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Background: Resistant and refractory migraine are commonly encountered in specialized headache centers. Several comorbidities, mostly psychiatric conditions, have been linked to migraine worsening; however, there is little knowledge of the comorbidity profile of individuals with resistant and refractory migraine. Methods: REFINE is a prospective observational multicenter international study involving individuals with migraine from 15 headache centers. Participants were categorized into three groups based on the European Headache Federation criteria: non-resistant and non-refractory (NRNRM), resistant (ResM), and refractory (RefM). We explored the prevalence of 20 comorbidities at baseline in the three groups. Results: Of the 689 included patients (82.8% women), 262 (38.0%) had ResM, 73 (10.4%) had RefM and 354 (51.4%) NRNRM. A higher prevalence of psychiatric comorbidities, trigger points, temporomandibular joint disorders, thyroiditis, and cerebrovascular diseases was observed in the RefM group, followed by ResM and NRNRM. Multiple comorbidities were more common in the RefM group, followed by the ResM group and by the NRNRM group (41.6% vs. 24.5% vs. 14.1% respectively; p < 0.001). At the sensitivity analysis, exploring participants with chronic migraine, significant differences among the NRNRM, ResM, and RefM groups were found in the prevalence of anxiety (p < 0.001), asthma and rhinitis (p = 0.013), bipolar and other psychiatric disorders (p = 0.049), cerebrovascular diseases (p < 0.001), depression (p < 0.001), obesity (p = 0.002), thyroiditis (p < 0.001), and trigger points (p = 0.008). Conclusion: REFINE data indicate that individuals with ResM and RefM have a higher burden of comorbidities than those with NRNRM. It can be postulated that those comorbidities may have an impact on the progression of migraine from a form that is easy to treat to a form that is resistant or refractory to treatments. Longitudinal studies are needed to understand the direction of the association between ResM or RefM and those comorbidities and if proper treatment of comorbidities might help overcome treatment resistance or refractoriness. [ABSTRACT FROM AUTHOR]

The article discusses the alleviation of the suffering of patients with chronic headaches. The medical community all over the world is awaiting BoNTA therapy which is efficacious, safe and convenient, especially in chronic daily headache patients. The article also reports that Scientific evidence on BoNTA mechanisms of action verifies its efficacy on migraine through the suppression of pain.

The article discusses the issues relating to the disability in migraine and complication of medication overuse. It mentions the management of multimorbid patients with migraine. It also mentions the ways of rehabilitation from medication overuse along with the information on the risk for triptans and moderate risk for analgesics/anti-inflammatory nonsteroidal drugs.

The article reflects on the partnership between the European Headache Federation and "The Journal of Headache and Pain." It cites factors that demonstrate the success of the federation. It discusses the significance of the partnership in headache medicine. It encourages submission of manuscripts to the journal.

The article focuses on a series of Tutorials related to headache medicine, which will be featured in the succeeding issues of the "Journal of Headache Pain" in 2006. Such educational program represents an opportunity for sector experts, neophytes, clinicians and general practitioners to develop skills in headache diagnosis and treatment. It offers information on a pilot Tutorial that focused on the basic pharmacoeconomics concepts applied to migraine.

Reports on the activities and achievements of "The Journal of Headache and Pain" during year 2005. Number of regular peer-reviewed issues in the 2005 volume; Selection of JHP as the official journal of the European Headache Federation; Overview of the Global Campaign to Reduce the Burden of Headache Worldwide.

The study has been conducted in 9 European countries, interviewing 200 women in each country, aged 18-35, in fully working or studying period, to get a total of 1810 people. Migraine or severe headache was recognised and patients were studied to understand their behaviour. The features and severity of headache, the use of different drugs, the relationship between physicians and patients, the disability during attacks, the psychological aspects and the feeling of impotence that migraine patients experienced during their lives, are analysed and reported. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor of the 'Cephalalgia' journal, published in the December 2000 issue of the journal. Critique on M. Empl's paper on T-cell subset variations and integrins expression in migraine; Molecular events involved in migraine attacks; Implications of the conflicting results in Ebel's paper and the author's research; Importance of a more integrated research on migraine.

