Prevalence of cranial autonomic symptoms in frequent episodic tension-type headache: A post hoc analysis of the cross-sectional Migraine in Poland study.

BACKGROUND: Cranial autonomic symptoms (CASs) include lacrimation, conjunctival injection, rhinorrhea, nasal congestion, facial flushing or sweating, ptosis, and myosis. These symptoms may be associated with trigeminal autonomic cephalalgias (TACs) and migraine. OBJECTIVES: The aim of the study was to assess whether CASs are also reported by patients with frequent episodic tension-type headache (eTTH). MATERIAL AND METHODS: A cross-sectional online survey of a large Polish population was conducted between August 2021 and June 2022. The analysis assessed diagnostic criteria for migraine and eTTH, as well as the presence of allodynia, headache-related disability and symptoms of depression. RESULTS: The survey involved 3,225 respondents (age: 13-80 years, mean (M) = 38.9 years; 87.1% female). A total of 166 individuals met the diagnostic criteria for isolated frequent eTTH without migraine or probable migraine with or without aura. Allodynia was present during the majority of attacks in 40 (24.1%) eTTH subjects, while 86 (51.8%) eTTH respondents reported at least 1 CAS during their headache attacks. The presence of at least 1 CAS was more prevalent in migraine than in eTTH (p = 0.001). The respondents with at least 1 CAS during eTTH attacks reported a higher burden associated with pain (p = 0.024) and higher Patient Health Questionnaire-9 (PHQ-9) scores (p = 0.016). CONCLUSIONS: The prevalence of retrospectively reported CASs was high among individuals with eTTH, which may potentially contribute to diagnostic errors. Cranial autonomic symptoms in eTTH do not appear to be caused by severe pain or central sensitization.

The relationship between migraine and Hashimoto's thyroiditis: a single center experience.

Introduction: Hashimoto's thyroiditis (HT) is nowadays the leading cause of hypothyroidism with high and still growing prevalence in general population, but there are lack of data regarding migraine and HT connection. Methods: The aim of this study was to analyze the prevalence of HT in migraine and to check if the presence of HT influence migraine severity. This retrospective observational cohort study involved consecutive migraine patients consulted at our Headache Center with diagnosis of migraine. Electronic charts of patients were collected, including data on migraine type, presence of cranial autonomic symptoms (CAS), monthly migraine days (MMD), medication overuse headache (MOH), and the presence of comorbidities including HT. Results: We found 928 eligible migraine patients, 88.7% were women. The mean age was 36.09 years. 592 (63.8%) were diagnosed with episodic migraine (EM), the rest with chronic migraine (CM). MOH was additionally diagnosed in 258 (27.8%) patients. The duration of migraine was 15.99 years. 106 (11.4%) was diagnosed with HT, 148 (15.9%) with hypothyroidisms, while 84 (9.05%) had both diagnosis. Migraine patients with HT were significantly older (p < 0.001), were more frequently women (p = 0.0017), had longer duration of migraine (p < 0.001), had CAS more frequently (<0.001), developed CM (p = 0.0169) and depression more frequently (p = 0.0047) and had more MMD (p = 0.0195) as compared with individuals without HT. According to our multivariate logistic model, the presence CM was positively associated with HT (OR 1.76, p = 0.045), MOH and duration of migraine, while negatively associated with aura. Conclusion: HT is very prevalent in migraine patients. This is the first study considering migraine and HT to be comorbid and suggesting that HT may influence the course of migraine causing its chronification.

The midfacial segment pain: little known disorder in need of scientific evaluation.

Despite its inclusion in the International Classification of Orofacial Pain, tension-type orofacial pain has little support in the scientific literature. However, a similar-in-phenotype orofacial pain perceived in the middle segment of the face has been described by few case series from mostly ear, nose and throat clinics. The authors of these descriptions used the term 'midfacial segment pain'. Patients had no significant sinonasal disorder in these studies, but experienced symmetrical pain perceived mostly over the maxillary and ethmoid sinuses. No aura or autonomic symptoms were present apart from mild nasal congestion or rhinorrhoea in some individuals. This description appears similar to tension-type headache, but with midfacial location. In this viewpoint, we indicate a need to fill this gap in scientific knowledge and propose a multicentre interdisciplinary study that would give a detailed description of this type of orofacial pain.

