bluuebunny/crossref_metadata_2025 huggingface dataset:
Protriptyline, Chronic Tension‐Type Headaches, and Weight Loss in Women
Authors: Cohen Gary L.
Published: March 2003

Twenty‐five women with chronic tension‐type headaches were treated with protriptyline for 3 months, with attention paid to days of monthly headaches before and while taking the medication, as well as change in weight and side effects. One patient stopped the medication because of side effects and 2 did not return for follow‐up, yielding 22 patients. The typical dose of protriptyline was 20 mg every morning. Eighty‐six percent of patients had fewer headaches each month, with the mean dropping from 28.2 to 11.7 days. Seventy‐three percent had a 50% or greater reduction in the number of headaches per month. The average weight change was a loss of slightly over 3 pounds during the study period. The advantages and disadvantages of protriptyline in the treatment of chronic tension‐type headaches are discussed, as are mechanisms of action.
Pattern‐Reversal Visual Evoked Potentials in Migraineurs With or Without Visual Aura
Authors: Sener H. Özden , Haktanir Iklim , Demirci Serpil
Published: March 2003

To determine the possible electrophysiologic changes in migraineurs with or without visual aura, we investigatedpattern‐reversal visual evoked potentials in 39 patients. We compared the mean P100 latency and amplitude of 16patients with aura, 23 patients without aura, and 17 age‐ and sex‐matched normal subjects. There were no significantdifferences between groups. There was no correlation between age and the parameters in any group. However, in 7 of23 patients without aura, the P100 latency was longer than the mean control value + 2 SD. The mean disease duration inthis subgroup was significantly longer than the means of the remaining 16 patients without aura or the patients with aura(P<0.05 for each). This suggests the possibility that P100 latency prolongation is a consequence, but not an entitycaused by the pathogenetic mechanism of the disease from the beginning.
Transverse Sinus Thrombosis: An Unusual Cause of Headache
Authors: Wasson James , Redenbaugh James
Published: March 2003

A 24‐year‐old woman presented with headache of 6 days' duration, described as throbbing pain in the rightperiorbital region radiating to her right ear and neck. The pain was unresponsive to oral analgesics. She had nospeech or hearing difficulties, no previous history of migraines, and no family history of neurologic disease. Hermedications included oral contraceptives for 8 months' duration. This report describes the salient features of duralsinus thrombosis and recent advances in diagnostic and therapeutic procedures. The relationship between oralcontraceptives and protein S levels is also discussed. Cerebral dural sinus thrombosis should be considered inthe differential of new onset of headaches, seizures, or focal neurological deficits.
Mental Stress of Long Duration: EMG Activity, Perceived Tension, Fatigue, and Pain Development in Pain‐Free Subjects
Authors: Bansevicius Dalius , Westgaard Rolf H. , Jensen Chris
Published: March 2003

The study examined the relationship between pain development in the shoulder, neck, and facial regions and the EMG activity of underlying muscles, during prolonged exposure to a mental stressor. The subjective perception of tension and fatigue was recorded. Thirty‐six subjects were exposed to a two‐choice reaction‐time test for 1 hour. Electromyographic (EMG) recordings were performed bilaterally over the frontalis, temporalis, splenius, and trapezius muscles. Pain and perceived tension were scored on a visual analog scale, and fatigue on a Borg scale. Pain development was most pronounced in the shoulder and neck region. There was a weak tendency of those reporting pain in the shoulder region to generate higher EMG activity in the trapezius relative to those with no shoulder pain at the end of the test. No such relationship was observed for the other muscles. Perceived tension during the test was weakly related to pain and strongly related to fatigue at the end of the test, but not to EMG level. It is concluded that the mean level of the EMG response is of little consequence for pain development during stressful conditions. It is argued that other physiological responses such as prolonged activity in low‐threshold motor units, whereby the surface EMG response can serve as a marker, can be important for shoulder pain originating in the trapezius muscle.
Using Pretreatment Quality of Life Perceptions to Predict Response to Sumatriptan in Migraineurs
Authors: Litaker David G. , Solomon Glen D. , Genzen Jonathan R.
Published: March 2003

Quality of life perceptions vary for individuals with similar medical conditions and reflect disease impact. When correlated with subsequent response to treatment, such data may contribute useful insights in understanding the determinants of therapeutic effectiveness in selected medical conditions.

Two hundred thirty‐five migraine patients never previously treated with injectable sumatriptan completed a Short Form‐36 questionnaire before receiving a supervised test dose and a prescription for the medication. Medical records were examined to determine the number of comorbid conditions, headache characteristics (age at onset, headache frequency, duration of disease, aura, association with menses, unilaterality, and emesis), and documentation of sumatriptan's effect in relieving migraine during 12 months of follow‐up. Logistic regression was used to identify patient‐ and disease‐specific features most closely associated with the dependent variable, clinical response.

One hundred eighty‐four patients (78%) reported both relief of symptoms and continued usage of sumatriptan. Patients who experienced emesis with headaches (OR=2.05 [1.07, 3.91]) and those with higher pretreatment Physical Functioning scores (OR=3.27 [1.28, 8.37]) were more likely to respond to sumatriptan.

