The Evaluation of Atherosclerosis in Migraine Patients

Pain Practice

Volume 13, Issue 1, pages 41–45, January 2013

1. Fahri Halit Besir MD¹, 
2. Abdulkadir Koçer MD, MSc², 
3. Süber Dikici MD³, 
4. Sibel Yazgan MD¹, 
5. Şeyma Ozdem MD³

Article first published online: 24 APR 2012
DOI: 10.1111/j.1533-2500.2012.00551.x

Abstract  A potential association might exist between atherosclerosis and migraine. 

Carotid intima-media thickness (CIMT) is a marker of generalized atherosclerosis; hence, we aimed to assess CIMT in migraine patients. This study included 30 patients and 60 healthy controls aged between 20 and 40 years. 

Episodic migraine diagnosis was made according to the criteria of International Headache Society (IHS). 

Healthy controls who do not suffer any headache problems were selected from among hospital and laboratory staffs. All subjects were evaluated regarding some parameters and features known to be associated with migraine and vascular changes, that is, gender, age, body mass index, blood pressure, cholesterol, smoking habits, used hormonal contraceptives, and history of disease. The left common carotid arteries of the subjects were examined, and CIMT was measured with real-time gray-scale sonography. Mean values and standard deviations were calculated. All measurements were made in migraine-free periods. Migraine patients and control subjects were well matched for those parameters known to be associated with vascular changes, that is, gender, age, BMI, blood pressure, and cholesterol. CIMT values were higher in patients. 

The results showed that the mean CCA IMT values were 0.493 ± 0.074 mm and 0.409 ± 0.053 mm in migraine patients and controls, respectively (P < 0.001). 

There is a relationship between atherosclerosis and inflammation in migraine patients. The risk of cranial inflammatory arteriopathy increases in repeated attacks of migraine. Our study also supports that high number of attacks and attack duration are important in the development of atherosclerosis.

Association Between Headache and Serum 25-Hydroxyvitamin D; the Tromsø Study: Tromsø 6

Headache: The Journal of Head and Face Pain

1. Marie Kjærgaard MD^*, 
2. Anne Elise Eggen PhD, 
3. Ellisiv B. Mathiesen PhD, 
4. Rolf Jorde PhD

Article first published online: 13 SEP 2012DOI: 10.1111/j.1526-4610.2012.02250.x

Background.— High prevalence of headache has been associated with high latitude, thus suggesting a relation with vitamin D. However, there are so far no reports on the association between serum 25-hydroxyvitamin D (25[OH]D) and headache.

Objective.— To investigate the association between headache and serum 25(OH)D in a general population.

Methods.— Cross-sectional study based on questionnaires from 11,614 persons who participated in the sixth survey of the Tromsø Study (Tromsø 6) carried out in 2007-2008. The data were stratified according to smoking status and analyzed with regard to migraine and non-migraine headache. Adjustments were done for age, body mass index (BMI), gender, season, chronic diseases, education, physical exercise, and alcohol consumption.

Results.— Headache of non-migraine type was associated with low levels of serum 25(OH)D with an odds ratio (OR) of 1.20 (1.04-1.39) in the lowest quartile as compared to the highest serum 25(OH)D quartile. No significant association was found between migraine and serum 25(OH)D.

Conclusion.— Non-migraine headache was associated with low levels of serum 25(OH)D. Although adjustment were done for possible confounders, this finding may still reflect lifestyle rather than causality, and further studies are needed to investigate this. No association was found between serum 25(OH)D and migraine.

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Headache: The Journal of Head and Face Pain

1. Karin G. Johnson MD^*, 
2. Alexis M. Ziemba BA,
3. Jane L. Garb MSPH

Article first published online: 10 SEP 2012

DOI: 10.1111/j.1526-4610.2012.02251.x

© 2012 American Headache Society

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP).

Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment.

Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow-up ranged from 18 to 42 months.

Results.— Eighty-two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension-type headache, 6% chronic post-traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty-two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP.

Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.

Aspirin's Effect on Platelet Inhibition in Migraineurs

Headache: The Journal of Head and Face Pain

Volume 52, Issue 8, pages 1207–1218, September 2012

1. Jill T. Jesurum PhD^*, 
2. Cindy J. Fuller PhD,
3. Natalia Murinova MD, 
4. Colleen M. Truva RN, BSN, 
5. Sylvia M. Lucas MD, PhD

Objective.— To assess the effect of aspirin on platelet reactivity in migraineurs.

Background.— Migraineurs, particularly women with aura and high monthly migraine frequency, are at risk for ischemic stroke and myocardial infarction (MI). High on-aspirin platelet reactivity (HAPR), or aspirin resistance, has been reported in females and patients with coronary artery disease, and is associated with adverse outcomes.

Methods.— Using a single group, pretest/posttest design, 50 migraineurs without prior history of stroke or MI were prospectively treated for 14 to 21 consecutive days with 325 mg generic enteric-coated aspirin, after undergoing a 14-day aspirin washout. Platelet reactivity was measured after aspirin washout and following aspirin treatment. Subjects were screened for HAPR using the VerifyNow™ Aspirin Assay (Accumetrics, San Diego, CA, USA). HAPR was defined as ≥460 Aspirin Reaction Units (ARU; primary endpoint).

Results.— Fifty subjects, 44 (88%) female, aged (mean ± standard deviation) 43 ± 12 years were enrolled. Twelve (24%; 95% CI 12-36%) subjects, all female, had HAPR and were classified as aspirin resistant. Subjects with HAPR had lower baseline hemoglobin levels than those without HAPR (P = .03). Baseline hemoglobin was significantly correlated with final ARU (r = −0.39, P = .005).

Conclusions.— Findings of this exploratory study suggest that migraineurs have a higher prevalence of HAPR than healthy volunteers or patients with coronary artery disease taking aspirin 325 mg. The clinical implications of HAPR in migraine warrant further exploration due to the risk of stroke and MI and the potential need for antiplatelet therapy in this population.

Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache

1. Headache: The Journal of Head and Face Pain

   Volume 52, Issue 8, pages 1226–1235, September 2012

1. Dean H. Watson MAppSc^*, 
2. Peter D. Drummond PhD

Objective.— To investigate if and to what extent typical head pain can be reproduced in tension-type headache (TTH), migraine without aura sufferers, and controls when sustained pressure was applied to the lateral posterior arch of C1 and the articular pillar of C2, stressing the atlantooccipital and C2-3 segments respectively.

Background.— Occipital and neck symptoms often accompany primary headache, suggesting involvement of cervical afferents in central pain processing mechanisms in these disorders. Referral of head pain from upper cervical structures is made possible by convergence of cervical and trigeminal nociceptive afferent information in the trigemino-cervical nucleus. Upper cervical segmental and C2-3 zygapophysial joint dysfunction is recognized as a potential source of noxious afferent information and is present in primary headache sufferers. Furthermore, referral of head pain has been demonstrated from symptomatic upper cervical segments and the C2-3 zygapophysial joints, suggesting that head pain referral may be a characteristic of cervical afferent involvement in headache.

Methods.— Thirty-four headache sufferers and 14 controls were examined interictally. Headache patients were diagnosed according the criteria of the International Headache Society and comprised 20 migraine without aura (females n = 18; males n = 2; average age 35.3 years) and 14 TTH sufferers (females n = 11; males n = 3; average age 30.7 years). Two techniques were used specifically to stress the atlantooccipital segments (Technique 1 – C1) and C2-3 zygapophysial joints (Technique 2 – C2). Two techniques were also applied to the arm – the common extensor origin and the mid belly of the biceps brachii. Participants reported reproduction of head pain with “yes” or “no” and rated the intensity of head pain and local pressure of application on a scale of 0 -10, where 0 = no pain and 10 = intolerable pain.

