Differences and similarities between COVID-19 related-headache and COVID-19 vaccine related-headache. A case-control study. / Diferencias y similitudes entre la cefalea relacionada con la COVID-19 y la cefalea relacionada con la vacuna de la COVID-19. Un estudio de casos y controles.

INTRODUCTION: Headache is a frequent symptom at the acute phase of coronavirus disease 2019 (COVID-19) and also one of the most frequent adverse effects following vaccination. In both cases, headache pathophysiology seems linked to the host immune response and could have similarities. We aimed to compare the clinical phenotype and the frequency and associated onset symptoms in patients with COVID-19 related-headache and COVID-19 vaccine related-headache. SUBJECTS AND METHODS: A case-control study was conducted. Patients with confirmed COVID-19 infection and COVID-19-vaccine recipients who experienced new-onset headache were included. A standardised questionnaire was administered, including demographic variables, prior history of headaches, associated symptoms and headache-related variables. Both groups were matched for age, sex, and prior history of headache. A multivariate regression analysis was performed. RESULTS: A total of 238 patients fulfilled eligibility criteria (143 patients with COVID-19 related-headache and 95 subjects experiencing COVID-19 vaccine related-headache). Patients with COVID-19 related-headache exhibited a higher frequency of arthralgia, diarrhoea, dyspnoea, chest pain, expectoration, anosmia, myalgia, odynophagia, rhinorrhoea, cough, and dysgeusia. Further, patients with COVID-19 related-headache had a more prolonged daily duration of headache and described the headache as the worst headache ever experienced. Patients with COVID-19 vaccine-related headache, experienced more frequently pain in the parietal region, phonophobia, and worsening of the headache by head movements or eye movements. CONCLUSION: Headache caused by SARS-CoV-2 infection and COVID-19 vaccination related-headache have more similarities than differences, supporting a shared pathophysiology, and the activation of the innate immune response. The main differences were related to associated symptoms.

TITLE: Diferencias y similitudes entre la cefalea relacionada con la COVID-19 y la cefalea relacionada con la vacuna de la COVID-19. Un estudio de casos y controles.Introducción. La cefalea es un síntoma frecuente en la fase aguda de la enfermedad por coronavirus 2019 (COVID-19) y también uno de los efectos adversos más comunes tras la vacunación. En ambos casos, la fisiopatología de la cefalea parece estar relacionada con la respuesta inmunitaria del huésped y podría presentar similitudes. Nuestro objetivo fue comparar el fenotipo clínico y la frecuencia de los síntomas asociados y los síntomas de inicio en pacientes con cefalea relacionada con la COVID-19 y cefalea relacionada con la vacuna de la COVID-19. Sujetos y métodos. Se realizó un estudio de casos y controles. Se incluyó a pacientes con infección confirmada por COVID-19 y receptores de la vacuna de la COVID-19 que experimentaron un nuevo inicio de cefalea. Se administró un cuestionario estandarizado que incluyó variables demográficas, antecedentes previos de cefaleas, síntomas asociados y variables relacionadas con la cefalea. Ambos grupos se emparejaron por edad, sexo y antecedentes previos de cefaleas. Se realizó un análisis de regresión multivariante. Resultados. Un total de 238 pacientes cumplieron con los criterios de elegibilidad (143 pacientes con cefalea relacionada con la COVID-19 y 95 sujetos con cefalea relacionada con la vacuna de la COVID-19). Los pacientes con cefalea relacionada con la COVID-19 presentaron una mayor frecuencia de artralgia, diarrea, disnea, dolor torácico, expectoración, anosmia, mialgia, odinofagia, rinorrea, tos y disgeusia. Además, los pacientes con cefalea relacionada con la COVID-19 experimentaron una duración diaria más prolongada de la cefalea y describieron la cefalea como la peor que habían experimentado. Los pacientes con cefalea relacionada con la vacuna de la COVID-19 experimentaron con más frecuencia dolor en la región parietal, fonofobia y empeoramiento de la cefalea por movimientos de la cabeza o de los ojos. Conclusión. La cefalea causada por la infección por el SARS-CoV-2 y la cefalea relacionada con la vacunación de la COVID-19 presentan más similitudes que diferencias, lo que respalda una fisiopatología compartida y la activación de la respuesta inmunitaria innata. Las principales diferencias estuvieron relacionadas con los síntomas asociados.