Response to sumatriptan therapy was associated with specific pretreatment quality of life domains and headache features. These results may be useful in improving the efficiency of disease management strategies for patients with migraine.
Reduction of Migraine Attacks During the Use of Warfarin
Authors: Fragoso Yara D.
Published: March 2003

Two recent reports on reduction of migraine attacks during treatment with vitamin K antagonists have caught my attention.1,2 Being a migraine sufferer myself, with considerable improvement of my headache during the use of warfarin, I became interested in the subject. Recently, a young man sought my advice for migraine attacks which had worsened after the withdrawal of warfarin. The previous reports on migraine and warfarin involved elderly patients.1,2 I report now on these two patients in their 30s, one of them being myself (case 1), who have experienced reduction of migraine attacks during the use of warfarin.
Posttraumatic Migraine
Authors: Solomon Seymour
Published: March 2003

The term posttraumatic migraine has been used in several contexts. The purpose of this discussion is to outline the different circumstances in which migraine may follow trauma. Cases from the literature and from the Headache Unit of Montefiore Medical Center are reviewed.

Although trauma may be one of many triggers of migraine, trauma is sometimes the sole or predominant precipitating factor; eg, footballer's migraine. In the posttraumatic syndrome, some exacerbations of headache upon a background of chronic daily headache often fulfill the criteria of migraine. Trauma may trigger the first attack of migraine in a susceptible individual. Biochemical and epidemiologic studies suggest that trauma may be the main etiologic factor of migraine in some cases. Migraine may also follow trauma on the basis of chance.

Differentiating the different types of posttraumatic migraine has diagnostic, therapeutic, and legal implications.
Frequency of Factor V Leiden in Juvenile Migraine With Aura
Authors: Soriani Stefano , Borgna‐Pignatti Caterina , Trabetti Elisabetta , Casartelli Alessandro , Montagna Pasquale , Pignatti Pier Franco
Published: March 2003

Patients with migraine are known to be at risk for stroke. It has been reported that in a group of patients with cerebral ischemia and the Leiden mutation of factor V, 67% had classical migraine. We have studied the frequency of this mutation in a group of Italian children and adolescents affected by migraine with aura.

The Leiden mutation was detected in 2 (3.5%) of 57 patients and in 8 (3.7%) of 219 controls. The 2 patients carrying the mutation had no peculiar characteristics as compared with the rest of the migrainous population. In our study, the frequency of the Leiden mutation in patients was not different from that of controls. These data contrast with those collected in the Finnish population and in a group of northwestern Italian adult patients, but agree with results previously reported from The Netherlands.
Headache Associated With Pituitary Adenomas
Authors: Abe Takumi , Matsumoto Kiyoshi , Kuwazawa Jiro , Toyoda Izumi , Sasaki Ken
Published: March 2003

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved.

Fifty‐one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin‐secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.
Crying Migraine
Authors: Evans Randolph W.
Published: March 2003

Eighty‐five percent of migraineurs report triggers which include a diverse array of internal and external factors. Crying as a trigger has been reported in two women, without details, in only one prior study. In the present report, the clinical history of two women (aged 38 and 41 years, respectively) with migraines triggered by crying are detailed. In both women, the migraines were triggered by crying associated with sadness or emotional upset. Crying when happy or due to cutting onions was not a trigger. Only in the second patient was crying during a sad movie or theatrical production also a trigger. Crying may be a common underrecognized migraine trigger.
Transformed Migraine Is a Cause of Chronic Daily Headaches
Authors: Konno Shizuko , Meyer John Stirling , Margishvili Gaiane M. , Rauch Ronald A. , Haque Anwarul
Published: March 2003

Chronic daily headaches (CDH) consist of episodes of head pain occurring daily; more than 15 days each month; often associated with a history of migraine, with or without aura; or with a history of tension‐type headaches occurring alone or both occurring together. Chronic daily headaches are frequently associated with rebound headaches after ergotamine, barbiturate, caffeine, and analgesic abuse. We previously reported that migraineurs with typical intermittent headaches exhibited excessive cerebral cortical vasodilation after oral acetazolamide which usually precipitated and reproduced their typical headaches. In the present study, cerebral vasodilator responses were tested by measuring changes in local cerebral blood flow (ΔLCBF) utilizing xenon‐contrasted CT scanning, before and after oral administration of 14.3 mg/kg of acetazolamide, in 11 patients with CDH. The results were compared with 12 age‐matched typical migraineurs, with and without aura, who had a history of migraine attacks occurring at intervals of 1 month or longer. Global and subcortical gray and white matter ΔLCBFs were quantitated and compared between both groups. After acetazolamide, ΔLCBF increased in cortical gray matter by 11.8% among patients with CDH and by 16.7% among migraineurs, with no significant differences between groups. Typical migraine attacks were provoked by acetazolamide in 9 patients (82%) with CDH and in 11 (92%) migraineurs with intermittent headaches. These observations are taken as evidence that at least 82% of patients with CDH have transformed migraine as judged by the provocation by acetazolamide of typical migraine attacks associated with excessive ΔLCBF increases. Serotonin agonists should be considered in the treatment of CDH to avoid ergotamine, caffeine, barbiturate, and analgesic abuse.
Autonomic Dysfunction in Migraineurs
Authors: Mosek Amnon , Novak Vera , Opfer‐Gehrking Tonette L. , Swanson Jerry W. , Low Phillip A.
Published: March 2003

Objective.—To evaluate autonomic function and sympathovagal balance in migraineurs and healthy controls.

