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BackgroundMedically intractable chronic migraine (CM) is a disabling illness characterized by headache ≥15 days per month.MethodsA multicenter, randomized, blinded, controlled feasibility study was conducted to obtain preliminary safety and efficacy data on occipital nerve stimulation (ONS) in CM. Eligible subjects received an occipital nerve block, and responders were randomized to adjustable stimulation (AS), preset stimulation (PS) or medical management (MM) groups.ResultsSeventy-five of 110 subjects were assigned to a treatment group; complete diary data were available for 66. A responder was defined as a subject who achieved a 50% or greater reduction in number of headache days per month or a three-point or greater reduction in average overall pain intensity compared with baseline. Three-month responder rates were 39% for AS, 6% for PS and 0% for MM. No unanticipated adverse device events occurred. Lead migration occurred in 12 of 51 (24%) subjects.ConclusionThe results of this feasibility study offer promise and should prompt further controlled studies of ONS in CM.

Opinion statementThe conceptual shift of our understanding of migraine from a vascular disorder to a brain disorder has dramatically altered the approach to the development of new medicines in the field. Current pharmacologic treatments of acute migraine consist of nonspecific and relatively specific agents. Migraine-specific drugs comprise two classes, the ergot alkaloid derivatives and the triptans, serotonin 5-HT(1B/1D) receptor agonists. The ergots, consisting of ergotamine and dihydroergotamine (DHE), are the oldest specific antimigraine drugs available and are considered relatively safe and effective. Ergotamine has been used less extensively because of its adverse effects; DHE is better tolerated. The triptan era, beginning in the 1990s, was a period of considerable change, although these medicines retained vasoconstrictor actions. New methods of delivering older drugs include orally inhaled DHE and the transdermal formulation of sumatriptan, both currently under study. Novel medicines being developed are targeted at neural sites of action. Serotonin 5-HT(1F) receptor agonists have proven effective in phase II studies and have no vascular actions. Calcitonin gene-related peptide (CGRP) receptor antagonists are another promising nonvasoconstrictor approach to treating acute migraine. Olcegepant (BIBN4096BS) and telcagepant (MK-0974) have been shown to be safe and effective in phase I, II, and (for telcagepant) phase III clinical trials. Other targets under investigation include glutamate (AMPA/kainate), TRPV1, prostanoid EP4, and nitric oxide synthase. With new neural targets and the potential for therapeutic advances, the next era of antimigraine medications is near.

Migraine headaches can be a disabling condition for patients. Fortunately, most patients can be successfully managed in the outpatient setting, however, there are a number of patients who may not respond to the abortive treatments that they have been prescribed. These patients often present to the emergency department (ED) for further assistance with the management of their condition. Migraines are the fourth most common cause of ED visits and are associated with an estimated annual cost of $17 billion in the United States. Familiarity with abortive treatments is critical for providers in the ED as are treatments, such as valproic acid, that may be considered in patients who do not respond to other treatment options. Many providers are more familiar with the role of valproic acid in the treatment of mood and seizure disorders, but its tolerability and the successes reported in the primary literature make it a reasonable consideration for patients with migraine who fail to respond to other therapies. This article briefly summarizes the therapies considered first line for abortive treatment in the setting of migraines and provides an overview of the primary literature describing the use of valproic acid in these patients. [ABSTRACT FROM AUTHOR]

Copyright of Timisoara Physical Education & Rehabilitation Journal is the property of Sciendo and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

There is evidence that the prevalence of migraine in children and adolescents may be increasing. Current theories of migraine pathophysiology in adults suggest activation of central cortical and brainstem pathways in conjunction with the peripheral trigeminovascular system, which ultimately results in release of neuropeptides, facilitation of central pain pathways, neurogenic inflammation surrounding peripheral vessels, and vasodilatation. Although several risk factors for frequent episodic, chronic, and refractory migraine have been identified, the causes of migraine progression are not known. Migraine pathophysiology has not been fully evaluated in children. In this review, we will first discuss the evidence that early therapeutic interventions in the child or adolescent new onset migraineur, may halt or limit progression and disability. We will then review the evidence suggesting that many adults with chronic or refractory migraine developed their migraine as children or adolescents and may not have been treated adequately with migraine-specific therapy. Finally, we will show that early, appropriate and optimal treatment of migraine during childhood and adolescence may result in disease modification and prevent progression of this disease.

