Migraine with brainstem aura.

Migraine with brainstem aura has been long described but remains poorly understood. Previously known as "basilar" or "basilar artery" migraine, it is an uncommon subtype of migraine with aura, one seen primarily in children, adolescents, and younger adults. The condition is characterized by migraine headache accompanied by several neurological symptoms conventionally assigned to dysfunction of brainstem structures. Initially felt to be vascular in origin, partly due to prevailing concepts of migraine pathophysiology at the time, most now believe the aura symptoms of migraine with brainstem aura are secondary to neural circuitry dysfunction. The differential diagnosis is reasonably broad, and most patients warrant investigation to exclude conditions bearing high degrees of morbidity and mortality. Neuroimaging, specifically brain MRI without contrast, is recommended for migraine with brainstem aura. Depending on the clinical presentation certain cases may require consideration of contrasted or vascular imaging, EEG, or lumbar puncture with cerebrospinal fluid analysis. Migraine prophylaxis should involve lifestyle adjustments and preventive medical therapies shown to be effective in clinical trials of migraine, following evidence-based guidelines. The acute pharmacological management of attacks of migraine with brainstem aura remains a matter of controversy. The prognosis is generally favorable. Future refinements in the diagnostic criteria might possibly enhance diagnostic specificity and improved clinical research.

Improving to Four or Fewer Monthly Headache Days Per Month Provides a Clinically Meaningful Therapeutic Target for Patients with Chronic Migraine.

INTRODUCTION: Treatment target goals for patients receiving preventive migraine treatment are complicated to assess and not achieved by most patients. A headache "number" could establish an understandable treatment target goal for patients with chronic migraine (CM). This study investigates the clinical impact of reduced headache frequency to ≤ 4 monthly headache days (MHDs) as a treatment-related migraine prevention target goal. METHODS: All treatment arms were pooled for analysis from the PROMISE-2 trial evaluating eptinezumab for the preventive treatment of CM. Patients (N = 1072) received eptinezumab 100 mg, 300 mg, or placebo. Data for the 6-item Headache Impact Test (HIT-6), Patient Global Impression of Change (PGIC), and acute medication use days were combined for all post-baseline assessments and analyzed by MHD frequency (≤ 4, 5-9, 10-15, > 15) in the 4 weeks preceding assessment. RESULTS: Based on pooled data, the percentage of patient-months with ≤ 4 MHDs associated with "very much improved" PGIC was 40.9% (515/1258) versus 22.9% (324/1415), 10.4% (158/1517), and 3.2% (62/1936) of patient-months with 5-9, 10-15, and > 15 MHDs, respectively. Rates of patient-months with ≥ 10 days of acute medication use were 1.9% (21/1111, ≤ 4 MHDs), 4.9% (63/1267, 5-9 MHDs), 49.5% (670/1351, 10-15 MHDs), and 74.1% (1232/1662, > 15 MHDs). Of patient-months with ≤ 4 MHDs, 37.1% (308/830) were associated with "little to none" HIT-6 impairment versus 19.9% (187/940), 10.1% (101/999), and 3.7% (49/1311) of patient-months with 5-9, 10-15, and > 15 MHDs, respectively. CONCLUSION: Participants improving to ≤ 4 MHDs reported less acute medication use and improved patient-reported outcomes, suggesting that 4 MHDs may be a useful patient-centric treatment target when treating CM. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT02974153) ( https://clinicaltrials.gov/ct2/show/NCT02974153 ).

Sinus, disabling tension-type, and temporomandibular joint headaches.

PURPOSE OF REVIEW: Clinicians frequently face questions from headache patients regarding the roles played by sinus issues, muscle tension, and temporomandibular joint (TMJ) problems. This review highlights new concepts regarding the diagnosis and management of these headache conditions and their differentiation from migraine. RECENT FINDINGS: Recent research has clarified the roles played by pathology in the paranasal sinuses and TMJ in patients reporting headache. Additional information from physiologic studies in patients with tension-type headache (TTH) has improved the understanding of this condition. SUMMARY: Improved understanding of sinus headache, disabling TTH, and TMJ headache and their differentiation from migraine will lead to reductions in unnecessary diagnostic procedures and unwarranted medical and surgical procedures. More expedient recognition of the origin of headache should lead to improved therapeutic outcomes.