Results.— None of the subjects reported head pain during application of techniques on the arm. Head pain referral during the cervical examination was reported by 8 of 14 (57%) control participants, all TTH patients and all but 1 migraineur (P < .002). In each case, participants reported that the referred head pain was similar to the pain they usually experienced during TTH or migraine. The frequency of head pain referral was identical for Techniques 1 and 2. The intensity of referral did not differ between Technique 1 and Technique 2 or between groups. Tenderness ratings to thumb pressure were comparable between the Techniques 1 and 2 when pressure was applied to C1 and C2 respectively and across groups. Similarly, there were no significant differences for tenderness ratings to thumb pressure between Technique 1 and Technique 2 on the arm or between groups. While tenderness ratings to thumb pressure for Technique 2 were similar for both referral (n = 41) and non-referral (n = 7) groups, tenderness ratings for Technique 1 in the referral group were significantly greater when compared with the non-referral group (P = .01).

Conclusions.— Our data support the continuum concept of headache, one in which noxious cervical afferent information may well be significantly underestimated. The high incidence of reproduction of headache supports the evaluation of musculoskeletal features in patients presenting with migrainous and TTH symptoms. This, in turn, may have important implications for understanding the pathophysiology of headache and developing alternative treatment options.

Effect of Sex and Estrogens on Neuronal Activation in an Animal Model of Migraine

Headache: The Journal of Head and Face Pain

Article first published online: 22 AUG 2012

DOI: 10.1111/j.1526-4610.2012.02249.x

1. Rosaria Greco PhD^*, 
2. Cristina Tassorelli MD, 
3. A. Stefania Mangione PhD, 
4. Antonella Smeraldi PhD, 
5. Marta Allena MD, 
6. Giorgio Sandrini MD, 
7. Giuseppe Nappi MD, 
8. Rossella E. Nappi MD

Objective.— In this study, we evaluated the influence of sex and estrogen treatment on nitroglycerin (NTG)-
induced neuronal activation in the rat brain.

Background.— Systemic NTG activates cerebral nuclei of rat involved in nociceptive transmission, as well as in neuroendocrine and autonomic functions. These changes are considered relevant for migraine, since NTG consistently induces spontaneous-like attacks in migraineurs.

Methods.— Intact and castrated male and female rats, and castrated female rats treated with estradiol benzoate (or placebo) were injected with NTG and sacrificed after 4 hours. Rats were perfused, and their brains were processed for Fos protein, a marker of neuronal activation.

Results.— Data showed a reduced expression of NTG-induced Fos protein in the paraventricular nucleus (PVH), supraoptic nucleus (SON), and nucleus trigeminalis caudalis (SPVC) of male rats in comparison with female rats. Furthermore, in castrated female rats, NTG-induced neuronal activation was reduced in PVH, SON, central nucleus of the amygdala (AMI), nucleus tractus solitarius (NTS), area postrema (AP), and SPVC, while in castrated male rats Fos expression was reduced uniquely in the SPVC. Chronic administration of estrogens restored Fos protein expression in PVH, SON, AMI, NTS, AP, and SPVC in castrated female rats.

Conclusion.— These data provide a support for the existence of a sexual dimorphism in NTG-induced neuronal activation, and they prompt a specific model for evaluating and modulating the influence of estrogens upon the cerebral structures implicated in the pathophysiology of migraine.

Spontaneous Trigeminal Allodynia in Rats: A Model of Primary Headache

Headache: The Journal of Head and Face Pain

1. M.L. Oshinsky PhD^*, 
2. M.M. Sanghvi MS, 
3. C.R. Maxwell PhD, 
4. D. Gonzalez MS, 
5. R.J. Spangenberg MLAS, 
6. M. Cooper BS, 
7. S.D. Silberstein MD

1.  michael.oshinsky@jefferson.edu

DOI: 10.1111/j.1526-4610.2012.02247.x

Abstract

Animal models are essential for studying the pathophysiology of headache disorders and as a screening tool for new therapies. Most animal models modify a normal animal in an attempt to mimic migraine symptoms. They require manipulation to activate the trigeminal nerve or dural nociceptors. At best, they are models of secondary headache. No existing model can address the fundamental question: How is a primary headache spontaneously initiated?