The results of the randomized clinical trial entitled: Migraine Intervention with Starflex Technology (MIST), produced surprising and disappointing results on the effect of PFO closure to decrease migraine headaches. There have been allegations of misrepresentation of the effectiveness of this device. These issues have significant implications in how randomized clinical trials are performed that will impact current and future planned trials of PFO closure to treat migraine headaches.

The prevalence of migraine headaches (MH) is 12% in the general population and increases to 40% in patients with patent foramen ovale. This study evaluated the prevalence of MH in patients with congenital heart disease (CHD). Of 466 patients contacted from the UCLA Adult Congenital Heart Disease Center, 395 (85%) completed a questionnaire to determine the prevalence of MH. Patients were stratified by diagnosis of right-to-left, left-to-right, or no shunt. A group of 252 sex-matched patients with acquired cardiovascular disease served as controls. The prevalence of MH was 45% in adults with CHD compared to 11% in the controls (p50% reduction in headache days per month. In conclusion, the prevalence of MH in all groups of adults with CHD is 3 to 4 times more than a sex-matched control population, with increasing prevalence of MH in patients with no shunt, left-to-right, and right-to-left shunt. The higher than expected frequency of MH in patients with CHD without an intracardiac shunt, suggests additional mechanisms to explain the significant association with MH.

Hyperostosis frontalis interna (HFI) has been reported in older women, but reports in men are rare. We present a novel case of migraine headache in a gentleman with Klinefelter's syndrome and HFI, along with a discussion of possible pathophysiologic mechanisms underlying both the headache and the HFI.

The objective was to retrospectively characterise the efficacy of memantine as preventive therapy in a series of patients with frequent migraine. Patients in a university headache clinic completed a survey regarding their experience with memantine, and medical records were reviewed. All patients who received memantine as preventive therapy for migraine over a 15-month period were mailed surveys and consent forms for record review. Patients were treated with memantine beginning at a dose of 5 mg/day, increasing if needed by 5 mg/week up to 10 mg twice a day. The majority of patients (36 out of 54) treated with memantine for at least 2 months reported a significant reduction in estimated headache frequency, and improved function. Side effects were uncommon and generally mild. This limited retrospective case review suggests that memantine may be an effective preventive therapy for patients with frequent migraine. A prospective trial is warranted.

The interrelations of migraine and vertigo are complex, eluding a simple localization either centrally or peripherally. Spontaneous episodic vertigo, benign paroxysmal positional vertigo, and Meniere's disease all occur more frequently in patients with migraine than in those without. Family studies support a hereditary predisposition to migraine associated vertigo. In this review, we discuss definitions, epidemiology, associated syndromes, neurootological abnormalities, genetics and treatment for patients with migraine and vertigo.

Effective acute treatment of headache begins with making an accurate diagnosis and ruling out secondary causes of headache. Once a primary headache is diagnosed, it is important to choose the right combination of behavioural therapy and acute care (abortive and symptomatic) therapy for each patient. Some patients may need preventive medication on a daily basis. If patients overuse acute medications and develop medication overuse headache (previously called analgesic rebound headache), they often seek medical attention due to the chronicity and/or intensity of their pain and resultant disability. For acute care of migraine, physicians should choose a triptan they know and expect to work. They should prescribe the dose and route of administration that will provide the most rapid and complete response to all the associated symptoms of migraine, in addition to the pain. The effectiveness of the 7 available triptans in early, double-blind, controlled trials is more similar than different. How and when to give them will be discussed. Treatment of cluster headache will be presented briefly.

A 38-year-old man with a history of migraine headaches with aura and one episode of ischemic stroke was found to have a patent foramen ovale (PFO). After percutaneous closure with the nickel-containing Amplatzer PFO occluder, the patient developed pericarditis, atrial fibrillation, and increased migraine headaches with aura that abated with oral prednisone. He tested positive for nickel hypersensitivity, which we conclude is the likely etiology of his pericarditis.