Prevalence of headaches and their relationship with obstructive sleep apnea (OSA) - Systematic review and meta-analysis.

Obstructive sleep apnea (OSA) is one of the most common sleep disorders; however, there are inconsistent results about the connection and occurrence of primary and secondary headaches in OSA. Therefore, the primary objectives were to estimate the prevalence and potential relationship between all types of headaches and OSA. A systematic review was conducted according to PRISMA 2020 guidelines. Studies were searched in PubMed, Embase, and Web of science up to July 2023. The Joanna Briggs Institute tool assessed the risk of bias. 1845 articles were identified, and 23 studies describing 15,402 patients were included. Pooled prevalence of all headaches in OSA was 33% (95% CI: 0.25-0.41), 33% for morning headaches (95% CI: 0.24-0.45), 25% for sleep apnea headaches (95% CI: 0.18-0.34), 19% for tension-type headache (95% CI: 0.15-0.23), and 16% for migraine (95% CI: 0.09-0.26). Relative risk for the occurrence of headache in OSA patients compared to the non-OSA people was 1.43 (95% CI: 0.92-2.25). OSA females and males had morning headaches with similar frequency. The prevalence of headaches in OSA was moderate. OSA did not increase the risk of headache. There is a need to conduct further studies focused on bidirectional connections between sleep disorders and headaches.

Sinonasal symptoms in migraine without aura: results from the cross-sectional 'Migraine in Poland' study.

Background: Migraine without aura (MwoA) is often mistaken for rhinosinusitis. The purpose of this study was to assess the prevalence of sinonasal symptoms, sinusitis-targeting medication use and burden of migraine in a large group of people with MwoA attacks accompanied by rhinologic symptoms. Methods: Data was collected in a cross-sectional online survey based on an adapted population-based study questionnaire. The analysis included the prevalence of rhinorrhea, mucopurulent nasal discharge, nasal congestion, facial pressure and tenderness to palpation, hyposmia/anosmia and osmophobia. Results: 1,679 (52.73%) MwoA people were identified among 3,225 respondents (women n = 2,809, 87.10%) aged 13-80 years (median age 39; standard deviation 10.4). 1004/1679 (59.8%) migraine patients reported one or more rhinologic symptoms and 341/1679 (20.3%) MwoA respondents had symptoms that met rhinosinusitis clinical diagnostic criteria during their headache attacks. In migraine patients, osmophobia was associated with hyposmia [n = 141 (12.7%) vs. n = 41 (7.2%); p = 0.001] and a sensation of unpleasant smells [n = 216 (19.4%) vs. n = 45 (8.5%); p = 0.001], while facial tenderness to palpation was associated with facial allodynia [n = 532 (50.4%) vs. n = 211 (33.9%); p < 0.001]. People with migraine accompanied by rhinosinusitis-like symptoms experienced more disease burden and used 'sinus medications' more often. Conclusion: MwoA patients with rhinosinusitis-like symptoms during migraine attacks require cautious assessment, especially that some symptoms seem to have little value in distinguishing between these disorders (i.e., facial tenderness, hyposmia), while many of these patients have a greater disease burden and therefore often choose medications targeting rhinologic instead of neurologic mechanisms.

Relationship between alcohol and primary headaches: a systematic review and meta-analysis.

