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Ángel Luis Guerrero-Peral,1 Jesús Porta-Etessam,2 Jaime Rodríguez-Vico,3 Mercedes Núñez,4 Antonio Ciudad,4 Silvia Díaz-Cerezo,4 Carla Garí-Peris,5 Francisco Javier Pérez-Sádaba,5 Luis Lizán,5 Sonia Santos-Lasaosa6 1Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; 2Neurology Department, Hospital Clínico San Carlos, Madrid, Spain; 3Neurology Department, Fundación Jimenez Diaz, Madrid, Spain; 4Medical Department, Eli Lilly, Madrid, Spain; 5Outcomes’ 10, Castellón, Spain; 6Neurology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, SpainCorrespondence: Mercedes Núñez, Eli Lilly, Av. de la Industria, 30, Alcobendas, Madrid, 28108, Spain, Tel +34 647447827, Email nunez_mercedes@lilly.comPurpose: We aimed to validate the Spanish version of the Decisional Conflict Scale (DCS) and analyze its psychometric properties in people with migraine.Patients and Methods: The DCS validation comprised two phases. First, a translation and cross-cultural adaptation following the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Good Practices: 1-preparation, 2-independent forward translation, 3-reconciliation, 4-back-translation, 5-harmonization, 6-clinical review, and 7-content validation in a group of migraine patients. Second, the analysis of the psychometric properties. The reliability or internal consistency of the DCS scale and subscales was assessed using Cronbach’s α value. The item-subscale correlation was also evaluated. A floor and ceiling effects for DCS score was considered when at least 15% of respondents obtained DCS > 90 (ceiling) or < 10 (floor). The construct validity was studied through the correlation between the DCS subscales and by the correlation between the DCS and other questionnaires (Decision Self-Efficacy Scale [DSES] and 9-item Shared Decision-Making [SDM-Q-9]). Spearman’s coefficients were estimated for the correlations.Results: The cross-cultural adaptation was conducted on 17 patients who completed the questionnaire in a mean of 2.4 ± 1.1 minutes. Generally, more than 75% of them considered that DCS items were adequate, easy to understand, and relevant. The psychometric properties were evaluated in a sample of n=128 patients. Accordingly, the internal consistency of DCS was high, with a Cronbach’s α of 0.97 for the scale and between 0.87 to 0.96 for subscales. Also, a slight floor effect was observed, with 24.2% of patients having DCS scores < 10. The correlation between subscales exceeded Spearman’s coefficient of 0.7. Whereas the correlation between the DCS and the other questionnaires was generally moderate (Spearman’s coefficient > 0.4).Conclusion: The Spanish version (Spain) of the DCS has very acceptable psychometric properties (reliability and construct validity) and good potential for assessing decisional conflicts among migraine patients.Keywords: migraine, decision-making, decisional conflict scale, psychometric properties, adaptation, Spanish

Introduction: Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding. Development: This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding. Conclusions: We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients., Introducción: La cefalea es uno de los motivos de consulta más comunes en neurología, siendo más frecuente durante la edad reproductiva. Por ello, es habitual encontrar en nuestras consultas pacientes embarazadas o en periodo de lactancia con dicha queja. Es importante conocer las opciones farmacológicas más seguras, cuáles no se deben emplear, así como cuándo sospechar cefaleas secundarias. Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología ha elaborado una guía con las recomendaciones consensuadas acerca de los algoritmos diagnósticos y terapéuticos que se deben emplear durante el embarazo y la lactancia

Background To evaluate whether preventive treatment can modify endothelial function and the oxidative stress profile of patients with migraines. Methods 88 treatment-naïve patients with migraines and 56 healthy sex/age matched controls underwent ultrasonography exams and blood tests at baseline, and again in the migraine patients after 3 months’ treatment with metoprolol or topiramate. Biomarkers for endothelial function and oxidative stress were analyzed. Results At baseline, patients with migraines had higher C-reactive protein (CRP; 2.55 vs. 1.64 mg/dL; p = 0.025) and lower high-density lipoprotein (HDL) cholesterol (61.7 vs. 66.8 mg/dL; p = 0.048), nitrate (19.4 vs. 27.3 µM; p = 0.037), and isoprostane levels (181 vs. 238 µM; p = 0.036) than matched controls. After treatment biomarker levels improved in patients with migraine, including CRP (2.55 mg/dL at baseline vs. 1.75 mg/dL at 3 months; p = 0.045); HDL cholesterol levels were the exception (significantly decreased). Treatment responders (> 50% reduction from baseline in migraine frequency) had higher nitrate (24.2 vs. 13.8 µM; p = 0.022) and nitrite levels (10.4 vs. 3.4 µM; p = 0.002) than non-responders after treatment. Conclusion Patients with migraines exhibit endothelial and oxidative dysfunction, which can be modified with prophylactic therapy.

Resumen: Introducción: La cefalea es un motivo de consulta frecuente en atención primaria (AP), sin embargo, se trata de una patología infradiagnosticada e infratratada. Uno de los posibles factores es la falta de formación de los profesionales de AP en cefaleas. Métodos: Estudio descriptivo transversal mediante encuesta autoadministrada a los médicos de AP de nuestro sector sanitario. Se recogieron variables sociodemográficas, variables relacionadas con la formación previa en neurología y cefaleas y variables en relación con sus necesidades formativas. Resultados: Completaron la encuesta 104 médicos de AP, de los cuales el 53% fueron mujeres y la edad media fue 49 años. La mayoría de los encuestados trabajan en un centro de salud urbano (42,3%) y se han formado vía MIR (77,9%). El 65,4% dedica más tiempo a una consulta de cefaleas que a otras consultas y solo un 32,7% utiliza la Clasificación Internacional de Cefaleas. El 68,3% declara tener un interés alto o muy alto en cefaleas y al 75,9% le gustaría mejorar su formación, eligiendo cursos teórico-prácticos y ponencias de actualización como la herramienta más útil. Un 90% utiliza triptanes en su práctica clínica diaria y el 78% emplea tratamientos preventivos. El fármaco más utilizado es amitriptilina y solo un 22,1% elige topiramato. Conclusiones: Los profesionales de AP están en contacto constante con pacientes con cefaleas y muestran interés en la formación en esta patología, lo que podría ayudarnos a diseñar programas docentes dirigidos a mejorar la calidad asistencial en este ámbito. Abstract: Introduction: Headache is a frequent reason for consultation with primary care (PC) physicians. However, the condition is underdiagnosed and undertreated. One reason for this may be the lack of specific training on headache in PC. Methods: We conducted a descriptive cross-sectional study of data gathered with a self-administered survey that was completed by PC physicians from our health district. We collected sociodemographic data and information on previous training in neurology and headache, and training needs. Results: The survey was completed by 104 PC physicians, 53% of whom were women; mean age was 49 years. Most respondents worked in urban settings (42.3%) and had been trained via residency (77.9%). Although 65.4% spent more time with patients with headache than with other patients, only 32.7% used the International Classification of Headache Disorders. In our sample, 68.3% of respondents reported a high or very high interest in headache, and 75.9% wished to receive further training on the condition; theoretical and practical courses and update lectures were regarded as the most useful tools. In clinical practice, 90% used triptans and 78% used preventive treatments. The most frequently used drug was amitriptyline; only 22.1% choose topiramate. Conclusions: PC physicians are in frequent contact with patients with headache and show interest in receiving training on this condition. This could be helpful in designing training programmes aimed at improving quality of care in this area.

