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To optimize chronic migraine (CM) ascertainment and phenotype definition, provide adequate clinical management and health care procedures, and rationalize economic resources allocation, we performed an exploratory multicenter pilot study aimed at establishing a CM database, the first step for developing a future Italian CM registry. We enrolled 63 consecutive CM patients in four tertiary headache centers screened with face-to-face interviews using an ad hoc dedicated semi-structured questionnaire gathering detailed information on life-style, behavioral and socio-demographic factors, comorbidities, and migraine features before and after chronicization and healthcare resource use. Our pilot study provided useful insights revealing that CM patients (1) presented in most cases symptoms of peripheral trigeminal sensitization, a relatively unexpected feature which could be useful to unravel different CM endophenotypes and to predict trigeminal-targeted treatments' responsiveness; (2) had been frequently admitted to emergency departments; (3) had undergone, sometime repeatedly, unnecessary or inappropriate investigations; (4) got rarely illness benefit exemption or disability allowance only. We deem that the expansion of the database-shortly including many other Italian headache centers-will contribute to more precisely outline CM endophenotypes, hence improving management, treatment, and economic resource allocation, ultimately reducing CM burden on both patients and health system. [ABSTRACT FROM AUTHOR]

Treatment of chronic migraine with medication overuse requires withdrawal from acute medications. However, guidelines and clear indications for different intensity regimens, i.e., day hospital (DH) vs. inpatient treatment, are not available. Patients completed disability, quality of life (QoL) and depression questionnaires; headaches frequency and overused medications category were collected. Mann-Whitney U test and Chi square were used to assess differences between inpatients and DH patients; Bonferroni correction was applied. 194 patients aged 43.9 ± 12 (160 females) were enrolled (100 from DH, 94 inpatients). Inpatients were older, less educated and with lower employment rates. Inpatients had higher MIDAS scores ( P = 0.003) and headache frequency ( P = 0.002). They had lower QoL for restrictive ( P = 0.002) and preventive components; no difference was found for disability, mood state and QoL emotional component. Patients treated during hospitalization had higher disease severity and lower quality of life, but similar disability and mood state than those treated in DH. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to present the results of a questionnaire investigating parafunctions (particularly clenching and grinding) in patients with chronic migraine presenting sign of temporomandibular disorder. The questionnaire was elaborated by the Dental Clinic of the University of Milano and completed by 125 patients experiencing chronic migraine and attending the Neurological Institute Carlo Besta for an inpatient withdrawal protocol to treat medication overuse. Our results showed high percentages of parafunctions, which were present in 80 % of patients. We note that patient information on possible behaviours and coexisting conditions which may be involved in the mechanisms of chronic headaches, as well as education about these factors, are crucial aspects in the management of chronic headache patients. We suggest that patients suffering from chronic migraine with medication overuse headache should be evaluated in relation to the possible presence of parafunctions, and as far as the need for interocclusal devices, in order to limit the role of temporomandibular dysfunctions as trigger factors or coexisting conditions favouring the development/maintaining of headache chronification. [ABSTRACT FROM AUTHOR]

Temporomandibular disorders are among the potential comorbidities of migraine, and recent reports showed that they may have a role in promoting its progression into chronic migraine (CM). In order to clarify the possible role of neuromuscular components of the stomatognathic system in patients with CM, we studied 18 patients admitted as inpatients at our Headache Unit to undergo a withdrawal protocol for medication overuse, who underwent orthosis, after clinical and instrumental gnathological evaluation. They were subsequently evaluated after 6 months. The values of electromyographic parameters as well as of pain outcomes showed a significant decrease after orthosis. The implementation of gnathological and neuromuscular concepts can have a relevant role in the management of CM patients, in the contest of a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Chronic migraine (CM) represents an important medical issue, due to morbidity, high disability, presence of comorbidities, and medication overuse (MO). The prophylaxis of CM has not been extensively explored so far. Patients with CM are often treated with two or more compounds, although there is no clear evidence that polytherapy may be superior to monotherapy. We evaluated the percentage of prescription of polytherapy for the prophylaxis of CM in a clinical sample. We examined the charts of 98 CM patients admitted to our Headache Center for inpatient withdrawal program to stop MO. Results showed that only one drug for prophylaxis was prescribed in 20.4% cases, two or more drugs in 79.6%, with 63.3% of the total sample falling in the group 'true polytherapy', i.e. all the drugs prescribed on daily basis were given to treat CM, and not only to treat concomitant conditions. In more than 60% cases a combination of drugs indicated for migraine prophylaxis and drugs only indicated for other conditions (mainly for psychiatric disorders) was prescribed. Our survey indicates that polytherapy may be rather common in CM, and suggests that comorbidities may strongly influence treatment choices. [ABSTRACT FROM AUTHOR]

