Headache is one of the most common symptoms of idiopathic intracranial hypertension (IIH). The ai... more Headache is one of the most common symptoms of idiopathic intracranial hypertension (IIH). The aim of this study was to investigate the applicability of the diagnostic criteria for ''Headache attributed to IIH'' included in the current classification of headache disorders, particularly as far as the main headache features. A consecutive clinical series of IIH patients with demonstration of increased intracranial pressure by lumbar puncture in the recumbent position were enrolled. Among a total of 22 patients, headache was reported by 14. The proportion of patients reporting the main headache features required by diagnostic criteria were: 93 % for daily or nearly-daily occurrence; 71.5 % for diffuse/non-pulsating pain; 57 % for aggravation by coughing/straining. Thus, these three headache features, at least one of which is required for diagnosis of headache attributed to IIH, were present in the vast majority of our sample, suggesting that their inclusion should be regarded as appropriate. The analysis of our results may suggest possible changes in the current ICDH-2 criteria for headache attributed to IIH, based on the following considerations: the existence of remarkable differences as far as the relative frequency of each headache feature; the fact that diffuse and non-pulsating pain-included in the current classification as a single requirement-were not always found together; the high frequency of migrainous associated symptoms (nausea or photophobia-phonophobia were present in 71.5 % cases).
Chronic migraine (CM) represents an important medical issue, due to morbidity, high disability, p... more Chronic migraine (CM) represents an important medical issue, due to morbidity, high disability, presence of comorbidities, and medication overuse (MO). The prophylaxis of CM has not been extensively explored so far. Patients with CM are often treated with two or more compounds, although there is no clear evidence that polytherapy may be superior to monotherapy. We evaluated the percentage of prescription of polytherapy for the prophylaxis of CM in a clinical sample. We examined the charts of 98 CM patients admitted to our Headache Center for inpatient withdrawal program to stop MO. Results showed that only one drug for prophylaxis was prescribed in 20.4% cases, two or more drugs in 79.6%, with 63.3% of the total sample falling in the group ''true polytherapy'', i.e. all the drugs prescribed on daily basis were given to treat CM, and not only to treat concomitant conditions. In more than 60% cases a combination of drugs indicated for migraine prophylaxis and drugs only indicated for other conditions (mainly for psychiatric disorders) was prescribed. Our survey indicates that polytherapy may be rather common in CM, and suggests that comorbidities may strongly influence treatment choices.
We applied the recent International Headache Society (IHS) criteria for headache related to spont... more We applied the recent International Headache Society (IHS) criteria for headache related to spontaneous intracranial hypotension (SIH) to 90 consecutive patients with a final diagnosis of SIH confirmed by cerebral magnetic resonance imaging with contrast. Orthostatic headache (developing within 2 h of standing or sitting up) was present in 67 patients (75%) but appeared within 15 min after standing or sitting-as required by point A of the criteria-in only 53 (59%). Forty-four (49%) patients did not satisfy point A, including 22 (24%) with non-orthostatic headache and 14 (16%) with headache developing Ն 15 min after standing or sitting up; 80 (89%) did not satisfy point D. Only three (3%) patients had headache fully satisfying the IHS criteria. These findings indicate that the current IHS criteria do not capture most patients with SIH-associated headache. Excluding the requirement for response to epidural blood patch (criterion D) and considering headaches appearing within 2 h of sitting or standing up would capture more patients. ᮀ International Headache Society criteria, headache, orthostatic headache, classification, spontaneous intracranial hypotension
Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised ... more Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by two main clinical characteristics: pain and oculofacial autonomic phenomena. Three headache forms are grouped as TACs: cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) [1]. These are distinguished mainly on the basis of attack duration. It lasts from 15 to 180 min in CH, from 2 to 30 min in PH and from 5 to 240 s in SUNCT. The most effective drug preventative in PH is indomethacin even if in few cases other non-steroidal anti-inflammatory drugs have been reported to be effective [2]. SUNCT is commonly described as drug resistant. Recent studies report that lamotrigin may be the drug of choice for SUNCT [3, 4].
