Headache Medicine

Brazilian Headache Congress 2024 Between Socrates and Silicon: The odyssey of knowledge

Alan Chester Feitosa de Jesus — 2024-09-30

Chronicle about the latest Brazilian Headache Congress, held in Foz do Iguaçu in August 2024.

Headache Medicine: 30 years advancing headache science

Marcelo Moraes Valença — 2024-09-30

Editorial
Headache Medicine: 30 years advancing headache science

Idiopathic intracranial hypertension in a patient with a history of migraine: a case report

Christian Gonçalves — 2024-09-30

Introduction
Idiopathic intracranial hypertension (IIH) is marked by elevated intracranial pressure without a known cause, often affecting women of childbearing age and linked to obesity. Diagnosing IIH can be tricky, especially in patients with chronic headaches like migraines. This report discusses a case of IIH in a long-term migraine sufferer, stressing the importance of early detection and effective treatment.
Case Report
A 44-year-old woman with migraines since menarche sought medical help in August 2021 due to more frequent and intense headaches, occurring three times a week with light and sound sensitivity and nausea. An MRI in September 2021 showed rare anomalies. Initially treated with topiramate and nortriptyline, her headaches decreased to twice a month by May 2022. However, in November 2022, an ophthalmologist found bilateral papilledema, and she reported retroocular pain and transient visual obscurations. A lumbar puncture confirmed IIH with an opening pressure of 32.5 cmH2O, and she was prescribed acetazolamide. Despite some headache relief, she experienced nausea and visual distortions. Adjustments in her medication and a five-kilogram weight loss improved her symptoms, though issues in the left eye's visual field persisted.
Comment
This case highlights the challenges of managing IIH in migraine patients. New headache patterns and visual symptoms were key to suspecting IIH, confirmed by lumbar puncture. Acetazolamide effectively reduced her intracranial pressure, while nortriptyline helped manage sleep issues. Weight loss significantly improved symptoms, emphasizing the need for a multidisciplinary approach between neurologists and ophthalmologists are for optimal care.

Boundaries of visual phenomena in migraine: the charles bonnet’s syndrome - report of two cases

Davy Henrique Sousa Pelliciari — 2024-09-30

Introduction
Two patients were referred to a tertiary headache center due to complex visual phenomena that might be related to migraine aura. Eventually, it turned out that they were Charles Bonnet syndrome (CBS) patients. The syndrome is characterized by vivid visual hallucinations in the absence of other psychiatric symptoms, often in patients with optical morphophysiological disorders. The pathophysiology of CBS remains uncertain, and the syndrome lacks robust diagnostic criteria. So far, reports on CBS are scarce in Brazilian neurological literature, leading to challenges in identification and diagnosis. The condition is primarily recognized through anamnesis and clinical examination.
Objective
To report two cases of CBS to draw the attention of headache specialists about this syndrome.
Case reports
The first case involves a 93-year-old male patient, retired, who reported experiencing vivid hallucinations sometimes of an old white car and sometimes a group of children. Despite the clarity of these visions, the patient remained aware that they were not real. In the second case, a 70-year-old male farmer began experiencing hallucinations involving scratches, scribbles, letters, stones, and women in his visions.
Conclusion
Here two cases of CBS were reported concerning a not so rare condition, but for sure very uncommon to headache specialists.

The influence between migraine preven drugs and sumatriptan succinate on motor activity

Edison Matos Novak — 2024-09-30

Background and aim

The motor effect of sumatriptan succinate (SS) and whether or not it is associated
with different classes of migraine preventive drugs has yet to be studied. We aimed to analyze such drugs' influence on animal motor activity, verifying their effect when used alone or in combination.

Methods

Male Norvegicus rats (n=98) were treated with routinely prescribed migraine preventive drugs and divided into five groups: isotonic saline solution (ISS, control), propranolol, topiramate, flunarizine, and amitriptyline. After five days of daily treatment, the animals received acute treatment with either ISS or Sumatriptan succinate (SS). The drug's influence on motor function behavior was assessed with the rotarod and open field tests.