Recent data have suggested that interferon-β (IFN-β) may aggravate headaches in multiple sclerosis (MS) patients. The aim of this study was to investigate the life-time prevalence of primary headaches in MS patients treated with interferons in comparison with patients treated with other disease-modifying agents. Attention was focused on the onset of headache and the changes in pre-existing headaches in relation to the onset of therapy. The study was open-labelled and not randomized. We studied 150 consecutive MS patients treated with IFN-β (109 patients: 54 with 1b, 55 with 1a) and with other drugs (41 patients: 14 with glatiramer acetate, 27 with azathioprine). All patients underwent a semi-structured interview to diagnose headache type, according to the International Headache Society criteria. The frequency of primary headaches was higher in the interferon-group (72%) compared to patients in the other group (54%) (P = 0.03). Worsening of pre-existing headaches or development of de novo headache occurred only in the interferon-group (41 and 48%, respectively) and not in the other group (P < 0.001). These results show that headache should be considered among the side-effects of interferon in MS patients. [ABSTRACT FROM AUTHOR]

Improved health-related quality of life (HRQOL) and reduced activity limitations are prime objectives of migraine therapy, but no data on the effect of preventive treatments on these outcomes are available. We monitored changes in HRQOL using the Short Form 36 (SF-36) and headache-related activity limitations using the Migraine Disability Assessment Score (MIDAS) in 141 consecutive migraine without aura patients on prophylaxis. A total of 102 patients completed the 3-month study. Mean (SD) number of headache days/month dropped from 8.0 (3.7) to 5.0 (2.3) ( P < 0.001). Mean monthly consumption of acute drugs reduced from 7.4 (3.5) to 4.4 (3.1) ( P < 0.001). MIDAS total score reduced (improved) significantly. All SF-36 scale scores increased (improved), most significantly. This first study to assess prospectively the impact of prophylaxis on HRQOL and daily activities in a large series indicates that migraine prophylaxis has the potential to reduce the global burden of migraine on individuals and society. [ABSTRACT FROM AUTHOR]

This paper reviews results of placebo-controlled trials on topiramate (TPM) prophylaxis in migraine patients, and discusses issues regarding the use of this medication in clinical practice. Data from well conducted double-blind controlled trials and from a comparative trial show that TPM is effective against migraine, confirming the experience of physicians in various countries. Lack of major contraindications, high responder rate, good tolerability at the target dose (100 mg/day) following slow titration, and lack of weight gain make TPM one of the most effective and well accepted drugs for migraine prophylaxis. [ABSTRACT FROM AUTHOR]

Menstrual migraines are particularly difficult-totreat. Few studies on the use of triptans in short-term prophylaxis of menstrually related migraine have been recently conducted, but evidences of triptans’ efficacy in the specific case of pure menstrual migraine (PMM) are lacking.The aim of this study is to explore the efficacy and tolerability of naratriptan as short-term prophylaxis of pure menstrual migraine (PMM) attacks. A multi-centre, open, non comparative, pilot six-month study was conducted in women, aged 18 years or older, with regular menstrual cycles and with a history of migraine without aura exclusively associated to the perimenstrual period. After an observation period of three months, patients took for three consecutive menstrual cycles oral naratriptan 1 mg twice daily, starting two days before the expected onset of menstruation and continuing for six days. Ninety-eight women with a history of PMM were screened for study participation, and 61 entered the study. Fifty-nine comprised the intent-to-treat population. The mean number of PMM attacks decreased from 3.5±1.4 in the 3-month observation period to 1.6±1.3 in the 3-month treatment with naratriptan. The pecentage of responders (subjects who recorded a decrease-equal or more than 50%-in the mean number of attacks) was 61.4%. A tendency towards a decrease in headache severity and in the presence of associated symptoms was observed during treatment. At least one adverse event during the treatment period was reported by 19 patients (31.1%). No serious adverse events occurred. Naratriptan may be an effective and safe treatment option in the short-prophylaxis of PMM. [ABSTRACT FROM AUTHOR]