Spontaneous intracranial hypotension (SIH) is a rare disabling condition whose main clinical mani... more Spontaneous intracranial hypotension (SIH) is a rare disabling condition whose main clinical manifestation is orthostatic headache. We analysed clinical characteristics in relation to time to resolution in 90 consecutive patients diagnosed with SIH at our centre between 1993 and 2006. After excluding 7 patients lost to follow-up, the remaining 83 cases were divided into four groups: Group A (53 cases) with progressively worsening orthostatic headache; Group B (3 cases) with severe acute-onset orthostatic headache; Group C (9 cases) with fluctuating non-continuous headache, of mild severity, that, in 33% of cases, did not worsen on standing; Group D (18 cases), 5 with a previous history of headache, 14 with orthostatic headache, and 10 with altered neurological examination. Complete symptoms and neuroradiological resolution occurred during follow-up in Groups A, B and D, but was longer in Group D probably in relation to more severe clinical picture with altered neurological examination. However, after a mean of 52 months (range 24-108), none of the nine Group C patients had MRI indicating complete resolution. The main characteristic of Group C related to incomplete resolution was delayed diagnosis. These preliminary findings suggest that early diagnosis of SIH correlates with better outcome, further suggesting that patients with a new headache that may worsen on standing or sitting should undergo MRI with contrast to expedite a possible SIH diagnosis, even if the pain is relatively mild.
... M Leone, D Dodick1, A Rigamonti, D D'Amico, L Grazzi, E Mea & G Bussone Carlo Besta ... more ... M Leone, D Dodick1, A Rigamonti, D D'Amico, L Grazzi, E Mea & G Bussone Carlo Besta National Neurological Institute, Milano, Italy, and 1Mayo Headache Center, Cerebrovascular Clinic, Mayo Clinic Scottsdale, Scottsdale AZ, USA Massimo Leone, Carlo Besta National ...
Alterations of the intracranial pressure (ICP) may be present in several conditions. The aim of t... more Alterations of the intracranial pressure (ICP) may be present in several conditions. The aim of this brief review is to focus on two relatively rare conditions characterized by alterations in cerebro-spinal fluid dynamics--Spontaneous Intracranial hypotension (SIH) and Idiopathic Intracranial hypertension (IIH)--in which headache is one of the key symptoms. The most relevant clinical features, the expected MRI findings, and the therapeutic options regarding both conditions are discussed.
We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with... more We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH). Thirty-six (61%) patients were women; the mean age was 47 years (range 20-68). Cerebral MRI with contrast confirmed SIH in all patients. Headache characteristics were obtained by direct semistructured interview; in a minority of cases information was completed retrospectively through a phone call. All SIH patients suffered from headache. Early recognition of SIH may avoid dangerous worsening due to delayed diagnosis. Orthostatic headache, the main symptom, suggests the diagnosis.
In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic ce... more In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic cephalalgias' (TACs) central mechanisms. Positron emission tomography studies have shown that the posterior inferior hypothalamic grey matter is activated during cluster headache attacks as well as in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Voxel-based morphometric MRI has also documented alteration in the same area in cluster headache patients. These data suggest that the cluster headache generator is located in this region and leads us to hypothesise that stimulation of this brain area could relieve intractable cluster headache just as deep brain stimulation improves intractable movements disorders. This view received support by the observation that high frequency stimulation of the ipsilateral hypothalamus prevented attacks in an otherwise intractable chronic cluster headache patient previously treated unsuccessfully by surgical procedures to the trigeminal nerve. So far, 16 patients with intractable cronic cluster headache (CCH) and one intractable SUNCT patient have been successfully treated by hypothalamic stimulation. The procedures were well tolerated with no significant adverse events. Hypothalamic DBS is an efficacious and safe procedure to relieve otherwise intractable CCH and SUNCT.
To investigate the presence of Restless Legs Syndrome (RLS) in Cluster Headache (CH) patients com... more To investigate the presence of Restless Legs Syndrome (RLS) in Cluster Headache (CH) patients compared to headache-free controls. Cross-sectional case-control study of CH patients presenting at tertiary headache centers over the period January-December 2008. Fifty consecutive patients (6 women and 44 men) of mean age of 39.7 year (standard deviation 10.9) with episodic or chronic CH diagnosed according to ICHD-II criteria and 50 headache-free subjects matched by age and sex were recruited. None of the CH patients had RLS. Six (12%) headache-free controls had RLS. Our data indicate no probable relationship between CH and RLS. However, since both conditions have a circadian rhythm and are associated with altered melatonin secretion, we conjecture that reduced nocturnal melatonin in CH likely allows sustained dopaminergic activity which could be protective against RLS in CH patients.