Results

Propranolol and flunarizine interfered with the motor activity (p=0.006 and 0.002, respectively). SS did not cause motor changes when administered alone. However the SS combined with amitriptyline increased the number of rearings (p=0,045) and reduced the immobility time (p=0.041).

Conclusions

SS exerted no motor effect, although flunarizine and propranolol could produced motor interference.

Characterization of adult patients with a diagnosis of migraine and osmophobia: the osmograine study

Brenda Benítez-Martínez — 2024-09-30

Introduction
Osmophobia is associated with a greater intensity of the headache, a more significant presence of affective symptoms, and the appearance of cutaneous allodynia.
Objectives
To determine the sociodemographic and clinical characteristics of patients with episodic and chronic migraine associated with osmophobia.
Methods
A cross-sectional analytical observational study, 100 patients were included.
Results
65% of the patients presented osmophobia, 64.6% of patients with osmophobia had chronic migraine, and 35.4% had episodic migraine without statistically significant differences p=0.120. Regarding the clinical characteristics, pulsatile pain was the most frequent in 49%, and severe intensity was present in 81%. Statistically significant
relationships were found between osmophobia and photophobia [(95.4 vs 77.1]; p=0.005), phonophobia ([96.9 vs 74.3); p=0.001) and allodynia ([75.4 vs 45.7); p=0.002). The that become chronic factors were more frequent in the group with osmophobia, in which an association with the excessive use of analgesics ([43.8%vs. 22.9%]; p=0.029) and a history of anxiety and depression ([32.8% vs. 14.3%]; p=0.045). In the multivariate model, the variables associated with osmophobia with statistically significant differences were photophobia, allodynia, and botulinum toxin application.
Conclusions
In this first study of osmophobia in migraine in Colombia, osmophobia is a frequent symptom in patients with chronic migraine; it has related to markers of central sensitization; it is also related to that become chronic factors and the use of botulinum toxin. Therefore, it is likely that osmophobia can predict the risk of that factor, causing the disease to become chronic.

Efficacy of craniosacral therapy in cervicogenic headache: a literature review

Bivishika Khadka — 2024-09-30

Background
Neck discomfort is a frequent problem that can impair quality of life and make it difficult to perform daily tasks. Pain from neck strain is not limited to the cervical spine; it can also radiate into the skull and result in a headache of cervical origin, known as cervicogenic headache. Craniosacral can cure a wide array of musculoskeletal and neurological conditions, including headaches, but there is little evidence in the literature of its efficacy, particularly regarding cervicogenic headaches.
Objective
To determine the effectiveness of craniosacral therapy (CST) for cervicogenic headache and improve our understanding of cervicogenic headache.
Methods
A review of the literature was performed using the following electronic search bases: PubMed, Google Scholar, Scopus and The Cochrane library. To perform the search, these MeSH terms were used: “Cervicogenic headache” AND “Neck pain” AND “Craniosacral therapy” AND ‘Headache’ between the date 2020 to 2022.
Results
Eleven articles were included in the literature review. Overall, the results of published articles indicate 97.5–100% of the patients thought the treatment program was satisfactory. No adverse effects were reported. It has been demonstrated that CST is particularly safe and effective in lowering the intensity of neck pain. It may also enhance the quality of life and functional impairment for up to three months following the intervention. In addition to the conventional medical therapy, CST may be a beneficial therapeutic option for persistent and recurrent neck discomfort.
Conclusion
This review shows that CST is very effective for the treatment of cervicogenic headaches. CST evaluation is feasible in randomized controlled trials and may offer insightful results to enhance therapeutic decision-making.