D’Amico D, La Mantia L, Rigamonti A, Usai S, Mascoli N, Milanese C&Bussone G. Prevalence of primary headaches in people with multiple sclerosis. Cephalalgia 2004. London. ISSN 0333-1024The aim was to investigate the lifetime prevalence of headache and primary headache (diagnoses according to International Headache Society criteria) in multiple sclerosis (MS). The relationships between headache and clinical features of MS and MS therapy were also investigated. We studied 137 patients with clinically definite MS; 88 reported headache, 21 of whom developed headache after the initiation of interferon. The prevalence of all headaches in the remaining 116 patients was 57.7%. Migraine was found in 25.0%, tension-type headache in 31.9%, and cluster headache in one patient. A significant correlation (P = 0.007, Fisher's exact test) between migraine and relapsing–remitting MS was found. Primary headaches are common in MS patients. Further studies are needed to clarify the mechanisms underlying this association, particularly the association between migraine and relapsing–remitting MS, and the role of interferon in the development of new headache. [ABSTRACT FROM AUTHOR]

Objectives.—To determine the suitability of the Migraine Disability Assessment (MIDAS) Questionnaire for assessing disability in children and adolescents with headache and to obtain preliminary information about disability in different primary headaches. Background.—During the last decade, researchers have begun to employ standardized methodologies to investigate the global impact of primary headaches. Disease-specific instruments have been developed to measure headache-related disability. The MIDAS Questionnaire, which is the most extensively studied of these instruments, was designed to assess the overall impact of headaches over the 3 months before compilation. The MIDAS Questionnaire is an optimal tool to assess headache-related disability in adults. Methods.—Ninety-five patients aged 7 to 17 years with tension-type headache, migraine, or both completed the validated Italian form of the MIDAS questionnaire on 2 occasions. Test-retest reliability was assessed by the Spearman rank correlation test. The Cronbach α assessed internal consistency. The patients answered questions about the adequacy of the questionnaire. Results.—The Cronbach α was .8. Correlation coefficients were generally high for the overall MIDAS score and for the items investigating disability in school and in family/leisure activities; they were lower for the items about housework. Most patients thought that the MIDAS Questionnaire was useful (98.9%) and that it captured the impact of their headaches (58.9%); 41% thought that questions about disability in housework were useless, 44.2% suggested adding questions regarding inability to do homework. All primary headaches had a considerable impact on daily activities, but patients with migraine tended to have lower headache frequencies and lower total disability time; those with tension-type headache suffered more days in which activities, although performed, were substantially impaired.... [ABSTRACT FROM AUTHOR]

Nitrite concentrations in plasma were investigated in a population of migraine and cluster headache patients and a group of healthy non-headache controls. A hundred migraine patients and 69 cluster headache patients in the interictal period, and 112 controls, were studied. Significantly higher nitrite concentrations were found in migraine patients, with and without aura, and cluster headache patients, in remission and cluster phase, than in controls. These findings suggest that a basal dysfunction in the L-arginine-NO pathway may be involved in the peripheral mechanisms predisposing subjects with neurovascular headaches to individual attacks. [ABSTRACT FROM AUTHOR]

We have developed and tested an Italian version of the Migraine Disability Assessment (MIDAS) questionnaire, an established instrument for assessing headache-related disability. A multistep process was used to translate and adapt the questionnaire into Italian, which was then tested on 109 Italian migraine without aura patients, 86 (78.9%) of whom completed the form a second time 21 days later. Overall MIDAS score had good test-retest reliability (Spearman's correlation 0.77), closely similar to that found in English-speaking migraineurs, and individual responses were also satisfactorily reliable. Internal consistency was good (Cronbach's alpha 0.7). These findings support the use of the MIDAS questionnaire as a clinical and research tool with Italian patients. [ABSTRACT FROM AUTHOR]