BACKGROUND: Headache is one of the most common neurological symptoms. Many previous studies have indicated a relationship between primary headaches and alcohol. Drinking has been associated with increased risk of tension-type headache (TTH) and migraine. However, recently published studies have not confirmed this relationship. The existing literature is inconclusive; however, migraine patients avoid alcohol. Therefore, the primary objective was to provide a reliable assessment of alcohol intake in people with primary headaches; the secondary objective was to identify any potential relationship between alcohol consumption and headache risk. METHODS: This study was based on PubMed, Embase and Web of Science database searches performed on 11 July 2023. This systematic review was registered in PROSPERO (CRD42023412926). Risk of bias for the included studies was assessed using the Joanna Briggs Institute critical appraisal tools. Meta-analyses were performed using Statistica software. The Risk Ratio (RR) was adopted as the measure of the final effect. Analyses were based on a dichotomous division of the respondents into "non-drinkers" and "drinkers" for headache patients and matched non-headache groups. RESULTS: From a total of 1892 articles, 22 were included in the meta-analysis. The majority demonstrated a moderate or high risk of bias. The first part of the meta-analysis was performed on data obtained from 19 migraine studies with 126 173 participants. The risk of migraine in alcohol drinkers is approximately 1.5 times lower than in the group of non-drinkers (RR = 0.71; 95% CI: 0.57-0.89). The second part involved 9 TTH studies with 28 715 participants. No relationship was found between TTH diagnosis and alcohol consumption (RR = 1.09; 95% CI: 0.93-1.27). Two of the included cluster-headache articles had inconclusive results. CONCLUSIONS: Alcohol consumption and migraine are inversely correlated. The exact mechanism behind this observation may indicate that migraine leads to alcohol-avoidance, rather than alcohol having any protective role against migraine. There was no relationship between TTH and drinking. However, further studies related to primary headaches and alcohol consumption with low risk of bias are required. Additionally, patients and physicians should consider the latest medical data, in order to avoid the myths about alcohol consumption and primary headaches.

Migraine symptoms, healthcare resources utilization and disease burden in a large Polish migraine cohort : Results from 'Migraine in Poland'-a nationwide cross-sectional survey.

BACKGROUND: The Migraine in Poland study is the first large scale nationwide cross-sectional online survey of symptoms, approaches to management, treatment patterns, quality of life, and sociodemographic characteristics of the Polish migraine patients' cohort, conducted from August 2021 to June 2022. METHODS: A cross-sectional online survey was designed based on the American Migraine Prevalence and Prevention (AMPP) Study. Participants were recruited through broad advertisement through various channels. The survey included questions allowing for the diagnosis of migraine without aura (MwoA) based on the third edition of the International Classification of Headache Disorders (ICHD-3). Moreover, the questionnaire assessed sociodemographic and headache features, comorbidities, consultation rates with medical professionals, as well as the use of abortive or preventive treatment, including non-pharmacological methods, psychological symptoms and the burden of migraine. RESULTS: A structured online questionnaire was submitted by 3225 respondents aged 13 to 80 (mean age 38.9, 87.1% women). In this group 1679 (52.7%) of participants fulfilled ICHD-3 diagnostic criteria for MwoA, which was in most cases (88.3%) confirmed by a medical professional in the past. In this group the average number of monthly headache days was 4.7, while 47.8% of participants had at least 4 migraine days per month. Mean Migraine Disability Assessment score was 42.65 (median 32). Among MwoA respondents, 1571 (93.6%) had consulted their headache with a medical professional in the past - mostly neurologists (n = 1450 (83.4%) and primary care physicians (n = 1393 (82.9%). In the MwoA cohort, 1553 (92.5%) of participants declared the current use of some form of treatment, although only 193 (11.5%) respondents were currently on preventive medications. The most prevalent comorbidities included: chronic rhinitis (37.1%), allergies (35.9%) and low blood pressure (26.9%). Anxiety (20.4%) and depression (21.3%) were highly prevalent among participants. CONCLUSIONS: People with migraine in Poland face similar difficulties as their peers in other countries. Despite relatively high access to neurologist consultations and good diagnosis accuracy, migraine still poses diagnostic and therapeutic difficulties. In this context, migraine undertreatment in Polish population must be underlined, especially in context of high disease burden.