In the process of obtaining baseline periorbital von Frey thresholds in a wild-type Sprague-Dawley rat, we discovered a rat with spontaneous episodic trigeminal allodynia (manifested by episodically changing low periorbital pain threshold). Subsequent mating showed that the trait is inherited. Animals with spontaneous trigeminal allodynia allow us to study the pathophysiology of primary recurrent headache disorders.

To validate this as a model for migraine, we tested the effects of clinically proven acute and preventive migraine treatments on spontaneous changes in rat periorbital sensitivity. Sumatriptan, ketorolac, and dihydroergotamine temporarily reversed the low periorbital pain thresholds. Thirty days of chronic valproic acid treatment prevented spontaneous changes in trigeminal allodynia. After discontinuation, the rats returned to their baseline of spontaneous episodic threshold changes. We also tested the effects of known chemical and dietary human migraine triggers. On days when the rats did not have allodynia and showed normal periorbital von Frey thresholds, glycerol trinitrate and calcitonin gene related peptide induced significant decreases in the periorbital pain threshold.

This model can be used as a predictive model for drug development and for studies of putative biomarkers for headache diagnosis and treatment.

© 2012 American Headache Society

Aspirin's Effect on Platelet Inhibition in Migraineurs

Headache: The Journal of Head and Face Pain

DOI: 10.1111/j.1526-4610.2012.02143.x

1. Jill T. Jesurum PhD^*, 
2. Cindy J. Fuller PhD,
3. Natalia Murinova MD, 
4. Colleen M. Truva RN, BSN, 
5. Sylvia M. Lucas MD, PhD

Objective.— To assess the effect of aspirin on platelet reactivity in migraineurs.

Background.— Migraineurs, particularly women with aura and high monthly migraine frequency, are at risk for ischemic stroke and myocardial infarction (MI). High on-aspirin platelet reactivity (HAPR), or aspirin resistance, has been reported in females and patients with coronary artery disease, and is associated with adverse outcomes.

Methods.— Using a single group, pretest/posttest design, 50 migraineurs without prior history of stroke or MI were prospectively treated for 14 to 21 consecutive days with 325 mg generic enteric-coated aspirin, after undergoing a 14-day aspirin washout. Platelet reactivity was measured after aspirin washout and following aspirin treatment. Subjects were screened for HAPR using the VerifyNow™ Aspirin Assay (Accumetrics, San Diego, CA, USA). HAPR was defined as ≥460 Aspirin Reaction Units (ARU; primary endpoint).

Results.— Fifty subjects, 44 (88%) female, aged (mean ± standard deviation) 43 ± 12 years were enrolled. Twelve (24%; 95% CI 12-36%) subjects, all female, had HAPR and were classified as aspirin resistant. Subjects with HAPR had lower baseline hemoglobin levels than those without HAPR (P = .03). Baseline hemoglobin was significantly correlated with final ARU (r = −0.39, P = .005).

Conclusions.— Findings of this exploratory study suggest that migraineurs have a higher prevalence of HAPR than healthy volunteers or patients with coronary artery disease taking aspirin 325 mg. The clinical implications of HAPR in migraine warrant further exploration due to the risk of stroke and MI and the potential need for antiplatelet therapy in this population.

Effects of light deprivation on visual evoked potentials in migraine without aura

BMC Neurology 2011, 11:91doi:10.1186/1471-2377-11-91

Published:	27 July 2011

Research article

Gianluca Coppola , Julien Cremers , Pascale Gerard , Francesco Pierelli and Jean Schoenen

Abstract (provisional)

Background

The mechanisms underlying the interictal habituation deficit of cortical visual evoked potentials (VEP) in migraine are not well understood. Abnormal long-term functional plasticity of the visual cortex may play a role and it can be assessed experimentally by light deprivation (LD).