Evaluating the Impact of a Training Program in Shared Decision-Making for Neurologists Treating People with Migraine.

INTRODUCTION: Migraine symptoms vary significantly between patients and within the same patient. Currently, an increasing number of therapeutic options are available for symptomatic and preventive treatment. Guidelines encourage physicians to use shared decision-making (SDM) in their practice, listening to patients' treatment preferences in order to select the most suitable and effective therapy. Although training for healthcare professionals could increase their awareness of SDM, results concerning its effectiveness are inconclusive. This study aimed to analyze the impact of a training activity to promote SDM in the context of migraine care. This was addressed by evaluating the impact on patients' decisional conflict (main objective), patient-physician relationship, neurologists' perceptions of the training and patient's perception of SDM. METHODS: A multicenter observational study was conducted in four highly specialized headache units. The participating neurologists received SDM training targeting people with migraine in clinical practice to provide techniques and tools to optimize physician-patient interactions and encourage patient involvement in SDM. The study was set up in three consecutive phases: control phase, in which neurologists were blind to the training activity and performed the consultation with the control group under routine clinical practice; training phase, when the same neurologists participated in the SDM training; and SDM phase, in which these neurologists performed the consultation with the intervention group after the training. Patients in both groups with a change of treatment assessment during the visit completed the Decisional conflict scale (DCS) after the consultation to measure the patient's decisional conflict. Also, patients answered the patient-doctor relationship questionnaire (CREM-P) and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). The mean ± SD scores obtained from the study questionnaires were calculated for both groups and compared to determine whether there were significant differences (p < 0.05). RESULTS: A total of 180 migraine patients (86.7% female, mean age of 38.5 ± 12.3 years) were included, of which 128 required a migraine treatment change assessment during the consultation (control group, n = 68; intervention group, n = 60). A low decisional conflict was found without significant differences between the intervention (25.6 ± 23.4) and control group (22.1 ± 17.9; p = 0.5597). No significant differences in the CREM-P and SDM-Q-9 scores were observed between groups. Physicians were satisfied with the training and showed greater agreement with the clarity, quality and selection of the contents. Moreover, physicians felt confident communicating with patients after the training, and they applied the techniques and SDM strategies learned. CONCLUSION: SDM is a model currently being actively used in clinical practice for headache consultation, with high patient involvement in the process. This SDM training, while useful from the physician's perspective, may be more effective at other levels of care where there is still room for optimization of patient involvement in decision-making.

Diagnosis and treatment of trigeminal neuralgia: Consensus statement from the Spanish Society of Neurology's Headache Study Group.

INTRODUCTION: Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder affecting one or more branches of the trigeminal nerve. Despite its relatively low global prevalence, TN is an important healthcare problem both in neurology departments and in emergency departments due to the difficulty of diagnosing and treating the condition and its significant impact on patients' quality of life. For all these reasons, the Spanish Society of Neurology's Headache Study Group has developed a consensus statement on the management of TN. DEVELOPMENT: This document was drafted by a panel of neurologists specialising in headache, who used the terminology of the International Headache Society. We analysed the published scientific evidence on the diagnosis and treatment of TN and establish practical recommendations with levels of evidence. CONCLUSIONS: The diagnosis of TN is based on clinical criteria. Pain attributed to a lesion or disease of the trigeminal nerve is divided into TN and painful trigeminal neuropathy, according to the International Classification of Headache Disorders, third edition. TN is further subclassified into classical, secondary, or idiopathic, according to aetiology. Brain MRI is recommended in patients with clinical diagnosis of TN, in order to rule out secondary causes. In MRI studies to detect neurovascular compression, FIESTA, DRIVE, or CISS sequences are recommended. Pharmacological treatment is the initial choice in all patients. In selected cases with drug-resistant pain or poor tolerance, surgery should be considered.

[Postoperative pain after cardiac surgery: neurobiological basis and treatment]. / Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento.