Background.—The pathophysiology of migraine is still largely unknown. An imbalance of the autonomic nervous system could explain many of the clinical manifestations of the disorder.

Materials and Methods.—We undertook autonomic function tests in 17 women suffering from migraine (8 with aura) (average age 36 ± 7 years) and 16 healthy women (average age 34 ± 7 years). Autonomic nervous system studies consisted of tests of sympathetic function (the quantitative sudomotor axon reflex test, beat‐to‐beat blood pressure responses to the Valsalva maneuver, sustained handgrip, cold pressor test, and head‐up tilt and tests of parasympathetic function (heart rate responses to deep breathing and the Valsalva maneuver). The data from the tilt test were further evaluated by time‐frequency analysis (Wigner distribution).

Results.—Subjects with migraine with aura had a smaller increase of mean blood pressure during phase IV of the Valsalva maneuver (P<0.05) and a lower blood pressure increment during the handgrip test (P=0.08); their time‐frequency distribution showed reduced power at the nonrespiratory frequencies in the R‐R interval at both minutes 1 (P<0.03) and 5 (P<0.04) of head‐up tilt. Sympathovagal balance (a ratio of spectral power of nonrespiratory frequency variations in blood pressure to that at respiratory frequency variations in the R‐R interval) was significantly increased in migraineurs, both with and without aura, by 10 minutes of head‐up tilt.

Conclusion.—Subjects with migraine with aura had resting supine sympathetic hypofunction and intact parasympathetic function. With head‐up tilt, sympathovagal balance is increased. The dynamic alterations in autonomic nervous system function may contribute to the development of aura in patients with migraine.
Use of Cluster Analysis to Validate IHS Diagnostic Criteria for Migraine and Tension‐Type Headache
Authors: Bruehl Stephen , Lofland Kenneth R. , Semenchuk Elizabeth M. , Rokicki Lori A. , Penzien Donald B.
Published: March 2003

Cluster analysis was used to validate headache diagnostic criteria of the International Headache Society (IHS). Structured diagnostic interviews were conducted on 443 headache sufferers from a community sample, which was randomly split to allow replication. Hierarchical cluster analysis of symptoms in both subsamples revealed two distinct (P<.001) clusters: (1) unilateral pulsating pain, pain aggravated by activity, and photophobia and phonophobia, and (2) bilateral pressing/tightening pain, mild to moderate intensity, and absence of nausea/vomiting. These clusters were consistent with IHS migraine and tension‐type classifications, respectively. Replication using a non‐hierarchical clustering technique, k‐means cluster analysis, revealed a migrainelike patient cluster, reflecting more frequent pulsating, unilateral pain; more severe pain; and pain aggravated by activity; nausea, vomiting, photophobia, and phonophobia. A tensionlike patient cluster was also identified, reflecting more frequent pressing/tightening pain, mild to moderate pain, bilateral location, and absence of nausea/vomiting. These patient clusters were consistent across subsamples. International Headache Society diagnoses corresponded with classification based upon statistically derived clusters (P<.001). These results indicate that headache symptoms cluster empirically in a manner consistent with IHS criteria for migraine and tension‐type headaches. Criterion overlap problems regarding pain intensity and duration were identified. Overall, these data support migraine and tension‐type headache as distinct entities, and provide support for the IHS diagnostic criteria with minor modifications.
Posttraumatic Hemicrania Continua
Authors: Lay Christine L. , Newman Lawrence C.
Published: March 2003

Hemicrania continua is a rare, benign headache disorder characterized by a low‐level baseline hemicranial headache with superimposed exacerbations of more severe pain. Exacerbations last from minutes to days and may be associated with ipsilateral autonomic features such as ptosis, miosis, conjunctival injection, lacrimation, or rhinorrhea; when present, these features tend to be less pronounced than those seen with cluster headache. Response to treatment with indomethacin, in doses ranging from 25 to 300 mg per day, has been deemed a sine qua non of diagnosis. To date, in the majority of instances, hemicrania continua appears to have arisen de novo, without any identifiable trigger. We report four patients in whom the onset of hemicrania continua was temporally linked to head trauma.
Primary Chronic Daily Headache: Clinical and Pharmacological Aspects. A Clinic‐Based Study in Oman
Authors: Deleu Dirk , Hanssens Yolande
Published: March 2003

This study on primary chronic daily headache was based on the 1996 proposed revision of the diagnostic criteria of the International Headache Society (IHS). To investigate the relative frequency, clinical characteristics, and associated features of primary chronic daily headache in Omani patients, 171 patients visiting the Neurology Clinic at Sultan Qaboos University Hospital were evaluated. Forty‐five percent was diagnosed as suffering from primary chronic daily headache (female to male ratio, 1.7:1). Sixty‐two percent suffered from transformed migraine and 34% from chronic tension‐type headache. The average age across sexes was 32.3 ± 12.3 years. A dull heavy feeling in the head was reported by 58% of patients and was associated in less than one third with associated features characteristic of migraine. All headache types shared the same trigger factors. All patients were taking medication, predominantly analgesics, at the time of their first visit.