Headache in the elderly.

Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.

Tension-type headache.

PURPOSE OF REVIEW: This article provides an update on the appropriate diagnosis and evaluation of patients with tension-type headache, with reviews of the latest concepts regarding pathogenesis and the evidence-based recommendations for management of this disorder. RECENT FINDINGS: Pericranial myofascial mechanisms are probably of importance in episodic tension-type headache, whereas sensitization of central nociceptive pathways and inadequate endogenous antinociceptive circuitry seem to be more relevant in chronic tension-type headache. While acute treatment with simple analgesics is generally helpful, recent data attempting to document the efficacy of preventive therapies are unconvincing. SUMMARY: Tension-type headache is the most common form of headache in the general population. It is characterized by recurrent episodes of headache that are relatively featureless and mild to moderate in intensity. The diagnosis is based solely on the history and examination. Exclusion of secondary headaches or forms of migraine is important in the assessment process. Despite extensive investigation, the underlying pathophysiology remains a matter of speculation, with peripheral muscular and CNS components both likely involved. Acute management with simple analgesics, nonsteroidal anti-inflammatory drugs, and caffeine-containing compounds is typically effective. Preventive therapies include a number of nonpharmacologic recommendations as well as several antidepressant drugs. Prognosis is generally favorable.

Symptomatic treatment of migraine: when to use NSAIDs, triptans, or opiates.

OPINION STATEMENT: Migraine is a biologic disorder of the brain characterized by a heterogeneous array of symptoms and episodes of disabling headache. By definition, such attacks last between 4 and 72 h without treatment, with the disability arising from a variety of factors including severe pain, gastrointestinal symptoms such as nausea or vomiting, and sensory sensitivities to light, noise, or odor. All these features may be exacerbated by stimulation, motion, or activity, often rendering the patient completely immobile. Although retreat and rest, coupled with local application of ice, may provide some measure of comfort, most of those with migraine hunt for therapeutic solutions. In designing acute headache treatment strategies, it is imperative for clinicians to recognize the variability between individuals in the frequency, intensity, and duration of attacks. Certain patients require more aggressive options. It is also crucial to identify the significant intra-individual variability of migraine; most patients describe an assortment of headaches of different intensities and time to disability. Less intense episodes, which patients often term sinus, tension, or regular headaches, usually represent milder versions of migraine, simplifying both diagnostic and therapeutic approaches. Evidence-based guidelines and clinical experience support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of mild to moderate migraine attacks. Recommend migraine-specific agents (triptans and dihydroergotamine) when the attacks are more severe or have consistently failed to respond to the use of NSAIDs in the past. Encourage those with less frequent episodic migraine to use their acute agents at the earliest signs of headache. Advise those with frequent headache (>10 days per month) to limit acute treatments to only the most disabling episodes in order to avoid the "medication overuse" phenomenon. Consider rescue or back-up therapy. Do not use compounds containing butalbital or opiates (or place extreme limits on them), out of concern for progression to chronic migraine.

Basilar-type migraine.

Initially described more than 40 years ago, basilar-type migraine has posed diagnostic and therapeutic dilemmas for medical practitioners. Defined by the coexistence of migraine headache with neurological symptoms emanating from either the brainstem or simultaneously from both cerebral hemispheres, basilar-type migraine has been categorized as "atypical" or "complicated" and has been considered more akin to hemiplegic migraine than to migraine with typical aura. Despite the absence of any data convicting basilar-type migraine as a vasospastic condition, the use of triptans in such patients has been considered prohibited. This review focuses on the diagnosis, clinical presentation, available genetic information, and treatment considerations in patients with basilar-type migraine.

Neuromodulators for migraine prevention.