Cluster headache (CH) is a primary headache with excruciatingly painful attacks that are strictly... more Cluster headache (CH) is a primary headache with excruciatingly painful attacks that are strictly unilateral. About 10% of cases experience no significant remission, and about 15% of these do not respond to medication, so surgery is considered. Neuroimaging studies show that the posterior inferior hypothalamus is activated during CH attacks and is plausibly the CH generator. We report on 16 chronic CH patients, with headaches refractory to all medication, who received long-term hypothalamic stimulation following electrode implant to the posterior inferior hypothalamus. After a mean follow-up of 23 months, a persistent pain-free to almost pain-free state was achieved in 13/16 patients (15/18 implants; 83.3%) a mean of 42 days (range 1-86 days) after monopolar stimulation initiation. Ten patients (11 implants) are completely pain-free. A common side effect was transient diplopia, which limited stimulation amplitude. In one patient, a small non-symptomatic haemorrhage into the 3rd ventricle occurred following implant, but regressed 24 h later. Persistent side effects are absent except in one patient with bilateral stimulation, in whom stimulation was stopped to resolve vertigo and worsened bradycardia, but was resumed later without further problems. Hypothalamic stimulation is an effective, safe and well tolerated treatment for chronic drug-refractory CH. It appears as a valid alternative to destructive surgical modalities, and has the additional advantage of being reversible.
In the last ten years pathophysiology of primary headaches has received new insights from neuroim... more In the last ten years pathophysiology of primary headaches has received new insights from neuroimaging studies. Positron emission tomography (PET) showed activation of specific brain structures, brainstem in migraine and hypothalamic grey in trigeminal autonomic cephalalgias. This brain activation suggests it may intervene both in a permissive or triggering manner and as a response to pain driven by the first division of the trigeminal nerve. Voxel-based morphometry has suggested that there is a correlation between the brain area activated specifically in acute cluster headache - the posterior hypothalamic grey matter - and an increase in grey matter in the same region. New insights into mechanisms of head pain have emerged thanks to neuroimaging obtained in experimentally induced headaches, and during peripheral and central neurostimulation.
Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster heada... more Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster headache (CH). We assessed acute hypothalamic stimulation to resolve ongoing CH attacks in 16 patients implanted to prevent chronic CH, investigating 136 attacks. A pain intensity reduction of > or =50% occurred in 25 of 108 evaluable attacks (23.1%). Acute hypothalamic stimulation is not effective in resolving ongoing CH attacks, suggesting that hypothalamic stimulation acts by complex mechanisms in CH prevention.
In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these ci... more In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.
AIDA Cefalee is a database for the management of headache patients developed on behalf of the Ita... more AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.
Patients with chronic migraine (CM) have high frequence of psychiatric comorbidity or psychologic... more Patients with chronic migraine (CM) have high frequence of psychiatric comorbidity or psychological distress. The presence of depression, anxiety, panic or obsessive disorders in these patients contributes to poor quality of life and can influence prognosis and treatment. A systematic investigation of psychiatric comorbidity is needed in patients with CM especially in those with medication overuse (MO), in order to reach a more comprehensive clinical management. We assessed the psychological profile of 50 patients, 40 women and 10 men suffering from CM with MO. The Spectrum Project, a complementary way of describing and assessing psychopathology with structured clinical interviews, was used for the psychological evaluation of the patients to explore personality traits. Spectrum instruments mood disorders (MOODS), panic agoraphobic disorders (PAS) and obsessive-compulsive disorder (OBS) were applied to study patients. OBS-questionnaire was positive in 28% of the patients, MOODS-questionnaire in 44%, PAS-questionnaire in 46%. 19 on 50 patients (38%) presented positivity to 2 or to all questionnaires in variable associations. None of the patients of the studied group had complete normal findings in the questionnaires. Clinical records of patients with OBS-questionnaire positivity showed a worse clinical course and tendency to relapse. These results suggest that psychological assessment is an essential step in the evaluation and treatment of patients with CM and MO. The remarkable percentage of OBSquestionnaire positivity in this group indicates that obsessive-compulsive trait represents besides depression and anxiety, a major risk of chronification and overusing.