Mental health and headaches in university professors

Ana Beatriz Batáglia Sperandio — 2024-09-30

Introduction
There is a lot of discussion about the world's quality of life, mental health, disease improvement standards according to the WHO, and so many actions and attitudes in a movement to improve life, in addition to life expectancy.
Objectives
To determine the mental health status of university medical professors at Unifipa. emphasizing the relation between headache disabling and depression and anxiety’scores.
Methodology
Cross-sectional cohort in a single intervention, which consisted of responding to a health and quality of life questionnaire, focusing on mental health, and in this report, headaches.
Results
Participants’ number was 46. About 51% were between 31 and 40 years old; 56.5% were women, 67.4% were married or in a stable union, 21.7% had a master's degree and 26.1% had a PHD. Regarding mental health, it was noted that professors with severe depression showed the presence of a moderate or severe level of anxiety, while those with minimal depression showed a low level of anxiety. Regarding to the headaches, it was observed that HIT-test scores above 50 correlated more with higher depression and anxiety scores and lower HIT-test scores correlated with lower depression and anxiety scores.
Conclusion
Research is important to evaluate the university professors’ mental health and predict actions that can be taken to improve it. And headaches cause disabling when associated to depression and anxiety. We conclude that headache’s burden can related to worsening depression and anxiety’scores, even though not significantly.

Should anti-CGRP monoclonal antibodies always be the drug of first choice for migraine prophylaxis in Brazil? - a pharmacoeconomic study

Davy Henrique Sousa Pelliciari — 2024-09-30

Efficacy (success of therapy under ideal conditions), efficiency (the relationship between the costs and outcomes of a specific intervention), and effectiveness (the balance between efficacy and efficiency in clinical practice) are measures used to evaluate health interventions. Thus, in private practice and the public health system, the knowledge of these pharmacoeconomic data should influence the appropriate treatment choice. Migraine prophylaxis falls within this context. Traditional medications are available in the public health system, while galcanezumab is not routinely available. The present study aims to analyze the efficacy and effectiveness of galcanezumab and traditional therapeutic alternatives (amitriptyline, divalproex sodium, and topiramate). Efficacy data were obtained from the relevant literature (PubMed) and cost values from the ABCFarma magazine. The economic impact analysis considered the cost of living for an economically active adult in Brazil based on the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) and the Institute for Applied Economic Research (Instituto de Pesquisa Econômica Aplicada, IPEA). Efficacy: amitriptyline: 40%; divalproex sodium: 30%; topiramate: 31%; galcanezumab: 50%. Their annual costs were: amitriptyline R$ 240.00; sodium divalproate R$ 876.00; topiramate R$ 600.00; galcanezumab R$ 13,992.00. Efficiency: amitriptyline 200%; divalproex sodium 41.1%; topiramate 62%; galcanezumab 4%. Ultimately, effectiveness is amitriptyline 120%; divalproex sodium 35.7%; topiramate 46.5%; galcanezumab 27%. Galcanezumab is the most effective; however, in a broader analysis, where payers, availability, and patient conditions are considered, evaluating efficacy alone may not be feasible in practical contexts and, therefore, anti-CGRP antibodies will not always be the first-line medications in migraine prophylaxis.

The study protocol for a multicenter observational headache registry: Brazilian Headache Registry - REBRACEF II

Jesuély Spieckert de Souza — 2024-09-30

Objective
This article presents the protocol for the Brazilian Headache Registry (REBRACEF), the first national registry designed to systematically collect real-world data on patients with primary and secondary headaches at specialized centers in Brazil. The main objective is to describe the methods for patient selection, the registry infrastructure, data collection, and the standardized instruments used.
Methodology
REBRACEF is a prospective, observational, multicenter cohort study conducted in real-world settings.
Expected results
This protocol aims to standardize and enable the structuring of the registry, allowing its implementation in other centers across Brazil. It also ensures external feasibility by establishing a robust framework that can be replicated in other national and international healthcare institutions.
Conclusion
The registry protocol provides a standardized framework for the collection of real-world data on patients with primary and secondary headaches, facilitating the improvement of headache management and research in Brazil.