Background Face-to-face procedures have been postponed during COVID-19 pandemic. We aim to evaluate the impact of onabotulinumtoxinA follow-up delay in migraine during COVID-19 pandemic. Methods Subjective worsening, intensity of migraine attacks, and frequency of headache and migraine were retrospectively compared between patients with unmodified and interrupted onabotulinumtoxinA follow-up in Headache Units. Results We included 67 patients with chronic migraine or high-frequency episodic migraine under onabotulinumtoxinA treatment, 65 (97.0%) female, 44.5 ± 12.1 years old. Treatment administration was voluntarily delayed in 14 (20.9%) patients and nine (13.4%) were unable to continue follow-up. Patients with uninterrupted follow-up during lockdown presented 7.6 and 8.1 less monthly days with headache (adjusted p = 0.017) and migraine attacks (adjusted p = 0.009) compared to patients whose follow-up was interrupted, respectively. Conclusion Involuntary delay of onabotulinumtoxinA follow-up in patients with migraine due to COVID-19 pandemic was associated with a higher frequency of headache and migraine attacks. Safe administration of onabotulinumtoxinA during lockdown should be promoted. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05180-8.

To assess the characteristics of the management of patients with migraine who present to the emergency department (ED) with a migraine attack. Retrospective, observational study analyzing demographic, clinical, diagnostic and therapeutic characteristics of patients with migraine diagnosis presenting to ED for a migraine attack between 2016 and 2019. We reviewed the clinical records of 847 cases. 82.2% were women with mean age of 34.9 years. 87.2% had episodic migraine and 12.2% chronic migraine. 62.3% (528/847) had taken analgesics before visiting the ED [non-steroidal-anti-inflammatory drugs (NSAIDs) (300/528; 56.9%) and triptans (261/528; 49.5%)]. 25.4% (215/847) received blood testing and 6.4% (55/847) received cranial CT. Medication was administered in 77.2% cases (654/847). The median time-to-treatment was 70 min (IQR 42-120). NSAIDs (81%, 530/654), antiemetics (43.1%, 282/654) and metamizole (39% 255/654) were the most used. Triptans were administered in 7 cases (1.1%) and opioids in 84 (12.8%). At discharge, preventive treatment was prescribed or modified in 8.2% of cases (69/839) and triptans were prescribed in 129 cases (15.3%). 70.5% (592/839) were instructed to follow-up with their primary care provider (PCP), 21.5% (181/839) with a general neurologist and 7.9% (66/839) with a headache specialist. The majority of migraine patients were not receiving the recommended acute migraine-specific medication, both in the outpatient and in the ED setting, being especially remarkable the rare use of triptans in the ED. Furthermore, we found an elevated use of urgent complementary tests, mainly blood tests.

Neuromodulación; Estimulación; Migraña Neuromodulació; Estimulació; Migranya Neuromodulation; Stimulation; Migraine Introducción En los últimos años han surgido numerosos dispositivos de neuromodulación, invasivos y no invasivos, que se han aplicado en pacientes con cefaleas y neuralgias sin que exista una revisión actualizada de su eficacia y seguridad, ni recomendaciones de ninguna institución sanitaria sobre su uso específico en cada entidad nosológica. Métodos Neurólogos del Grupo de Cefaleas de la Sociedad Española de Neurología (SEN) y neurocirujanos expertos en neurocirugía funcional seleccionados por la Sociedad Española de Neurocirugía (SENEC), hemos realizado una revisión exhaustiva en el sistema Medline sobre neuromodulación en cefaleas y neuralgias. Resultados Presentamos una revisión actualizada y establecemos por primera vez unas recomendaciones consensuadas entre la SEN y la SENEC sobre el uso de la neuromodulación en cefaleas y neuralgias, adjudicando niveles de evidencia sobre su eficacia actual, específicamente en cada entidad nosológica. Conclusiones Los resultados actuales de los estudios proporcionan evidencias para la indicación de técnicas de neuromodulación en casos refractarios de cefaleas y neuralgias (sobre todo en migraña, cefalea en racimos y neuralgia del trigémino), seleccionados por neurólogos expertos en cefaleas, tras comprobar el agotamiento de las opciones farmacológicas. Adicionalmente, en el caso de la neuromodulación invasiva, se recomienda que los casos sean debatidos en comités multidisciplinarios y la cirugía sea realizada por equipos de neurocirujanos expertos en neurocirugía funcional y con una morbimortalidad aceptable. Introduction Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions. Methods Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia. Results We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition. Conclusions Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality. Esta guía no ha recibido ningún tipo de financiación pública ni privada.

Abiotrophia defectiva is a rare cause of endocarditis with a high embolization rate compared to other streptococcal endocarditis. Neurological complications may occur in 20-40% of cases, and include intracranial aneurysms and sub-arachnoid hemorrhage. Its isolation in the central nervous system (CNS) is extremely rare and is associated with previous neurosurgical procedures. We present the case of a 51-year-old patient who suffered an ischemic stroke as a complication of A. defectiva endocarditis, and the cases of CNS infections caused by this microorganism are reviewed. The relevance of the case lies in its singular character, due to the absence of previous valve disease in the patient without a recent history of invasive procedures or surgical interventions.

Introduction: When secondary headache is suspected and the patient is referred to the emergency department or to the outpatient neurology clinic, it is important to know which are the appropriate complementary examinations to perform and the suitable referral pathway for patients to follow.In order to establish recommendations on this matter, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to issue a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgias. Development: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with GECSEN's Executive Committee. For practical reasons, the document was divided into 2 articles: the first focuses on primary headaches and craniofacial neuralgias and this second article on secondary headaches and other craniofacial pain. In order for the recommendations to be helpful for daily practice, they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. Conclusions: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment. Resumen: Introducción: Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante sabre qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente.Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y qué circuitos seguir para así evitar la duplicación de consultas y retrasos en el diagnóstico y en el tratamiento.

Introducción: Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente. Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GEC-SEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitar la duplicación de consultas y retrasos en el diagnóstico y en el tratamiento, Introduction: When secondary headache is suspected and the patient is referred to the emergency department or to the outpatient neurology clinic, it is important to know which arethe appropriate complementary examinations to perform and the suitable referral pathway forpatients to follow.In order to establish recommendations on this matter, the Spanish Society of Neurology’sHeadache Study Group (GECSEN) has decided to issue a series of agreed recommendationsconstituting a referral protocol for patients with headache and/or craniofacial neuralgias. Development: Young neurologists with an interest and experience in headache were invitedto draft a series of practical guidelines in collaboration with GECSEN’s Executive Committee.For practical reasons, the document was divided into 2 articles: the first focuses on primaryheadaches and craniofacial neuralgias and this second article on secondary headaches and othercraniofacial pain. In order for the recommendations to be helpful for daily practice, they followa practical approach, with tables summarising referral criteria, examinations to be performed,and referral to other specialists.Conclusions: We hope to offer a guide and tools to improve decision-making regarding patientswith headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.

Introducción La infección por SARS-CoV-2 y la situación de pandemia hacen necesario un cambio en nuestra práctica clínica, en relación con la adopción de nuevas estrategias que permitan la asistencia integral de los pacientes con cefalea y neuralgia. Material y métodos Ante la elevada capacidad de transmisión del virus, determinados procedimientos, como la infiltración de onabotulinumtoxinA y la realización de bloqueos anestésicos, deben realizarse adoptando medidas que garanticen un nivel adecuado de seguridad. Resultados Nuestro objetivo es presentar una serie de recomendaciones basadas en las medidas establecidas por nuestro sistema sanitario para evitar el contagio. Diferenciaremos entre aquellas medidas relacionadas con el paciente y el facultativo, con la técnica, con la infraestructura (sala de espera y consulta) y con la gestión asistencial. Introduction: The COVID-19 pandemic has given rise to the need for changes in clinical practice, with new strategies to enable integrated care for patients with headache and neuralgia. Material and methods: Given the high spreadability of SARS-CoV-2, new safety measures are required in such procedures as onabotulinumtoxinA infiltration and nerve blocks. Results: We present a series of recommendations based on the measures implemented to prevent infection in our healthcare system. We differentiate between measures related to patients and physicians, to technique, to infrastructure (waiting room and consultation), and to healthcare management.

