Concomitant Migraine Research Articles

CARPAL TUNNEL SYNDROME AND MIGRAINE LATERALIZATION

Abstract Background/Aims: Within the scope of this research, we aimed to elucidate the relationship between carpal tunnel syndrome and migraine to explore both the pain intensity and the localization of carpal tunnel syndrome (CTS) in concomitant migraine. The primary outcome variable was elaborated as the pain lateralization, and the secondary outcome variable was the pain intensity. Methods: This was a cross-sectional, observational prospective study of 500 patients with a preliminary carpal tunnel syndrome diagnosis in our institution. After patients with missing data were excluded from the study, 413 remained, 365 (88.4%) women and 48 (11.6%) men. After recording the demographic characteristics, the patient's migraine pain year of onset of pain, pain characteristics, localization, frequency, duration, severity, triggering factors, symptoms, and findings accompanying the pain were recorded. Results: The lateralization of migraine was on the right side (only on the right or mostly on the right) in 25.9% and on the left side (only on the left or mostly on the left) in 26.4% of the patients. Almost half of the patients (47.7%) experienced bilateral migraine headaches. Carpal tunnel syndrome was in the right hand in 13.3%, in the left hand in 11.6%, and bilateral in 75.1%. Of 197 patients with bilateral pain, 68 (34.5%) had mild, 116 (58.9%) had moderate, and 13 (6.6%) had severe CTS. The VAS level of migraine pain was higher only in patients with CTS in the left hand and in those with moderate CTS. Conclusion: It has been determined that those with carpal tunnel syndrome on the right side have migraines mostly on the right, those with carpal tunnel syndrome on the left have migraines on the left, and those with carpal tunnel syndrome in both directions have migraines predominantly in both directions.

Elevated plasma levels of calcitonin gene-related peptide in individuals with rosacea: A cross-sectional case-control study.

Understanding the role of calcitonin gene-related peptide (CGRP) in the pathogenesis of rosacea might provide new therapeutic avenues for individuals with this disease. To compare plasma levels of CGRP between individuals with rosacea and healthy controls. In this cross-sectional case-control study conducted in Copenhagen, Denmark, we collected blood samples from the antecubital vein from adults with rosacea and from healthy controls. We enrolled 123 individuals with rosacea and 68 healthy controls. After adjusting for age and sex, plasma levels of CGRP were significantly higher in individuals with rosacea (mean, 95% confidence interval: 140.21 pmol/L, 128.50-151.92 pmol/L), compared with controls (110.77 pmol/L, 99.91-120.14 pmol/L, p = 0.002). Plasma levels of CGRP were not affected by age, sex, BMI, concomitant migraine, rosacea sub- or phenotype, concomitant disease or current treatment. Participants were not age-, sex- and BMI-matched. Elevated plasma levels of CGRP in individuals with rosacea suggest a role of CGRP in the pathogenesis of rosacea. Targeting CGRP signalling might hold therapeutic promise in people affected by this disease. NCT03872050.

Clinical characteristics of combined rosacea and migraine.

An overlap between the skin disease rosacea and the headache disease migraine has been established; however, the magnitude of this overlap and the distribution between subtypes/phenotypes remains unclear. The aim was to determine the magnitude of the overlap between rosacea and migraine, and to determine which subtypes/phenotypes were present in patients with concomitant rosacea and migraine. In this cross-sectional study, 604 patients with a diagnosis of either rosacea or migraine were phenotyped through a face-to-face interview with clinical examination, to determine prevalence and phenotype of rosacea, and prevalence and subtype of migraine. We found a prevalence of migraine of 54% in patients with rosacea, and a prevalence of rosacea of 65% in patients with migraine. Concomitant migraine was significantly associated with the rosacea features flushing (odds ratio = 2.6, 95% confidence interval = 1.4-4.7, p = 0.002), ocular symptoms (odds ratio = 2.4, 95% confidence interval = 1.5-3.9, p < 0.001), and burning (odds ratio = 2.1, 95% confidence interval = 1.3-3.4, p = 0.002), whereas papules/pustules were inversely related with concomitant migraine (odds ratio = 0.5, 95% confidence interval = 0.3-0.8, p = 0.006). No association was found between concomitant migraine and centrofacial erythema, rhinophyma, telangiectasia, edema, or dryness. Concomitant rosacea was not associated with any specific migraine subtype in patients with migraine. This study highlights a substantial overlap between rosacea and migraine, particularly in patients with certain rosacea features. Individuals with rosacea should be asked about concomitant migraine, and comorbidities should be considered when choosing between treatments.