Prevalence and profile of headache in school-going adolescents aged 10 – 19 years in Benin City: a cross sectional survey

Paul Ikhurionan — 2024-09-30

Introduction
Adolescent headaches significantly impact their daily functioning, academic performance, and quality of life. The occurrence of headaches is influenced by genetics, psychological stressors, and environmental exposures. Understanding these influences is crucial for effective management strategies.
Aim
To determine the prevalence, characteristics, and associated factors of headaches among school-going adolescents in Benin City, Nigeria.
Methods
This was a descriptive cross-sectional study among secondary school students. Using a structured questionnaire, data on sociodemographics, headache characteristics, triggers, and impacts were collected. The chi-square test was used to assess the association between the presence of headaches and categorical covariates. All analyses used a significance level of p<0.05.
Result
Of the 486 respondents 235 (48.4%) were boys and 251 (48.3%) were girls with a M:F ratio of 1:1.07. The mean age of the study participant was 13.7 (+ 1.78) years. The one-year prevalence of headache was 84%. 92 (18.9%) of those reporting headaches met the diagnostic criteria for chronic daily headache. The most common impact of headache was poor concentration (110; 22.6%). Psychological stress (55.3%) and poor sleep (26.1%) were the most commonly reported headache triggers.
Conclusion
More than four in five school-going adolescents have headache at one time in the past year. Reading and concentration problems are the most common adverse effect of headache in adolescents.

Profile of childhood headaches in a tertiary center

Nathiely Viana da Silva — 2024-09-30

Background
The aims of this study were to analyze the profile of childhood headache complaints in a tertiary headache center, verify the differences between children and adolescents, and provide the clinical characteristics that are related to the headaches.
Methods
A review of 384 medical records of children aged between 4-12 years old (n=206) and adolescents (n=178) aged >12 to 18 years old. The variables evaluated were reported as percentages, compared between children and adolescents and selected the variables that were related to headaches diagnosis.
Results
The majority of the sample were females (60.7%), diagnosis of migraine (70.3%), pulsatile pain (60.2%), episodic attacks (60.2%) and no need for imaging tests associated with the diagnosis (69.3%), which were associated with different clinical characteristics (LR X2(52); p<0.001; Log likelihood = -322.434; Pseud R2 = 0.154). The group of adolescents had a higher proportion of use of antidepressants (29.8%) as prophylactic medication than children, who on the other hand, had a higher prevalence of use of antivertiginous drugs (32%). The abortive medication used was common analgesics (37.8%) and the main outcome after treatment was discharge from the service (32%).
Conclusion
The evaluation and the treatment for these patients should take into account the main complaints, considering the particularities of each type of headache and also the age group, in order to identify, treat the disease properly and avoid chronification and continuity in the tertiary service, referring them to less complex services.

The relationship between the gut-brain axis and migraine

Aline Andretta Levis — 2024-09-30

The gut-brain axis and its role in migraine are increasingly recognized in the scientific community. This mini-review aims to explore the complex interaction between the gut microbiome and the central nervous system (CNS). The gut microbiota communicates bidirectionally with the brain through immune, endocrine, vagal, and other humoral pathways, influencing brain function and contributing to neuroinflammation and immune system disturbances. An imbalance in the gut microbiome can lead to systemic inflammatory responses, disrupted intestinal barrier integrity, and increased intestinal permeability, known as the "leaky gut syndrome." This condition is associated with a pro-inflammatory state that may trigger migraine attacks through the release of cytokines, activation of the trigeminovascular system, and modulation of pain processing pathways in the brain. Key components such as vagus nerve signaling, altered secretion of short-chain fatty acids (SCFAs), and neurotransmitter modulation play critical roles in this axis. The diet also significantly influences the microbiome, with high-fiber diets promoting anti-inflammatory SCFAs, while poor diets contribute to neuroinflammation and increased migraine susceptibility. Emerging evidence suggests that maintaining gut microbiome diversity and stability may alleviate migraine symptoms and enhance quality of life. This review highlights the importance of the gut-brain axis in migraine pathophysiology and suggests that targeting the microbiome could be an adjunctive therapeutic approach for migraine management.