Editorial. Focuses on natural killer (NK) cell-mediated link to migraine. Implications of the results of a study on lymphocyte trafficking in migraine; Link between NK cell activity and the concentration of L-arganine; Discussion on the possible consequences of the increased nitric oxide accumulation.

The aim of this study was to asses the clinical features, pattern of healthcare and drug utilization of migraine patients attending 10 Italian headache centres (HC). Migraine is underdiagnosed and undertreated everywhere throughout the world, despite its considerable burden. Migraine sufferers often deal with their problem alone using self-prescribing drugs, whereas triptans are used by a small proportion of patients. All patients attending for the first time 10 Italian HCs over a 3-month period were screened for migraine. Migraine patients underwent a structured direct interview about previous migraine diagnosis, comorbidity, headache treatments and their side-effects and healthcare utilization for migraine. Patient satisfaction with their usual therapy for the migraine attack was evaluated with the Migraine-Assessment of Current Therapy (ACT) questionnaire. The quality of life of migraine patients was assessed by mean of Short Form (SF)-12 and Migraine-Specific Quality of life (MSQ) version 2.1 questionnaires. Of the 2675 patients who attended HCs for the first time during the study period, 71% received a diagnosis of migraine and the first 953 subjects completed the study out of 1025 patients enrolled. Only 26.8% of migraine patients had a previous diagnosis of migraine; 62.4% of them visited their general practitioner (GP) in the last year, 38.2% saw a specialist for headache, 23% attended an Emergency Department and 4.5% were admitted to hospital for migraine; 82.8% of patients used non-specific drugs for migraine attacks, whereas 17.2% used triptans and only 4.8% used a preventive migraine medication. Triptans were used by 46.4% of patients with a previous diagnosis of migraine. About 80% of migraine patients took over-the-counter medications. The Migraine-ACT revealed that 60% of patients needed a change in their treatment of migraine attacks, 85% of whom took non-specific drugs. Both the MSQ version 2.1 and the SF-12 questionnaires indicated a poor quality of life of most patients. Migraine represents the prevalent headache diagnosis in Italian HCs. Migraine is still underdiagnosed in Italy and migraine patients receive a suboptimal medical approach in our country, despite the healthcare utilization of migraine subjects being noteworthy. A cooperative network involving GPs, neurologists and headache specialists is strongly desirable in order to improve long-term migraine management in Italy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study aims to evaluate the bedside use of the pocket-sized ultrasound (US) device for the detection of the intracavitary effusions. METHODS: We randomly enrolled 40 patients admitted to S. Andrea Hospital of Rome. Every patient received a clinical and biochemical evaluation and a bedside US examination to detect and estimate the intracavitary (pleural, pericardial and intra-abdominal) effusions; the US measurements have been compared to the computed tomography (CT) scans (as gold standard). RESULTS: The patients presented a high prevalence of effusions: right pleural 16/40 = 40% (esteemed volume 236.3±500.7 ml, mean±standard deviation m±SD), left pleural 8/40 = 20% (127.0±377.4 ml), pericardial 12/40 = 30% (47.5±72.8 ml) and intra-abdominal effusions 5/40 = 12.5% of cases (110.9±600.6 ml). Linear regression analysis showed a significant correlation between US and CT measurements: pleural r = 0.973 p < 1×10–38, pericardial r = 0.927 p < 1×10–39, intra-abdominal space r = 0.921 p < 1×10–59. The accuracy of the bedside US at the pleural, pericardial and abdominal level was respectively 98%, 93% and 96% (Cohen's kappa coefficient 0.966, 0.841 and 0.833). CONCLUSIONS: The present study showed a high prevalence of the intracavitary effusions and a high accuracy of the bedside US. The bedside US by a pocket-sized device is promising tool for its advantages of reproducibility and non-invasiveness of the device. [ABSTRACT FROM AUTHOR]

The Aids to Management are a product of the Global Campaign against Headache, a worldwide programme of action conducted in official relations with the World Health Organization. Developed in partnership with the European Headache Federation, they update the first edition published 11 years ago. The common headache disorders (migraine, tension-type headache and medication-overuse headache) are major causes of ill health. They should be managed in primary care, firstly because their management is generally not difficult, and secondly because they are so common. These Aids to Management, with the European principles of management of headache disorders in primary care as the core of their content, combine educational materials with practical management aids. They are supplemented by translation protocols, to ensure that translations are unchanged in meaning from the English-language originals. The Aids to Management may be individually downloaded and, as is the case for all products of the Global Campaign against Headache, are available without restriction for non-commercial use. [ABSTRACT FROM AUTHOR]