Migraine is a debilitating condition characterized by a cycle of painful headaches and headache-related symptoms interspersed with periods of worry, distress, and apprehension. The negative impact of migraine on patient functioning, workplace productivity, and other daily activities has been demonstrated through the use of a variety of clinician- and patient-reported assessment tools, including the Migraine-Specific Questionnaire and the Migraine Disability Assessment questionnaire. In addition to considering the frequency and severity of migraine, clinicians need to encourage more open dialogue with their patients about the impact of this disorder on daily activities and productivity. Only then can the most appropriate course of treatment be determined. Appropriately prescribed acute and preventive therapies should break the cycle of migraine and improve the daily activities of patients with this chronic condition. Divalproex sodium and topiramate are neuromodulators that are approved by the US Food and Drug Administration (FDA) for the prophylaxis (prevention) of migraine headache in adults. Non-FDA-approved neuromodulators sometimes used in the management of migraine headache include gabapentin, lamotrigine, levetiracetam, and zonisamide. All medications need to be titrated, and treatment-related adverse events need to be managed appropriately. Preventive medications should be taken for at least 2-3 months to ascertain their therapeutic effect.

Tension-type Headache in the Elderly.

Tension-type headache is the most common primary headache disorder seen in adults. Although the prevalence peaks in the fourth and fifth decades of life, significant fractions of the elderly continue to experience either episodic or chronic tension-type headaches. Many secondary headache disorders may present with headaches symptomatically compatible with the diagnosis of tension-type headache. Because numerous secondary headache disorders are more likely to be seen in older adults, the diagnosis of tension-type headache requires vigilance for and exclusion of organic disease. Once the diagnosis of tension-type headache is made, numerous nonpharmacologic and pharmacologic management options are available to reduce the frequency and severity of episodes. Special dosing considerations must be considered in the elderly. Advancing age is a positive prognostic factor in the remission of episodic and chronic tension-type headaches.

Tension-type headache in the elderly.

Tension-type headache is the most common primary headache disorder seen in adults. Although the prevalence peaks in the fourth and fifth decades of life, significant fractions of the elderly continue to experience either episodic or chronic tension-type headaches. Many secondary headache disorders may present with headaches symptomatically compatible with the diagnosis of tension-type headache. Because numerous secondary headache disorders are more likely to be seen in older adults, the diagnosis of tension-type headache requires vigilance for and exclusion of organic disease. Once the diagnosis of tension-type headache is made, numerous nonpharmacologic and pharmacologic management options are available to reduce the frequency and severity of episodes. Special dosing considerations must be considered in the elderly. Advancing age is a positive prognostic factor in the remission of episodic and chronic tension-type headaches.

Prevalence of migraine and response to sumatriptan in patients self-reporting tension/stress headache.

OBJECTIVE: This study was conducted to evaluate the prevalence of migraine and its responsiveness to migraine-specific therapy in patients with self-reported tension-type headache. METHODS: Patients were adults (n = 423) consulting one of 54 North American study sites including primary care clinics, neurology clinics, and headache clinics. The study comprised an initial diagnosis phase to determine the headache diagnosis of patients entering the study with self-reported tension/stress headache, including that previously diagnosed by a health care provider. Patients reporting tension/stress headache were evaluated and diagnosed as having migraine with or without aura, probable migraine, tension-type headache, or another headache type. Exclusion criteria included prior diagnosis of migraine or probable migraine and the presence of headache for at least 15 days monthly during either of the 2 months before screening. The initial phase was followed by a randomized, double-blind treatment phase to evaluate the efficacy of sumatriptan 100 mg tablets for the treatment of a single migraine attack in those meeting International Headache Society (IHS) criteria for migraine during the diagnosis phase. RESULTS: Of 423 patients reporting tension/stress headache at study entry, 84% (n = 357) were diagnosed at the clinic visit as fulfilling IHS criteria for migraine without aura or migraine with aura, and 65% (n = 276) were diagnosed with migraine only (i.e., with no other concurrent headache diagnosis). Three hundred thirty-two (332) patients entered the double-blind treatment phase. Headache relief rates 2h post-dose, the primary efficacy endpoint, did not significantly differ between sumatriptan and placebo (p = 0.099). However, improvements were significantly (p < 0.05) greater with sumatriptan than placebo on several other headache-related efficacy measures. CONCLUSIONS: Migraine headache may go unrecognized in patients with self-reported tension headache. Among patients having self-reported tension headache and diagnosed with migraine during the study, response to acute treatment with sumatriptan was inconclusive. Improvement with sumatriptan versus placebo was observed for some measures and not for others. The results should be interpreted in the context of study limitations including use of patient self-reports to assess headache diagnosis and possible lack of representativeness arising from the predominantly white sample.

