Prevalence of cranial autonomic parasympathetic symptoms in chronic migraine: Usefulness of a new scale

Cephalalgia ◽  
2015 ◽  
Vol 36 (4) ◽  
pp. 346-350 ◽  
Author(s):  
Nuria Riesco ◽  
Angel I Pérez-Alvarez ◽  
Laura Verano ◽  
Carmen García-Cabo ◽  
Juana Martínez-Ramos ◽  
...  
Keyword(s):  
Chronic Migraine ◽  
Nasal Congestion ◽  
Primary Headaches ◽  
Conjunctival Injection ◽  
Autonomic Symptoms ◽  
Cranial Autonomic Symptoms ◽  
Eyelid Oedema ◽  
Headache Clinic ◽  
First Time ◽  
New Criteria

Background Cranial autonomic symptoms (CAS) seem to appear in around half of migraine patients. Objective Our aim was to analyse the prevalence and profile of CAS, mainly of cranial autonomic parasympathetic symptoms (CAPS), in a series of patients with chronic migraine (CM) according the new criteria for autonomic symptoms in the current IHS classification. Patients and methods We recruited consecutive CM patients attending our headache clinic. Five CPAS were surveyed: lacrimation, conjunctival injection, eyelid oedema, ear fullness and nasal congestion. They were graded as 0 (absent), 1 (present and mild) and 2 (present and conspicuous); therefore the score in this CAPS scale ranges from 0 to 10 points. As a cranial autonomic sympathetic symptom (CSAS), we also asked about the presence of ptosis. Results We interviewed 100 CM patients. Their mean age was 45 years (18–63 years); 93 were females. Eighteen had no CAPS, while 82 reported at least one CAPS. There were only six patients with scores higher than 5, the mean and median CAPS being 2.1 and 2, respectively. Prevalence of CAPS was lacrimation (49%), conjunctival injection (44%), eyelid oedema (39%), ear fullness (30%) and nasal congestion (20%). Ptosis was reported by 42. Conclusion These results, by using for the first time an easy quantitative scale, confirm that (mild) CAPS are not the exception but the rule in CM patients. The score in this CAPS scale could be of help as a further endpoint in clinical trials or to be correlated with potential biomarkers of parasympathetic activation in primary headaches.

Unilateral Cranial Autonomic Symptoms in Migraine

Cephalalgia ◽  
2002 ◽  
Vol 22 (4) ◽  
pp. 256-259 ◽  
Author(s):  
P Barbanti ◽  
G Fabbrini ◽  
M Pesare ◽  
N Vanacore ◽  
R Cerbo
Keyword(s):  
Large Scale ◽  
Nasal Congestion ◽  
Migraine Treatment ◽  
Conjunctival Injection ◽  
Autonomic Symptoms ◽  
Therapeutic Implications ◽  
Ocular Symptoms ◽  
Cranial Autonomic Symptoms ◽  
Nasal Symptoms ◽  
Autonomic Reflex

Unilateral cranial autonomic symptoms (UAs) such as lacrimation, conjunctival injection, eyelid oedema and nasal congestion, which are the hallmark of trigeminal autonomic cephalgias, may also occur in an as yet undetermined proportion of migraine patients. We studied 177 consecutive migraineurs to assess the frequency of UAs and the clinical characteristics of such patients. UAs were reported by 81 patients (45.8%), ocular symptoms alone or in combination with nasal symptoms being the most frequent. The headache was more severe ( P< 0.0002) and more strictly unilateral ( P< 0.0004) in patients who reported UAs than in those without. Thus, the presence of UAs suggests an activation of the trigeminal-autonomic reflex, probably related to an over-activation of the trigeminal afferent arm. These findings could have therapeutic implications, given the potential large-scale recruitment of peripheral neurovascular 5-HT1B/1D receptors (the target of acute migraine treatment) in such patients.