INTRODUCTION: Despite the evolution of surgical techniques, pain continues to be one of the most frequent disorders in the postoperative period of cardiac surgery (CS), leading to the appearance of complications in the acute period and impairment of quality of life due to the appearance of chronic pain. In this narrative review, we aim to analyze the prognostic factors for the appearance of postoperative pain after CS, to locate and quantify the severity of neuropathic pain, and determine the most appropriate assessment methods in these patients. DEVELOPMENT: Postoperative pain in CS is a complex pain, which associates neuropathic, somatic and visceral components. Its origin is multifactorial; factors depending on the patient, the preoperative symptoms and the type of intervention, as well as sequelae derived from the surgery itself, determine the variability in its manifestation. Multiple studies have tried to identify the risk factors for its development, but the quantification of pain is limited by the subjective perception of the patients. CONCLUSIONS: Neurologists can play a relevant role in the differentiation of the different types of pain after CS, thanks to the understanding of its neurobiological bases, properly handling neuromodulators that control the neuropathic component of pain and collaborating in the indication of invasive techniques, necessary occasionally in the management of these patients.

TITLE: Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento.Introducción. A pesar de la evolución de las técnicas quirúrgicas, el dolor sigue siendo uno de los trastornos más frecuentes en el postoperatorio de la cirugía cardíaca (CCA), lo que condiciona la aparición de complicaciones en la fase aguda y el deterioro de la calidad de vida por la aparición de dolor crónico. En esta revisión narrativa pretendemos analizar los factores pronósticos de la aparición de dolor postoperatorio tras CCA, localizar y cuantificar la gravedad del dolor neuropático y determinar cuáles son los métodos de evaluación más adecuados en estos pacientes. Desarrollo. El dolor postoperatorio en la CCA es un dolor complejo, que asocia componentes neuropáticos, somáticos y viscerales. Su origen es multifactorial; factores dependientes del paciente, de la clínica preoperatoria y el tipo de intervención, así como de secuelas derivadas de la propia cirugía, determinan la variabilidad en su manifestación. Múltiples estudios han intentado identificar los factores de riesgo de su desarrollo, pero la cuantificación del dolor se ve limitada por la percepción subjetiva del paciente. Conclusiones. Los neurólogos pueden tener un papel relevante en la diferenciación de los distintos tipos de dolor tras CCA, gracias a la comprensión de sus bases neurobiológicas, manejando adecuadamente neuromoduladores que controlen el componente neuropático del dolor y colaborando en la indicación de técnicas invasivas, necesarias ocasionalmente en el manejo de estos pacientes.

Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento / Postoperative pain after cardiac surgery: neurobiological basis and treatment

Introducción: A pesar de la evolución de las técnicas quirúrgicas, el dolor sigue siendo uno de los trastornos más frecuentes en el postoperatorio de la cirugía cardíaca (CCA), lo que condiciona la aparición de complicaciones en la fase aguda y el deterioro de la calidad de vida por la aparición de dolor crónico. En esta revisión narrativa pretendemos analizar los factores pronósticos de la aparición de dolor postoperatorio tras CCA, localizar y cuantificar la gravedad del dolor neuropático y determinar cuáles son los métodos de evaluación más adecuados en estos pacientes. Desarrollo: El dolor postoperatorio en la CCA es un dolor complejo, que asocia componentes neuropáticos, somáticos y viscerales. Su origen es multifactorial; factores dependientes del paciente, de la clínica preoperatoria y el tipo de intervención, así como de secuelas derivadas de la propia cirugía, determinan la variabilidad en su manifestación. Múltiples estudios han intentado identificar los factores de riesgo de su desarrollo, pero la cuantificación del dolor se ve limitada por la percepción subjetiva del paciente. Conclusiones: Los neurólogos pueden tener un papel relevante en la diferenciación de los distintos tipos de dolor tras CCA, gracias a la comprensión de sus bases neurobiológicas, manejando adecuadamente neuromoduladores que controlen el componente neuropático del dolor y colaborando en la indicación de técnicas invasivas, necesarias ocasionalmente en el manejo de estos pacientes.(AU)

INTRODUCTION: Despite the evolution of surgical techniques, pain continues to be one of the most frequent disorders in the postoperative period of cardiac surgery (CS), leading to the appearance of complications in the acute period and impairment of quality of life due to the appearance of chronic pain. In this narrative review, we aim to analyze the prognostic factors for the appearance of postoperative pain after CS, to locate and quantify the severity of neuropathic pain, and determine the most appropriate assessment methods in these patients. DEVELOPMENT: Postoperative pain in CS is a complex pain, which associates neuropathic, somatic and visceral components. Its origin is multifactorial; factors depending on the patient, the preoperative symptoms and the type of intervention, as well as sequelae derived from the surgery itself, determine the variability in its manifestation. Multiple studies have tried to identify the risk factors for its development, but the quantification of pain is limited by the subjective perception of the patients. CONCLUSIONS: Neurologists can play a relevant role in the differentiation of the different types of pain after CS, thanks to the understanding of its neurobiological bases, properly handling neuromodulators that control the neuropathic component of pain and collaborating in the indication of invasive techniques, necessary occasionally in the management of these patients.(AU)

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment.