The objective was to evaluate the presence of a positive family history (FH) of vascular risk factors between patients with migraine with aura (MA) and migraine without aura (MO), and in chronic migraine (CM) compared to other headache types. As migraine patients are typically too young to have developed vascular events, studying older relatives of migraine patients may be a practical means of evaluating associations between vascular risk factors and migraine. A cross-sectional study of a clinic-based sample of adults with migraine headache was carried out at the University of Utah. Predictor variables comprised first or second degree relatives with stroke, hypertension, diabetes or hypercholesterolaemia. Outcome measures comprised diagnosis of MA, MO or CM according to the revised International Headache Society criteria. There was no significant difference in FH of vascular risk factors in MA compared to MO (adjusted OR 1.04, 95% CI 0.61-1.78). CM was associated with a decreased risk of FH of stroke (OR=0.11, 95% CI 0.02-0.87, p=0.036). There was no significant difference in FH of vascular risk factors in MA patients compared to MO. CM patients were more likely to have a negative FH of stroke compared to other headache types, suggesting that CM is likely a neuronal disease rather than a vascular one.

The social perception of headache, everywhere at low levels in industrialised countries, becomes totally absent in developing ones. Headache disorders came into the World Health Organization's strategic priorities after publication of the 2001 World Health Report. Among the leading causes of disability, migraine was ranked 19th for adults of both sexes together and 12th for females. The Global Campaign (GC) to Reduce the Burden of Headache Worldwide was planned by the major international headache organizations together with WHO in order to identify and remove those cultural, social and educational barriers recognised as responsible factors for the inadequate treatment of headache disorders worldwide. Within the GC activities, the education of the medical body will represents a central pillar. An International Team for Specialist Education (ITSE) has been created to train physicians from all over the world through the acquisition of a university level Master Degree in Headache Medicine. Once trained as headache specialists, physicians will become trainers, offering education in this field to other health care providers in their own countries. In this way they will give life to a cultural chain raising awareness locally of headache, its burden and its medical control.

ObjectivesTo examine the relationship between patent foramen ovale (PFO) or atrial septal defect (ASD) with the incidence of migraine headache (MHA) and assess whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA.BackgroundMigraine headache is present in 12% of adults and has been associated with interatrial communications. This study examined the relationship between PFO or ASD with the incidence of MHA and assessed whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA.MethodsA sample of 89 (66 PFO/23 ASD) adult patients underwent transcatheter closure of an interatrial communication using the CardioSEAL (n = 22), Amplatzer PFO (n = 43), or the Amplatzer ASD (n = 24) device.ResultsBefore the procedure, MHA was present in 42% of patients (45% of patients with PFO and 30% of patients with ASD). At three months after the procedure, MHA disappeared completely in 75% of patients with MHA and aura and in 31% of patients with MHA without aura. Of the remaining patients, 40% had significant improvement (>or=2 grades by the Migraine Disability Assessment Questionnaire) of MHA.ConclusionsTranscatheter closure of PFO or ASD results in complete resolution of MHA in 60% of patients (75% of patients with migraine and aura) and improvement in symptoms in 40% of the remaining patients. Interatrial communications may play a role in the etiology of MHA either through paradoxic embolism or humoral factors that escape degradation in bypassing the pulmonary circulation. A randomized trial is needed to determine whether transcatheter closure of interatrial shunts is an effective treatment for MHA.

Gene mutations within the P/Q type neuronal calcium channel in familial hemiplegic migraine (FHM) suggest a therapeutic role for calcium-channel blockade. The authors have previously reported abortive therapy of FHM with IV verapamil. Here the authors describe four cases of sporadic hemiplegic migraine (SHM) responsive to verapamil, administered either orally or IV. The findings indicate that verapamil is effective therapy for both SHM and FHM.

David R Spiegel, Justin Smith, Ryan R Wade, Nithya Cherukuru, Aneel Ursani, Yuliya Dobruskina, Taylor Crist, Robert F Busch, Rahim M Dhanani, Nicholas Dreyer Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA, USA Abstract: Transient global amnesia (TGA) is a clinical syndrome characterized by the sudden onset of an extraordinarily large reduction of anterograde and a somewhat milder reduction of retrograde episodic long-term memory. Additionally, executive functions are described as diminished. Although it is suggested that various factors, such as migraine, focal ischemia, venous flow abnormalities, and epileptic phenomena, are involved in the pathophysiology and differential diagnosis of TGA, the factors triggering the emergence of these lesions are still elusive. Recent data suggest that the vulnerability of CA1 neurons to metabolic stress plays a pivotal part in the pathophysiological cascade, leading to an impairment of hippocampal function during TGA. In this review, we discuss clinical aspects, new imaging findings, and recent clinical–epidemiological data with regard to the phenotype, functional anatomy, and putative cellular mechanisms of TGA. Keywords: transient global amnesia, vascular, migraines, psychiatric