Efficiency of occlusal splint therapy on orofacial muscle pain reduction: a systematic review.

BACKGROUND: This systematic review aims to examine the existing original studies to determine the effectiveness of occlusal splints (OSs) in the management of orofacial myalgia and myofascial pain (MP) in comparison with no treatment or other interventions. MATERIALS AND METHODS: Based on the inclusion and exclusion criteria of this systematic review, randomized controlled trials were qualified, in which the effectiveness of occlusal splint therapy in the management of muscle pain was examined in comparison with no treatment or other interventions. This systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. The authors searched three databases (PubMed, CINAHL (The Cumulative Index to Nursing and Allied Health Literature) and Scopus) for English publications published between January 1, 2010, and June 1, 2022. The last database search was carried out on June 4, 2022. Data were extracted from the included studies and assessed for risk of bias using the revised Cochrane risk-of-bias tool for randomized trials. RESULTS: Thirteen studies were identified for inclusion in this review. In total, 589 patients were diagnosed with orofacial muscle pain who underwent education and various forms of therapy including different types of OSs, light emitting diode therapy, acupuncture, low-level laser therapy, device-supported sensorimotor training, Kinesio Taping, myofunctional therapy, and physical therapy. All studies included demonstrated a high risk of bias. CONCLUSIONS: There is insufficient evidence regarding whether OS therapy in the treatment of orofacial myalgia and MP offers an advantage over other forms of interventions or no treatment. Further reliable clinical studies in this area are needed to improve the quality of research, which should be performed with larger groups of blinded respondents and controls. CLINICAL RELEVANCE: Due to the large-scale nature of orofacial muscle pain, it is assumed that each dental clinician will meet patients with orofacial muscle pain repeatedly in daily practice; hence, the review of the effectiveness of OSs in the management of orofacial myalgia and MP is necessary.

COVID-19-related headache and innate immune response - a narrative review.

Headache is one of the most prevalent, although often underreported, symptoms of coronavirus disease 2019 (COVID-19). It is generally accepted that this symptom is a form of secondary headache due to systemic viral infection. There are several hypotheses that try to explain its aetiopathogenesis. One of the most compelling is related to innate immune response to viral infection. This rationale is supported by similarities to other viral infections and the temporal overlap between immunological reactions and headache. Moreover, several key factors in innate immunity have been shown to facilitate headache e.g. interferons, interleukin (IL) -1-ß, IL-6, and tumour necrosis factor. There is also a possibility that the virus causes headache by the direct activation of afferents through pattern recognition receptors (i.e. Toll-like receptor 7). Moreover, some data on post-COVID-19 headache and after vaccination against SARS-CoV-2 infection suggests a similar cytokine-mediated pathomechanism in these clinical situations. Future research should look for evidence of causality between particular immune response factors and headache. Identifying key molecules responsible for headache during acute viral infection would be an important step towards managing one of the most prevalent secondary headache disorders.

Excellent Response to OnabotulinumtoxinA: Different Definitions, Different Predictors.

The identification of patients who can benefit the most from the available preventive treatments is important in chronic migraine. We explored the rate of excellent responders to onabotulinumtoxinA in a multicenter European study and explored the predictors of such response, according to different definitions. A pooled analysis on chronic migraineurs treated with onabotulinumtoxinA and followed-up for, at least, 9 months was performed. Excellent responders were defined either as patients with a ≥75% decrease in monthly headache days (percent-based excellent responders) or as patients with <4 monthly headache days (frequency-based excellent responders). The characteristics of excellent responders at the baseline were compared with the ones of patients with a <30% decrease in monthly headache days. Percent-based excellent responders represented about 10% of the sample, whilst frequency-based excellent responders were about 5% of the sample. Compared with non-responders, percent-based excellent responders had a higher prevalence of medication overuse and a higher excellent response rate even after the 1st and the 2nd injection. Females were less like to be frequency-based excellent responders. Chronic migraine sufferers without medication overuse and of female sex may find fewer benefits with onabotulinumtoxinA. Additionally, the excellent response status is identifiable after the first cycle.