Migraine is associated with reduced productivity in work-related activities. The degree to which problems with work are, in turn, associated to the level of migraine-related disability as well as to headache frequency has been poorly explored. The aim of the study was to assess if migraine patients with different degrees of work difficulties showed a different level of migraine-related disability. A consecutive sample of patients with episodic migraine (EM) or with chronic migraine (CM) with medication overuse (MO) attending the Headache Centre of the Neurological Institute C. Besta of Milan was studied. All patients completed the MIDAS and the WHODAS 2.0 questionnaires. The total scores of both questionnaires, frequency of headaches, average pain intensity, and the scores of each subscale of the WHODAS 2.0 were calculated separately for EM and CM patients. The score of WHODAS 2.0 'Work difficulties' subscale was used to divide the studied patients into two groups, i.e. those above and those below the median 'Work difficulties' subscale score. Independent sample t test was used to compare these two groups as far as all the other studied variables. A total of 296 patients (102 with EM and 194 with CM-MO) were enrolled. Patients with higher work difficulties score also displayed higher scores in the other WHODAS 2.0 subscales; for those with CM-MO, the differences were significant. The results of this study indicate that having more and more severe workplace problems is associated to a higher disability level in migraineurs. Further studies are needed to better understand workplace disability in different migraine forms, particularly in a qualitative way. [ABSTRACT FROM AUTHOR]

Migraine, particularly migraine with aura (MA), may be a risk factor for ischemic stroke (IS). The reasons for this association are unknown. We investigated the presence of genetic abnormalities of the protein C system in 83 MA patients, 31 IS patients, and 124 healthy controls, all aged under 45 years. We found an increased frequency of activated protein C resistance due to Arg5O6Gln factor V mutation, and of protein S deficiency in both disorders, with figures higher than those reported in the general population and significantly different from those found in controls. These prothrombotic genetic abnormalities may be shared risk factors in IS and MA, and may play a role in increasing the risk of cerebrovascular disease in migraineurs. [ABSTRACT FROM AUTHOR]

Patients with chronic migraine (CM) and medication overuse headache (MOH) have high frequency of psychiatric comorbidity or psychopathological traits, the presence of which can influence the clinical course. The presence of subclinical obsessive compulsive disorder (OCD) is underestimated in migraine patients. The aim of this study was to estimate the prevalence and profile of obsessive-compulsive (OBS) trait in a sample of CM patients with MOH using the OBS questionnaire of Spectrum Collaborative Project. According to the new international classification of headache disorders (ICHD-III beta) criteria, 106 patients (15 M, 91 F, mean age 47.3 years) were selected in a consecutive clinical series. Our results showed that 36 % of patients with CM and MOH were positive at OBS-questionnaire. As far as the profile of OBS trait, we performed an evaluation of prevalence of items separating the first part of the questionnaire (childhood/adolescence and doubts in lifetime) from the other five domains: 21 % of the patients showed prevalence of items in childhood/adolescence domain; 79 % in doubts in lifetime domain; as for other five domains, 10.5 % of patients had prevalence of pathological answers among hypercontrol, 5.2 % in spending time, 23.7 % in perfectionism, 29 % in repetition and automation, and 31.5 % in specific themes (obsessive thoughts). The presence of subclinical OCD in migraine patients, and the link between progression to CM, particularly through MO, and OBS trait is still not well defined. The use of specific tools to assess this possible comorbidity should be encouraged in clinical and research settings. [ABSTRACT FROM AUTHOR]

Considering the great chapter of migraines, it is important to note the signs and symptoms caused by an alteration of the relationship of the facial musculature and the occlusal freeway space (FWS) that is the distance from maximal intercuspation to the habitual rest position (measurable in 1.4-2.5 mm). To any mandible position changing (detected by periodontal, muscle and joint proprioceptors), there is an influence on the neuromuscular system and then an alteration of the FWS. A group of 60 patients with chronic migraine (CM) underwent a withdrawal of overused medication and were subjected to electromyographic and kinesiographic evaluation. All those who presented an alteration of the FWS at rest position have been subjected to treatment with orthosis device for about 12 months. The aim of our work is to obtain and define a correct mandibular position, physiological, in agreement with the neuromuscular structures of the patient. Clinical results obtained on this pool of patients, in terms of reduction of the VAS, let us understand the importance of the inviolability of the FWS and to eliminate any type of mandibular deviation with respect to the closure trajectory induced by TENS in patients suffering from CM. [ABSTRACT FROM AUTHOR]