INTRODUCTION: It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

CGRP en migraña: de la fisiopatología a la terapéutica / Calcitonin gene–related peptide in migraine: from pathophysiology to treatment

Introducción: En los últimos años se ha observado que moléculas como el péptido relacionado con el gen de la calcitonina (CGRP) y, en menor grado, el péptido activador de la adenilato-ciclasa pituitaria estaban elevadas durante los ataques de migraña y en la migraña crónica tanto en líquido cefalorraquídeo como en suero y que su reducción farmacológica tenía una significación clínica con una mejoría en la migraña de los pacientes. Es lógico por tanto que una de las principales líneas de investigación en migraña se base en el papel del CGRP en la fisiopatología de esta entidad. Desarrollo: Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología nos planteamos la redacción de este documento, cuyo objetivo es abordar, basándonos en la evidencia publicada, cuestiones tan importantes como el papel del CGRP en la fisiopatología de la migraña, el mecanismo de acción de los anticuerpos monoclonales y de los gepantes, el análisis crítico de los resultados de los diferentes estudios, el perfil del paciente que podría ser candidato al tratamiento con anticuerpos monoclonales y su impacto en términos de farmacoeconomía. Conclusiones: El desarrollo clínico de los gepantes, antagonistas del CGRP, para el tratamiento agudo del ataque de migraña y de los anticuerpos monoclonales contra ligando y contra el receptor del CGRP ofrecen resultados esperanzadores para nuestros pacientes. (AU)

Introduction: It has been observed in recent years that levels of such molecules as calcitonin gene–related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase–activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients’ migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. Development: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. Conclusions: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients. (AU)

I Reunión Post-European Headache Federation: revisión de las novedades presentadas en el Congreso de la European Headache Federation de 2020 / 1st Post-European Headache Federation Meeting: a review of the latest developments presented at the 2020 European Headache Federation Congress

Introducción: Tras la celebración del congreso de la European Headache Federation (EHF), reconocidos neurólogos españoles expertos en el tratamiento de la migraña expusieron en la Reunión Post-EHF las principales novedades presentadas en el congreso y relacionadas con ese ámbito. Desarrollo: Se abordan los principales datos presentados relacionados con el tratamiento de la migraña crónica y episódica; concretamente, los relacionados con los tratamientos preventivos y la experiencia en vida real en el manejo de la enfermedad. Se hizo una importante revisión de las nuevas dianas terapéuticas y las posibilidades que ofrecen en cuanto al conocimiento de la fisiopatología de la migraña y su tratamiento. Asimismo, se hizo una actualización de las novedades presentadas en el tratamiento de la migraña con fremanezumab, anticuerpo monoclonal recientemente autorizado por la Agencia Europea de Medicamentos. Se hizo una actualización de las novedades en investigación básica en la patología, así como una relación de los síntomas de migraña y COVID-19. Finalmente, se abordaron las implicaciones de la migraña en la carga sanitaria asistencial y económica, y su impacto en la sociedad. Conclusiones: En la reunión se hizo un resumen del contenido presentado en el 14 Congreso de la EHF, que tuvo lugar a finales de junio y principios de julio de 2020.(AU)

Introduction: After the European Headache Federation (EHF) Congress, renowned Spanish neurologists specialised in migraine presented the most significant latest developments in research in this field at the Post-EHF Meeting. Development: The main data presented concerning the treatment of chronic and episodic migraine were addressed, with attention paid more specifically to those related to preventive treatments and real-life experience in the management of the disease. An important review was carried out of the new therapeutic targets and the possibilities they offer in terms of understanding the pathophysiology of migraine and its treatment. An update was also presented of the latest developments in the treatment of migraine with fremanezumab, a monoclonal antibody recently authorised by the European Medicines Agency. Participants were also given an update on the latest developments in basic research on the pathology, as well as an overview of the symptoms of migraine and COVID-19. Finally, the repercussions of migraine in terms of its burden on the care and economic resources of the health system were addressed, along with its impact on society. Conclusions: The meeting summarised the content presented at the 14th EHF Congress, which took place in late June/early July 2020.(AU)