Studies evaluating sensory function of the entire trigeminocervical region in patients with cluster headache (CH), migraine (MH), and tension-type headache (TH) are required. The purpose of the present study was to evaluate and compare sensory function in the trigeminocervical region in patients with CH, MH, and TH and healthy controls (HC).Quantitative sensory testing (QST), including pressure pain threshold (PPT), tactile detection threshold (TDT), prick detection threshold (PDT), and two-point detection threshold (2PDT), was evaluated in 139 patients with headache (CH = 16, MH = 52, TH = 71) and 30 HC. Test sites included bilaterally the first, second, and third divisions of trigeminal nerve (V1, V2, and V3), cervical spine, and thenar eminence.TH presented significantly lower PPT values compared with CH (p 0.015), MH (p 0.048), and HC (p 0.009), while MH demonstrated significantly lower values than HC (p = 0.001-0.023). When analyzing TDT, CH in the symptomatic side presented significantly higher values in V1 compared with MH (p = 0.001), TH (p 0.001), and HC (p 0.001) and in V2 compared with TH (p = 0.035). No statistically significant differences were found for PDT (p 0.005). With regard to 2PDT, CH-s presented significantly higher values in V1 with respect to HC (p = 0.016) but lower values in V2 compared with MH (p 0.001) and TH (p = 0.003).The results of the present study indicate specific and different altered mechanical sensory thresholds in CH, MH, and TH patients compared with HC subjects.

Introduction: When a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential, or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected.In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. Development: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with the Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. Conclusions: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment. Resumen: Introducción: Cuando tras una correcta anamnesis y exploración neurológica se diagnostica a un paciente con una cefalea primaria o una neuralgia craneofacial en urgencias o atención primaria y se decide derivar a neurología por complejidad es útil conocer si además se deberían solicitar exploraciones complementarias y la preferencia (urgente, preferente o normal) con la que se debería derivar para que el paciente llegue a la consulta del neurólogo sin demoras innecesarias en pacientes con dolores incapacitantes o con sospecha de organicidad.Por este motivo, el Grupo de Estudio de Cefalea de la Sociedad Española de Neurología, ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología que han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. Esta primera centrada en las cefaleas o neuralgias craneofaciales primarias y una segunda que se focaliza en las cefaleas secundarias. El enfoque es práctico con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea, valorando exploraciones a priorizar y qué circuitos seguir para así evitar la duplicación de consultas y retrasos en el diagnóstico y en el tratamiento.

Resumen: Introducción: Cuando tras una correcta anamnesis y exploración neurológica se diagnostica a un paciente con una cefalea primaria o una neuralgia craneofacial en urgencias o atención primaria y se decide derivar a neurología por complejidad es útil conocer si además se deberían solicitar exploraciones complementarias y la preferencia (urgente, preferente o normal) con la que se debería derivar para que el paciente llegue a la consulta del neurólogo sin demoras innecesarias en pacientes con dolores incapacitantes o con sospecha de organicidad.Por este motivo, el Grupo de Estudio de Cefalea de la Sociedad Española de Neurología, ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología que han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. Esta primera centrada en las cefaleas o neuralgias craneofaciales primarias y una segunda que se focaliza en las cefaleas secundarias. El enfoque es práctico con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea, valorando exploraciones a priorizar y qué circuitos seguir para así evitar la duplicación de consultas y retrasos en el diagnóstico y en el tratamiento. Abstract: Introduction: When a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care, and is referred to a neurologist due to the complexity of the case, it is useful to know whether additional examination should be sought and the priority (urgent, preferential or normal) with which the patient should be seen. This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected.In order to issue recommendations on this matter, the Spanish Society of Neurology's Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgia. Development: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with Spanish Society of Neurology's Headache Study Group Executive Committee. For practical reasons, the document was divided into 2 articles: this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches. In order for the recommendations to be helpful for daily practice they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. Conclusions: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment. Palabras clave: Cefalea, Neuralgia, Atención primaria, Urgencias, Pruebas complementarias, Derivación, Keywords: Headache, Neuralgia, Primary care, Emergency department, Complementary test, Patient referral

Background The prevalence of cardiac cephalalgia is unknown and there is limited information about its clinical features. We aimed to assess the prevalence of cardiac cephalalgia, its clinical characteristics and associated factors. Methods We conducted a prospective study of patients with suspected acute coronary syndrome admitted to the Cardiology Service at Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain, over a one-year period. We interviewed patients within the first 24 hours of admission using a standardized case-report form to assess the presence of headache in relation to the acute coronary syndrome and its characteristics. Results We included 438 patients, 381 with confirmed myocardial ischemia. Prevalence of cardiac cephalalgia was 14.2% (n = 54). The most common features were frontal location, pressing quality and moderate intensity. Pain referred to the jaws (aOR 2.61; 95% CI 1.33–5.12; p = 0.005), palpitations (aOR 3.65; 95% CI 1.57–8.50; p = 0.003) and circumflex coronary artery as the culprit artery for the myocardial ischemia (aOR 3.8; 95% CI 1.07–13.74; p = 0.021) were related to cardiac whereas history of hypertension was inversely associated (aOR 0.37: 95% CI 0.18–0.74; p = 0.005). Conclusion The prevalence of cardiac cephalalgia was 14.2%. Our study provides valuable information about cardiac cephalalgia characteristics that suggest revision of current diagnostic criteria.