Can calcitonin gene-related peptide monoclonal antibody improve migraine and restless legs syndrome?

BackgroundA significant association between migraine and restless legs syndrome (RLS) has been reported, and their coexistence is not uncommon. We report a patient with concomitant migraine and RLS who showed improvement of both migraine and RLS symptoms after treatment with galcanezumab, a calcitonin gene-related peptide (CGRP) monoclonal antibody. Case presentationA 47-year-old woman had been treated in our outpatient headache clinic for migraine without aura. She had RLS since childhood and had been treated with dopamine agonists and α2δ ligands. Over the past 2 months, the patient suffered from frequent migraine headaches and worsening RLS symptoms, despite ongoing treatment. Therefore, galcanezumab was started. After 1 month, the number of headache days decreased from 20 to 4, and her score on the International RLS Study Group Rating Scale improved from 38 to 10. Her photo/phono/osmo-phobia were also markedly improved. The efficacy of galcanezumab for both headache and RLS was sustained over 5 months. ConclusionWe report a case of improvement of both migraine and RLS after treatment with CGRP monoclonal antibody. Additional studies are needed to clarify how CGRP antagonism affects RLS symptoms in patients with migraine and RLS comorbidity.

The potential impact of nutritional intake on symptoms severity in patients with comorbid migraine and irritable bowel syndrome

BackgroundSpecific dietary recommendations for migraine patients with comorbid irritable bowel syndrome (IBS) are lacking. This work aimed to study the severity scores of such two common pain-related disorders in relation to various macronutrients and micronutrients intake.MethodsA cross-sectional study was conducted on patients with concomitant migraine and IBS. The frequency and intensity of migraine attacks and the severity of IBS were evaluated. Data on dietary intake were collected using food frequency questionnaires and 24-hour dietary recall.ResultsOne-hundred patients with a median age of 36 years participated. The severity scores for migraine and IBS were positively correlated with fat and copper and negatively correlated with fiber and zinc intake. Copper intake was an independent predictor of the severity of both migraine and IBS (P 0.033, < 0.001). Patients with episodic migraine (n = 69) had a significantly higher frequency of cooked, fresh vegetables, and wheat bran bread intake (P 0.009, 0.004, 0.021) and lower frequency of hydrogenated oils intake (P 0.046), in comparison to patients with chronic migraine (n = 31). Patients with moderate intensity of migraine (n = 37) had a significantly higher frequency of herbal drinks intake (P 0.014) than patients with a severe intensity of migraine (n = 63). Patients with mild (n = 13) and moderate IBS (n = 41) had a significantly higher frequency of wheat bran bread and sen bread intake (P 0.003, 0.022) than patients with severe IBS (n = 46).ConclusionPatients with comorbid migraine and IBS are advised to adhere to a diet low in fat and copper and rich in fiber and zinc.

Intraoperative Electrocochleography Correlates to Outcomes in Transmastoid and Middle Cranial Fossa Superior Semicircular Canal Dehiscence Repair.