Cerebral Blood Flow and Other Predictors of Responsiveness to Erenumab and Fremanezumab in Migraine-A Real-Life Study.

Introduction: Monoclonal antibodies (mAbs) showed efficacy in migraine prevention. The aim of this study was to check if baseline clinical parameters and cerebral blood flow (CBF) measured by transcranial Doppler (TCD) may help predict mAbs efficacy. Methods: Electronic charts of migraineurs treated with erenumab or fremanezumab, with baseline TCD evaluations were collected, including data on migraine type, pain localization, monthly migraine days (MMD), medication overuse headache (MOH), mean blood flow velocity (Vm), and pulsatility index (PI) in cerebral arteries. Results: A total of 123 patients were enrolled, mean age 38, 75 years, 87 with chronic migraine, 61 with MOH, 72 were good responders (GR), and reported ≥50% reduction in MMD, 43 ≥75% reduction in MMD. Baseline Vm values in MCAs were significantly lower in GR as compared with non-responders. MAbs responsiveness ≥50% was positively associated with unilateral pain localization (OR: 6.53, 95% CI: 2.01-23.93; p = 0.003) and HIT-6 score (OR: 1.14, 95% CI: 1.01-1.30; p = 0.036) whereas negatively associated with Vm in right MCA (OR: 0.96, 95% CI: 0.92-0.99; p = 0.012), and having no relatives with migraine (OR: 0.40, 95% CI: 0.16-0.95; p = 0.040). Conclusions: Baseline Vm in MCA is lower in mAbs GR as compared with non-responders which may reflect increased secretion of CGRP with further vasodilation in GR. Simple clinical features and baseline CBF in anterior circulation might help to predict the patient's responsiveness.

Headache onset after vaccination against SARS-CoV-2: a systematic literature review and meta-analysis.

BACKGROUND: Vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are used to reduce the risk of developing Coronavirus Disease 2019 (COVID-19). Despite the significant benefits in terms of reduced risk of hospitalization and death, different adverse events may present after vaccination: among them, headache is one of the most common, but nowadays there is no summary presentation of its incidence and no description of its main features. METHODS: We searched PubMed and EMBASE covering the period between January 1st 2020 and August 6th, 2021, looking for record in English and with an abstract and using three main search terms (with specific variations): COVID-19/SARS-CoV-2; Vaccination; headache/adverse events. We selected manuscript including information on subjects developing headache after injection, and such information had to be derived from a structured form (i.e. no free reporting). Pooled estimates and 95% confidence intervals were calculated. Analyses were carried out by vaccine vs. placebo, by first vs. second dose, and by mRNA-based vs. "traditional" vaccines; finally, we addressed the impact of age and gender on post-vaccine headache onset. RESULTS: Out of 9338 records, 84 papers were included in the review, accounting for 1.57 million participants, 94% of whom received BNT162b2 or ChAdOx1. Headache was generally the third most common AE: it was detected in 22% (95% CI 18-27%) of subjects after the first dose of vaccine and in 29% (95% CI 23-35%) after the second, with an extreme heterogeneity. Those receiving placebo reported headache in 10-12% of cases. No differences were detected across different vaccines or by mRNA-based vs. "traditional" ones. None of the studies reported information on headache features. A lower prevalence of headache after the first injection of BNT162b2 among older participants was shown. CONCLUSIONS: Our results show that vaccines are associated to a two-fold risk of developing headache within 7 days from injection, and the lack of difference between vaccine types enable to hypothesize that headache is secondary to systemic immunological reaction than to a vaccine-type specific reaction. Some descriptions report onset within the first 24 h and that in around one-third of the cases, headache has migraine-like features with pulsating quality, phono and photophobia; in 40-60% of the cases aggravation with activity is observed. The majority of patients used some medication to treat headache, the one perceived as the most effective being acetylsalicylic acid.