Methods

We have compared the effects of LD on VEP in migraine patients without aura between attacks (MO, n=17) and in healthy volunteers (HV, n=17). Six sequential blocks of 100 averaged VEP at 3.1 Hz were recorded before and after 1 hour of LD. We measured VEP P100 amplitude of the 1st block of 100 sweeps and its change over 5 sequential blocks of 100 responses.

Results

In HV, the consequence of LD was a reduction of 1st block VEP amplitude and of the normal habituation pattern. By contrast, in MO patients, the interictal habituation deficit was not significantly modified, although 1st block VEP amplitude, already lower than in HV before LD, further decreased after LD.

Conclusions

Light deprivation is thought to decrease both excitatory and subsequent inhibitory processes in visual cortex, which is in line with our findings in healthy volunteers. The VEP results in migraine patients suggest that early excitation was adequately suppressed, but not the inhibitory mechanisms occurring during long term stimulation and habituation. Accordingly, deficient intracortical inhibition is unlikely to be a primary factor in migraine pathophysiology and the habituation deficit

What initiates a migraine attack? Conclusions from four longitudinal studies of quantitative EEG and steady-state visual-evoked potentials in migraineurs.

Acta Neurol Scand: 2011: 124 (Suppl. 191): 56–63. © 2011 John Wiley & Sons A/S.

Bjørk M, Stovner LJ, Hagen K, Sand T.

Objectives – Quantitative electroencephalograpic (QEEG) frequency spectra and steady-state visual-evoked potentials (SSVEP) are indicators of corticothalamic excitability (e.g., arousal). Increased interictal excitability is suggested to be an important element in the migraine pathophysiology. In this paper, we summarize our results from four studies of QEEG and SSVEP recordings in migraineurs interictally and in the days before an attack with the intention to shed light on attack-initiating mechanisms.

Material and methods – Thirty-two healthy controls, 33 migraineurs without and eight with aura each had three EEGs with photic stimulation on different days. Using the patient headache diaries, we classified the recordings as interictal, preictal, ictal, or post-ictal retrospectively. Interictal recordings were compared pairwise with attack-related EEGs from the same patient as well as with control EEGs. We also correlated clinical variables with the QEEG and SSVEP data.

Results – Between attacks, we found increased relative theta activity and attenuated medium-frequency photic responses in migraineurs without aura compared with those in controls. Within 36 h before the attack, slow and asymmetric EEG activity developed. Increased trigger sensitivity and photophobia correlated with higher theta power and depressed photic responses. Attack duration, migraine history duration, and pain intensity were associated with EEG slowing.

Conclusions – A general tendency toward EEG slowing and depression of photic responses characterized the migraine group. This pattern was also related to increased severity of symptoms. A change in cortical activity occurred within 36 h before attacks. Our results indicate that thalamocortical hypoexcitability is associated with attack initiation and sensory hypersensitivity in migraine.

What initiates a migraine attack? Conclusions from four longitudinal studies of quantitative EEG and steady-state visual-evoked potentials in migraineurs.

Acta Neurol Scand: 2011: 124 (Suppl. 191): 56–63. © 2011 John Wiley & Sons A/S.
Bjørk M, Stovner LJ, Hagen K, Sand T. 


Objectives – Quantitative electroencephalograpic (QEEG) frequency spectra and steady-state visual-evoked potentials (SSVEP) are indicators of corticothalamic excitability (e.g., arousal). Increased interictal excitability is suggested to be an important element in the migraine pathophysiology. In this paper, we summarize our results from four studies of QEEG and SSVEP recordings in migraineurs interictally and in the days before an attack with the intention to shed light on attack-initiating mechanisms.


