Cranial autonomic symptoms in episodic and chronic migraine: a cross sectional study in Iran

Background Cranial autonomic symptoms are common in migraine, with eye redness and tearing being the most common ones. Their identification can help to avoid misdiagnosis, predict the disease course, and select the appropriate treatment. Methods This was a cross-sectional study of 904 patients who presented with migraine to a headache referral clinic. The participants filled out a questionnaire about their headache characteristics, as well as the presence of cranial autonomic symptoms. A total of 904 patients, 698 women (77.2%) and 206 men (22.8%), were included in the study, with a mean (SD) age of 38.05 (11.76) years. Results About 70% of subjects with chronic migraine and 56.2% of those with episodic migraine reported one or more cranial autonomic symptoms. The two most commonly reported autonomic symptoms were eye redness (36.06%) and tearing (21.02%). Chronic migraine (43.4% vs. 29.5%), unilateral headache (56.8% vs. 48.7%), and blurred vision (20% vs. 14.7%) were significantly more frequent in migraineurs with cranial autonomic symptoms. Headache intensity and frequency in subjects with cranial autonomic symptoms were significantly higher than in those without cranial autonomic symptoms. Conclusion We found higher percentages of cranial autonomic symptoms in patients with unilateral headaches, frequent and severe attacks and blurred vision. A diagnosis of cranial autonomic symptoms accompanying migraine may predict more severe disease and the possibility of evolution into chronic migraine.

Visual Processing During the Interictal Period Between Migraines: A Meta-Analysis

Migraine is a poorly understood neurological disorder and a leading cause of disability in young adults. Migraines are characterized by severe pulsating unilateral headache and visual symptoms. Whether visual function is also impaired in the interictal period between migraines remains controversial. Thus, this meta-analysis investigated the evidence for altered visual function as measured electrophysiologically via pattern-reversal visual evoked potential (VEP) amplitudes and habituation in adult migraineurs with or without visual aura and control in the interictal period. Twenty-three studies were selected for random effects meta-analysis, demonstrating slightly diminished VEP amplitudes and substantially reduced habituation in the early P100 component in migraineurs without aura and with aura compared to controls. No differences were found between migraineurs with and without aura. Although heterogeneity between studies and insufficient published data for VEP latencies and the earlier N75 VEP component data was observed and require further testing, P100 anomalies may indicate abnormal functioning of the fast-conducting magnocellular visual pathway, in episodic migraineurs.

MANAGEMENT OF MIGRAINE THROUGH PANCHKARMA - A CASE STUDY

Ardhavabhedaka is a type of Shiroroga. It is unilateral headache with Compli- cations of blindness and hearing loss. It can be clinically correlated with migraine based on clinical manifestation. Affecting at least 1 adult in every 7 in the world (WHO). It is 3 time more common in women than men. it causes moderate to severe pain that is throbbing or pulsating, requiring long-term management. It causes personal suffer- ing, impaired quality of life and high financial cost. Nasya Karma and Shirodhara are the prime treatment modalities for Shirogata disease. A 19 year old girl patient came to OPD with complaining of severe headache. Shirodhara done with milk + Dashmool - Kwath and Mahanarayan tail. After done this Panchkarma treatment patient got highlysignificant relief in the cardinal symptoms of Ardhavabhedaka. Keywords: Migraine, Ardhavbhaedaka, Shirodhara

Sluder's neuralgia- A sequalae of nasogastric tube feeding

Management of nutritional needs is of paramount importance in cancer patients and nasogastric feeding is the most common method. Nasal cavity being a richly innervated region, is also a hallway for the exposure of the same to external environment. Any trauma or pressure to these nerve endings result in unilateral headache mimicking Sluder’s neuralgia. Nasogastric tube may irritate the nasal mucosa and exert pressure on the nasal turbinates. We believe that the persistent headache in patients with NG tube is distinctly significant that it interferes with the physical comfort of patient. It also influences the sleep patterns, thereby causing repercussions in the emotional well-being. Head and neck oncologists being the primary clinicians, it is imperative to consider the Sluder’s neuralgia in patients with nasogastric tube feeding. This mandates a prospective study to describe the clinical features and the treatment of ‘NGT neuralgia’.

