Cranial autonomic symptoms in episodic migraine: An observational study from headache clinic of a tertiary care center of North India

Introduction: The presence of cranial autonomic symptoms (CAS) is a hallmark of trigeminal autonomic cephalalgia like cluster headache but their presence in migraine is also not uncommon. Like in trigeminal autonomic cephalalgias, the activation of the trigeminal autonomic reflex pathway is thought to be the possible explanation of the presence of cranial autonomic symptoms in migraine also. Previous studies suggested that around half of the patients of migraine suffer from these symptoms. The aim of our study was to observe the frequency of cranial autonomic symptoms in episodic migraine patients along with their clinical and autonomic characteristics. Methods and Materials: Fifty patients of episodic migraine attending the headache clinic of Dr. RMLIMS, Lucknow and fulfilling the diagnostic criteria of International classification of headache disorder third edition beta were randomly selected and enrolled in the study. The detailed interview regarding presence of cranial autonomic symptoms was recorded along with the clinical characteristics, demographic features and autonomic profile of the migraine patients. Results: About three-fourth (72%) of the patients were females. The mean age of study participants was 27.7±8.3 years. A considerable number of patients (54%) had a long duration (5-10 years) of illness and 70% of patients had severe headaches. Photophobia was the most common (88%) associated clinical symptoms while lacrimation was the most common (56%) cranial autonomic symptom in migraine patients. Among 50 patients of migraine 74% of patients were having at least one cranial autonomic symptoms. Conclusion: Cranial autonomic symptoms are common in patients of episodic migraine. More severe headache is more likely to be associated with the development of cranial autonomic symptoms.

Transient Visual Disturbance is Associated with Disability and Suicidal Risk in Patients with Migraine Without Aura

Background: Patients with migraine without aura frequently report transient visual disturbances (TVD) other than typical visual aura, but the clinical correlates are not determined. Method: Patients with migraine without aura (MO) that attended the headache clinic were enrolled. Structured questionnaires were self-administered by the patients including headache profiles, comorbidities, lifetime suicidal ideation and attempts, six-item Headache Impact Test, Migraine Photophobia Score, Migraine Disability Assessment, Hospital Anxiety and Depression Scale, Beck Depression Inventory, and Pittsburgh Sleep Quality Index. A semi-structured visual phenomenon questionnaire was also used to assess the characteristics of TVDs. TVD is defined as any zigzag flashes, flickering dots/lines, or blurred/foggy vision associated with headache and with a Visual Aura Rating Scale < 4. Headache specialists interviewed with the participants for the ascertainment of diagnosis and verified of the questionnaires.Result: MO patients (n = 7,200, female/male = 3.56, mean age: 40.1 ± 13.4 years) were divided into 2 subgroups based on the presence (n=2,488) or absence of TVDs (n= 4,712). Patients with TVD had higher headache-related disability, more psychiatric comorbidities and were more likely to be photophobic. Suicidal ideation and attempts were more common in patients with TVD than in those without (ideation: 31.9% vs. 18.1%, OR = 1.92 [95% CI: 1.71−2.15], p < 0.001; attempt: 8.2% vs. 3.5%, OR = 2.23 [95% CI: 1.80−2.75], p < 0.001). The associations remained after adjustment of confounding factors.Conclusion: Presence of transient visual disturbance may suggest a higher migraine-related disability, higher level of photophobia and higher suicidal ideation/attempts in MO patients.

A GENDER BASED COMPARISON TO STUDY THE PSYCHIATRIC COMORBIDITIES OF MIGRAINE ON THE BASIS OF ITS SEVERITY.

Background: There is lack of data from india on the difference of presenting psychiatric comorbidities of migraineurs among male and female population. Objectives: the objective of the study were to quantify the impairment i.e disability due to migraine severity, associated depression and anxiety among male and female migraineurs of comparable characteristics. Materials And Methods: we interviewed 105 consecutive newly diagnosed migraine patients (both male and female) visiting headache clinic in a tertiary care centre between September 2019 to march 2020.Age and sex matched healthy subjects (n=105, later 5 dropped) were used. PHQ9, MIDAS, and GAD7 scales were administered. Predictors were analysed using regression analysis. Result: both male and female migraineurs have shown similar result with preponderance of anxiety disorder more in female than male migraineurs. Prevalence of clinically signicant anxiety(48%) and depressive (41%) symptoms, higher among female than male. Female gender, headache related disability, and severity of anxiety and depressive symptoms predicted worse mental component summary scores. Conclusion: incidence of clinically signicant anxiety and depressive symptoms is much higher among migraineurs and the severity was comparatively higher among female than male. These ndings goes with studies from other parts of world and Indian prospects.