Resumen: Introducción y objetivos: La cefalea post-stent carotídeo es aquella cefalea de aparición durante el procedimiento o en las horas posteriores, sin que haya datos de la existencia de una complicación del mismo. El objetivo de este estudio es definir las características de esta cefalea a partir de nuestra experiencia clínica. Pacientes y método: Estudio transversal prospectivo observacional de una muestra de pacientes sometidos a stenting carotídeo en el Hospital Clínico Universitario Lozano Blesa. Se estudiaron variables sociodemográficas, factores de riesgo cardiovascular, afectación carotídea y antecedentes de cefalea primaria. Se realizó una entrevista estructurada antes del procedimiento y en las siguientes 24 h. Resultados: Se incluyeron un total de 56 pacientes con una media de edad de 67 ± 9,52 años; un 84% eran hombres. La cefalea apareció en 12 pacientes (21,4%), siendo el 83,3% hombres con una media de edad de 60,58 ± 9,31 años. En el 58,4% (n = 7) comenzó en las primeras 6 h y en el 33,3% (n = 4) durante el procedimiento. En el 33,3% (n = 4) la duración fue menor de 10 min, y en el 41,7% (n = 5) osciló entre 10-120 min. Localizaron el dolor en la región frontotemporal el 58,3% (n = 7); el 58,3% (n = 7) lo describe como unilateral. Es opresivo en un 66,7% (n = 8), de intensidad moderada en un 50% (n = 6) y el 75% de los pacientes no precisó analgesia. No se observó ninguna relación estadísticamente significativa con las variables estudiadas, excepto la edad (p = 0,007). Conclusiones: En nuestra serie, la cefalea post-stent carotídeo es de intensidad leve-moderada, unilateral, opresiva y de breve duración. Si bien son necesarios más estudios para poder definir mejor sus características y factores de riesgo. Abstract: Introduction and objectives: Headache after carotid artery stenting is a headache with onset during the procedure or in the first few hours after it, and where there is no evidence to suggest a complication of that procedure. The purpose of this study is to describe the main features of these headaches based on our clinical experience. Patients and methods: Observational prospective study of a sample of patients undergoing carotid artery stenting at Hospital Clínico Universitario Lozano Blesa, in Zaragoza, Spain. We recorded sociodemographic characteristics, cardiovascular risk factors, carotid artery disease, and history of primary headache; data were gathered using structured interviews completed before and 24 hours after the procedure. Results: We included 56 patients (mean age 67 ± 9.52 years); 84% were men. Twelve patients (21.4%) experienced headache, 83.3% of whom were men; mean age was 60.58 ± 9.31 years. Headache appeared within the first 6 hours in 7 patients (58.4%) and during the procedure in 4 (33.3%). Pain lasted less than 10 minutes in 4 patients (33.3%) and between 10 and 120 minutes in 5 (41.7%). Headache affected the frontotemporal area in 7 patients (58.3%); 7 patients (58.3%) described pain as unilateral. It was oppressive in 8 patients (66.7%) and of moderate intensity in 6 (50%). Nine patients (75%) required no analgesics. We found no statistically significant associations with any of the variables except for age (P = .007; t test). Conclusions: In our sample, headache after carotid artery stenting was mild to moderate in intensity, unilateral, oppressive, and short-lasting. Further studies are necessary to gain a deeper knowledge of its characteristics and associated risk factors. Palabras clave: Stent, Angioplastia carotídea, Cefalea, Factores de riesgo, Keywords: Stenting, Carotid artery angioplasty, Headache, Risk factors

La odontalgia atipica (OA) se define como un dolor dental continuo en uno o varios dientes, en ocasiones precedido por procedimientos dentales, y que tras un examen completo no se detecta patologia dental. Se presupone un origen neuropatico cuya respuesta a tratamientos locales y sistemicos es insatisfactoria. Presentamos el caso clinico de una paciente de 50 anos con OA tras extraccion dental, que presento una reduccion significativa del dolor despues del tratamiento local con OnabotulinumtoxinA (OnabotA) en el area sintomatica. La respuesta a la administracion de OnabotA en esta paciente concuerda con las observadas previamente en series reducidas de casos, por lo que podria ser una alternativa terapeutica en este tipo de dolores de dificil control.

Resumen: OnabotulinumtoxinA ha demostrado ser eficaz como tratamiento preventivo en pacientes con migraña crónica (MC). El Grupo de Estudio de Cefalea de la Sociedad Española de Neurología ha considerado que sería de interés, a los 5 años de la aprobación en España de la onabotulinumtoxinA, reunir a un grupo de expertos en el tratamiento de pacientes con MC para elaborar con la evidencia actual y nuestra experiencia unas recomendaciones dirigidas a facilitar su uso en la práctica clínica diaria. Con este fin planteamos 12 preguntas que nos hacemos como médicos y que también nos realizan nuestros pacientes. Cada autor ha contestado una pregunta y luego el documento ha sido revisado por todos. Esperamos que esta revisión constituya una herramienta práctica para ayudar a los neurólogos que tratan a pacientes con MC. Abstract: OnabotulinumtoxinA has been demonstrated to be effective as a preventive treatment in patients with chronic migraine (CM). Five years after the approval of onabotulinumtoxinA in Spain, the Headache Study Group of the Spanish Society of Neurology considered it worthwhile to gather a group of experts in treating patients with CM in order to draw up, based on current evidence and our own experience, a series of guidelines aimed at facilitating the use of the drug in daily clinical practice. For this purpose, we posed 12 questions that we ask ourselves as doctors, and which we are also asked by our patients. Each author responded to one question, and the document was then reviewed by everyone. We hope that this review will constitute a practical tool to help neurologists treating patients with CM. Palabras clave: Consenso, Migraña crónica, OnabotulinumtoxinA, Toxina botulínica A, Tratamiento preventivo, Recomendaciones, Keywords: Consensus, Chronic migraine, OnabotulinumtoxinA, Botulinum neurotoxin A, Preventive treatment, Guidelines

espanolResumen La sospecha de cefalea secundaria dependera del perfil temporal y de las caracteristicas del dolor, y es siempre elevada en aquellos pacientes con cefalea aguda de reciente comienzo y cefalea cronica de instauracion progresiva. El diagnostico se basa en una adecuada anamnesis y una rigurosa exploracion neurologica. La realizacion de determinadas pruebas (analiticas, de neuroimagen y estudio de liquido cefalorraquideo), orientadas en funcion de las caracteristicas de la cefalea, es necesaria cuando existan criterios de alarma (epidemiologicos, clinicos y evolutivos), cuando no se cumplan los criterios de cefalea primaria y cuando el diagnostico de esta se realiza por exclusion, como en el caso de la cefalea tusigena, por esfuerzo fisico, por actividad sexual y en trueno, entre otras. EnglishBoth time pattern and pain features define secondary headache suspicion. Clinical suspicion is high in those patients with acute recent onset cephalea and chronic progressive headache. Diagnosis relies on proper anamnesis and deep neurological exam. If warning signs (epidemiological, clinical or evolutionary), or if non-fulfilment of the primary headache criterion are present or in case of diagnosis of exclusion (coughing headache, by physical exertion, by sexual activity and thunderclap headache, among others), diagnostic tests according with headache features, (analytical tests, neuroimaging studies and cerebrospinal fluid study) are required.

Resumen Introduccion La pandemia COVID-19 ha provocado un inusitado impulso a la telemedicina (TM). Analizamos el impacto de la pandemia en la TM aplicada en las consultas de cefaleas espanolas, revisamos la literatura y lanzamos unas recomendaciones para implantar la TM en las consultas. Metodo Tres fases: 1) Revision de la base Medline desde el ano 1958 (primera experiencia de TM); 2) Formulario Google Forms enviado a todos los neurologos del Grupo de Estudio de Cefaleas de la Sociedad Espanola de Neurologia (GECSEN), y 3) Consenso on-line de expertos GECSEN para emitir recomendaciones para implantar la TM en Espana. Resultados La pandemia por COVID-19 ha empeorado los tiempos de espera presenciales, incrementando el uso de todas las modalidades de TM antes y despues de abril de 2020: telefono fijo (del 75% al 97%), telefono movil (del 9% al 27%), correo electronico (del 30% al 36%) y videoconsulta (del 3% al 21%). Los neurologos son conscientes de la necesidad de ampliar la oferta con videoconsultas, claramente in crescendo, y otras herramientas de e-health y m-health. Conclusiones Desde el GECSEN recomendamos y animamos a todos los neurologos que asisten a pacientes con cefaleas a implantar recursos de TM, teniendo como objetivo optimo la videoconsulta en menores de 60-65 anos y la llamada telefonica en mayores, si bien cada caso debe individualizarse. Se debera contar previamente con la aprobacion y asesoramiento de los servicios juridicos e informaticos y de la direccion del centro. La mayoria de los pacientes con cefalea y/o neuralgia estable son candidatos a seguimiento mediante TM, tras una primera visita que tiene que ser siempre presencial.