Documento de revisión y actualización de la cefalea por uso excesivo de medicación (CUEM) / Document of revision and updating of medication overuse headache (MOH)

Introducción: La cefalea con uso excesivo de medicación es una cefalea secundaria en la que el uso regular o frecuente de medicación analgésica produce un aumento de la frecuencia de una cefalea de base, pasando de episódica a crónica. La prevalencia de esta entidad está en torno al 1-2%, siendo más frecuente en mujeres entre 30 y 50 años con comorbilidades psiquiátricas como depresión o ansiedad y otros procesos de dolor crónico. Es importante conocer el manejo de esta entidad. Por este motivo, el Grupo de Estudios de Cefaleas de la Sociedad Española de Neurología ha pretendido realizar este documento de consenso sobre esta patología.DesarrolloEsta guía ha sido redactada por un grupo de expertos a partir de la revisión de la evidencia científica publicada y estableciendo recomendaciones prácticas para su adecuado manejo y tratamiento. El tratamiento de la cefalea con uso excesivo de medicación tiene varios pilares fundamentales y suele ser complejo: información y educación sobre el desarrollo de la cefalea con uso excesivo de medicación, tratamiento preventivo, suspensión del fármaco de uso frecuente y tratamiento de deshabituación. Es importante el seguimiento de pacientes con riesgo de recurrencias.ConclusionesEsperamos que este documento resulte de utilidad y permita su aplicación práctica en la consulta diaria y que sirva para actualizar y mejorar el conocimiento del manejo de esta patología. (AU)

Introduction: Medication overuse headache is a secondary headache in which the regular or frequent use of analgesics can increase the frequency of the episodes, causing the transition from episodic to chronic headache. The prevalence of medication overuse headache is approximately 1-2%, with higher rates among women aged 30-50 years and with comorbid psychiatric disorders such as depression or anxiety, or other chronic pain disorders. It is important to be familiar with the management of this disease. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a consensus document addressing this disorder.DevelopmentThese guidelines were prepared by a group of neurologists specialising in headache after a systematic literature review and provides consensus recommendations on the proper management and treatment of medication overuse headache. The treatment of medication overuse headache is often complex, and is based on 4 fundamental pillars: education and information about the condition, preventive treatment, discontinuation of the drug being overused, and treatment for withdrawal symptoms. Follow-up of patients at risk of recurrence is important.ConclusionsWe hope that this document will be useful in daily clinical practice and that it will update and improve understanding of medication overuse headache management. (AU)

[Chronic migraine with daily headache. Literature review]. / Migraña crónica con cefalea diaria. Revisión de la bibliografía.

INTRODUCTION: Despite representing a significant number of cases, patients with chronic migraine and daily headache are frequently excluded from large therapeutic clinical trials. These individuals have hardly been studied and could have specific properties. Development. A third of patients with chronic migraine may suffer from headaches every day, representing up to 1.7 - 3.3% of patients in a general neurology consultation. These patients are excluded from most studies, so little information is available. They may have a longer lasting migraine and different response to treatment. Patients with chronic migraine and daily headache may have complex pathophysiological mechanisms that favor the daily manifestation of migraine. The management of these patients is a therapeutic challenge, and OnabotulinumtoxinA may be useful. CONCLUSION: Patients with chronic migraine and daily headache may have specific clinical and therapeutic characteristics. New studies could lead to differentiate it from chronic migraine.