Treatment Realities of Headache Disorders in Rural Germany by the Example of the Region of Western Pomerania

(1) Background: Headache disorders are among the most disabling medical conditions but the supply with experienced providers is outpaced by the demand for service. It is unclear to what extent particularly patients in rural regions are affected by limited access to comprehensive care. Furthermore, it is unknown what role general practitioners (GPs) play in headache care. (2) Methods: First-time consultations to a specialised headache clinic at a tertiary care centre were asked to participate. Their socio-demographic background, general and headache-specific medical history, disability and quality of life (QoL) were assessed. Additionally, 176 GPs in neighbouring districts were contacted regarding headache management. (3) Results: We assessed 162 patients with first-time consultations (age 46.1 ± 17.0 years, 78.1% female), who suffered from migraine (72%), tension type, cluster and secondary headaches (each 5–10%). About 50% of patients received a new headache-diagnosis and 60% had treatment inconsistent with national guidelines. QoL was significantly worse in all domains compared to the general population. About 75% of GPs see headache patients at least several times per week, and mostly treat them by themself. (4) Conclusions: More than every second headache patient was neither correctly diagnosed nor received guideline adherent treatment. Headache-related disability is inferior to what is expected from previous studies. Access to specialised health care is more limited in rural than in urban regions in Germany and GPs request more training.

New Daily Persistent Headache in a Pediatric Population

Introduction: New daily persistent headache (NDPH) is a primary headache disorder characterized by an intractable, daily, and unremitting headache lasting for at least 3 months. Currently, there are limited studies in the pediatric population describing the characteristics of NDPH. Objective: The objective of the current study is to describe the characteristics of NDPH in pediatric patients presenting to a headache program at a tertiary referral center. Methods: The participants in the current study were pediatric patients who attended the Headache Clinic at Children’s National Hospital between 2016 and 2018. All patients seen in the Headache Clinic were enrolled in an institutional review board–approved patient registry. Results: Between 2016 and 2018, NDPH was diagnosed in 245 patients, representing 14% of the total headache population. NDPH patients were predominantly female (78%) and white (72%). The median age was 14.8 years. The median pain intensity was 6 of 10 (standard deviation = 1.52). Most patients reported experiencing migrainous features, namely, photophobia (85%), phonophobia (85%), and a reduced activity level (88%). Overall, 33% of patients had failed at least 1 preventive medication, and 56% had failed at least 1 abortive medication. Furthermore, 36% of patients were additionally diagnosed with medication overuse headache. Conclusion: NDPH is a relatively frequent disorder among pediatric chronic headache patients. The vast majority of these patients experience migrainous headache characteristics and associated symptoms and are highly refractory to treatment—as evidenced by a strong predisposition to medication overuse headache and high rates of failed preventive management.

E-diary use in clinical headache practice: A prospective observational study

Aim To determine whether our E-diary can be used to diagnose migraine and provide more reliable migraine-related frequency numbers compared to patients’ self-reported estimates. Methods We introduced a self-developed E-diary including automated algorithms differentiating headache and migraine days, indicating whether a patient has migraine. Reliability of the E-diary diagnosis in combination with two previously validated E-questionnaires was compared to a physician’s diagnosis as gold standard in headache patients referred to the Leiden Headache Clinic (n = 596). In a subset of patients with migraine (n = 484), self-estimated migraine-related frequencies were compared to diary-based results. Results The first migraine screening approach including an E-headache questionnaire, and the E-diary revealed a sensitivity of 98% and specificity of 17%. In the second approach, an E-migraine questionnaire was added, resulting in a sensitivity of 79% and specificity of 69%. Mean self-estimated monthly migraine days, non-migrainous headache days and days with acute medication use were different from E-diary-based results (absolute mean difference ± standard deviation respectively 4.7 ± 5.0, 6.2 ± 6.6 and 4.3 ± 4.8). Conclusion The E-diary including algorithms differentiating headache and migraine days showed usefulness in diagnosing migraine. The use emphasised the need for E-diaries to obtain reliable information, as patients do not reliably recall numbers of migraine days and acute medication intake. Adding E-diaries will be helpful in future headache telemedicine.