Clinical characteristics of acute rhinosinusitis in COVID-19 a post hoc analysis of a longitudinal study.

BACKGROUND: Acute rhinosinusitis (ARS) is a common and well-defined disorder, primarily of viral aetiology, with rhinovirus and coronavirus accounting for more than 50% of viral ARS. The fight with COVID-19 pandemic resulted in an increased availability viral testing, which in turn allowed testing for presence of SARS-Cov-2 in all patients presenting common cold (or ARS) symptoms. The aim of this study was to assess the clinical characteristics of acute rhinosinusitis in patients diagnosed with COVID-19. METHODOLOGY/PRINCIPAL: This study is a post-hoc analysis. Patients symptoms were evaluated using a structured questionnaire twice: directly after a positive SARS-Cov-2 result and 7-12 days following the first evaluation. Subjects were asked about presence of nasal and systemic symptoms as well as headache. RESULTS: A total of 130 COVID-19 symptomatic patients were recruited into the study, 58 (45%) patients met EPOS2020 diagnostic criteria for ARS. Of all ARS patients, 72% presented with rhinorrhoea, 69% with pain perceived over paranasal sinuses, 62% with nasal congestion, 52% with cough, 45% with olfactory dysfunction, 38% with fever, 33% with facial pressure and in 22% pain was exacerbated by sinus palpation. CONCLUSIONS: Half of COVID-19 subjects has ARS. The course of SARS-Cov-2 ARS does not seem to differ significantly from ARS of other aetiologies. Since ARS in the course of COVID-19 seems to meet the definition of ARS proposed by EPOS 2020, we hypothesize that substances validated for ARS treatment, such as intranasal corticosteroids could be effective in SARS-Cov-2 ARS.

COVID-19-related headache and sinonasal inflammation: A longitudinal study analysing the role of acute rhinosinusitis and ICHD-3 classification difficulties in SARS-CoV-2 infection.

BACKGROUND: The genesis of headache in coronavirus disease 2019 (COVID-19) is currently unclear and the multitude of disease symptoms often further hinders locating the source of pain. Interestingly, many subjects with COVID-19 have symptoms of acute rhinosinusitis. The relation between nasal symptoms and headache in SARS-CoV-2 infection remains unknown. METHODS: This bi-center longitudinal study evaluated symptoms in consecutive COVID-19 patients in the participating practices. The first assessment was performed during the initial consultation after infection confirmation. That was followed up by a second consultation after a median 9 days. RESULTS: 130 patients were included in the study (80 women, 50 men; mean age 46.9 years). Headache was highly prevalent at the first visit (72%) and significantly associated with acute rhinosinusitis symptoms. The odds ratio for headache in subjects with rhinosinusitis was 3.5. Headache could be attributed to systemic viral infection in 96% and to acute rhinosinusitis in 51% of cases according to 3rd edition of the International Classification of Headache Disorders. Criterium C.3 (exacerbation of headache by pressure applied over paranasal sinuses) and C.4 (ipsilaterality of headache and sinusitis) had low sensitivity in headache attributed to acute rhinosinusitis. CONCLUSIONS: Nasal inflammation is associated with headache in COVID-19, although the pain mechanism lies probably in a systemic reaction to the virus. 3rd edition of the International Classification of Headache Disorders criteria for headache attributed to acute rhinosinusitis need adjusting to the current understanding of acute sinonasal infection.

Is There a Gender Difference in the Response to onabotulinumtoxinA in Chronic Migraine? Insights from a Real-Life European Multicenter Study on 2879 Patients.