Questionnaires used to assess the quality of life of patients with migraine and other headache disorders: an integrative review

Adriana de Almeida Soares — 2024-09-30

Introduction
According to the World Health Organization (WHO), quality of life is an individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concerns. Despite the subjectivity, quality of life may be measured through some assessment instruments in various diseases, including migraine and other headache disorders. Objective: This study aimed to review the main instruments used to assess the quality of life of patients with migraine and/or other headache disorders.
Method
This was an integrative literature review using articles with historical data on the main instruments used to assess the quality of life of patients with migraine or other headache disorders.
Results
Seven instruments for assessing the quality of life in patients with headache and other disorders were described. They were: Migraine Disability Assessment Scale (MIDAS), Headache Impact Test (HIT-6), Headache Disability Index (HDI), Short Form Health Survey (SF 36), Migraine Specific Quality of Life Questionnaire (MSQ), Migraine Severity (MIGSEV), and Migraine Functional Impact Questionnaire (MFIQ).
Conclusion
The quality of life of patients with headache may be compromised, but despite its subjectivity, it can be measured through assessment instruments.

Petasites hybridus in migraine prophylaxis: literature review

Raimundo Pereira Silva-Néto — 2024-09-30

Introduction
Over the past 25 years, Petasites hybridus has been used effectively in migraine prophylaxis. It acts on its pathophysiological mechanisms, modulating nociception, reducing the release of CGRP, decreasing inflammatory mediators and blocking calcium channels.
Objective
To review clinical studies already published on Petasites hybridus in migraine prophylaxis, with emphasis on the initial study by Grossmann and Schmidramsl in 2000.
Methods
This study was an integrative and retrospective review of articles on the use of Petasites hybridus in the prophylactic treatment of migraine that were published in English in the last 25 years.
Results
Five clinical studies were found, all placebo-controlled, three of which were double-blind, involving 488 patients with migraine aged between 6 and 60 years. These studies showed that Petasites hybridus was superior to placebo, proving its effectiveness in the prophylactic treatment of migraine and with good tolerability, including by children and adolescents.
Conclusions
Clinical studies proved that Petasites hybridus was well tolerated by children and adults and effective in migraine prophylaxis, reducing the number of days with headache by ≥ 50% in the first three months.

Idiopathic siderosis of the CNS: report and review

Isabela da Costa Rodrigues — 2024-09-30

Superficial siderosis (SS) of the central nervous system (CNS) is a potentially disabling disorder characterized by the deposition of ferrous iron and hemosiderin, products of hemolysis, in the leptomeninges and superficial layers of the cerebral and cerebellar cortexes, as well as the brainstem and spinal cord. Persisting in the subarachnoid space, accumulation leads to demyelination, axonal loss and subsequent atrophy and neurodegeneration mediated by free radicals. In most cases, a potentially causative spinal or cranial dural abnormality is identified. The classification of SS is based on anatomical distribution, etiology and clinical manifestations, resulting in distinct subtypes: Classical infratentorial (i) SS (type 1), secondary SSi (type 2) and cortical SS (c). The classical clinic manifests with sensorineural hypoacusis, cerebellar ataxia and occasionally myelopathic and radicular signs. Although it is not a classic symptom of SS, infrequently some patients develop chronic intracranial hypertension, which is believed to be associated with obstruction of the interventricular foramen and/or malabsorption of cerebrospinal fluid (CSF). When present, the headache is usually a consequence of intracranial hypotension and its intensity varies according to the type of dural defect and the rate of bleeding or CSF leakage through a fistula. Diagnosis is established by means of magnetic resonance imaging (MRI) of the entire neuroaxis combined with clinical assessment. As alternatives aimed at preventing the progression of the disease and preserving the patient's functional integrity, in addition to controlling the deficits generated by siderosis, surgical closure of the dura mater and chelation are the main therapeutic alternatives.