We concluded that primary chronic daily headache is very common with the relative frequency of transformed migraine being similar to that found in Mediterranean studies. Also in Oman, chronic use/overuse of analgesics and nonsteroidal anti‐inflammatory drugs is a problem that coexists with primary chronic daily headache. Finally, the proposed revised IHS criteria are highly recommended as a standard classification system for this type of headache.
Amino Acids in the Saliva of Patients With Migraine
Authors: Rajda C. , Tajti J. , Komoróczy R. , Seres E. , Klivényi P. , Vécsei L.
Published: March 2003

There are a number of hypotheses concerning the pathogenesis of migraine, but they are frequently conflicting. In addition to the vascular hypothesis, clinical data are available that excitatory amino acids may play an important role in the development of the disease. In this study, free amino acid concentrations were measured by RP‐HPLC in the saliva of 23 migraineurs without aura, 14 migraineurs with aura, and 20 healthy subjects. Significantly higher concentrations of glutamic acid, serine, glycine, arginine, and tyrosine were found in the saliva samples of both groups of migraineurs relative to the control group. It is suggested that amino acids causing hyperexcitability in the central nervous system may be linked to the pathogenesis of migraine.
Migraine With Prolonged Aura
Authors: Bento Mariana Santos , Esperança Paula
Published: March 2003

We present the case of a 29‐year‐old man with a long history of migraine with aura, in whom migraine with prolonged aura was induced after the sudden withdrawal of prophylactic therapy.
Simultaneous Occurrence of Ipsilateral Cluster Headache and Chronic Paroxysmal Hemicrania: A Case Report
Authors: Centonze Vincenzo , Bassi Antonia , Causarano Vito , Dalfino Lidia , Centonze Angelo , Albano Ottavio
Published: March 2003

A 42‐year‐old man came to our headache unit in October 1995 complaining of recurrent attacks of headache, which had begun in February 1991. Chronic cluster headache was diagnosed, and he was given verapamil, 360 mg per day. The attacks ceased in the following months and verapamil was stopped in March 1996. In May 1997, a recurrence of the attacks required the readministration of verapamil, 360 mg per day. The attacks decreased (one to three per week), but after 2 months the patient reported a worsening in his condition due to the appearance of shorter attacks, which were diagnosed as chronic paroxysmal hemicrania. The administration of indomethacin, 225 mg per day, resulted in the disappearance of the short attacks.

The concomitant occurrence of attacks of cluster headache and chronic paroxysmal hemicrania suggests the presence of shared factors in the pathophysiology of the two forms of headache. This hypothesis is supported by previous reports in the literature.
Hungarian Migraine Epidemiology
Authors: Bánk J. , Márton S.
Published: March 2003

Objective.–A population‐based epidemiological survey of migraine without aura and migraine with aura completed by mailed questionnaire in Hungary. The diagnosis and classification of migraine was according to the criteria of the International Headache Society.

Methods.–The validity of the self‐administered headache questionnaire was evaluated by a neurologist using clinical interviews. The study population was a random sample of 2000 men and women aged between 15 and 80 years. The questionnaire was completed by 813 of 1910 people (392 men and 421 women), providing a 42.6% participation rate.

Results.–Sixty‐seven percent of these people experienced some kind of headache during their lives. The 1‐year prevalence of migraine without aura was 7.6% (the female/male ratio was 3:1), while the 1‐year prevalence of migraine with aura was 2% (female/male ratio was 2:1). Most migraineurs experienced headache attacks 1 to 4 times monthly, which lasted 24 hours. The most characteristic accompanying signs were nausea and phonophobia. Stress, sleep deprivation, hot weather, and fasting were the most common precipitating factors of a migraine attack. In the migraine with aura group, the most common aura was a visual disturbance. Only 43% of migraineurs had ever consulted a physician for headache, and only 15% of patients had missed work or school because of a migraine attack in the previous year. Most of the patients suffering from migraine without aura were between 20 and 40 years old, while migraineurs with aura were over 40 years old. According to this investigation, the prevalence of migraine was not lower than in Western countries.
Benign Hot Bath‐Related Headache
Authors: Negoro Kiyoshi , Morimatsu Mitsunori , Ikuta Naomi , Nogaki Hiroshi
Published: March 2003

We describe three cases of women with hot bath‐related headache who reported that their severe paroxysmal headache could be provoked by pouring hot water over themselves or by soaking in a hot bath. In one patient, the headache was also brought on by exposure to cold wind. Another patient had headaches after she dived into a pool and started swimming. Neurological examination, routine laboratory tests, electroencephalography, and brain imaging showed no abnormality in any of the patients. Hot bath‐related headache is a benign headache unassociated with a structural lesion.
Intravenous Propofol: Unique Effectiveness in Treating Intractable Migraine
Authors: Krusz John Claude , Scott Virginia , Belanger Jeanne
Published: March 2003

Objective.–To report the unique effectiveness of propofol, an intravenous anesthetic agent, in treating refractory migraines and other headaches in the setting of an outpatient headache center.