TITLE: Migraña crónica con cefalea diaria. Revisión de la bibliografía.Introducción. A pesar de suponer un número no desdeñable de casos, los pacientes con migraña crónica y cefalea diaria son frecuentemente excluidos de los grandes ensayos clínicos terapéuticos. Estos individuos apenas han sido estudiados en la bibliografía y podrían presentar características específicas. Desarrollo. Un tercio de los pacientes con migraña crónica podría sufrir cefalea todos los días del mes, lo que supone hasta un 1,7-3,3% de los pacientes atendidos en una consulta de neurología general. Al ser excluidos de la mayor parte de los estudios, apenas hay información sobre sus características clínicas y respuesta al tratamiento, y pueden tener una historia de migraña más prolongada y una diferente respuesta al tratamiento. Los pacientes con migraña crónica y cefalea diaria podrían presentar mecanismos fisiopatológicos complejos que favorezcan la manifestación diaria de la migraña. El manejo de estos pacientes es un reto terapéutico, y se ha propuesto la utilidad de la onabotulinumtoxinA. Conclusiones. Los pacientes con migraña crónica y cefalea diaria pueden presentar características clínicas y terapéuticas específicas. Nuevos estudios podrían llevar a plantear su consideración diferenciada de la migraña crónica.

Document of revision and updating of medication overuse headache (MOH). / Documento de revisión y actualización de la cefalea por uso excesivo de medicación (CUEM).

INTRODUCTION: Medication overuse headache is a secondary headache in which the regular or frequent use of analgesics can increase the frequency of the episodes, causing the transition from episodic to chronic headache. The prevalence of medication overuse headache is approximately 1-2%, with higher rates among women aged 30-50 years and with comorbid psychiatric disorders such as depression or anxiety, or other chronic pain disorders. It is important to be familiar with the management of this disease. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a consensus document addressing this disorder. DEVELOPMENT: These guidelines were prepared by a group of neurologists specialising in headache after a systematic literature review and provides consensus recommendations on the proper management and treatment of medication overuse headache. The treatment of medication overuse headache is often complex, and is based on 4 fundamental pillars: education and information about the condition, preventive treatment, discontinuation of the drug being overused, and treatment for withdrawal symptoms. Follow-up of patients at risk of recurrence is important. CONCLUSIONS: We hope that this document will be useful in daily clinical practice and that it will update and improve understanding of medication overuse headache management.

Persistent headache after COVID-19: Pathophysioloy, clinic and treatment.

SARS-CoV-2 is the virus responsible for the COVID-19 pandemic. The acute infection is characterised not only by respiratory symptoms, but also by multiple systemic manifestations, including neurological symptoms. Among these, headache is a frequent complaint. As the pandemic progresses and the population of patients recovering from COVID-19 grows, it is becoming apparent that the headache present in the acute stage of the infection may persist for an indeterminate period, becoming a major problem for the patient and potentially leading to disability. In this review we describe the pathophysiological and clinical aspects of persistent headache after COVID-19 based on the information currently available in the literature and the authors' clinical experience.

El SARS-CoV-2 (Síndrome Respiratorio Agudo Grave ­ Coronavirus 2) es el virus responsable de la pandemia por la Enfermedad por el Coronavirus de 2019 (COVID-19). La fase aguda de la enfermedad se caracteriza no sólo por síntomas respiratorios, sino que el cuadro clínico puede estar acompañado de múltiples síntomas sistémicos, incluyendo los neurológicos. Entre ellos, la cefalea es una queja frecuente. A medida que avanza la pandemia y crece la población de pacientes que se recuperan del COVID-19, se está observando que la cefalea presente en la fase aguda de la infección puede persistir durante un periodo de tiempo indeterminado, convirtiéndose un problema capital para el paciente y llegando a condicionar discapacidad. En esta revisión proporcionamos información acerca de los aspectos fisiopatológicos y clínicos de la cefalea persistente tras el COVID-19 en base a la información disponible en la literatura actual y la experiencia clínica de los autores.

[Response prediction for chronic migraine preventive treatment by gray matter morphometry in magnetic resonance imaging: a pilot study]. / Predicción de la respuesta al tratamiento preventivo en migraña crónica mediante la medición de la sustancia gris en resonancia magnética: estudio piloto.