Pituitary apoplexy is a result of rapid enlargement of the pituitary, due to episodes of hyperplasia, which outpaces vascular development resulting in ischemia and potential infarction of pituitary tissue. This can present in several different ways from asymptomatic to hormonal deficiencies. Here we present a case of spontaneous reduction of a non-functioning pituitary mass, likely due to apoplexy, in which the mass went from compromising the optic chiasm to complete reduction and relief of the optic chiasm. The infarction happened spontaneously without treatment and complications. This may encourage future conservative management of pituitary tumors, rather than immediate surgical intervention., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mullins et al.)

Copyright of Revista Odontología Vital is the property of Universidad Latina de Costa Rica and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Revista Odontología Vital is the property of Universidad Latina de Costa Rica and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Psychological inflexibility is a multifaceted construct reflecting a rigid dominance of psychological reactions over chosen values and contingencies in guiding action. Psychological inflexibility has been related to depressive and anxiety symptoms and has been studied as a target of treatment for different forms of psychopathology. This construct, however, remains understudied among some at-risk groups. To close this gap in knowledge, the current study examined cross-sectional relations between psychological inflexibility and (1) symptoms of depression among adults with migraines (n = 2936) and (2) symptoms of anxiety and depression among adults at-risk for cardiovascular disease (n = 921). Results indicate that psychological inflexibility significantly related to depressive and anxiety symptoms among these populations. Results are discussed in terms of treatment implications for such persons. • Nearly half of the US population has a chronic medical condition. • Depression and anxiety are common among patients with chronic medical conditions. • Psychological inflexibility is significantly related to depressive symptoms in migraineurs. • Psychological inflexibility is significantly related to distress in patients with cardiovascular disease risk. [ABSTRACT FROM AUTHOR]

Headache is a common finding in the postpartum period, caused by a spectrum of different conditions. Most headaches in the postpartum period are self-limiting and benign in etiology, but there are some potentially serious causes to be considered. We disclose two cases of postpartum headache, initially considered as post-dural puncture headache (PDPH), that evolved into a harmful condition and showed that an expanded differential diagnosis for headache in the postpartum is mandatory, requiring a high level of attention from health professionals. In fact, a careful examination of the medical history, physical examination, and the recognition for the need for early neuroradiological imaging should increase diagnostic accuracy.

Fragranced consumer products—such as air fresheners, cleaning supplies, and personal care products— pervade society. This study investigated the occurrence and types of adverse effects associated with exposure to fragranced products in Australia, and opportunities for prevention. Data were collected in June 2016 using an on-line survey with a representative national sample (n = 1098). Overall, 33% of Australians report health problems, such as migraine headaches and asthma attacks, when exposed to fragranced products. Of these health effects, more than half (17.1%) could be considered disabling under the Australian Disability Discrimination Act. Additionally, 7.7% of Australians have lost workdays or a job due to illness from fragranced product exposure in the workplace, 16.4% reported health problems when exposed to air fresheners or deodorizers, 15.3% from being in a room after it was cleaned with scented products, and 16.7% would enter but then leave a business as quickly as possible due to fragranced products. About twice as many respondents would prefer that workplaces, health care facilities and professionals, hotels, and airplanes were fragrance-free rather than fragranced. While 73.7% were not aware that fragranced products, even ones called green and organic, emitted hazardous air pollutants, 56.3% would not continue to use a product if they knew it did. This is the first study in Australia to assess the extent of adverse effects associated with exposure to common fragranced products. It provides compelling evidence for the importance and value of reducing fragranced product exposure in order to reduce and prevent adverse health effects and costs.

Migraine is a common neurological disorder that significantly impacts patients around the world. In the United States, one in six individuals suffers from a migraine disorder. Despite its high prevalence, the etiology of migraine is not well understood. Multiple factors likely contribute to the development of both acute and chronic migraine, making the consensus as to the cause and treatment difficult. Presented here are three case studies involving adult males suffering from chronic migraine. Each subject provided a medical history and underwent physical, psychological, and neurological examinations. In addition, relevant bloodwork and cervical spine X-rays were obtained. Physical examination, laboratory studies, imaging, and psychological metrics were unremarkable with the notable exception of the three-hour oral glucose tolerance tests. All three patients displayed hypoglycemia at three hours. Furthermore, their symptoms markedly improved with the initiation of a ketogenic diet. These data are suggestive of a potential link between postprandial hypoglycemia and chronic migraine. Despite the small sample size, we feel that this report presents possible evidence for a connection between postprandial hypoglycemia and chronic migraine. Furthermore, properly controlled studies of larger sample sizes are required, but we suggest that clinicians consider screening patients for this easily overlooked metabolic disturbance, especially in the absence of other options., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Amendolara et al.)