Background.–We initially observed the dramatic abolition of ongoing migraine in patients (n=6) being treated with propofol in preparation for epidural and other nerve blocks in the headache and pain clinic. The reduction of headache severity was virtually 100%. We decided to treat an additional cohort of patients with intravenous propofol in the headache clinic; these patients had intractable migraines that were refractory to the usual abortive treatments. Subanesthetic doses of propofol were employed in this study. This is the first known report of the utility of this agent specifically for the treatment of intractable headache.

Methods.–Seventy‐seven patients were treated for intractable headache in the clinic with intravenous propofol, for both migraine and nonmigrainous headache refractory to the usual methods of abortive treatment.

Results.–The average reduction in headache intensity was 95.4% after an average of 20 to 30 minutes of intravenous propofol treatment, using a patient‐rated visual analog scale of 0 to 10. Sixty‐three of 77 patients reported complete abolition of their headache. The average dose of propofol was 110 mg, which is well within the usual range of preanesthetic doses and is clearly subanesthetic. Moreover, only three of the treated patients reported a return of the headache on the day following treatment.

The neuropharmacology of propofol and the putative multiple mechanisms of action upon various neurotransmitter systems in the brain, particularly gamma aminobutyric acid A receptor subtypes, are discussed to explain the results in our patients.

Conclusions.–The use of intravenous propofol may represent a new, rapid, and highly effective form of abortive headache treatment in the headache clinic or emergency room setting and may offer an alternative to other treatment modalities for acute migraine and other severe intractable headaches. The effectiveness of propofol raises many new questions about the pathophysiology of migraine and other headaches.
Treatment of Tension‐type Headache With Botulinum Toxin Type A: A Double‐Blind, Placebo‐Controlled Study
Authors: Rollnik Jens D. , Tanneberger Oliver , Schubert Margot , Schneider Udo , Dengler Reinhard
Published: March 2003

Objective.–To determine whether injections of botulinum toxin could be of therapeutic value in the treatment of tension‐type headache.

Background.–Botulinum toxin A is very effective at reducing muscle tenderness and pain in many diseases. Increased muscle tension may contribute to tension‐type headache.

Methods.–We performed a double‐blind, placebo‐controlled study with 21 patients fulfilling the International Headache Society criteria for tension‐type headache. Participants were randomly assigned to treatment (pericranial injection of 10 × 20 mouse units botulinum toxin A) or placebo (injection of isotonic saline in the same manner).

Results.–After 4, 8, and 12 weeks, no significant differences between placebo and treatment could be observed (with respect to visual analog scale, frequency and duration of headache attacks, consumption of analgesics, pressure pain threshold, total tenderness score, and quality‐of‐life parameters).

Conclusions.–The findings of our study strongly support the hypothesis that peripheral mechanisms, such as increased muscle tenderness, only play a minor role in the pathogenesis of tension‐type headache.
Botulinum Toxin Type A as a Migraine Preventive Treatment
Authors: Silberstein Stephen , Mathew Ninan , Saper Joel , Jenkins Stephen ,   for the BOTOX Migraine Clinical Research Group
Published: March 2003

Objective.—To assess the safety and efficacy of botulinum toxin type A (BOTOX; Allergan, Inc) in the prevention of migraine.

Background.—Current migraine preventive therapies are often unsatisfactory because of their limited efficacy, adverse effects, and drug interactions. Botulinum toxin type A injections often reduce the pain associated with conditions such as cervical dystonia, achalasia, rectal fissures, and myofascial pain syndrome. An open‐label, noncontrolled study of botulinum toxin type A suggested benefits for patients with migraine.

Design and Methods.—This was a double‐blind, vehicle‐controlled study of 123 subjects with a history of two to eight moderate‐to‐severe migraine attacks per month, with or without aura. Participants were randomized to receive single administrations of vehicle or botulinum toxin type A, 25 U or 75 U, injected into multiple sites of pericranial muscles at the same visit. During a 1‐month baseline period and for 3 months following injection, subjects kept daily diaries in which they recorded migraine frequency, migraine severity, and the occurrence of migraine‐associated symptoms.

Results.—Compared with vehicle treatment, subjects in the 25‐U botulinum toxin type A treatment group showed significantly fewer migraine attacks per month, a reduced maximum severity of migraines, a reduced number of days using acute migraine medications, and reduced incidence of migraine‐associated vomiting. Both the 25‐U and 75‐U botulinum toxin type A groups were significantly better than the vehicle group on subject global assessment. Botulinum toxin A treatment was well tolerated, with only the 75‐U treatment group exhibiting a significantly higher rate of treatment‐related adverse events than vehicle.