INTRODUCTION: Topiramate is the only oral preventative with level of evidence I for the treatment of chronic migraine. AIM: To evaluate gray matter parameters, obtained with magnetic resonance imaging (MRI), as biomarkers of the response to topiramate in chronic migraine patients. PATIENTS AND METHODS: The sample was composed by 57 chronic migraine patients, screened for first time in a Headache Unit due to chronic migraine. MRI acquisitions were performed at a 3 T unit. Afterwards, topiramate preventive treatment began. Response and tolerability were evaluated after three months, defining response as at least 50% reduction in headache days per month. We included patients that tolerated topiramate. T1- and diffusion-weighted MRI were processed to obtain gray matter (68 cortical and 16 subcortical regions) descriptive parameters. A logistic regression model was employed for the predictive assessment. RESULTS: Forty-two patients tolerated the treatment and were analyzed, responding 23 of them (54.7%). The final prediction model was built with gray matter parameters with significant results. In this model, higher left cuneus curvature and right insula area values were associated with a higher probability of response, while higher right inferior parietal cortex volume and left superior temporal gyrus area values were associated with a lower probability. The accuracy of the predictive model was 95%. CONCLUSION: The gray matter parameters may be useful biomarkers of preventive treatment response with topiramate in chronic migraine.

TITLE: Predicción de la respuesta al tratamiento preventivo en migraña crónica mediante la medición de la sustancia gris en resonancia magnética: estudio piloto.Introducción. El topiramato es el único tratamiento preventivo oral con nivel de evidencia I para la migraña crónica. Objetivo. Evaluar los parámetros de la sustancia gris, obtenidos mediante resonancia magnética, como marcadores de respuesta al tratamiento con topiramato en pacientes con migraña crónica. Pacientes y métodos. La muestra se compuso de 57 pacientes con migraña crónica atendidos por primera vez en una unidad de cefaleas como consecuencia de migraña crónica, a los que se realizó una resonancia magnética de 3 T. Posteriormente, se inició el tratamiento preventivo con topiramato. Se evaluaron la respuesta y la tolerancia a los tres meses y se definió respuesta como disminución de al menos un 50% en el número de días de cefalea al mes. Mediante procesamiento de imágenes de resonancia magnética ponderadas en T1 y difusión, se obtuvieron los parámetros de la sustancia gris (68 estructuras corticales y 16 subcorticales). Se obtuvo un modelo de regresión logística para la valoración predictiva. Resultados. Se analizó a 42 pacientes que toleraron el tratamiento, con respuesta terapéutica en 23 de ellos (54,7%). El modelo final de predicción se construyó con parámetros de la sustancia gris con resultados significativos. En dicho modelo, a mayor curvatura del cúneo izquierdo y área de la ínsula derecha, mayor probabilidad de respuesta, y menor probabilidad a mayor volumen de la corteza inferior parietal derecha y área del giro temporal superior izquierdo. La precisión del modelo predictivo fue del 95%. Conclusión. Los parámetros de la sustancia gris pueden ser marcadores útiles de respuesta al tratamiento preventivo con topiramato en la migraña crónica.

[Specialised headache units, a feasible alternative in Spain]. / Unidades especializadas de cefalea, una alternativa viable en España.

INTRODUCTION: Visits due to headaches are the most frequent cause of demand for neurological treatment in primary care and neurology services. Headache units improve the quality of care, reduce waiting lists, facilitate access to new treatments of proven efficacy and optimise healthcare expenditure. However, these units have not been implemented on a widespread basis in Spain due to the relatively low importance attributed to the condition and also the assumption that such units have a high cost. AIM: To define the structure and minimum requirements of a headache unit with the intention of contributing to their expansion in hospitals in Spain. SUBJECTS AND METHODS: We conducted a consensus study among professionals after reviewing the literature on the structure, functions and resources required by a headache unit designed to serve an area with 350,000 inhabitants. RESULTS: Eight publications were taken as a reference for identifying the minimum resources needed for a headache unit. The panel of experts was made up of 12 professionals from different specialties. The main resource required to be able to implement these units is the professional staff (both supervisory and technical), which can mean an additional cost for the first year of around 107,287.19 euros. CONCLUSIONS: If we bear in mind the direct and indirect costs due to losses in labour productivity per patient and compare them with the estimated costs involved in implementing these units and their expected results, everything points to the need for headache units to become generalised in Spain.