Background: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. Methods: Through a retrospective records review, we identified patients with a well‐established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1–10 Likert scale, both before and 30 minutes after the injection. Results: Eighty‐eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= −6 to −3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001). Conclusion: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk. [ABSTRACT FROM AUTHOR]

Background/objective: Headaches present commonly in general practice, and doctors face uncertainties and pressures in dealing with them. This study identifies key characteristics of headaches investigated through head imaging, in the hope of strengthening existing guidelines.Method: A 7-year retrospective analysis of head imaging scans ordered for investigating headaches among patients aged ≥18 in an Australian general practice setting.Results: A total of 109 of the 517 (21.1%) patients required head imaging, although 14 (2.7%) of these had repeat scans. Three-quarters were females, and most of the headaches were recurrent (56.9%), severe (62.4%) or had associated red flags (78.0%). Computed tomography (CT) and magnetic resonance imaging (MRI) were the only scans adopted (4:1 and 1:1 for first and repeat scans, respectively). Twelve (11.0%) scans had findings likely to explain the headaches after the initial scans, with no difference in findings between diagnoses from CTs and MRIs (P = 0.41). Repeat scans offered no additional benefits, and roughly one in three patients were referred to third-party carers (mostly neurologists). Females had more recurrent headaches (OR = 2.63; CI = 1.09-6.35; P = 0.03). Patients with psycho-morbidities were less likely to have scan findings that explained their headaches (OR = 0.22; CI = 0.06-0.88; P = 0.03), and, though not quite significant, were also more likely to undergo imaging (OR = 1.47; CI 0.96-2.27; P = 0.08).Conclusion: Significant intracranial findings were uncommon following imaging for headaches, and MRIs offer no advantages over CTs. Repeating head scans within 5 years offers no clear benefits. Psycho-morbidities should be considered when deciding the imaging needs, given the lesser chance of findings. Larger studies will help validate these findings. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence and experience of migraines in adolescents with surgically confirmed endometriosis compared with those without endometriosis.Design: Cross-sectional study conducted within The Women's Health Study: From Adolescence to Adulthood-an ongoing longitudinal cohort.Setting: Boston Center for Endometriosis.Patient(s): Adolescent females enrolled November 2012 through November 2016. The case group included adolescents surgically diagnosed with endometriosis. The control group included adolescents without endometriosis, recruited from the local community and clinics.Intervention(s): Not available.Main Outcome Measure(s): An extensive online health questionnaire regarding medical history, lifestyle, medication use, anthropometrics, and symptom experience and treatments. Migraine diagnosis was self-reported. Migraine pain and noncyclic pelvic pain severity were rated using an 11-point numerical rating scale. Cyclic pelvic pain was categorized.Result(s): Adolescents with endometriosis were more likely to experience migraines (69.3%) than those without endometriosis (30.7%) (multivariable odds ratio = 4.77, 95% confidence interval 2.53, 9.02). For each 1-point increase in the migraine numerical rating scale, the odds of endometriosis increased by 22% (multivariable odds ratio = 1.22, 95% confidence interval 1.03, 1.44; Ptrend = .02). Among those with endometriosis, age of menarche was associated inversely with the odds of migraines. Participants with endometriosis and migraines have more dysmenorrhea than those without migraines.Conclusion(s): Adolescents with endometriosis are more likely to experience migraines than adolescents without endometriosis. A linear relationship exists between migraine pain severity and the odds of endometriosis, suggesting heightened pain sensitivity for adolescents with endometriosis. Due to the strong correlation, patients who present with either condition should be screened for comorbidity to maximize the benefits of care. [ABSTRACT FROM AUTHOR]