To determine the degree to which electrocochleography (ECoG) correlates with auditory and vestibular outcomes after repair of superior semicircular canal dehiscence (SSCD) via transmastoid (TM) and middle cranial fossa (MCF) approaches. Retrospective review. Academic tertiary referral center. Adults with SSCD who underwent repair between 2005 and 2019. Pre-, intra-, and postoperative ECoG. Patient-reported vestibular and auditory symptoms; pre-, intra-, and postoperative ECoG measures, dizziness handicap inventory (DHI) scores. Forty-six patients underwent SSCD repair (40 unilateral, six bilateral) between 2005 and 2019, including 24 MCF and 28 TM approaches. There were no differences in preoperative, intraoperative, or postrepair ECoG SP/AP values between the MCF and TM groups (p 0.12, 0.77, 0.58). Patients had subjective improvement in vestibular symptoms (or stable vestibular function in patients operated for predominantly auditory manifestations) with both approaches (MCF: 87.5%; TM: 92.3%; p 0.64). A successful outcome correlated with intraoperative SP/AP ratio normalization (p 0.0005). Similarly, DHI scores were similar in both groups preoperatively (p 0.66) and returned to their preoperative baseline postoperatively with both (p 0.52). Reported vestibular symptoms persisted or worsened more often in patients with migraine (66.6% vs. 28.9%, p 0.03), and with persistently abnormal ECoG measures, though the latter was not statistically significant in this population (38% vs. 15%, p 0.10). Patients had subjective improvement or stability in auditory symptoms using either approach (MCF: 96%; TM: 100%; p 0.62), also correlating with SP/AP ratio normalization (p 0.008). Correction of abnormal preoperative ECoG reliably correlates to patient symptom improvement after SSCD repair. No significant differences in postoperative outcomes were noted between patients undergoing TM versus MCF repair. Circumspection regarding the likelihood of an ideal outcome after SSCD repair should be exercised when counseling patients with concomitant migraine. It is not certain whether outcomes differ between the two dominant approaches for SSCD repair. Surgeons and patients would benefit from an intraoperative metric that reflects satisfactory plugging of SSCD. To highlight the reliability and unique utility of intraoperative ECoG and demonstrate the correlation between ECoG correction and symptom improvement for SSCD repair. To report subjective and objective outcomes following SSCD repair and encourage adoption of intraoperative ECoG monitoring. Level V. IRB review considers this study exempt (HUM00169949).

Features of pain syndrome in genital endometriosis and migraine

Migraine is often concurrent with endometriosis; however, the mechanisms of comorbidity of these conditions are inadequately studied. Pain is considered as the most significant clinical symptom and maladaptive manifestation of both migraine and endometriosis. Studying the relationship between the clinical manifestations of pain syndrome in patients with endometriosis and migraine is important, since it will contribute to the understanding of the mechanisms of comorbidity of these diseases.Objective: to analyze the features of pain syndrome in patients with migraine and genital endometriosis to clarify the neurogenic mechanisms of their comorbid relationship.Patients and methods. A total of 125 patients who had gone to a gynecologist for endometriosis were examined for the presence of migraine. In accordance with the inclusion criteria, 79 patients (mean age, 34.68±7.11 years) with genital endometriosis confirmed by diagnostic laparoscopy participated in the further study. Two age-matched groups were formed: a study group consisted of 38 patients with endometriosis and concomitant migraine; a comparison group included 41 patients with endometriosis without migraine. All the patients underwent clinical neurological examination, questionnaire survey, pelvic ultrasound, assessment of the severity of pelvic pain according to the pelvic pain index, and determination of the level of central sensitization (CS) using the CS Inventory.Results and discussion. 42% out of the 125 patients who had visited their gynecologist for endometriosis suffered from concomitant migraine, which confirms the comorbidity of these diseases. Chronic pelvic pain (CPP), dysmenorrhea, dyspareunia, and dyschesia were more common in patients with endometriosis and migraine; there were more patients with asymptomatic endometriosis in the comparison group. The patients of the two groups did not differ in the presentation of different forms of endometriosis, which favors the leading role of central mechanisms in the pathogenesis of pain syndrome in comorbidity of these diseases.In addition, there was a statistically significant increase in the presentation of CPP and dysmenorrhea in patients with chronic migraine compared to those with episodic migraine and to those without migraine. Significantly higher levels of CS according to CSI and pelvic pain index were found in patients with chronic migraine and endometriosis, which suggests that CS plays a key role in the comorbidity of these diseases.Conclusion. The phenomenon of CS is one of the mechanisms of comorbidity of migraine and endometriosis, contributes to both the worsening of various painful manifestations of endometriosis and the increase in migraine attacks, thereby causing obvious maladaptation in patients. The role of CS in the comorbidity of migraine and endometriosis opens up possibilities for the elaboration of a comprehensive interdisciplinary approach to treating these diseases.