INTRODUCTION: Migraine is mostly a female disorder because of its lower prevalence in men. Less than 20% of patients included in the available studies on migraine treatments are men; hence, the evidence on migraine treatments might not apply to men. The aims of the present study were to provide reliable information on the effectiveness of onabotulinumtoxinA (BT-A) for chronic migraine in men and to compare clinical benefits between men and women. METHODS: We performed a pooled patient-level gender-specific analysis of real-life data on BT-A for chronic migraine of patients followed-up to 9 months. We reported the 50% responder rates during each BT-A cycle, defined as percentage of reduction in monthly headache days (MHDs) compared to baseline, along with 75% and 30% responder rates. We also reported the mean decrease in MHDs and in days of acute medication use (DAMs) during each BT-A cycle as compared to baseline. We also evaluated the reasons for stopping the treatment within the third cycle. RESULTS: We included an overall cohort of 2879 patients, 522 of whom (18.1%) were men. In men, 50% responder rates were 27.7% during the first BT-A cycle, 29.2% during the second, and 35.6% during the third cycle; in women, the corresponding rates were 26.6%, 33.5%, and 41.0%. In the overall cohort, responder rates did not differ between men and women during the first two cycles; during the third cycle, the distribution was different (P < 0.001) mostly because of higher rates of treatment stopping and non-responders in men. In the propensity score matched cohort, the trend was maintained but lost its statistical significance. Both men and women had a significant decrease in MHDs and in DAMs with BT-A treatment (P < 0.001). There were no gender differences in those changes with the only exception of MHD decrease which, during the third cycle, was lower in men than in women (7.4 vs 8.2 days, P = 0.016 in the overall cohort and 9.1 vs 12.5 days, P = 0.009 in the propensity score matched cohort). At the end of follow-up, 152 men and 485 women stopped BT-A treatment (29.1% vs 20.6%; P < 0.001). The relative proportion of patients stopping treatment because of inadequate response (less than 30% decrease in MHDs from baseline) was higher in men than in women (42.8% vs 39.6%), while the proportion of patients stopping because of adverse events was higher in women than in men (5.6% vs 0%; P = 0.031). CONCLUSIONS: Our pooled analysis suggests that the response to BT-A is significant in both men and women with a small gender difference in favor of women. Men tended to stop the treatment more frequently than women. We emphasize the need for more gender-specific data on migraine treatments from randomized controlled trials and observational studies.

Changes in Cerebral Blood Flow after Erenumab Treatment in Good and Non-Responders-A Pilot Study of Migraine Patients.

Erenumab showed efficacy in migraine prevention, however we cannot identify which patients to treat by predicting efficacy response. The aim of this study was to compare changes in cerebral blood flow (CBF) reflected by transcranial Doppler (TCD) in erenumab good responders (GR) and non-responders, in order to identify a parameter that could predict the treatment response. In this study, migraineurs treated with erenumab underwent clinical and TCD evaluations before and 6 weeks after the treatment, including data on migraine type, monthly migraine days (MMD), medication overuse headache (MOH) presence, mean blood flow velocity (Vm) and pulsatility index (PI) in cerebral arteries (CA). GR were defined as reporting ≥50% reduction in MMD. Thirty women were enrolled, of mean age 40.53 years, 20 with chronic migraine, 14 with MOH, and 19 were GR. Baseline Vm values in right CA and basilar artery (BA) were significantly lower in GR as compared with non-responders. Vm values in all arteries significantly increased after the treatment as compared with corresponding baseline values, but only in GR. A significant negative correlation was observed between baseline Vm in right CA and treatment effectiveness. Baseline Vm in right CA and basilar artery is reduced in erenumab GR as compared with non-responders. This asymmetry normalizes after the treatment with significant Vm increase in CA which may reflect CBF increase in GR only. Lower baseline Vm in right CA may predict erenumab efficacy; however, these results should be replicated in a larger cohort.

Early Management of OnabotulinumtoxinA Treatment in Chronic Migraine: Insights from a Real-Life European Multicenter Study.