Background Erenumab was approved in Europe for migraine prevention in patients with ≥4 monthly migraine days (MMD). In Spain, Novartis started a personalized managed access program which allowed free access to erenumab before official reimbursement. The Headache Study Group of the Spanish Neurological Society started a registry to monitor real-world safety and efficacy, and all Spanish headache experts were invited to participate. Methods Patients fulfilled ICHD3 criteria for migraine and had ≥ 4MMD. Sociodemographic and clinical data were registered as well as MMD, headache frequency (MHD), prior and concomitant preventive treatment, medication overuse headache (MOH), migraine evolution, adverse events, and PROs: HIT6, MIDAS, and PGIC. A >50% reduction of MMD after 3 months was considered as response. Results We included 210 patients (female 86.7%, mean age 46.4 years old) from 22 hospitals from February 2019 – to – June 2020. Most patients (89.5%) suffered from chronic migraine with a mean evolution of 8.6 years. MOH was present in 70% of patients, and 17.1% had migraine with aura. Average of prior preventive treatment failure was >7 (BoNT/A had been used by 95.2%). Most patients (67,6%) started with erenumab 70mg. 61% of patients were also taking oral preventive drugs or getting simultaneous BoNT/A (27.6%). Responder rate was 37.1% and the mean reduction of MMD was -6.28 and MHD: -8.6. Regarding PROs: MIDAS: -35 p., HIT6: -11.6 p., PIGC: 4.7 p. Predictors of good response were: HIT6 score ( p =0.01), prior preventive treatment failures ( p =0.026), absence of MOH ( p =0.039), and simultaneous BoNT/A treatment ( p

Background and objective: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus. Methods: This is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms. Results: We recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P = .320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment. Conclusion: Anti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19. Resumen: Antecedentes y objetivo: El péptido relacionado con el gen de la calcitonina (CGRP, por sus siglas en inglés), es un neuropéptido involucrado en la fisiopatología de la migraña, que también es conocido por participar en la regulación del sistema respiratorio y en algunas enfermedades inmunológicas como la sepsis. Hemos analizado el impacto del uso de los antagonistas de CGRP en pacientes con migraña durante la pandemia de COVID-19, causada por el coronavirus SARS-CoV-2. Métodos: Estudio transversal multicéntrico desarrollado entre mayo y noviembre de 2020, en el que la Sociedad Española de Neurología distribuyó a nivel nacional una encuesta de la que recogimos datos sobre la presencia, las características y la gravedad de síntomas de COVID-19, entre los que se encontraba la cefalea, en pacientes con migraña tratados con anticuerpos monoclonales (AcM) anti-CGRP, y los comparamos con los de pacientes con migraña que no recibían dicho tratamiento. También realizamos un subanálisis de los pacientes con síntomas de COVID-19. Resultados: Identificamos 300 pacientes con migraña: 51,7% (155/300) recibían AcM anti-CGRP; el 87,3% eran mujeres (262/300) y la edad media (desviación estándar) de la muestra fue de 47,1 (11,6) años. Un total de 41 pacientes (13,7%) cumplían los criterios diagnósticos de COVID-19, sin diferencias estadísticamente significativas entre los pacientes que recibían tratamiento con AcM anti-CGRP y los que no (16,1% y 11,0%, respectivamente; p = 0,320). De los pacientes con COVID-19, el 48,8% (20/41) acudieron a urgencias y el 12,2% (5/41) fueron hospitalizados. Igualmente, no se detectaron diferencias clínicas entre los pacientes que recibían dicho tratamiento y los que no. Conclusión: El tratamiento con AcM anti-CGRP parece un recurso seguro en la práctica clínica, y no se asocia a un mayor riesgo de COVID-19.

Objective Previous studies have demonstrated that emotional stress, changes in lifestyle habits and infections can worsen the clinical course of migraine. We hypothesize that changes in habits and medical care during coronavirus disease 2019 (COVID-19) lockdown might have worsened the clinical course of migraine. Design Retrospective survey study collecting online responses from migraine patients followed-up by neurologists at three tertiary hospitals between June and July 2020. Methods We used a web-based survey that included demographic data, clinical variables related with any headache (frequency) and migraine (subjective worsening, frequency, and intensity), lockdown, and symptoms of post-traumatic stress. Results The response rate of the survey was 239/324 (73.8%). The final analysis included 222 subjects. Among them, 201/222 (90.5%) were women, aged 42.5 ± 12.0 (mean±SD). Subjective improvement of migraine during lockdown was reported in 31/222 participants (14.0%), while worsening in 105/222 (47.3%) and was associated with changes in migraine triggers such as stress related to going outdoors and intake of specific foods or drinks. Intensity of attacks increased in 67/222 patients (30.2%), and it was associated with the subjective worsening, female sex, recent insomnia, and use of acute medication during a headache. An increase in monthly days with any headache was observed in 105/222 patients (47.3%) and was related to symptoms of post-traumatic stress, older age and living with five or more people. Conclusions Approximately half the migraine patients reported worsening of their usual pain during the lockdown. Worse clinical course in migraine patients was related to changes in triggers and the emotional impact of the lockdown.

Tratamiento preventivo; Cefalea con uso excesivo de medicación; Opioides Tractament preventiu; Cefalea per ús excessiu de medicaments; Opioides Preventive treatment; Medication overuse headache; Opioids Introducción La cefalea con uso excesivo de medicación es una cefalea secundaria en la que el uso regular o frecuente de medicación analgésica produce un aumento de la frecuencia de una cefalea de base, pasando de episódica a crónica. La prevalencia de esta entidad está en torno al 1-2%, siendo más frecuente en mujeres entre 30 y 50 años con comorbilidades psiquiátricas como depresión o ansiedad y otros procesos de dolor crónico. Es importante conocer el manejo de esta entidad. Por este motivo, el Grupo de Estudios de Cefaleas de la Sociedad Española de Neurología ha pretendido realizar este documento de consenso sobre esta patología. Desarrollo Esta guía ha sido redactada por un grupo de expertos a partir de la revisión de la evidencia científica publicada y estableciendo recomendaciones prácticas para su adecuado manejo y tratamiento. El tratamiento de la cefalea con uso excesivo de medicación tiene varios pilares fundamentales y suele ser complejo: información y educación sobre el desarrollo de la cefalea con uso excesivo de medicación, tratamiento preventivo, suspensión del fármaco de uso frecuente y tratamiento de deshabituación. Es importante el seguimiento de pacientes con riesgo de recurrencias. Conclusiones Esperamos que este documento resulte de utilidad y permita su aplicación práctica en la consulta diaria y que sirva para actualizar y mejorar el conocimiento del manejo de esta patología. Introduction Medication overuse headache is a secondary headache in which the regular or frequent use of analgesics can increase the frequency of the episodes, causing the transition from episodic to chronic headache. The prevalence of medication overuse headache is approximately 1-2%, with higher rates among women aged 30-50 years and with comorbid psychiatric disorders such as depression or anxiety, or other chronic pain disorders. It is important to be familiar with the management of this disease. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a consensus document addressing this disorder. Development These guidelines were prepared by a group of neurologists specialising in headache after a systematic literature review and provides consensus recommendations on the proper management and treatment of medication overuse headache. The treatment of medication overuse headache is often complex, and is based on 4 fundamental pillars: education and information about the condition, preventive treatment, discontinuation of the drug being overused, and treatment for withdrawal symptoms. Follow-up of patients at risk of recurrence is important. Conclusions We hope that this document will be useful in daily clinical practice and that it will update and improve understanding of medication overuse headache management.