Transverse Sinus Stenosis in Refractory Chronic Headache Patients: An Observational Study.

Background: Transverse sinus stenosis is a common brain MRI finding in chronic migraine (CM) and chronic tension-type headache (CTTH) patients in clinical practice; however, its clinical and diagnostic role is unclear. The aim of the study is to determine the frequency of transverse sinus stenosis in these headache patients resistant to preventive treatments and to verify whether this is a useful finding for identifying patients with intracranial hypertension.Methods: This is an observational study. Patients with refractory CM and CTTH underwent a 3T-magnetic resonance venography (MRV) before cerebrospinal fluid (CSF) opening pressure measurement. Transverse sinus stenosis was determined using the combined conduit score. Patients with opening pressure >200 repeated MRV study 1 month after CSF withdrawal to evaluate changes in neuroimaging findings.Results: We analyzed MRV studies of 40 patients (32 F, 8 M; mean age, 49.4 ± 10.8; mean body mass index, 26.7 ± 6.4; 39 CM and 1 CTTH with concomitant episodic migraine). Nineteen cases (47.5%) had evidence of transverse sinus stenosis: bilateral in seven patients (17.5%) and unilateral in 12 cases (30%). No statistically significant differences in transverse sinus stenosis distribution were found between patients with opening pressure <200 mmH2O and those with opening pressure >200 mmH2O. On Spearman bivariate test, there was no correlation between opening pressure and combined conduit score. No changes in neuroimaging findings were found 1 month after CSF withdrawal.Conclusion: Transverse sinus stenosis is a frequent radiological finding (47.5%) in CM and CTTH patients refractory to preventive treatments. However, this finding is not suggestive of intracranial hypertension. Whether transverse sinus stenosis may be a possible risk factor for chronic headache or a comorbidity needs to be evaluated in larger epidemiological studies.

Efficacy and safety of lasmiditan in patients using concomitant migraine preventive medications: findings from SAMURAI and SPARTAN, two randomized phase 3 trials

ObjectiveTo study the efficacy and safety of lasmiditan for acute treatment of migraine in patients using migraine preventive medications.BackgroundWhile lasmiditan has been proven to be an effective acute treatment for migraine, its effectiveness has not been examined when used concurrently with migraine preventives.MethodsSAMURAI and SPARTAN were similarly designed, double-blind, phase 3, placebo-controlled studies of patients 18 years or older with 3 to 8 migraine attacks per month. Patients were randomized to treat a migraine attack with oral lasmiditan 50 mg (SPARTAN only), 100 mg, 200 mg, or placebo. Migraine preventives were allowed as long as doses were stable for 3 months prior to screening and were unchanged during the study. Preventive medications with established or probable efficacy, as recommended by the American Academy of Neurology, the American Headache Society, and the European Headache Federation, plus botulinum toxin type A and candesartan, were included. Within the subgroups of patients using and not using preventive therapies, lasmiditan and placebo groups were analyzed for the outcome of pain-free at 2 h and other efficacy outcomes. The subgroups of patients using and not using preventive therapies were compared and interaction p-values were calculated for safety and efficacy outcomes.ResultsIn these trials, 698 of 3981 patients (17.5%) used migraine preventive treatments. Among patients using preventives, all lasmiditan doses resulted in significantly more patients being pain-free at 2 h, compared to placebo (p < 0.05). Primary efficacy outcome (pain-free at 2 h), key secondary outcome (most bothersome symptom-free at 2 h) and all other efficacy outcomes were not significantly different between patients using or not using migraine preventives (all interaction p-values ≥0.1). Rates of adverse events were similar for patients using and not using preventive medications.ConclusionsLasmiditan was more effective than placebo for the acute treatment of migraine in patients concurrently using migraine preventive medications. Lasmiditan efficacy and safety measures were similar for patients using and not using preventive medications.Trial registrationSAMURAI (NCT02439320) and SPARTAN (NCT02605174). Registered 18 March 2015.