Conclusions.—Pericranial injection of botulinum toxin type A, 25 U, was found to be a safe treatment that significantly reduced migraine frequency, migraine severity, acute medication usage, and associated vomiting.
Naratriptan Efficacy in Migraineurs Who Respond Poorly to Oral Sumatriptan
Authors: Stark Stuart , Spierings Egilius L.H. , McNeal Scott , Putnam Gayla P. , Bolden‐Watson Carolyn P. , O'Quinn Stephen
Published: March 2003

Objectives.—To determine whether 347 patients would respond to a 50‐mg oral dose of sumatriptan, even though they considered themselves poor responders to this acute therapy for migraine, and to investigate whether oral naratriptan can be an effective acute therapy for migraine in the subset of patients who did not respond to sumatriptan under double‐blind, well‐controlled conditions.

Background.—Although most migraineurs respond to sumatriptan, there remains a need for an effective alternative for those who do not respond. Naratriptan is a more potent and more lipophilic member of this class of agent and could prove beneficial in such patients. This is the first well‐controlled study to assess the value of another 5‐HT1B/1D agonist in this difficult patient subset.

Methods.—This study comprised two migraine attacks. The first (attack 1) was a single‐blind assessment of the efficacy of sumatriptan (50 mg orally) in patients with a history of poor response to the drug. The second (attack 2) was a randomized, parallel group, double‐blind, placebo‐controlled trial of naratriptan (2.5 mg orally) in nonresponders to oral sumatriptan.

Results.—Attack 1: About two thirds of this selected migraine population did not respond to sumatriptan. Attack 2: Naratriptan was statistically superior to placebo for headache relief at 2 hours and 4 hours, as well as for most other features of migraine attacks. These data suggest an intrinsic efficacy of naratriptan in this patient subset and not a coincidental response. No unexpected tolerability issues arose.

Conclusions.—Naratriptan is an alternative therapy for migraineurs who respond poorly to oral sumatriptan. No response to one “triptan” does not necessarily predict no response to them all.
Further Development and Testing of the Migraine‐Specific Quality of Life (MSQOL) Measure
Authors: Patrick Donald L. , Hurst Bryan C. , Hughes Janette
Published: March 2003

Objective.—To evaluate the longitudinal performance of the migraine‐specific quality of life (MSQOL) instrument.

Methods.—Psychometric tests evaluated data obtained from 1383 migraineurs who completed the 20‐item MSQOL questionnaire during a noncomparative, long‐term, observational study of zolmitriptan (Zomig), 5 mg, for the acute treatment of migraine attacks of any intensity.

Results.—There was a relationship between a history of a high frequency of migraine attacks and low baseline MSQOL scores, indicating a lower quality of life. Principal components analyses confirmed three domains and an overall score. Cronbach α coefficients for the overall score (.93) indicated high internal consistency. Responsiveness analysis over 180 days of treatment indicated a significantly greater improvement in MSQOL scores (P < .05) in treatment responders compared with nonresponders. The average effect size (0.25) and Guyatt responsiveness statistic (0.46) for the MSQOL instrument exceeded those for the eight domains of the Medical Outcomes Study Short Form Health Survey (MOS SF‐36) (−0.05 to 0.14 and 0.01 to 0.12, respectively). Change from baseline for responders in MSQOL total score was 4.7 to 5.4 compared with 1.1 to 2.7 for nonresponders.

Conclusions.—Cumulative evidence for the MSQOL instrument meets established criteria for validity, consistency, and reproducibility and shows moderate responsiveness to treatment. This instrument fulfils the need for an MSQOL measure to be used as an adjuvant measure in the assessment of long‐term outcomes of therapy.
Interobserver Reliability in Physical Examination of the Cervical Spine in Patients With Headache
Authors: Van Suijlekom Hans A. , De Vet Henrica C.W. , Van Den Berg Suzanne G.M. , Weber Wilhelm E.J.
Published: March 2003

Objective.—To assess interobserver reliability of two expert headache neurologists when examining the cervical spine of patients with headache.

Background.—The diagnosis of cervicogenic headache involves the physical examination of the cervical spine.

Methods.—Twenty‐four patients diagnosed as having migraine, tension‐type headache, or cervicogenic headache were included in the study. After interview, each patient's cervical spine was examined in a structured way. Reliability was assessed by Cohen's kappa.

Results.—Reduced range of motion in the cervical spine showed kappa scores indicating moderate agreement. Provocation of headache revealed moderate‐to‐substantial agreement. Assessment of zygapophyseal joint pressure pain showed slight‐to‐fair agreement. The kappa values of the circumscribed characteristic tender points showed agreement ranging from “not better than chance” to “substantial agreement.”

Conclusions.—Our study showed that the interobserver reliability of expert headache neurologists was satisfactory in the majority of the physical examination tests of the cervical spine in patients with different headache syndromes. However, standardization of the clinical tests in order to improve their reliability is recommended.
Olfactory Hallucinations During Migraine in an Adolescent With an MRI Temporal Lobe Lesion
Authors: McAbee Gary , Sagan Allison , Winter Lori
Published: March 2003

Objective.—To report the first example of an abnormal magnetic resonance imaging (MRI) test in a patient with migraine and olfactory hallucinations and to provide additional evidence for a possible role of the temporal lobe in migraine.