BACKGROUND Previous studies have shown worse cognitive performance in cluster headache (CH) patients compared to healthy controls; however, little is known about cognitive performance in episodic CH (ECH) patients outside and inside the active cluster (AC). OBJECTIVE Our aim is to compare cognitive function in ECH patients outside and inside the AC. METHODS In this cross-sectional, observational study, four neuropsychological tests (Trail Making Test [TMT], Stroop Test [ST], verbal fluency [VF], and Symbol Digit Modalities Test [SDT]) were completed by 21 ECH patients at two different points in time: outside and inside the AC. We also assessed self-reported sleep quality and the presence of anxiety or depressive symptoms. Scores were compared. RESULTS There was not any difference between the scores of the neuropsychological tests performed outside and inside the AC (TMT-A: 23 vs. 23.5; p = 0.984; TMT-B: 96.5 vs. 85.9; p = 0.104; ST word reading: 101.0 vs. 101.2; p = 0.938; ST color naming: 73.0 vs. 73.4; p = 0.858; ST color word: 44.0 vs. 46.0; p = 0.498; SDMT: 44.0 vs. 44.6; p = 0.961; VF phonemic: 29.5 vs. 30.2; p = 0.714; VF semantic: 20 vs. 21; p = 0.489). We found a worsening in the sleep quality component of the Pittsburgh Sleep Quality Index median scores in patients outside the AC (2 vs. 1; p = 0.046). CONCLUSIONS Our findings suggest that patients with ECH have a similar cognitive performance outside and during the AC.

Introduction: Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions. Methods: Neurologists from the Spanish Society of Neurology’s (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia. Results: We present an updated review and establish the first set of consensus recommendations of the SEN and SENEC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition. Conclusions: Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality. Resumen: Introducción: En los últimos años han surgido numerosos dispositivos de neuromodulación, invasivos y no invasivos, que se han aplicado en pacientes con cefaleas y neuralgias sin que exista una revisión actualizada de su eficacia y seguridad, ni recomendaciones de ninguna institución sanitaria sobre su uso específico en cada entidad nosológica. Métodos: Neurólogos del Grupo de Cefaleas de la Sociedad Española de Neurología (SEN) y neurocirujanos expertos en neurocirugía funcional seleccionados por la Sociedad Española de Neurocirugía (SENEC), hemos realizado una revisión exhaustiva en el sistema Medline sobre neuromodulación en cefaleas y neuralgias. Resultados: Presentamos una revisión actualizada y establecemos por primera vez unas recomendaciones consensuadas entre la SEN y la SENEC sobre el uso de la neuromodulación en cefaleas y neuralgias, adjudicando niveles de evidencia sobre su eficacia actual, específicamente en cada entidad nosológica. Conclusiones: Los resultados actuales de los estudios proporcionan evidencias para la indicación de técnicas de neuromodulación en casos refractarios de cefaleas y neuralgias (sobre todo en migraña, cefalea en racimos y neuralgia del trigémino), seleccionados por neurólogos expertos en cefaleas, tras comprobar el agotamiento de las opciones farmacológicas. Adicionalmente, en el caso de la neuromodulación invasiva, se recomienda que los casos sean debatidos en comités multidisciplinarios y la cirugía sea realizada por equipos de neurocirujanos expertos en neurocirugía funcional y con una morbimortalidad aceptable.

To compare the cost of adverse events (AEs) associated with preventive treatment of migraine with fremanezumab, versus erenumab, galcanezumab, and onabotulinumtoxinA. A probabilistic modeling analy...

BACKGROUND: OnabotulinumtoxinA is an effective preventive treatment for chronic migraine. In chronic migraine, besides a reduction in headache frequency, a decreased reliance on oral prophylactics is also indicative of treatment effectiveness. This study aimed to quantify the change in the use of oral prophylactics after treatment with onabotulinumtoxinA in patients with chronic migraine.; METHODS: This was a retrospective, multicentric, cross-sectional study. Patients with chronic migraine (ICHD-3b) that had been treated with onabotulinumtoxinA were enrolled consecutively. We collected parameters related to each patient's pre-treatment situation, as well as their current one, focusing on frequency and intensity of migraine, number of oral prophylactics and the respective cycle of onabotulinumtoxinA. Univariate and logistic regression analyses were performed.; RESULTS: We included 542 patients. 90.0% were taking oral preventive treatments. During treatment with onabotulinumtoxinA, 47.8% withdrew at least one prophylactic and 41.6% stopped using oral prophylactics altogether. Factors associated with a reduction or cessations of oral prophylactics were: having>50% improvement in frequency and intensity, remission to episodic migraine, the use of topiramate as an initial treatment, an increased number of infiltrations and a shorter chronification period (pfive cycles of onabotulinumtoxinA, >50% improvement in pain intensity and topiramate as an initial treatment were predictors of a reduction in oral prophylactics (AUC of 70.3%; p

Fundamento. La epilepsia mioclonica juvenil (EMJ) es un sindrome epileptico clasico que carece de consenso pleno sobre la posibilidad de suspension de tratamiento con farmacos antiepilepticos (FAE). Metodo. Estudio observacional, retrospectivo de una serie de pacientes con diagnostico de EMJ de mas de 20 anos de evolucion, atendiendo a la evolucion de aquellos con retirada de FAE. Resultados . Se estudiaron veinte pacientes (edad media 44,1 anos, 55% hombres) con EMJ de 30 anos de evolucion media y edad media al inicio de 14,2 anos. El tipo de crisis motora mas frecuente fue la combinacion de mioclonicas y tonico-clonicas (70%); el 60% de los pacientes llevan mas de cinco anos libres de crisis. A cuatro pacientes (20%) se les suspendieron los FAE, a dos de ellos con edad media 23 anos y un tiempo medio libre de crisis de 7,5 anos, que recayeron, y a los otros dos con edad media 39 anos y tras 23,5 anos libres de crisis, que llevan dos y nueve anos sin crisis en la actualidad. Conclusiones. Existe la posibilidad de suspender FAE en pacientes con EMJ con libertad de crisis mantenida en el tiempo. Sugerimos tener en cuenta la edad de suspension y la existencia previa de un tiempo prolongado de libertad de crisis.

BACKGROUND During 24-hour on-call shifts medical residents are exposed to diverse circumstances such as sleep deprivation and stress. OBJECTIVE Our aim is to assess the effect of 24-hour on-call shifts on medical residents' headache-related disability. METHODS The Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test (HIT-6), the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS) questionnaires were administered to medical residents who had never performed on-call shifts at baseline and 6 months after beginning 24-hour on-call shifts. Scores were compared. RESULTS About 66 medical residents completed this study. About 21.2% (n = 14) had history of migraine, 42.4% (n = 28) had a history of tension-type headache (TTH) and 12.1% (n = 8) had a history of both migraine and TTH. Among medical residents with migraine, the median MIDAS score was significantly higher after starting 24-hour on-call shifts than at a baseline (4.0 vs 8.0; Wilcoxon, P = .001), meaning that, on average, disability increased from little or no disability, to moderate disability. No difference in HIT-6 scores was found. The median score of PSQI and HADS was higher at 6 months (PSQI: 7.0 vs 8.0; P = .003), (HADS: 5.0 vs 8.0; P

Background and purpose: Migraine is a common and costly neurological disorder. The aims of this study were to quantify the costs of chronic (CM) and episodic migraine (EM) in Spain, evaluating the impact of psychiatric comorbidities and disability, and to estimate the economic savings associated with reducing the number of migraine-days by 50%. Methods: This was an observational, cross-sectional analysis of data from migraine patients who participated in the Spanish Migraine Atlas. The participants were invited to complete a structured questionnaire including the following scales: the Headache Needs Assessment, the Hospital Anxiety and Depression Scale, and the Migraine Disability Assessment Scale (MIDAS). Results: A total of 475 patients were included, of whom 187 had CM (39.4%). Total costs per patient/year were: €16 578.2 ± €34 568.1 for CM and €6227.8 ± €6515.7 for EM. A higher degree of disability, according to MIDAS, significantly increased the total cost of migraine, while the presence of psychiatric comorbidity increased costs for EM patients only. A reduction of 1 migraine-day per month decreased average total costs by €744.14 per patient/year for EM and €663.20 per patient/year for CM, while a reduction in the number of migraine-days by 50% would result in economic savings of €2232.44 per patient/year (R2 = 0.927) for EM and €6631.99 per patient/year (R2 = 0.886) for CM. Conclusions: The costs associated with migraine were driven by migraine frequency and the degree of disability, whereas psychiatric comorbidity only influenced the cost of EM. These results highlight the need to optimize migraine management to reduce the economic migraine burden. Future studies are needed to confirm our results.