TITLE: Unidades especializadas de cefalea, una alternativa viable en España.Introducción. Las consultas por cefalea son el motivo más frecuente de demanda de atención de causa neurológica en la atención primaria y en los servicios de neurología. Las unidades de cefalea mejoran la calidad asistencial, reducen las listas de espera, facilitan el acceso a nuevos tratamientos de eficacia contrastada y optimizan el gasto sanitario. No obstante, la implantación de estas unidades no está extendida en España debido a la relativa importancia atribuida a la patología y a la suposición de que su coste es elevado. Objetivo. Definir la estructura y los requerimientos mínimos de una unidad de cefalea con la intención de contribuir a su extensión en los hospitales de España. Sujetos y métodos. Estudio de consenso entre profesionales tras la revisión de la bibliografía sobre la estructura, las funciones y los recursos de una unidad de cefalea para un área de 350.000 habitantes. Resultados. Se tomaron como referencia ocho publicaciones para la identificación de recursos mínimos necesarios de una unidad de cefalea. El panel de expertos estuvo integrado por 12 profesionales de diferentes especialidades. El principal recurso para la implementación de estas unidades son profesionales (superiores y técnicos), lo que puede suponer un coste adicional para el primer año de alrededor de 107.287,19 euros. Conclusiones. Si consideramos los costes directos e indirectos debidos a las pérdidas por productividad laboral por paciente y los comparamos con los costes estimados de implantación de estas unidades y su expectativa de resultados, todo apunta a que es necesaria la generalización de unidades de cefalea en España.

Impact of the COVID-19 pandemic on headache management in Spain: an analysis of the current situation and future perspectives. / Impacto de la pandemia COVID-19 en la atención al paciente con cefalea en España: análisis de situación con una mirada al futuro.

INTRODUCTION: The COVID-19 pandemic has had a great impact on healthcare systems. Spain, where headache is the main reason for outpatient neurology consultation, is one of the countries with the most reported cases of the disease. OBJECTIVE: This study aimed to analyse the impact of the COVID-19 pandemic on headache units in Spain and to evaluate how neurologists see the future of these units. METHODS: We conducted a cross-sectional online survey of headache units during the sixth week of the state of alarm declared in Spain in response to the pandemic. RESULTS: The response rate was 74%, with the participation of centres with different characteristics and from all Autonomous Communities of Spain. Limitations in face-to-face activity were reported by 95.8% of centres, with preferential face-to-face consultation being maintained in 60.4%, and urgent procedures in 45.8%. In 91.7% of centres, the cancelled face-to-face activity was replaced by telephone consultation. 95.8% of respondents stated that they would use personal protection equipment in the future, and 86% intended to increase the use of telemedicine. The majority foresaw an increase in waiting lists (93.8% for initial consultations, 89.6% for follow-up, and 89.4% for procedures) and a worse clinical situation for patients, but only 15% believed that their healthcare structures would be negatively affected in the future. CONCLUSIONS: As a consequence of the pandemic, headache care and research activity has reduced considerably. This demonstrates the need for an increase in the availability of telemedicine in our centres in the near future.

Evidence of and experience with the use of onabotulinumtoxinA in trigeminal neuralgia and primary headaches other than chronic migraine. / Evidencia y experiencia del uso de onabotulinumtoxinA en neuralgia del trigémino y cefaleas primarias distintas de la migraña crónica.

INTRODUCTION: In the field of headaches, onabotulinumtoxinA (onabotA) is well established as a treatment for chronic migraine (CM). In recent years, it has been used increasingly to treat other primary headaches (high-frequency episodic migraine, trigeminal-autonomic cephalalgias, nummular headache) and trigeminal neuralgia. As this treatment will progressively be incorporated in the management of these patients, we consider it necessary to reflect, with a fundamentally practical approach, on the possible indications of onabotA, beyond CM, as well as its administration protocol, which will differ according to the type of headache and/or neuralgia. DEVELOPMENT: This consensus document was drafted based on a thorough review and analysis of the existing literature and our own clinical experience. The aim of the document is to serve as guidelines for professionals administering onabotA treatment. The first part will address onabotA's mechanism of action, and reasons for its use in other types of headache, from a physiopathological and clinical perspective. In the second part, we will review the available evidence and studies published in recent years. We will add an "expert recommendation" based on our own clinical experience, showing the best patient profile for this treatment and the most adequate dose and administration protocol. CONCLUSION: Treatment with onabotA should always be individualised and considered in selected patients who have not responded to conventional therapy.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment. / CGRP en migraña: de la fisiopatología a la terapéutica.

INTRODUCTION: It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.