THUR 084 Cranial autonomic symptoms in cluster headache induced by nitroglycerin

2018 ◽  
Vol 89 (10) ◽  
pp. A9.3-A9
Author(s):  
DY Wei ◽  
PJ Goadsby
Keyword(s):  
Cluster Headache ◽  
Nasal Congestion ◽  
Ethics Committee ◽  
Conjunctival Injection ◽  
Headache Attack ◽  
Autonomic Symptoms ◽  
Cranial Autonomic Symptoms ◽  
Cluster Headache Attack ◽  
Episodic Cluster Headache ◽  
Periorbital Swelling

IntroductionCluster headache (CH) is characterised by attacks of unilateral excruciating headache, ipsilateral cranial autonomic symptoms (CAS) and/or agitation. Studying of CAS can further our understanding of CH pathophysiology, but is limited by the episodic nature of the disease. Nitroglycerin (NTG) is known to induce CH. The aim of this study is to characterise CAS induced by NTG.MethodsCH patients received intravenous NTG 0.5 mcg/kg/min over 20 min. CAS and headache phenotype were recorded. The study was approved by the NHS Research Ethics Committee.ResultsTwenty-three patients participated: 83% male and 61% episodic cluster headache. The most common spontaneous CAS reported were lacrimation, nasal congestion and conjunctival injection. Agitation was reported in 96%. Nitroglycerin induced ipsilateral CAS in 91% of the patients, with 74% with ipsilateral pain. Most commonly induced CAS were nasal congestion, lacrimation and periorbital swelling. Agitation was reported in 61%. The majority of the CAS (80%) induced by NTG presented before the onset of severe pain.ConclusionWe demonstrate that NTG effectively triggers ipsilateral cranial autonomic symptoms in CH patients and that they often present in a phase before the onset of pain reflecting the underlying pathways during a cluster headache attack.

scholarly journals Dramatic response of intravenous lidocaine in a patient with status like SUNA

2018 ◽  
Vol 1 ◽  
pp. 251581631880481 ◽  
Author(s):  
Debashish Chowdhury ◽  
Ashish Duggal ◽  
Arun Koul ◽  
Ankur Gupta
Keyword(s):  
Relevant Literature ◽  
Sustained Response ◽  
Primary Headaches ◽  
Conjunctival Injection ◽  
Intravenous Lidocaine ◽  
Autonomic Symptoms ◽  
Cranial Autonomic Symptoms

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare primary headaches that can sometimes present with a status like pattern which can be highly disabling. Intravenous (IV) lidocaine has been reported to be useful in status like SUNCT but its use in status like SUNA remains unexplored. We report a patient of episodic SUNA who despite on multiple conventional drugs had status like presentation. He had an excellent sustained response to IV lidocaine. Relevant literature on treatment of status like SUNCT/SUNA is briefly reviewed. IV lidocaine can be a very useful treatment for status like SUNA.

scholarly journals Cranial autonomic symptoms: prevalence, phenotype and laterality in migraine and two potentially new symptoms

2021 ◽  
Author(s):  
Nazia Karsan ◽  
Karthik Nagaraj ◽  
Peter J Goadsby
Keyword(s):  
Cluster Headache ◽  
Chronic Migraine ◽  
Nasal Congestion ◽  
Hemicrania Continua ◽  
Headache Frequency ◽  
Voice Change ◽  
Autonomic Symptoms ◽  
Cranial Autonomic Symptoms ◽  
Common Diagnosis ◽  
Facial Swelling