The case of a 24-year-old male with complaints of migraine headaches was referred for echocardiography. The rest of medical history was unremarkable. Agitated saline contrast bubble study showed evidence of a right to left intracardiac shunt, probably secondary to a patent foramen ovale. Results of a transesophageal echocardiogram suggested the possibility of an anomalous venous circulation and eventually identified as anomalous left-sided superior vena cava with cardiac magnetic resonance imaging.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare delayed complication of cerebral radiation therapy. A 53-year-old female initially presented with headache, confusion and left homonymous hemianopia. Her medical history was notable for cerebellar hemangioblastoma, which was treated with radiation in 1987. Her initial brain MRI (magnetic resonance imaging) revealed cortical enhancement in the right temporo-parieto-occipital region. She improved spontaneously in 2 weeks and follow-up scan at 4 weeks revealed no residual enhancement or encephalomalacia. She presented 6 weeks later with aphasia. Her MRI brain revealed similar contrast-enhancing cortical lesion but on the left side. Repeat CSF studies was again negative other than elevated protein. She was treated conservatively and recovered completely within a week. Before diagnosing SMART syndrome, it is important to rule out tumor recurrence, encephalitis, posterior reversible encephalopathy syndrome (PRES) and stroke. Typically the condition is self-limiting, and gradually resolves.

Takotsubo syndrome (TS) describes a transient type of dilated cardiomyopathy that mimics acute coronary syndrome (ACS) on initial presentation. Classic TS presents with marked dilation and ballooning of the left ventricular apex with hyperdynamic basal segments. The most frequent etiology is from emotional and stressful triggers; recently, evidence suggests neurologic and psychiatric involvement. There are increasing reports of TS occurring secondary to migraine abortives. We describe a unique case of TS in a woman after taking sumatriptan to abort her headache., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Valentine et al.)

The presence of cataplexy in people with narcolepsy has a well-documented tight association with very low or non-detectable levels of the central nervous system neuropeptide, hypocretin (also termed orexin) while levels of hypocretin are normal in people with narcolepsy without cataplexy. There is evidence to suggest that hypocretin may have an association with pain, migraines and headaches in people with narcolepsy. However, these studies have not compared findings across narcolepsy with and without cataplexy. Currently, there are no studies published to determine whether pain, migraines and headaches are just common symptoms experienced by all people with narcolepsy or whether the presence of the cataplexy symptom (and thus assumed low levels of hypocretin) exacerbates these symptoms. Also, it is unclear whether general health and wellbeing (including psychological wellbeing) is similarly affected by hypocretin levels, or may be confounded by different levels of other health symptoms, such as pain. This review poses a number of research questions that need to be explored about whether the presence or absence of cataplexy is differentially associated with different types, severity and location of chronic pain; frequency, location and types of migraines and headaches; and general health and wellbeing among people with narcolepsy. A greater understanding of the role of hypocretin in these health complaints could aid in the development of more appropriate treatments for pain, migraines and headaches amongst people with and without narcolepsy.

ABSTRACT Nitrates, such as cardiac therapeutics and food additives, are common headache triggers, with nitric oxide playing an important role. Facultative anaerobic bacteria in the oral cavity may contribute migraine-triggering levels of nitric oxide through the salivary nitrate-nitrite-nitric oxide pathway. Using high-throughput sequencing technologies, we detected observable and significantly higher abundances of nitrate, nitrite, and nitric oxide reductase genes in migraineurs versus nonmigraineurs in samples collected from the oral cavity and a slight but significant difference in fecal samples. IMPORTANCE Recent work has demonstrated a potentially symbiotic relationship between oral commensal bacteria and humans through the salivary nitrate-nitrite-nitric oxide pathway (C. Duncan et al., Nat Med 1:546–551, 1995, http://dx.doi.org/10.1038/nm0695-546 ). Oral nitrate-reducing bacteria contribute physiologically relevant levels of nitrite and nitric oxide to the human host that may have positive downstream effects on cardiovascular health (V. Kapil et al., Free Radic Biol Med 55:93–100, 2013, http://dx.doi.org/10.1016/j.freeradbiomed.2012.11.013 ). In the work presented here, we used 16S rRNA Illumina sequencing to determine whether a connection exists between oral nitrate-reducing bacteria, nitrates for cardiovascular disease, and migraines, which are a common side effect of nitrate medications (U. Thadani and T. Rodgers, Expert Opin Drug Saf 5:667–674, 2006, http://dx.doi.org/10.1517/14740338.5.5.667 ).