Material and methods – Thirty-two healthy controls, 33 migraineurs without and eight with aura each had three EEGs with photic stimulation on different days. Using the patient headache diaries, we classified the recordings as interictal, preictal, ictal, or post-ictal retrospectively. Interictal recordings were compared pairwise with attack-related EEGs from the same patient as well as with control EEGs. We also correlated clinical variables with the QEEG and SSVEP data.


Results – Between attacks, we found increased relative theta activity and attenuated medium-frequency photic responses in migraineurs without aura compared with those in controls. Within 36 h before the attack, slow and asymmetric EEG activity developed. Increased trigger sensitivity and photophobia correlated with higher theta power and depressed photic responses. Attack duration, migraine history duration, and pain intensity were associated with EEG slowing.


Conclusions – A general tendency toward EEG slowing and depression of photic responses characterized the migraine group. This pattern was also related to increased severity of symptoms. A change in cortical activity occurred within 36 h before attacks. Our results indicate that thalamocortical hypoexcitability is associated with attack initiation and sensory hypersensitivity in migraine.

Causes of headache in patients with a primary diagnosis of sinus headache

European Archives of Oto-Rhino-Laryngology (May 2011)

Foroughipour M, Sharifian SM, Shoeibi A, Ebdali Barabad N, Bakhshaee M; 

Headache is a common occurrence among the general population. Although the pain could be a symptom of acute sinusitis, chronic sinusitis is not considered as a usual cause of headache. In addition, autonomic-related symptoms in the sinonasal region may be associated with vascular pain. Confusion regarding these symptoms could lead to an incorrect diagnosis of sinusitis. A prospective cross-sectional study was conducted at two tertiary referral centers with residency programs in otorhinolaryngology, head and neck surgery and neurology. The study included 58 patients with a diagnosis of "sinus headache" made by a primary care physician. Exclusion criteria were as follows: previous diagnosis of migraine or tension-type headache; evidence of sinus infection during the past 6 months; and the presence of mucopurulent secretions. After comprehensive otorhinolaryngologic and neurologic evaluation, appropriate treatment was started according to the final diagnosis and the patient was assessed monthly for 6 months. The final diagnoses were migraine, tension-type headache and chronic sinusitis with recurrent acute episodes in 68, 27 and 5% of the patients, respectively. Recurrent antibiotic therapy was received by 73% of patients with tension-type headache and 66% with migraine. Sinus endoscopy was performed in 26% of the patients. Therapeutic nasal septoplasty was performed in 16% of the patients with a final diagnosis of migraine, and 13% with tension-type headache. Many patients with self-described or primary care physician labeled "sinus headache" have no sinonasal abnormalities. Instead, most of them meet the IHS criteria for migraine or tension-type headache.

Management of vestibular migraine

1. Therapeutic Advances in Neurological Disorders 
May 2011 vol. 4 no. 3 183-191
2. Alexandre R. Bisdorff, Centre Hospitalier Emile Mayrisch, rue Emile Mayrisch, Esch-sur-Alzette, 4003 Luxembourg    alexbis@pt.lu

Vestibular Migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo. The duration of attacks varies from seconds to days, usually lasting minutes to hours, and they mostly occur independently of headaches. Long-lasting individual attacks are treated with generic antivertiginous and antiemetic drugs. Specific antimigraine drugs are unlikely to be very effective for rescue. The mainstay of the management of vestibular migraine is prophylactic medication. To date, there are no controlled trials available; the body of knowledge builds on case series and retrospective or observational studies. Most drugs are also used for the prevention of migraine headaches. The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established. Nonpharmacological measures such as diet, sleep, hygiene and avoidance of triggers are recommended as they are for migraine. Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

Pneumatized superior turbinate as a cause of headache.

Head Face Med. 2007 Jan 9;3:3.

Homsioglou E, Balatsouras DG, Alexopoulos G, Kaberos A, Katotomichelakis M, Danielides V.