Effect of Pramipexole on Headache Relief in Patients with Concomitant Migraine and Restless Legs Syndrome; A Randomized, Controlled, Clinical Trial

BackgroundMigraine is one of themost common hereditary disease, and considerable attention is always paid to trigger factors of migraine attacks and drugs effective in the prophylaxis of such complications. Recent studies are indicative of the high prevalence of migraine together with restless legs syndrome (RLS). Some hypotheses about a common dysfunction in dopamine synthesis in both diseases are proposed. However, no single mechanism to explain this concurrence and no effective drug for patients with these two diseases is found yet.ObjectivesThe current study aimed at investigating the effect of pramipexole, an effective agent in the relief of RLS, through a randomized, clinical trial on the frequency of migraine headache attacks during three months.MethodsIn the current study, the patients with concomitant migraine and RLS were divided into two groups. One group (case) received propranolol and pramipexole, and the other group (control) received propranolol and placebo. The two groups were questioned before and after the intervention about themigraine disability assessment score (MIDAS), frequency, and severity of migraine attacks.ResultsAccording to the results, the MIDAS scores of the case group showed a greater reduction compared to that of the control group (52.67% vs. 35.74%). Moreover, the mean frequency of migraine attacks showed a greater reduction in the case group than in the control group (62.38% vs. 39.85%).ConclusionsThe current study results showed that pramipexole can be effective in reducing the frequency of migraine attacks and improving patients’ activities of daily living.

Systematic review of the beneficial effects of thrombin and vitamin K inhibitors on migraine treatment

Background: Prophylactic migraine therapy includes beta-blockers, anticonvulsants, tricyclic antidepressants and calcium channel modulators. These drugs have been serendipitously identified as agents capable of migraine control. In order to reduce drug intake, interactions and potential adverse events, patients who have high blood pressure and migraine are often prescribed beta-blockers or calcium channel antagonists. Patients with epilepsy and migraine can use anticonvulsants, those with depression and migraine can be treat with antidepressants, and those with heart arrhythmia or recurrent vertigo and concomitant migraine can benefit from use of calcium channel antagonists. The beneficial effects of vitamin K or thrombin inhibitors on migraine attacks were first described decades ago, and there may be a place for these drugs in migraine prophylaxis. Objective: To investigate the potential beneficial effects of this class of anticoagulants regarding prevention of migraine attacks. Method: Systematic review of the literature including papers with patients’ results. Results: A search of the literature yielded 16 papers with data on patients using inhibitors of vitamin K or thrombin for thromboembolic conditions. Articles typically reported on single cases or small case series. In all but one of these reports, the effect of the drug was remarkable in decreasing migraine severity. Conclusion: Although the level of recommendation is low due to the lack of proper clinical trials, vitamin K or thrombin inhibitors may be useful for migraine management in patients who also require anticoagulation. For these individuals, use of this class of anticoagulants could avoid adding extra drugs for migraine management.

Concomitant Migraine and Temporomandibular Disorders are Associated With Higher Heat Pain Hyperalgesia and Cephalic Cutaneous Allodynia.