Abstract BackgroundWhilst cranial autonomic symptoms (CAS) are typically associated with the trigeminal autonomic cephalalgias (TAC’s), they have also been reported in migraine. Identification and understanding of these symptoms in migraine is important to ensure timely diagnosis and effective management. MethodsMigraineurs seen within our tertiary headache service between 2014-2018 ( n =340): cohort one, and a separate cohort of headache patients seen between 2014-May 2021 reporting voice change and/or throat swelling as CAS were selected ( n =64); cohort two. We examined, as a service evaluation, our records regarding age, sex, diagnosis, headache and CAS frequency and laterality as acquired from the first consultation, during which a detailed headache history is taken by a trained physician. ResultsCohort 1: Mean age 43 (range 14-94, SD 15). The most common diagnosis was chronic migraine (78%). Median monthly headache frequency was 26 days (IQR 15-75). At least one CAS was reported in 74%, with a median of two (IQR 0-3). The most common were nasal congestion (32%), lacrimation (31%) and aural fullness (25%). Most patients reported unilateral headache (80%) and strictly unilateral CAS (64%). There was a positive association between headache and CAS laterality (ꭓ 2 1 = 20.7, P < 0.001), with a positive correlation between baseline headache frequency and number of CAS reported ( r = 0.11, P = 0.047). Cohort two: mean age 49 (range 23-83, SD 14). Diagnoses were chronic migraine (50%), chronic cluster headache (11%), undifferentiated continuous lateralised headache (9%), SUNCT/SUNA (8%), hemicrania continua (8%), episodic migraine (8%), episodic cluster headache (3%) and trigeminal neuropathies (3%). Most (89%) described trigeminal distribution pain; 25% involving all three divisions. Throat swelling was reported by 54, voice change by 17, and both by 7. The most common CAS reported were lacrimation ( n = 47), facial swelling ( n = 45) and rhinorrhoea ( n = 37). There was significant agreement between the co-reporting of throat swelling (ꭓ 2 1 = 7.59, P = 0.013) and voice change (ꭓ 2 1 = 6.49, P = 0.02) with aural fullness. ConclusionsCAS are common in migraine, are associated with increasing headache frequency and tend to co-lateralise with headache. Voice change and throat swelling should be recognized as possible parasympathetically-mediated CAS. They may be co-associated and associated with aural fullness, suggesting a broadly somatotopic endophenotype.

Classification, diagnostic criteria, and epidemiology

2020 ◽  
pp. 177-181
Author(s):  
Thijs H. Dirkx ◽  
Peter J. Koehler
Keyword(s):  
Cluster Headache ◽  
Epidemiological Data ◽  
Hemicrania Continua ◽  
Paroxysmal Hemicrania ◽  
Primary Headaches ◽  
Conjunctival Injection ◽  
Headache Disorders ◽  
Cranial Autonomic Symptoms ◽  
Unilateral Headache

The trigeminal autonomic cephalalgias (TACs), including cluster headache, paroxysmal hemicrania, SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing), SUNA (with cranial autonomic symptoms), and hemicrania continua, belong to the primary headaches. They are characterized by severe unilateral headache attacks in association with ipsilateral cranial autonomic features. Cluster headache is the most frequent of the TACs. The other TACs are rare, but epidemiological data are scarce and variable. The various types of TAC are distinguished not only by differences in attack frequency and duration, but also by differences with respect to treatment response. The typical headache syndromes, fulfilling the International Classification of Headache Disorders-3 criteria, have also been described in association with other disorders and imaging is required to exclude intracranial pathology in all newly diagnosed patients.

scholarly journals Prevalence of parafunctional habits and temporomandibular dysfunction symptoms in patients attending a tertiary headache clinic

2010 ◽  
Vol 68 (3) ◽  
pp. 377-380 ◽  
Author(s):  
Yára Dadalti Fragoso ◽  
Heloísa Helena Carvalho Alves ◽  
Sidney Oliveira Garcia ◽  
Alessandro Finkelsztejn
Keyword(s):  
Chronic Migraine ◽  
Orofacial Pain ◽  
Outpatient Service ◽  
Episodic Migraine ◽  
Primary Headaches ◽  
Further Training ◽  
Analgesic Drugs ◽  
Temporomandibular Dysfunction ◽  
High Prevalence ◽  
Headache Clinic

OBJETIVE: To investigate the most prevalent forms of headache in a tertiary outpatient service, and to assess the frequency of associated parafunctional habits and temporomandibular dysfunction symptoms (TMD). METHOD: All new patients referred to the Headache Outpatient Service in UNIMES during 2008 were prospectively assessed by the neurologist and the dental surgeon. RESULTS: Eighty new patients were assessed; chronic migraine and episodic migraine without aura were the most prevalent conditions, accounting for 66.3% of all cases. There was significantly higher use of analgesics/days for the chronic migraine patients. The prevalence of parafunctional habits was 47.5% and the prevalence of TMD symptoms was 35%. CONCLUSION: The high prevalence of primary headaches, parafunctional habits and TMD symptoms and the inadequate use of analgesic drugs suggest that primary healthcare units need further training in the field of headache and orofacial pain.