Source

Department of Otolaryngology, Medical School, Democritus University of Thrace. Dragana, Alexandroupolis, Greece. homsioglou@hol.gr

Abstract

BACKGROUND:

A pneumatized superior turbinate is a rare cause of headache. Nasal endoscopy alone, does not provide us with adequate information for this inaccessible area of the superior nasal cavity. A coronal computed tomography (CT) must be obtained to confirm the diagnosis.

CASE PRESENTATION:

We present a 40-year-old female with migraine-type headache and nasal obstruction. Nasal endoscopy revealed a mild septal deviation, a right middle concha bullosa and a paradoxically curved middle turbinate on the left side. Coronal CT-scan showed also the presence of a superior concha bullosa on the left, which was in close contact with the nasal septum. The patient underwent septoplasty and bilateral endoscopic sinus surgery, including partial removal of both the pneumatized middle turbinates in conjunction with gentle lateralization and resection of the lower half of the left superior turbinate. Prompt relief from headache and nasal symptoms was obtained.

CONCLUSION:

Pneumatized superior concha causing migrainous headache is a rare finding. Endoscopic surgery may provide permanent relief of symptoms.

A Double-Blind Placebo-Controlled Pilot Study of Sublingual Feverfew and Ginger (LipiGesic(TM) M) in the Treatment of Migraine.

Headache. 2011 Jun 1.

 doi: 10.1111/j.1526-4610.2011.01910.x. [Epub ahead of print]

Cady RK, Goldstein J, Nett R, Mitchell R, Beach ME, Browning R.

Source

From the Headache Care Center, Springfield, MO, USA (R.K. Cady); San Francisco Headache Clinic, San Francisco, CA, USA (J. Goldstein); Texas Headache Associates, San Antonio, TX, USA (R. Nett); PuraMed BioScience, Inc., Schofield, WI, USA (R. Mitchell); Clinvest/A Division of Banyan Group, Inc., Springfield, MO, USA (M.E. Beach and R. Browning).

Abstract

Background.- Therapeutic needs of migraineurs vary considerably from patient to patient and even attack to attack. Some attacks require high-end therapy, while other attacks have treatment needs that are less immediate. While triptans are considered the "gold standard" of migraine therapy, they do have limitations and many patients are seeking other therapeutic alternatives. In 2005, an open-label study of feverfew/ginger suggested efficacy for attacks of migraine treated early during the mild headache phase of the attack. 

Methods/Materials.- In this multi-center pilot study, 60 patients treated 221 attacks of migraine with sublingual feverfew/ginger or placebo. All subjects met International Headache Society criteria for migraine with or without aura, experiencing 2-6 attacks of migraine per month within the previous 3 months. Subjects had <15 headache days per month and were not experiencing medication overuse headache. Inclusion required that subjects were able to identify a period of mild headache in at least 75% of attacks. Subjects were required to be able to distinguish migraine from non-migraine headache. Subjects were randomized 3:1 to receive either sublingual feverfew/ginger or a matching placebo and were instructed but not required to treat with study medication at the earliest recognition of migraine. 

Results.- Sixty subjects treated 208 evaluable attacks of migraine over a 1-month period; 45 subjects treated 163 attacks with sublingual feverfew/ginger and 15 subjects treated 58 attacks with a sublingual placebo preparation. Evaluable diaries were completed for 151 attacks of migraine in the population using feverfew/ginger and 57 attacks for those attacks treated with placebo. At 2 hours, 32% of subjects receiving active medication and 16% of subjects receiving placebo were pain-free (P = .02). At 2 hours, 63% of subjects receiving feverfew/ginger found pain relief (pain-free or mild headache) vs 39% for placebo (P = .002). Pain level differences on a 4-point pain scale for those receiving feverfew/ginger vs placebo were -0.24 vs -0.04 respectively (P = .006). Feverfew/ginger was generally well tolerated with oral numbness and nausea being the most frequently occurring adverse event. 

Conclusion.- Sublingual feverfew/ginger appears safe and effective as a first-line abortive treatment for a population of migraineurs who frequently experience mild headache prior to the onset of moderate to severe headache.