Resumen: Introducción: En el campo de las cefaleas, onabotulinumtoxinA (onabotA) tiene indicación bien establecida en la migraña crónica (MC). Además, en los últimos años su uso se está extendiendo a otras cefaleas primarias (migraña episódica de alta frecuencia, cefaleas trigémino-autonómicas, cefalea numular) y a la neuralgia del trigémino. Al ser una opción terapéutica que se va a ir incorporando de forma progresiva en el manejo de estas entidades, creemos que es necesario reflejar con un carácter eminentemente práctico cuáles son las posibles indicaciones de onabotA, más allá de la MC, así como su protocolo de administración, que diferirá en función del tipo de cefalea y/o neuralgia. Desarrollo: A partir de una revisión de la bibliografía existente y de nuestra propia experiencia clínica, se ha elaborado este documento de consenso cuyo objetivo es servir de guía a aquellos profesionales que quieran aplicar estas técnicas en su actividad asistencial. En la primera parte se abordará el mecanismo de acción de onabotA y la razón de su utilización en diversas cefaleas distintas de la MC desde un punto de vista fisiopatológico y clínico. En la segunda parte se hará una revisión de la evidencia disponible y los estudios publicados en los últimos años. Para cada una de estas entidades, se añadirá una «recomendación de experto», basada en la propia experiencia clínica, que refleje el perfil de paciente que puede ser candidato a este tratamiento, las dosis y el protocolo de administración de onabotA. Conclusión: El tratamiento con onabotA en entidades distintas a la MC debe ser siempre individualizado y se planteará en pacientes seleccionados que no hayan respondido a la terapia convencional. Abstract: Introduction: In the field of headaches, onabotulinumtoxinA (onabotA) is well established as a treatment for chronic migraine (CM). In recent years, it has been used increasingly to treat other primary headaches (high-frequency episodic migraine, trigeminal-autonomic cephalalgias, nummular headache) and trigeminal neuralgia. As this treatment will progressively be incorporated in the management of these patients, we consider it necessary to reflect, with a fundamentally practical approach, on the possible indications of onabotA, beyond CM, as well as its administration protocol, which will differ according to the type of headache and/or neuralgia. Development: This consensus document was drafted based on a thorough review and analysis of the existing literature and our own clinical experience. The aim of the document is to serve as guidelines for professionals administering onabotA treatment. The first part will address onabotA's mechanism of action, and reasons for its use in other types of headache, from a physiopathological and clinical perspective. In the second part, we will review the available evidence and studies published in recent years. We will add an “expert recommendation” based on our own clinical experience, showing the best patient profile for this treatment and the most adequate dose and administration protocol. Conclusion: Treatment with onabotA should always be individualised and considered in selected patients who have not responded to conventional therapy.

Background Cluster headache is one of the most disabling of all headache conditions. Although some studies have investigated the psychological profile of patients with cluster headache, research on its impact on cognitive function in patients with episodic cluster headache outside the cluster bout is scant. Methods Cross-sectional study to evaluate various aspects of neuropsychological assessment and cognitive function including working memory, selective attention, verbal fluency, and executive function in 40 patients with episodic cluster headache. The patients were compared with 40 age-, gender-, and level of education-matched healthy controls. Results Episodic cluster headache patients performed significantly worse than healthy controls on all cognitive tests, except for the Interference Score (P = 0.281). They had significantly higher Hospital Anxiety Scale scores (P = 0.002). However, we found no significant association between cognitive performance, anxiety, sleep quality, and disease duration. Conclusions Patients with episodic cluster headache outside the bout showed worse executive functioning, working memory, language, and selective attention compared with healthy controls, regardless of the duration of disease or sleep quality.

Miguel Malo-Urriés,1 César Hidalgo-García,1 Elena Estébanez-de-Miguel,1 José Miguel Tricás-Moreno,1 Sonia Santos-Lasaosa,2 Marjan Jahanshahi3 1Physiotherapy Research Unit, Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain; 2Neurology Service, University Clinical Hospital Lozano Blesa, Zaragoza, Spain; 3Cognitive Motor Neuroscience Group, Department of Clinical and Movement Neurosciences, University College London Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK Background: Based on inconsistent sensory alterations demonstrated in cluster headache (CH), the aim of this study was to determine whether patients with CH develop sensory changes in the symptomatic side compared to the asymptomatic side.Methods: Quantitative sensory testing (QST), including pressure pain threshold (PPT), tactile detection threshold (TDT), prick detection threshold (PDT), and two-point detection threshold (2PDT), was evaluated in 16 patients (seven women; age 41.9±6.8 years) with CH. Test sites included the first, second, and third divisions of the trigeminal nerve, cervical spine, and thenar eminence in the symptomatic and asymptomatic sides.Results: The symptomatic side, compared to the asymptomatic side, presented significantly decreased PPT in the first (P=0.011; 423.81±174.05 kPa vs 480.13±214.99 kPa) and second (P=0.023; 288.88±140.80 kPa vs 326.38±137.33 kPa) divisions of the trigeminal nerve, significantly increased TDT in the first (P=0.002; 2.44±0.40 vs 1.74±0.24) and second (P=0.016; 1.92±0.34 vs 1.67±0.09) divisions, and increased 2PDT in the first division (P=0.004; 18.13±4.70 mm vs 15.0±4.92 mm) and neck (P=0.007; 45.31±20.65 mm vs 38.44±16.10 mm).Conclusion: These results support the prior evidence suggesting a specific pattern of alteration of sensory function with alterations in the symptomatic side compared to the asymptomatic side. Keywords: cluster headache, trigeminal autonomic cephalalgia, quantitative sensory testing