LASH syndrome: New cases with a broadening clinical phenotype

Cephalalgia ◽  
2019 ◽  
Vol 39 (12) ◽  
pp. 1595-1600
Author(s):  
Todd D Rozen
Keyword(s):  
Clinical Phenotype ◽  
Case Series ◽  
Autonomic Symptoms ◽  
Dopamine Agonist Therapy ◽  
Cranial Autonomic Symptoms ◽  
Time Period ◽  
Entire Duration ◽  
Headache Onset ◽  
Hormonal Modulation ◽  
Headache Clinic

Objective To describe three new cases of the headache syndrome of long-lasting autonomic symptoms with hemicrania (LASH), and to establish a clinical phenotype utilizing all LASH cases noted in the medical literature. Methods A case series of patients was evaluated in an academic headache clinic over a two-year time period. LASH syndrome was defined by episodic headache attacks with associated cranial autonomic symptoms that start before headache onset, last the entire duration of the headache and continue on for a period of time after the headache ceases. Results Three patients were noted to have LASH syndrome in a two-year time period (2017–2018). One patient was diagnosed with primary LASH, while two others had probable secondary LASH from a secretory pituitary tumor. The primary LASH patient was female. She had on average one headache per week lasting 1–3 days in duration. She experienced migrainous associated symptoms along with their cranial autonomic symptoms. She also developed a fixed Horner's syndrome along with a typical headache attack, which was present for 6 months at the time of consultation. She had complete headache relief with indomethacin and her miosis and ptosis also resolved with treatment. Secondary LASH was diagnosed in two patients (one male, one female) both with prolactin secreting pituitary microadenomas. One of the patients had his headaches abolish with dopamine agonist therapy while the other patient did not respond to hormonal modulation but became pain free on indomethacin. Secondary LASH patients had less frequent headache episodes and lacked any migrainous associated features, but exhibited agitation with headache. Conclusion LASH syndrome may be rare, but more reported cases are entering the headache literature. The temporal profile of onset and offset of cranial autonomic symptoms is key to making the diagnosis. Primary and secondary LASH may present differently based on gender predominance, the presence of migrainous associated features, and attack frequency. Secondary LASH appears to be indomethacin responsive, suggesting that medication effectiveness should not obviate the need to do testing for secondary etiologies.

SUNCT, SUNA and pituitary tumors: Clinical characteristics and treatment

Cephalalgia ◽  
2012 ◽  
Vol 33 (3) ◽  
pp. 160-170 ◽  
Author(s):  
Prin Chitsantikul ◽  
Werner J Becker
Keyword(s):  
Clinical Characteristics ◽  
Pituitary Tumors ◽  
Management Program ◽  
Temporal Region ◽  
Conjunctival Injection ◽  
Tumor Removal ◽  
Autonomic Symptoms ◽  
Major Improvement ◽  
Cranial Autonomic Symptoms ◽  
Headache Assessment

Background Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare types of trigeminal autonomic cephalalgias (TACs). Objective To describe a series of patients with SUNCT and SUNA including relationship to pituitary tumors. Method All patients diagnosed with SUNCT or SUNA in the Calgary Headache Assessment and Management Program were reviewed. Results Six patients (five SUNCTs and one SUNA) were identified. The pain was severe, sharp, showed fixed-laterality, involved mainly the orbito-fronto-temporal region and was associated with autonomic symptoms. Attack duration ranged from 3 to 300 seconds and frequency was 1–200 paroxysms/day. MRI showed ipsilateral pituitary adenomas to the pain in five out of five of the SUNCT patients. Patients with adenomas underwent surgery. Pathology included three prolactinomas, and one mixed adenoma and gangliocytoma. One patient has remained headache free for 4 years after surgery. One was pain free for a year, and then headaches returned with tumor recurrence. Another had major improvement, and two have not improved. Patients were generally refractory to medications. Conclusion All five of our patients with typical SUNCT had pituitary tumors, with headache ipsilateral to the pituitary tumors in all cases. Tumor removal provided major improvement in three out of five patients. Medical treatment was only partially effective.

scholarly journals Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?