The aim of this study was to assess differences in the levels of hyperalgesia and cutaneous allodynia (CA) among women with migraine, temporomandibular disorders (TMD), or both. Eighty women participated in the study. Mean ages for the control group, TMD group, migraine group, and migraine+TMD group were 26.15 (95% confidence interval [CI], 28.73 to 23.57), 31.65 (95% CI, 37.82 to 25.48), 35.05 (95% CI, 40.37 to 29.73), and 34.20 (95% CI, 37.99 to 30.41) years, respectively. The 12-item Allodynia Symptom Checklist was administered to assess CA. All participants underwent the Quantitative Sensory Test to determine the cold-pain and heat-pain thresholds. Mechanical pain thresholds were assessed using Semmes-Weinstein monofilaments. One-way analysis of variance and χ tests were used for statistical analysis. Alpha was set at 0.05 level for statistical significance. For all sites evaluated, the mean cold-pain threshold values were significantly lower in the TMD, migraine, and TMD+migraine groups compared with the control group. However, the mean heat-pain threshold values in the extracephalic region were significantly smaller only for the TMD+migraine group compared with the control group (41.94°C; 95% CI, 40.54 to 43.34 vs. 44.79°C; 95% CI, 43.45 to 46.12; P=0.03). Mechanical hyperalgesia in orofacial and neck sites was significantly lower in the TMD and TMD+migraine groups compared with the control group. Mean total 12-item Allodynia Symptom Checklist score in the TMD+migraine group was significantly higher than in the migraine group (9.53; 95% CI, 7.45 to 11.60 vs. 6.95; 95% CI, 5.35 to 8.55; P=0.02). More pronounced levels of hyperalgesia and CA were found in patients with both TMD and migraine. Thus, it is suggested that the concomitant presence of TMD and migraine may be related to intensification of central sensitization.

Prevalence of Irritable Bowel Syndrome (IBS), Migraine and Co-Existing IBS-Migraine in Medical Students.

Irritable Bowel Syndrome (IBS) and migraine frequently co-exist. Stress is a major contributing factor for both. Our medical students are subjected to stress related to the implicit responsibility of courses. But the prevalence of IBS, migraine and co-existing migraine in medical students is not known. To estimate the prevalence of migraine, IBS and co-existing IBS and migraine among medical students. A Cross-Sectional Survey. Self-reported questionnaire based study, was conducted in which migraine was defined according to International Headache Society (IHS) criteria while IBS by both Asian criteria and Rome III criteria. Both preclinical (n=142) and clinical students (n=151) of four medical colleges (government and private) of Dhaka and Sylhet district participated in the study. Statistical Analysis: Student's t-test and chi-square test were used to compare the distributions of continuous data and categorical data respectively with significance level set at 0.05 or less. Among the 293 students (mean age 21.09 ± 2.24 years) volunteered in the study (Males= 177), 14 (4.8%, 11 males, 3 females, p = 0.175) met the criteria for IBS with comparable prevalence among preclinical and clinical (4.2% vs. 5.3%, p = 0.787) students from both private and government institutions (2.1% vs. 7.2%, p = 0.055). IBS-D was the most prevalent subtype (n = 8, M = 6) and abdominal pain relieved by defecation (n = 11), was the most prevalent symptom. Fifty percent (n = 7) of IBS patients considered their bowel habit as normal. Among the 221 (75.4%) students with headache, only 51 (17.4%, 20 males and 31 females, p = 0.001) were diagnosed of migraine, with comparable prevalence among preclinical and clinical students (16.2% vs. 18.5%, p = 0.645). Only 17 (33%) subjects with migraine had accompanying aura. Common triggers were stress (n = 43), lack of sleep (n = 42), and daily life events. Twelve (23.5%) subjects with migraine had migraine-associated frequent disability. Only two female students with IBS-D (14.3%) had concomitant IBS and migraine. IBS and concomitant migraine - IBS prevalence was found to be low in our medical students, but migraine prevalence corresponds to other countries as well as in medical students.