Introduction Epidemiological research has documented a strong association between medication-overuse headache (MOH)and psychiatric disorders, emotional disturbances, and disordered personality traits, which are associated with worse outcomes, poorer quality of life, and higher costs to the health care system. Objectives Identifying risk factors for progression of headache into MOH represents one of the most relevant public health priorities and psychiatric comorbidity has been identified as a potential factor related to chronic phases. Aims The aim of the present study was to determine whether depression and insomnia complaints were associated with satisfaction and enjoyment with one's own life in Medication-overuse headache (MOH) patients, and whether insomnia complaints were able to explain part of the variance of QoL explained by depression. Methods Participants were 187 consecutive adult outpatients admitted to the outpatient headache clinic. Patients were administered the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Beck Depression Inventory–II (BDI-II), and the Athens Insomnia Scale (AIS). Results The BDI was associated with all the dimensions of the Q-LES-Q, with more severe depression being associated independently with lower satisfaction and enjoyment with one's own life. The AIS was independently and significantly associated only with physical health, such that patients with more insomnia complaints were 3.1 times ( P < 0.001) more likely to report lower physical health satisfaction. Conclusions Our findings confirmed that MOH has a negative impact on quality of life, and suggested that depression and insomnia were independently associated with satisfaction and enjoyment of life in MOH patients. [ABSTRACT FROM AUTHOR]

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect. [ABSTRACT FROM AUTHOR]

Migraine is a disabling neurological disease that affects 14.7 % of Europeans. Studies evaluating the economic impact of migraine are complex to conduct adequately and with time become outdated as healthcare systems evolve. This study sought to quantify and compare direct medical costs of chronic migraine (CM) and episodic migraine (EM) in five European countries. Cross-sectional data collected via a web-based survey were screened for migraine and classified as CM (≥15 headache days/month) or EM (<15 headache days/month), and included sociodemographics, resource use data and medication use. Unit cost data, gathered using publicly available sources, were analyzed for each type of service, stratified by migraine status. Univariate and multivariate log-normal regression models were used to examine the relationship between various factors and their impact on total healthcare costs. This economic analysis included data from respondents with migraine in the UK, France, Germany, Italy, and Spain. CM participants had higher level of disability and more prevalent psychiatric disorders compared to EM. CM participants had more provider visits, emergency department/hospital visits, and diagnostic tests; the medical costs were three times higher for CM than EM. Per patient annual costs were highest in the UK and Spain and lower in France and Germany. CM was associated with higher medical resource use and total costs compared to EM in all study countries, suggesting that treatments that reduce headache frequency could decrease the clinical and economic burden of migraine in Europe. Comparing patterns of care and outcomes among countries may facilitate the development of more cost-effective care, and bring greater recognition to patients affected by migraine. [ABSTRACT FROM AUTHOR]

Migraine is a disabling neurological disease that affects 14.7 % of Europeans. Studies evaluating the economic impact of migraine are complex to conduct adequately and with time become outdated as healthcare systems evolve. This study sought to quantify and compare direct medical costs of chronic migraine (CM) and episodic migraine (EM) in five European countries. Cross-sectional data collected via a web-based survey were screened for migraine and classified as CM (≥15 headache days/month) or EM (<15 headache days/month), and included sociodemographics, resource use data and medication use. Unit cost data, gathered using publicly available sources, were analyzed for each type of service, stratified by migraine status. Univariate and multivariate log-normal regression models were used to examine the relationship between various factors and their impact on total healthcare costs. This economic analysis included data from respondents with migraine in the UK, France, Germany, Italy, and Spain. CM participants had higher level of disability and more prevalent psychiatric disorders compared to EM. CM participants had more provider visits, emergency department/hospital visits, and diagnostic tests; the medical costs were three times higher for CM than EM. Per patient annual costs were highest in the UK and Spain and lower in France and Germany. CM was associated with higher medical resource use and total costs compared to EM in all study countries, suggesting that treatments that reduce headache frequency could decrease the clinical and economic burden of migraine in Europe. Comparing patterns of care and outcomes among countries may facilitate the development of more cost-effective care, and bring greater recognition to patients affected by migraine. [ABSTRACT FROM AUTHOR]

The article presents a guideline on the management of common headache disorders in primary care. In Europe, headache disorders are amongst the top ten causes of disability. Migraine, tension-type headache and medication-overuse headache are important in primary care because they are common and responsible for almost all headache-related burden. Management of these three belongs largely in primary care.