Background.—The relationship between the temporal lobe and migraine with or without hallucinations is unclear and continues to evolve. Clinical and functional neuroimaging studies (positron emission tomography/single photon emission computed tomography) have lent support to the possibility of a relationship. Anatomical neuroimaging with computed tomography has previously been normal.

Methods.—The history and findings of an adolescent with migraine and olfactory hallucinations is reported.

Results.—Brain MRI demonstrated a mass in the temporal lobe.

Conclusions.—Magnetic resonance imaging should be considered in patients with olfactory hallucinations and migraine. In addition, the role of the temporal lobe in migraine warrants further study.
Reversible Cognitive Decline Accompanies Migraine and Cluster Headaches
Authors: Meyer John S. , Thornby John , Crawford Kate , Rauch Gaiane M.
Published: March 2003

Vascular headaches, including migraine, cluster, and migrainous transformation to chronic daily headaches, are disabling. During and shortly after headache intervals, difficulties are reported in concentration, comprehension, and communication, not accounted for by nausea, photophobia, or sonophobia. These interfere with interpersonal relations and performance at work with economic loss. The hypothesis tested and reported here is that cognitive impairments comprise an important part of vascular headache diatheses. One hundred ninety‐six otherwise normative subjects suffering from migraine or cluster, but not tension‐type, headaches (136 women, 63 men; mean age, 46 years) participated in an outpatient prospective trial. One hundred thirty‐three patients had migraine without aura, 39 migraine with aura, 11 periodic cluster (by IHS criteria), and 13 had migrainous transformation into chronic daily headaches. Neuropsychological testing was compared with and without headaches, by combined Mini‐Mental Status Examination (MMSE), Cognitive Capacity Screening Examination (CCSE), and Hamilton Depression Rating Scale (HDRS). During headache intervals, significant decline was measured in both CCSE and MMSE scores (P < .001) without HDRS change in all types of vascular headache and independent of headache severity, which often improved, or associated physical symptoms. Cognitive decline was promptly relieved by serotonin agonists and sleep. Disorders of cerebral serotoninergic projection systems appear to cause these reversible cognitive impairments.
The Efficacy of Divalproex Sodium in the Prophylactic Treatment of Children With Migraine
Authors: Caruso June M. , Brown William D. , Exil Gerald , Gascon Generoso G.
Published: March 2003

Objective.—To determine the beneficial use of divalproex sodium as a prophylactic treatment for migraine in children.

Background.—Previous studies for treatment of migraine in adults have shown a greater than 50% reduction in migraine attack frequencies. Few data exist, however, regarding the efficacy and safety of divalproex sodium use in children with migraine.

Methods.—We studied the incidence of headache relief in our patients with migraine aged 16 years and younger treated with divalproex sodium prophylactically at our institution from July 1996 to December 1998 to determine medication dosage used, concomitant headache medications, and possible adverse effects.

Results.—A total of 42 patients, ranging in age from 7 to 16 years (mean age, 11.3 years), were treated with divalproex sodium for headache. All had a history of migraine with or without aura. Baseline headache frequency during a minimum 6‐month period was one to four headaches per month. Divalproex sodium dosage ranged from 15 mg/kg/day to 45 mg/kg/day. Of the 42 patients, 34 (80.9%) successfully discontinued their abortive medications. After 4 months' treatment, 50% headache reduction was seen in 78.5% of patients, 75% reduction in 14.2% of patients, and 9.5% of patients became headache‐free.

Conclusion.—These results indicate divalproex sodium to be an effective and well‐tolerated treatment for the prophylaxis of migraine in children.
Perceptions of Pain in Women With Headache: A Laboratory Investigation of the Influence of Pain‐Related Anxiety and Fear
Authors: Bishop Kelly L. , Holm Jeffrey E. , Borowiak Dana M. , Wilson Brian A.
Published: March 2003

The present study compared the responses of women with headache (chronic tension‐type, n = 27; migraine, n = 27) and controls (n = 27) to an acute pain laboratory task, the cold pressor test. Participants' pain perception (ie, threshold and tolerance) and their fear/anxiety associated with pain were assessed during days 1, 2, or 3 of menses.

Analyses pertaining to participants' responses to the cold pressor test (ie, pain threshold and tolerance) failed to show statistically significant group differences, even when covarying pain‐related anxiety/fear. Analyses did, however, reveal significant group differences between migraineurs and controls in cognitive anxiety. Correlational analyses also revealed that cognitive anxiety, somatic anxiety, fear, and escape/avoidance were all significantly correlated with pain tolerance in the group with chronic tension‐type headache, but not in the other two groups. Subsequent multiple regressions, however, showed that the relationship between anxiety and pain tolerance was primarily a function of somatic anxiety. These results suggest that headache frequency plays a role in mediating the relationship between fear of pain and pain tolerance and that the models by Lethem and colleagues and McCracken may be relevant for understanding tension headache sufferers' responses to head pain.
Prevalence and Clinical Characteristics of Headache in Medical Students in Oman
Authors: Deleu D. , Khan M.A. , Humaidan H. , Al Mantheri Z. , Al Hashami S.
Published: March 2003

Objectives.—To perform a descriptive epidemiological study of headache in medical students at Sultan Qaboos University, analyzing prevalence, symptom profile, and pattern of health care utilization.