The aim of the present study was to investigate the possible relationships between the presence of headache-related photophobia and migraine-associated allodynia-a hallmark of central sensitization-among patients with different migraine types. A sample of 456 migraineurs was studied. Our results showed that photophobia was present in a high proportion of patients, with similar figures in patients with episodic migraine or CM, and confirmed that the prevalence of allodynia was higher among CM patients than in those with episodic migraine. We found a clear association between migraine-related allodynia and photophobia only in CM patients. Overall, these findings suggest that light stimulation may contribute to central sensitization of pain pathways in migraineurs, possibly contributing to progression into chronic forms. The possible connections underlying this type of sensitization is offered by the recently published data on a non-image-forming visual retino-thalamo-cortical pathway which may allow photic signals to converge on a thalamic region which is selectively activated during migraine headache. [ABSTRACT FROM AUTHOR]

Patients with chronic migraine (CM) and medication overuse (MO) have high frequency of psychiatric comorbidity. Aims of this open label, prospective, independent study were: to evaluate the efficacy of duloxetine in a sample of patients with MO due to CM and with concomitant depression; to investigate, if the presence of OCD influences the outcome in this subgroup of patients. A total of 50 consecutive patients (40 F,10 M, aged 20−65 years, mean 39.4 years) from those attending our Headache Center to undergo an inpatient withdrawal programme followed by anti-migraine prophylaxis was enrolled. After a 1-month baseline period, all patients were prescribed duloxetine 30 mg in the morning for the first week, and 60 mg for the following 12 weeks. They filled a daily headache diary during the whole study period. They also completed Hamilton depression rating scale (HDRS) and migraine disability assessment scale (MIDAS) at baseline and at the 12-week follow-up. The primary outcome measure was the percentage of responders, i.e. of patients with a reduction ≥50 % in headache frequency as well as in symptomatic drug consumption. Comparison between patients with and without OCD was performed. Our results showed a rather high responder rate in the total sample (64 %), while none of the patients with OCD fell among responders. MIDAS and HDRS scores had a more evident decrease in patients without OSD. These findings suggest that duloxetine may be effective in patients with MO due to CM and with comorbid depression. They also confirm the importance of a systematic assessment of the psychopathological profile in these patients, and indicate that clinicians should be aware of the relevant prognostic role of OCD in favoring a poor outcome and persistent disability in headache patients with MO. [ABSTRACT FROM AUTHOR]

Patients with chronic migraine (CM) and medication overuse (MO) have a high frequency of psychiatric comorbidity or psychopathological traits, the presence of which may have important implications for the course of the CM and the MO, both for response to treatment and possible relapses. Overuse of symptomatic drugs is regarded as one of the most important risk factor for the transformation of episodic migraine into CM and drug-seeking tendency due to fear of headache in chronic migraine patients shares with obsessive-compulsive disorder (OCD) the compulsive quality of the behavior. Aim of this study was to review the clinical history of a sample of CM patients with MO in which an obsessive-compulsive trait was identified, performing a comparison with a sample of patients without obsessive-compulsive trait. We selected 14 patients with positivity to Spectrum Project OBS (obsessive-compulsive disorder) questionnaire and other 14 patients with negativity to the same tool from among a sample of patients who were enrolled in a previous study on the psychopathological profile of patients suffering from CM with MO. According to data obtained from the clinical records referring to the previous 5 years, patients with OBS questionnaire positivity showed a worse clinical course and a tendency to early relapse in MO after symptomatic medication withdrawal. Our results show that the comorbidity of OCD should be always evaluated in patients with CM and MO as it may play a relevant role-particularly if not treated-among the risk factors favoring the progression of episodic migraine to the chronic form, and/or the tendency to a pathological behavior that prompts the overuse of symptomatic medications. [ABSTRACT FROM AUTHOR]