Botulinum toxin type A (BoNT-A) has been recently suggested as prophylaxis therapy for the treatment of primary headache chronic forms. Several studies on its efficacy are available, but results are often contradictory and not univocal. The effects of BoNTA on chronic forms of both tension- type headache and migraine have been investigated. In this study we introduce our five-year long experience with BoNT-A (Botox((R)), Allergan, Irvine, CA). The employed dosage was 100 U and the Fixed Sites-Fixed Doses (FSFD) protocol was used. The period of study was April 2001 to July 2006. A sum of 1347 patients suffering from chronic daily headache (CDH) were treated. We registered in these patients the number of headache days per month and observed their reduction in relation to the number of injections. The best results were found after 12 months of treatment, with patients being free of attacks 23 days per month. The BoNT-A treatment was safe and well tolerated, as only 1.6% of patients reported adverse events, and they were all mild and transient. In conclusion, BoNT-A therapy appears to be an efficacious new therapeutic choice in the prophylaxis of CDH, especially for patients not responding to previous prophylactic treatments. [ABSTRACT FROM AUTHOR]

Hypothalamus-pituitaryadrenal (HPA) axis activity was monitored in 20 women with chronic migraine (CM), previously affected by medication overuse headache (MOH), in comparison to healthy women (20 subjects) by measuring salivary cortisol, testosterone, dehydroepiandrosterone-sulphate (DHEA-S) levels, and their ratios, one week after the end of the MOH rehabilitation procedure. The participants were instructed how to collect saliva samples at home, a procedure that was performed twice a day (08:00 a.m. and 8:00 p.m.). Morning and evening levels of cortisol were significantly increased in CM patients with respect to controls. With regard to the cortisol/DHEA-S ratio, an inverse marker of psycho-physical wellbeing, CM women showed significantly higher values than controls. Moreover, testosterone/cortisol ratios (anabolic/catabolic index of physical performance) were significantly lower in CM patients than in controls. In the present study, CM appears not to be associated with an impairment of cortisol and DHEAS circadian fluctuation; however, CM patients present alterations in HPA axis function that might contribute to metabolic and psychological alterations that have also been associated with CM. [ABSTRACT FROM AUTHOR]

Many reports indicate that nitric oxide (NO) could be involved in migraine without aura (MWA), an extremely diffuse clinical event. Since monocyte may be a relevant source of NO, we analysed monocyte activation in MWA patients, in a period in which they were free of symptoms. NO basal production by MWA peripheral monocytes was significantly higher than in healthy subjects (91.25 ± 8.6 μm/106 cells vs. 22.6 ± 3.2 μm /106 cells). Interestingly, even the release of prostaglandin E2 (PGE2), was higher in MWA patients than in healthy subjects (3137 ± 320 pg/106 cells vs. 1531 ± 220 pg/106 cells). The incubation of monocytes from healthy subjects and MWA patients with N-nitro-l-arginine methyl ester caused a marked decrease of both NO and PGE2 release. We hypothesise that NOS and cyclooxygenase pathways in monocytes are linked and are, in MWA patients, up-regulated, even in a symptoms-free period. NO and PGE2 hyperproduction could therefore be involved in the neurovascular modifications leading to migraine attacks. [ABSTRACT FROM AUTHOR]

An abstract of the article "Frovatriptan vs almotriptan for treatment of menstrual migraine: a double-blind, randomized, cross-over, multicenter Italian study" by M. Bartolini, M. A. Giamberardino, C. Lisotto, P Martelletti, D. Moscato, B. Panascia and colleagues is presented.

Presents a letter to the editor about headache induced by accidental nitric acid inhalation, published in April 1, 2004 issue of the journal "Cephalalgia."