Headache is one of the most common symptoms of idiopathic intracranial hypertension (IIH). The ai... more Headache is one of the most common symptoms of idiopathic intracranial hypertension (IIH). The aim of this study was to investigate the applicability of the diagnostic criteria for ''Headache attributed to IIH'' included in the current classification of headache disorders, particularly as far as the main headache features. A consecutive clinical series of IIH patients with demonstration of increased intracranial pressure by lumbar puncture in the recumbent position were enrolled. Among a total of 22 patients, headache was reported by 14. The proportion of patients reporting the main headache features required by diagnostic criteria were: 93 % for daily or nearly-daily occurrence; 71.5 % for diffuse/non-pulsating pain; 57 % for aggravation by coughing/straining. Thus, these three headache features, at least one of which is required for diagnosis of headache attributed to IIH, were present in the vast majority of our sample, suggesting that their inclusion should be regarded as appropriate. The analysis of our results may suggest possible changes in the current ICDH-2 criteria for headache attributed to IIH, based on the following considerations: the existence of remarkable differences as far as the relative frequency of each headache feature; the fact that diffuse and non-pulsating pain-included in the current classification as a single requirement-were not always found together; the high frequency of migrainous associated symptoms (nausea or photophobia-phonophobia were present in 71.5 % cases).
Chronic migraine (CM) represents an important medical issue, due to morbidity, high disability, p... more Chronic migraine (CM) represents an important medical issue, due to morbidity, high disability, presence of comorbidities, and medication overuse (MO). The prophylaxis of CM has not been extensively explored so far. Patients with CM are often treated with two or more compounds, although there is no clear evidence that polytherapy may be superior to monotherapy. We evaluated the percentage of prescription of polytherapy for the prophylaxis of CM in a clinical sample. We examined the charts of 98 CM patients admitted to our Headache Center for inpatient withdrawal program to stop MO. Results showed that only one drug for prophylaxis was prescribed in 20.4% cases, two or more drugs in 79.6%, with 63.3% of the total sample falling in the group ''true polytherapy'', i.e. all the drugs prescribed on daily basis were given to treat CM, and not only to treat concomitant conditions. In more than 60% cases a combination of drugs indicated for migraine prophylaxis and drugs only indicated for other conditions (mainly for psychiatric disorders) was prescribed. Our survey indicates that polytherapy may be rather common in CM, and suggests that comorbidities may strongly influence treatment choices.
We applied the recent International Headache Society (IHS) criteria for headache related to spont... more We applied the recent International Headache Society (IHS) criteria for headache related to spontaneous intracranial hypotension (SIH) to 90 consecutive patients with a final diagnosis of SIH confirmed by cerebral magnetic resonance imaging with contrast. Orthostatic headache (developing within 2 h of standing or sitting up) was present in 67 patients (75%) but appeared within 15 min after standing or sitting-as required by point A of the criteria-in only 53 (59%). Forty-four (49%) patients did not satisfy point A, including 22 (24%) with non-orthostatic headache and 14 (16%) with headache developing Ն 15 min after standing or sitting up; 80 (89%) did not satisfy point D. Only three (3%) patients had headache fully satisfying the IHS criteria. These findings indicate that the current IHS criteria do not capture most patients with SIH-associated headache. Excluding the requirement for response to epidural blood patch (criterion D) and considering headaches appearing within 2 h of sitting or standing up would capture more patients. ᮀ International Headache Society criteria, headache, orthostatic headache, classification, spontaneous intracranial hypotension
Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised ... more Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by two main clinical characteristics: pain and oculofacial autonomic phenomena. Three headache forms are grouped as TACs: cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) [1]. These are distinguished mainly on the basis of attack duration. It lasts from 15 to 180 min in CH, from 2 to 30 min in PH and from 5 to 240 s in SUNCT. The most effective drug preventative in PH is indomethacin even if in few cases other non-steroidal anti-inflammatory drugs have been reported to be effective [2]. SUNCT is commonly described as drug resistant. Recent studies report that lamotrigin may be the drug of choice for SUNCT [3, 4].
Spontaneous intracranial hypotension (SIH) is a rare disabling condition whose main clinical mani... more Spontaneous intracranial hypotension (SIH) is a rare disabling condition whose main clinical manifestation is orthostatic headache. We analysed clinical characteristics in relation to time to resolution in 90 consecutive patients diagnosed with SIH at our centre between 1993 and 2006. After excluding 7 patients lost to follow-up, the remaining 83 cases were divided into four groups: Group A (53 cases) with progressively worsening orthostatic headache; Group B (3 cases) with severe acute-onset orthostatic headache; Group C (9 cases) with fluctuating non-continuous headache, of mild severity, that, in 33% of cases, did not worsen on standing; Group D (18 cases), 5 with a previous history of headache, 14 with orthostatic headache, and 10 with altered neurological examination. Complete symptoms and neuroradiological resolution occurred during follow-up in Groups A, B and D, but was longer in Group D probably in relation to more severe clinical picture with altered neurological examination. However, after a mean of 52 months (range 24-108), none of the nine Group C patients had MRI indicating complete resolution. The main characteristic of Group C related to incomplete resolution was delayed diagnosis. These preliminary findings suggest that early diagnosis of SIH correlates with better outcome, further suggesting that patients with a new headache that may worsen on standing or sitting should undergo MRI with contrast to expedite a possible SIH diagnosis, even if the pain is relatively mild.