Effect of migraine attack on pupil size, accommodation and ocular aberrations

Purpose: To evaluate the pupil size, accommodation, and ocular higher-order aberrations (HOAs) in patients with migraine during migraine attacks and compare them with interictal period and healthy controls. Methods: This prospective, case–control study included 48 eyes of 24 patients with migraine and 48 eyes of 24 age and sex-matched healthy controls. Measurements were performed using a Hartmann Shack aberrometer. Accommodative responses to accommodative stimulus ranging from 0 to 5 diopters (D) in increments of 0.5 D were recorded. Spherical, coma, trefoil aberration, and root mean square (RMS) of total HOAs were assessed. Patients with migraine were measured twice during the interictal phase and during migraine attack. Results: The mean pupil size significantly decreased during migraine attack (5.85 ± 0.19 mm) compared with the interictal phase (6.05 ± 0.19 mm) in the patients with migraine ( p = 0.012). There was a significant increase in the accommodative response to accommodative stimulus of 1.5 to 5 D during migraine attack. No significant change was observed in HOAs during migraine attack. In addition, no ictal or interictal period measurements were statistically significantly different from the controls. Comparing symptomatic and non-symptomatic sides in 17 migraine patients with unilateral headache, no significant difference was found in any of the measurements in both ictal and interictal periods. Conclusion: Our results suggest the presence of a subtle oculosympathetic hypofunction in patients with migraine during the ictal period compared to the interictal period. The accommodation status of the eye seems to be affected by this autonomic dysfunction.

The locus of Action of CGRPergic Monoclonal Antibodies Against Migraine: Peripheral Over Central Mechanisms

Migraine is a complex neurovascular disorder characterized by attacks of moderate to severe unilateral headache, accompanied by photophobia among other neurological signs. Although an arsenal of antimigraine agents is currently available in the market, not all patients respond to them. As Calcitonin Gene-Related Peptide (CGRP) plays a key role in the pathophysiology of migraine, CGRP receptor antagonists (gepants) have been developed. Unfortunately, further pharmaceutical development (for olcegepant and telcagepant) was interrupted due to pharmacokinetic issues observed during the Randomized Clinical Trials (RCT). On this basis, the use of monoclonal antibodies (mAbs; immunoglobulins) against CGRP or its receptor has recently emerged as a novel pharmacotherapy to treat migraines. RCT showed that these mAbs are effective against migraines producing fewer adverse events. Presently, the U.S. Food and Drug Administration approved four mAbs, namely: (i) erenumab; (ii) fremanezumab; (iii) galcanezumab; and (iv) eptinezumab. In general, specific antimigraine compounds exert their action in the trigeminovascular system, but the locus of action (peripheral vs. central) of the mAbs remains elusive. Since these mAbs have a molecular weight of ∼150 kDa, some studies rule out the relevance of their central actions as they seem unlikely to cross the Blood-Brain Barrier (BBB). Considering the therapeutic relevance of this new class of antimigraine compounds, the present review has attempted to summarize and discuss the current evidence on the probable sites of action of these mAbs.

Probable neurosarcoidosis presenting as acute on chronic otorrhoea: a difficult diagnosis

An elderly African American woman presented to our clinic following 9 months of right-sided unilateral headache, otorrhoea and progressive hearing loss. Despite treatment with topical and oral antibiotics, her clinical condition worsened, and imaging showed mastoid coalescence with an associated subgaleal abscess. She underwent right mastoidectomy and was discharged 3 days later on broad-spectrum intravenous antibiotics despite negative operative cultures. Six weeks later, she was hospitalised with diplopia secondary to a right lateral rectus palsy. Imaging showed abscess resolution but progressive bony remodelling and enhancement of the lateral extending into anterior skull base. Chest CT demonstrated upper lobe predominant pulmonary micronodules, and mastoid biopsy on revision surgery was notable for non-caseating granulomas. Further extensive work-up could not identify an alternative cause, and a presumptive diagnosis of neurosarcoidosis was made. The patient was initiated on intravenous steroids, experienced symptomatic improvement and was thereafter transitioned to oral steroid taper on discharge.

Comparative clinical study of Nasya Karma and Shirodhara with Prapaundarikadi Taila in Ardhavabhedaka w.s.r. to Migraine

Background: Ardhavabhedaka is a type of Shiroroga with the cardinal feature of unilateral headache, which if left untreated leads to complications like blindness and hearing loss. This disease can be correlated to Migraine head-ache based on the clinical manifestations. Nasya Karma and Shirodhara are the prime treatment modalities for Shirorogas. Objectives: To evaluate the effects of Nasyakarma and Shirodhara in the management of Ardhavabhedhaka. Material and Methods: Patients presenting with the classical features of Ardhavabhedaka and between the age group of 18 to 60 years irrespective of sex were selected and allotted in Group A and B with 20 patients in each group. Group A was administered with Nasya with Prapaundarikadi Taila and Group B with Shirodhara with Prapaundarikadi Taila for 7 days. Result: Data was tabulated and analyzed using Student t-test, paired proportion test, which showed marked improvement in patients with Ardhavabhedaka in both the groups. Nasya and Shirodhara with Prapaundarikadi Taila is proved effective in all patients. According to percentage wise relief in the symptoms of Ardhavabhedaka in Group A and B, Group A showed comparatively better relief. Conclusion: On the basis of the results of this study, it can be clearly concluded that Nasya performed with Prapaundarikadi Taila provided significant relief in the signs and symptoms of Ardhavabhedaka than Shirodhara performed with Prapaundarikadi Taila.