Cephalalgia ◽  
2013 ◽  
Vol 34 (5) ◽  
pp. 382-391 ◽  
Author(s):  
Sabrina Khan ◽  
Jean Schoenen ◽  
Messoud Ashina
Keyword(s):  
Sensory Processing ◽  
Randomized Clinical Trials ◽  
Therapeutic Potential ◽  
Nasal Congestion ◽  
Treatment Strategies ◽  
Current Treatment ◽  
Sphenopalatine Ganglion ◽  
Conjunctival Injection ◽  
Autonomic Symptoms ◽  
Parasympathetic Ganglion

Objective The objective of this article is to review the prospect of treating migraine with sphenopalatine ganglion (SPG) neurostimulation. Background Fuelled by preliminary studies showing a beneficial effect in cluster headache patients, the potential of treating migraine with neurostimulation has gained increasing interest within recent years, as current treatment strategies often fail to provide adequate relief from this debilitating headache. Common migraine symptoms include lacrimation, nasal congestion, and conjunctival injection, all parasympathetic manifestations. In addition, studies have suggested that parasympathetic activity may also contribute to the pain of migraineurs. The SPG is the largest extracranial parasympathetic ganglion of the head, innervating the meninges, lacrimal gland, nasal mucosa, and conjunctiva, all structures involved in migraine with cephalic autonomic symptoms. Conclusion We propose two possible mechanisms of action: 1) interrupting the post-ganglionic parasympathetic outflow to inhibit the pain and cephalic autonomic symptoms, and 2) modulating the sensory processing in the trigeminal nucleus caudalis. To further explore SPG stimulation in migraineurs as regards therapeutic potential and mode of action, randomized clinical trials are warranted.

The phenotype of migraine with unilateral cranial autonomic symptoms documents increased peripheral and central trigeminal sensitization. A case series of 757 patients

Cephalalgia ◽  
2016 ◽  
Vol 36 (14) ◽  
pp. 1334-1340 ◽  
Author(s):  
P Barbanti ◽  
C Aurilia ◽  
V Dall’Armi ◽  
G Egeo ◽  
L Fofi ◽  
...  
Keyword(s):  
Outcome Prediction ◽  
Case Series ◽  
Phenotypic Characteristics ◽  
Autonomic Symptoms ◽  
Face To Face ◽  
Cranial Autonomic Symptoms ◽  
Targeted Treatments ◽  
Headache Clinic ◽  
Trigeminal Activation ◽  
Chronic Migraineurs

Background Migraine with unilateral cranial autonomic symptoms (UAS) is a putative migraine endophenotype with convincing response to trigeminal-targeted treatments that still needs a thorough characterization. Objective The objective of this article is to carefully investigate the clinical phenotype of migraine with UAS in a large group of patients for more accurate migraine diagnoses, improved clinical management, and better outcome prediction. Methods We studied 757 consecutive episodic and chronic migraineurs in a tertiary headache clinic with face-to-face interviews, detailing in depth their lifestyle, sociodemographic and headache characteristics. Results Migraineurs with UAS (37.4%) differed from the general migraine population with respect to longer attack duration (OR = 2.47, p < 0.02, having >72-hour long attacks), more strictly unilateral (OR = 3.18, p < 0.001) and severe headache (OR = 1.72, p = 0.011), more frequent allodynia (OR = 3.03, p < 0.001) and photophobia (OR = 1.87, p = 0.019). Conclusions Migraine patients with UAS are characterized not only by symptoms due to intense peripheral trigeminal activation but also to central sensitization. Our study broadens the knowledge on the clinical and phenotypic characteristics of migraine with UAS, suggests pathophysiological implications, and supports the need for future prospective clinical studies.

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