... M Leone, D Dodick1, A Rigamonti, D D'Amico, L Grazzi, E Mea & G Bussone Carlo Besta ... more ... M Leone, D Dodick1, A Rigamonti, D D'Amico, L Grazzi, E Mea & G Bussone Carlo Besta National Neurological Institute, Milano, Italy, and 1Mayo Headache Center, Cerebrovascular Clinic, Mayo Clinic Scottsdale, Scottsdale AZ, USA Massimo Leone, Carlo Besta National ...
Alterations of the intracranial pressure (ICP) may be present in several conditions. The aim of t... more Alterations of the intracranial pressure (ICP) may be present in several conditions. The aim of this brief review is to focus on two relatively rare conditions characterized by alterations in cerebro-spinal fluid dynamics--Spontaneous Intracranial hypotension (SIH) and Idiopathic Intracranial hypertension (IIH)--in which headache is one of the key symptoms. The most relevant clinical features, the expected MRI findings, and the therapeutic options regarding both conditions are discussed.
We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with... more We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH). Thirty-six (61%) patients were women; the mean age was 47 years (range 20-68). Cerebral MRI with contrast confirmed SIH in all patients. Headache characteristics were obtained by direct semistructured interview; in a minority of cases information was completed retrospectively through a phone call. All SIH patients suffered from headache. Early recognition of SIH may avoid dangerous worsening due to delayed diagnosis. Orthostatic headache, the main symptom, suggests the diagnosis.
In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic ce... more In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic cephalalgias' (TACs) central mechanisms. Positron emission tomography studies have shown that the posterior inferior hypothalamic grey matter is activated during cluster headache attacks as well as in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Voxel-based morphometric MRI has also documented alteration in the same area in cluster headache patients. These data suggest that the cluster headache generator is located in this region and leads us to hypothesise that stimulation of this brain area could relieve intractable cluster headache just as deep brain stimulation improves intractable movements disorders. This view received support by the observation that high frequency stimulation of the ipsilateral hypothalamus prevented attacks in an otherwise intractable chronic cluster headache patient previously treated unsuccessfully by surgical procedures to the trigeminal nerve. So far, 16 patients with intractable cronic cluster headache (CCH) and one intractable SUNCT patient have been successfully treated by hypothalamic stimulation. The procedures were well tolerated with no significant adverse events. Hypothalamic DBS is an efficacious and safe procedure to relieve otherwise intractable CCH and SUNCT.
To investigate the presence of Restless Legs Syndrome (RLS) in Cluster Headache (CH) patients com... more To investigate the presence of Restless Legs Syndrome (RLS) in Cluster Headache (CH) patients compared to headache-free controls. Cross-sectional case-control study of CH patients presenting at tertiary headache centers over the period January-December 2008. Fifty consecutive patients (6 women and 44 men) of mean age of 39.7 year (standard deviation 10.9) with episodic or chronic CH diagnosed according to ICHD-II criteria and 50 headache-free subjects matched by age and sex were recruited. None of the CH patients had RLS. Six (12%) headache-free controls had RLS. Our data indicate no probable relationship between CH and RLS. However, since both conditions have a circadian rhythm and are associated with altered melatonin secretion, we conjecture that reduced nocturnal melatonin in CH likely allows sustained dopaminergic activity which could be protective against RLS in CH patients.