Resumen: Introducción: Los años de residencia son la base fundamental para el ejercicio posterior de cualquier especialidad médica. El objetivo de nuestro estudio es evaluar la situación actual, grado de implicación y calidad percibida en la formación como neurólogos de los residentes, específicamente en el área de cefaleas. Métodos: Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) se diseñó una encuesta autoadministrada que fue enviada vía e-mail a todos socios los residentes de Neurología (mayo de 2015). Resultados: Completaron la encuesta 53 residentes (53/426: 12,4%; R1: 6%; R2: 25,5%; R3: 23,5% y R4: 45% de 13 comunidades autónomas). Las áreas que más les interesan son por orden: vascular, cefalea y epilepsia. El 85% considera que el área de cefalea está infravalorada. Más de la mitad (52,8%) no rotan en consultas específicas de cefaleas y solo el 35,8% terminan su formación con dominio de la técnica de bloqueos anestésicos e infiltración de toxina. El 81,1% considera que la investigación es escasa o nula. El 69,8% nunca ha realizado un póster/comunicación, el 79,3% no ha publicado y solo un 15% colabora en proyectos de investigación en esta área. El 40% considera que no ha recibido una formación adecuada. Conclusiones: La cefalea está entre las enfermedades que más interesan a nuestros residentes, sin embargo, consideramos que hay que mejorar su formación tanto en el ámbito asistencial como investigador, así como la visión que tienen de ella. Aumentar los cursos, crear páginas web formativas, involucrarles en investigación y considerar obligatoria la rotación en una unidad especializada son algunos de los objetivos fundamentales que planteamos desde el GECSEN. Abstract: Introduction: The years of residency are the pillars of the subsequent practice in every medical specialty. The aim of our study is to evaluate the current situation, degree of involvement, main interests, and perceived quality of the training received by Spanish residents of neurology, specifically in the area of headache. Methods: A self-administered survey was designed by the Headache Study Group of the Spanish Society of Neurology (GECSEN) and was sent via e-mail to all residents who were members of the Society as of May 2015. Results: Fifty-three residents completed the survey (N = 426, 12.4%): 6% were first year residents, 25.5% second year, 23.5% third year, and 45% fourth year residents, all from 13 different Spanish autonomous communities. The areas of greatest interest are, in this order: Vascular neurology, headache, and epilepsy. Of them, 85% believe that the area of headache is undervalued. More than half of residents (52.8%) do not rotate in specific Headache Units and only 35.8% complete their training dominating anaesthetic block and toxin infiltration techniques. Of them, 81.1% believe that research is scarce or absent; 69.8% have never made a poster/presentation, 79.3% have not published and only 15% collaborate on research projects in this area. Lastly, 40% believe that they have not received adequate training. Conclusions: Headache is among the areas that interest our residents the most; however, we believe that we must improve their training both at a patient healthcare level and as researchers. Thus, increasing the number of available courses, creating educational web pages, involving residents in research, and making a rotation in a specialised unit mandatory are among the fundamental objectives of the GECSEN. Palabras clave: Residentes, Neurología, Cefalea, Investigación, Formación, Docencia, Keywords: Residents, Neurology, Headache, Research, Training, Teaching

Neurological involvement in Behcet's disease is rare, especially at the onset. It can present in the form of parenchymal changes or as damage to the vascular structures in its nonparenchymal form. The coexistence of both kinds of manifestations in the same patient is exceptional. We report the case of a 32-year-old patient with a history of deep venous thrombosis, who was being treated for holocranial headache, apathy, and oral and genital ulcers. Brain magnetic resonance imaging showed hyperintense lesions in the basal ganglia and white matter, and the vascular study evidenced venous thrombosis of the left transverse sinus. After confirming the diagnosis of Behcet's disease with parenchymal and nonparenchymal cerebral involvement, immunosuppressive and corticosteroid therapy was started, resulting in the remission of the symptoms.

Sleep and circadian rhythm disturbances are common in patients with neurodegenerative diseases such as Huntington's disease (HD). The aim of this study was to evaluate variability in circadian blood pressure (BP) to determine the association between abnormal circadian BP and sleep quality in patients with HD.Cross-sectional, multicenter study of 38 HD mutation carriers (23 premanifest and 15 early stage patients) who were compared to 38 age- and sex-matched controls. BP was evaluated by ambulatory blood pressure monitoring (ABPM). Based on the percentage decrease in nocturnal BP, subjects were classified as either dippers (≥10%) or non-dippers (10%). Sleep quality and daytime sleepiness were measured, respectively, using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Daytime Sleepiness Scale (ESS) and the scores on these indices were correlated with the ABPM findings.Sixty-three percent HD mutation carriers were non-dippers (86.7% of the symptomatic and 47.8% of the premanifest patients) versus 23.7% of controls (p = 0.001). In the HD group, sleep quality was significantly more impaired (PSQI5) (p = 0.016) with more excessive daytime sleepiness (ESS9) (p = 0.001) than in the control group. Nocturnal non-dipping was associated with worse sleep quality in patients (p = 0.011) but not in controls.These results show that patients with HD present early disturbances in the circadian rhythm of BP and that this altered nocturnal BP is associated with poor sleep quality. These findings suggest the potential role of subtle hypothalamic dysfunction in this population.

Resumen: Introducción: La relación entre el trastorno del control de impulsos (TCI) y el trastorno de conducta del sueño REM (TCSR) no se ha aclarado todavía y los resultados de la literatura son contradictorios. Nuestro objetivo es valorar la asociación entre estos 2 trastornos y, a su vez, su presencia en dependencia de la terapia dopaminérgica. Métodos: Un total de 73 pacientes diagnosticados de enfermedad de Parkinson, en tratamiento con un único agonista dopaminérgico, fueron incluidos en el estudio, tras valoración clínica y habiendo completado el cuestionario de pregunta única para el TCSR y el cuestionario abreviado para los trastornos impulsivo-compulsivos en la enfermedad de Parkinson. Resultados: La edad media ± desviación estándar de los pacientes fue de 68,88 ± 7,758 años. De ellos, 26 pacientes (35,6%) se clasificaron dentro de un TCSR-probable, presentando mayor prevalencia de síndrome rígido acinético no tremórico, más años de tratamiento con levodopa y con agonistas dopaminérgicos, y una relación significativa con el TCI (p = 0,001) en comparación con el grupo sin TCSR-probable.En cuanto al tratamiento con agonistas dopaminérgicos, se demostró la asociación significativa de la administración por vía oral con una mayor prevalencia de TCI, mientras que esta vía también se relacionó con mayor tendencia a desarrollar TCSR, diferencias en este caso no significativas. Conclusiones: Nuestros datos confirman que el TCSR se relaciona con el TCI en la enfermedad de Parkinson. Abstract: Introduction: The relationship between impulse control disorder (ICD) and REM sleep behaviour disorder (RBD) has not yet been clarified, and the literature reports contradictory results. Our purpose is to analyse the association between these 2 disorders and their presence in patients under dopaminergic treatment. Methods: A total of 73 patients diagnosed with Parkinson's disease and treated with a single dopamine agonist were included in the study after undergoing clinical assessment and completing the single-question screen for REM sleep behaviour disorder and the short version of the questionnaire for impulsive-compulsive behaviours in Parkinson's disease. Results: Mean age was 68.88 ± 7.758 years. Twenty-six patients (35.6%) were classified as probable-RBD. This group showed a significant association with ICD (P=.001) and had a higher prevalence of non-tremor akinetic rigid syndrome and longer duration of treatment with levodopa and dopamine agonists than the group without probable-RBD. We found a significant correlation between the use of oral dopamine agonists and ICD. Likewise, patients treated with oral dopamine agonists demonstrated a greater tendency toward presenting probable-RBD than patients taking dopamine agonists by other routes; the difference was non-significant. Conclusions: The present study confirms the association between RBD and a higher risk of developing symptoms of ICD in Parkinson's disease. Palabras clave: Enfermedad de Parkinson, Trastorno de conducta del sueño REM, Trastorno de control de impulsos y conductas relacionadas, Agonistas dopaminérgicos, Single-Question Screen for REM Sleep Behavior Disorder, Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire, Keywords: Parkinson's disease, REM sleep behaviour disorder, Impulse control disorder and related behaviours, Dopamine agonists, Single-Question Screen for REM Sleep Behavior Disorder, Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire