventory, and Toronto Alexithymia Scale‐20 for the evaluation of depressive, anxiety, and alexithymic symptoms, respectively. A personality profile was also obtained by means of the Tridimensional Personality Questionnaire (TPQ). Results.— We consecutively enrolled 465 migraine patients, diagnosed according to the ICHD‐II criteria. Seventy (15%) of these patients met the repeater definition. The repeater group had more severe disability and was affected to a greater degree by chronic migraine, regardless of symptomatic drug overuse, than the non‐repeater group. As regards the psychometric variables, repeaters were more alexithymic, anxious, and depressed than non‐repeaters. The personality profile, as measured by the TPQ, revealed that the repeater patients scored higher on the harm avoidance scale and their subscales than the non‐repeater patients. Conclusions.— According to the findings of our study, the repeater migraineur is typically triptan‐naïve, more alexithymic, and more depressed than the non‐repeater migraineur. A clinical and psychometric evaluation of repeater patients who go to the ED because of migraine attacks may help to understand this epidemiological and clinical phenomenon. From a clinical point of view, these psychometric findings may not only shed light on the epidemiology of migraine in the ED, but may also help to design a specific therapeutic protocol for this subgroup of migraine patients.     

Perspectives regarding what constitutes a “good death” among Thai nurses: A cross‐sectional study

Palliative care is a crucial component in improving peoples' end‐of‐life period. It is important to understand the wishes of people at the end of life and the perceptions of their healthcare providers regarding these wishes. As nurses play a key role in patient care, in this study we set out to determine nurses' perceptions regarding what constitutes a “good death”, comparing what they thought their older patients would prefer to their own preferences for their own end‐of‐life care. Questionnaires asking about various options of end‐of‐life care were distributed to nurses, and they were asked how they thought older people would respond to each of the questions and what their own preferences would be if they were terminally ill. In total, 656 participants were enrolled and they rated relief from suffering as the most important component, both for themselves and for those in their care. More than 80% of nurses agreed with all of the statements on the questionnaire. However, some of the nurses' preferences for their own end of life differed from those they expected their patients to value.