Background.—Headache is one of the most common complaints in medical practice. To our knowledge, headache has not been the subject of investigation in medical students in the Arabian Gulf.

Methods.—Lifetime and last‐year prevalence of headache was based on a detailed structured headache assessment questionnaire. Besides demographic data, headache characteristics and pattern of health care utilization were evaluated. In addition, questions were included referring to the use of traditional remedies. Interviewers included three previously trained final‐year medical students. The evaluation was done per cohort, and the students were guided through the assessment questionnaire by the interviewers. Migraine and tension‐type headache were diagnosed according to the criteria of the International Headache Society.

Results.—Four hundred three students (95.3%) completed the questionnaire: 151 men (37.5%) and 252 women (62.5%). The lifetime and last‐year prevalence of headache was 98.3% and 96.8%, respectively. A positive family history of headache was found in 57.6% of students. The prevalence rate of migraine and tension‐type headache was found to be the same (12.2%), with a difference in distribution across sexes: 6.6% of the men and 15.5% of the women had migraine, while 13.9% of the men and 11.1% of the women suffered from tension‐type headache. Only 23.3% of students sought medical assistance during headache episodes, and 80.3% took medication: 24.6% took prescribed medication, 72.9% took nonprescription medication, and only 2.5% took traditional remedies. Acetaminophen (83.1%) followed by mefenamic acid (24.6%) were the most commonly used drugs.

Conclusions.—The results of this prospective epidemiological study show that headache is highly prevalent among medical students at this university. The high prevalence rate of migraine sufferers in this student population might be due to the high female‐to‐male ratio (1.7:1). It is likely that analgesic use/overuse also coexists with headache in medical students at Sultan Qaboos University, since a large majority of them rely on nonprescription medications.
Antiepileptic Drugs: How They Work in Headache
Authors: Cutrer F. Michael
Published: March 2003

Antiepileptic drugs (AEDs) are promising agents for the prevention of migraine and other head pain. Migraine and epilepsy share several clinical features and respond to many of the same pharmacologic agents, suggesting that similar mechanisms may be involved in their pathophysiology. The mechanisms of action of AEDs are not fully understood, and a single drug may have more than one mechanism, both in epilepsy and in migraine. Valproate, topiramate, and gabapentin are likely to affect nociception by modulating gamma‐aminobutyric acid‐ (GABA‐) and/or glutamate‐mediated neurotransmission. All three AEDs enhance GABA‐mediated inhibition. Valproate and gabapentin interfere with GABA metabolism to prevent its ultimate conversion to succinate, and topiramate potentiates GABA‐mediated inhibition by facilitating the action of GABA receptors. In addition, topiramate acts directly on non‐N‐methyl‐D‐aspartate, alpha‐amino‐3‐hydroxy‐5‐methylisoxazole‐4‐propionic acid/kainate glutamate receptors. Valproate, topiramate, and possibly gabapentin inhibit sodium ion channels. All three drugs modulate calcium ion channel activity. Valproate blocks T‐type calcium ion channels; topiramate inhibits high‐voltage‐activated L‐type calcium ion channels; and gabapentin binds to the α2δ subunit of L‐type calcium ion channels. AEDs may be useful in migraine prevention through such mechanisms as modulating the biochemical phenomena of aura or acting directly on the nociceptive system. Further evaluations of AEDs in migraine models will provide a better understanding of the pathophysiology and prevention of migraine.
Quality‐of‐Life Differences Between Patients With Episodic and Transformed Migraine
Authors: Meletiche Dennis M. , Lofland Jennifer H. , Young William B.
Published: March 2003

Objective.—To determine whether there are any differences in health‐related quality of life between patients with migraine and those with transformed migraine.

Background.—There are no published reports comparing the health‐related quality of life between patients with migraine and patients with transformed migraine.

Methods.—We conducted a retrospective analysis examining the health‐related quality of life of patients with transformed migraine and migraine seen at a specialty headache clinic. Data collected included the Short Form‐36 (SF‐36) and the Migraine Disability Assessment questionnaires as well as demographic information. Both of these forms are part of the initial evaluation at the headache clinic. A t test with Bonferroni correction was used to test for significant differences in the SF‐36 domains between the groups.

Results.—Data were collected for 90 patients, 46 with transformed migraine and 44 with migraine. There were no significant differences between groups with respect to sex, race, or age. Over the last 90 days prior to their first visit, patients with transformed migraine reported having a headache an average of 69 days compared with patients with migraine who averaged 18 days with headache (P<.05). Compared with patients with migraine, patients with transformed migraine had statistically (P<.05) and clinically significant (difference >5 points) lower mean scores on seven of the eight SF‐36 domains and both the mental and physical summary scores of the SF‐36.

Conclusions.—The results of this study suggest that patients with transformed migraine have a lower health‐related quality of life than patients with migraine. These findings indicate that the headache chronicity associated with transformed migraine has a significant influence on quality of life. The results highlight the importance of effective management of headaches to avoid the progression of migraine to the more disabling transformed migraine.