Cluster headache (CH) is a primary headache with excruciatingly painful attacks that are strictly... more Cluster headache (CH) is a primary headache with excruciatingly painful attacks that are strictly unilateral. About 10% of cases experience no significant remission, and about 15% of these do not respond to medication, so surgery is considered. Neuroimaging studies show that the posterior inferior hypothalamus is activated during CH attacks and is plausibly the CH generator. We report on 16 chronic CH patients, with headaches refractory to all medication, who received long-term hypothalamic stimulation following electrode implant to the posterior inferior hypothalamus. After a mean follow-up of 23 months, a persistent pain-free to almost pain-free state was achieved in 13/16 patients (15/18 implants; 83.3%) a mean of 42 days (range 1-86 days) after monopolar stimulation initiation. Ten patients (11 implants) are completely pain-free. A common side effect was transient diplopia, which limited stimulation amplitude. In one patient, a small non-symptomatic haemorrhage into the 3rd ventricle occurred following implant, but regressed 24 h later. Persistent side effects are absent except in one patient with bilateral stimulation, in whom stimulation was stopped to resolve vertigo and worsened bradycardia, but was resumed later without further problems. Hypothalamic stimulation is an effective, safe and well tolerated treatment for chronic drug-refractory CH. It appears as a valid alternative to destructive surgical modalities, and has the additional advantage of being reversible.
In the last ten years pathophysiology of primary headaches has received new insights from neuroim... more In the last ten years pathophysiology of primary headaches has received new insights from neuroimaging studies. Positron emission tomography (PET) showed activation of specific brain structures, brainstem in migraine and hypothalamic grey in trigeminal autonomic cephalalgias. This brain activation suggests it may intervene both in a permissive or triggering manner and as a response to pain driven by the first division of the trigeminal nerve. Voxel-based morphometry has suggested that there is a correlation between the brain area activated specifically in acute cluster headache - the posterior hypothalamic grey matter - and an increase in grey matter in the same region. New insights into mechanisms of head pain have emerged thanks to neuroimaging obtained in experimentally induced headaches, and during peripheral and central neurostimulation.
Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster heada... more Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster headache (CH). We assessed acute hypothalamic stimulation to resolve ongoing CH attacks in 16 patients implanted to prevent chronic CH, investigating 136 attacks. A pain intensity reduction of > or =50% occurred in 25 of 108 evaluable attacks (23.1%). Acute hypothalamic stimulation is not effective in resolving ongoing CH attacks, suggesting that hypothalamic stimulation acts by complex mechanisms in CH prevention.
In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these ci... more In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.
AIDA Cefalee is a database for the management of headache patients developed on behalf of the Ita... more AIDA Cefalee is a database for the management of headache patients developed on behalf of the Italian Neurological Association for Headache Research (ANIRCEF). The system integrates a diagnostic expert system able to suggest the correct ICHD-II diagnosis once all clinical characteristics of a patient's headache have been collected. The software has undergone a multicentre validation study to assess: its diagnostic accuracy; the impact of using the software on visit duration; the userfriendliness degree of the software interface; and patients' acceptability of computer-assisted interview. Five Italian headache centres participated in the study. The results of this study validate AIDA Cefalee as a reliable diagnostic tool for primary headaches that can improve diagnostic accuracy with respect to the standard clinical method without increasing the time length of visits even when used by operators with basic computer experience.
Patients with chronic migraine (CM) have high frequence of psychiatric comorbidity or psychologic... more Patients with chronic migraine (CM) have high frequence of psychiatric comorbidity or psychological distress. The presence of depression, anxiety, panic or obsessive disorders in these patients contributes to poor quality of life and can influence prognosis and treatment. A systematic investigation of psychiatric comorbidity is needed in patients with CM especially in those with medication overuse (MO), in order to reach a more comprehensive clinical management. We assessed the psychological profile of 50 patients, 40 women and 10 men suffering from CM with MO. The Spectrum Project, a complementary way of describing and assessing psychopathology with structured clinical interviews, was used for the psychological evaluation of the patients to explore personality traits. Spectrum instruments mood disorders (MOODS), panic agoraphobic disorders (PAS) and obsessive-compulsive disorder (OBS) were applied to study patients. OBS-questionnaire was positive in 28% of the patients, MOODS-questionnaire in 44%, PAS-questionnaire in 46%. 19 on 50 patients (38%) presented positivity to 2 or to all questionnaires in variable associations. None of the patients of the studied group had complete normal findings in the questionnaires. Clinical records of patients with OBS-questionnaire positivity showed a worse clinical course and tendency to relapse. These results suggest that psychological assessment is an essential step in the evaluation and treatment of patients with CM and MO. The remarkable percentage of OBSquestionnaire positivity in this group indicates that obsessive-compulsive trait represents besides depression and anxiety, a major risk of chronification and overusing.
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