INTRODUCTION: OnabotulinumtoxinA (BT-A) quarterly was the first treatment approved specifically for chronic migraine (CM). It is unclear whether three cycles are better than two to assess early BT-A response. METHODS: We performed a retrospective analysis on real-life prospectively collected data in 16 European headache centers. All the centers provided data on patients treated with BT-A for CM over the first three cycles of treatment. For each treatment cycle we defined patients as "good responders" if reporting a ≥ 50% reduction in monthly headache days compared with the three months before starting BT-A, "partial responders" if reporting a 30-49% reduction in monthly headache days, and "non-responders" if reporting a < 30% reduction in monthly headache days or stopping the treatment before the third cycle. RESULTS: We included 2879 patients. Seven hundred and eighty-four (64.6%) of the 1213 patients reporting a good response during the first and/or the second cycle had a good response during the third cycle; 309 (49.3%) of the 627 patients reporting a partial response (but no good response) during the first and/or the second cycle had a good response during the third cycle; only 65 (6.3%) of the 1039 patients who did not respond during both the first two cycles achieved a good response during the third cycle. Multivariate analyses showed that partial or good response during the first or the second cycle were independently associated with good response during the third cycle. CONCLUSIONS: Our data suggest that patients with CM responding to BT-A during the first two cycles will likely benefit from the third cycle of treatment, while the probability that non-responders to the first two cycles start responding during the third cycle is low. These results can help guide the individual decision to stop or continue treatment after the second cycle in patients who have not responded to the first two cycles.

Etiology of 'Sinus Headache'-Moving the Focus from Rhinology to Neurology. A Systematic Review.

'Sinus headache and/or facial pain' (SH) is a common complaint encountered by otorhinolaryngologists, neurologists and general practitioners. However, several studies suggested that the majority of those cases may be attributed to primary headaches (i.e., migraine and tension-type headache (TTH). The purpose of this review is to evaluate the etiology of SH. The first part includes cross-sectional studies analyzing the prevalence of respective diagnoses in subjects with SH. The majority of these publications indicate that migraine and TTH are the most prevalent causes of SH, although most of these studies were conducted in a clinical setting. The second part of this review included treatment trials in subjects with SH. The findings from this part of the review show that SH without rhinosinusitis responds well to pharmacotherapy targeted at primary headaches. This observation further supports a neurologic etiology of the majority of SH cases.

The Prevalence of Different Types of Headache in Patients with Subjective Tinnitus and Its Influence on Tinnitus Parameters: A Prospective Clinical Study.

Both tinnitus and headache are very prevalent conditions in the general population, with bidirectional co-occurrence of them. A number of studies revealed a high prevalence of headache in tinnitus patients; however, most of them used self-reported symptoms, questionnaires, or health databases and were retrospective. The aim of this study was to evaluate the prevalence of different types of headache in a cohort of tinnitus patients and to assess the influence of headache on tinnitus parameters, focusing on appropriate headache and tinnitus diagnosis verified by clinical examination. This prospective study involved 286 patients diagnosed with subjective non-pulsating tinnitus. Patients' clinical information was thoroughly assessed by the multidisciplinary team, including tinnitus characteristics and severity according to the Tinnitus Handicap Inventory (THI), loudness assessed by the Visual Analogue Scale (VAS), audiometry, type of headache diagnosed according to the third edition of the International Classification of Headache Disorders, severity of headache assessed by the Numeric Rating Scale (NRS), and impact of headache using the Headache Impact Test (HIT). In total, 141 (49.3%) tinnitus patients were diagnosed with headache, most of them with tension-type headache or migraine. They were significantly younger; mostly women; had bilateral tinnitus, vertigo, and depression more frequently; and had hearing loss less frequently as compared with the non-headache group. In total, 82 (58.16%) patients had the same localization of tinnitus and headache. Younger age, female gender, higher tinnitus burden measured by THI, and coexistence of hearing loss were independent variables connected with the occurrence of headache in the tinnitus group. According to our study, headaches impact tinnitus on many different levels and may be an important co-factor for tinnitus subtyping. We recommend screening for headache coexistence in all tinnitus patients.