Intercepting migraine: results of early therapy with nonspecific and migraine-specific agents.

Migraine is a pervasive neurologic disorder characterized by recurrent attacks of disabling headache. Despite significant morbidity with impact that may be physical, emotional, social, and economic, treatment of these attacks is often delayed. Patients frequently delay therapy until the more severe or "textbook" symptoms arise, often mistaking the earliest stages as representative of "tension" or "sinus" headaches. Clinicians may recommend deferral of treatment until the more severe levels of pain are seen, perhaps in a misguided attempt to conserve pharmaceutical resources. Patients and clinicians seem more comfortable with perspectives of "being sure it's a migraine" and "not wasting the medication on milder headaches." Therefore, patients and clinicians must learn the latest lessons in migraine: 1) mild migraine usually progresses to more severe levels if left untreated, 2) early treatment is more effective than delayed treatment, 3) early treatment may result in lower rates of adverse events and headache recurrence, and 4) early treatment is cost effective. As clinicians advocate the early treatment of migraine in its mild phase, evidence to support this recommendation has finally become available. I educate my migraineurs to consider each typical headache to be a version of migraine. Most patients with migraine will experience "little" headaches that they often mislabel as tension, sinus, regular, stress, or normal headaches. Instead of these terms, I have them consider their attacks as "small migraines" and "big migraines," with the smaller headaches often evolving into the bigger episodes. Given such a foundation, I advise them to treat at the beginning of the headache, perhaps earlier than they would have previously identified it as a migraine. They must capture the attack while it "whispers migraine" instead of delaying until the attack "shouts migraine." Early treatment of migraine is successful for most patients. However, there are situations in which treatment of the mild phase is not advisable or possible. In patients with frequent or daily migraine, treatment must be reserved for the most disabling attacks. We must advise treatment as soon as the migraine becomes moderate to severe. Certain patients, or certain headaches in some patients, may not progress through a mild phase, perhaps because of rapid escalation or because migraine is already severe upon awakening. Here we encourage migraineurs to treat as soon as possible, often with parenteral formulations of medication. The reaction of the patient (speed of dosing) and the action of the medication (speed of onset of the drug) will ultimately play roles in the successful interception of each attack.

Migraine headaches: treatment limitations and opportunities.

In recent years, migraine treatment options have expanded to the extent that the practicing clinician now has a myriad of pharmacologic agents in varied drug classes and delivery systems from which to choose. Drug classes most commonly employed for treatment of migraine attacks include non-migraine-specific agents, such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, barbiturates, combination analgesics, and antiemetics, and migraine-specific agents, such as triptans and ergot alkaloids and derivatives. Delivery options range from conventional, orally disintegrating, and rapid-release tablets to injection, nasal spray, and suppository. The US Headache Consortium offers guidelines classifying migraine treatments into different groups based on evidence of clinical benefit (Table 1). Clinicians must be aware of the advantages and limitations of each class and delivery system and possible opportunities to improve their usefulness in different clinical contexts.

Migraine and tension-type headache: an assessment of challenges in diagnosis.

The difficulty in distinguishing episodic tension-type headache from migraine headache is widely acknowledged. The misdiagnosis of migraine as tension-type headache has potentially significant consequences because it may preclude patients with disabling headaches from receiving appropriate treatment. This article explores the symptomatologic, epidemiologic, and pathophysiologic relationships among migraine and tension-type headaches with the aim of elucidating ways to improve their diagnosis and treatment. Clinical, epidemiologic, and pharmacologic data converge to suggest that rigid adherence to the IHS criteria in diagnosing migraine and tension-type headache may result in misdiagnosis of some headaches. Many migraine attacks are accompanied by tension headache-like symptoms, such as neck pain. Conversely, IHS-defined tension-type headaches are often accompanied by migraine-like symptoms, such as photophobia or phonophobia and aggravation by activity. The health-care provider caring for patients with headache should be cognizant of these overlaps and their implications for the management of patients with headache.