Does pramipexole treatment improve headache in patients with concomitant migraine and restless legs syndrome?

Background: Recent studies have suggested a link between migraines and restless legs syndrome (RLS). Although these disorders may share a dopaminergic dysfunction in the hypothalamic A11 nucleus that contributes to this association, there have been no clinical studies evaluating the effect of dopaminergic treatment on migraine symptoms in patients with concomitant migraines and RLS.

Does pramipexole treatment improve headache in patients with concomitant migraine and restless legs syndrome?

Recent studies have suggested a strong link between migraines and restless legs syndrome (RLS). It is possible that these disorders share a dopaminergic dysfunction in the hypothalamic A11 nucleus that contributes to this association. However, there have been no clinical studies to evaluate the effect of dopaminergic treatment on migraine symptoms in patients with concomitant migraines and RLS. We present an illustrative patient with concomitant RLS and migraine who showed improvement in her headache frequency and RLS symptoms following immediate-release pramipexole (P-IR) treatment and provide review results from the medical records of patients who experienced both migraines and RLS in our previous cross-sectional study. Ten patients (nine patients from the previously completed single-center study) received P-IR treatment were included in the study. RLS symptoms improved markedly in all of the subjects. Five out of the 10 patients (50%) reported improvement in migraine headaches. Of these five patients, four (80%) had reported morning headaches before P-IR treatment. Our results indicate that the identification of RLS in migraine patients is clinically significant and that dopaminergic treatment may improve both migraines, particularly morning headache (80% improvement in this study), and RLS symptoms. However, further clinical studies are warranted to verify our results.

Does Pramipexole Treatment Improve Headache in Patients with Concomitant Migraine and Restless Legs Syndrome?

Does Pramipexole Treatment Improve Headache in Patients with Concomitant Migraine and Restless Legs Syndrome?

Comparing treatments for endometriosis-related pain symptoms in patients with migraine without aura

Endometriosis is a gynecological disorder defined by the presence of endometrial-like tissue outside the uterus. Several studies have found an epidemiological correlation between endometriosis and migraine, probably due to the association of both diseases with female hormones. Progestins or combined oral contraceptives are the first-line medical therapy in women with endometriosis; however, it is well known that in some women the use of combined oral contraceptives could exacerbate migraine. This observation poses a challenge to clinicians who must concomitantly treat endometriosis-related symptoms and migraine. This review summarizes the available literature on the medical treatment of endometriosis in women suffering concomitant migraine without aura until March 2012. Due to the lack of available studies on this topic, it is difficult to draw definitive conclusions. Further studies evaluating hormonal therapies are needed; in particular, progestin therapy should be reconsidered in women with migraine and concomitant endometriosis.

Focal Common Carotid Artery Intramural Hematoma

Isolated focal common carotid artery dissection is a rare condition. A 43-year-old healthy woman suffered for the first time from a transient episode of word-finding difficulties, which was associated with her typical migraine headaches. A month prior to this event she had suffered from a minor whiplash injury. On routine work-up we found an isolated focal left common carotid mural hematoma and tiny acute left posterior watershed lesions on diffusion weighted images. Focal isolated common carotid artery dissection is a rare condition not to be overlooked. This case presents an incidental finding possibly of traumatic nature. In the presence of concomitant migraine its causal embolic relation to the transient word-finding difficulties must remain open.

Aspirin Sensitive Asthma: Provocation Tests Do Not Work in Such Patients

In response to the impressive scientific review article by Randerath and Galetke, we want to share our own experiences with the treatment of asthma and nasal polyps, in these times of increasing funding shortages, to show that there are simpler solutions to the problem. Small practices cannot present high case numbers or evidence- based study designs. We tested the tolerability of salix (willow) and acetylsalicylic acid (ASA) in 536 patients with allergies using electroacupuncture according to the method of Voll (EAV) in 115 patients with rhinoconjunc tivitis and in 65 asthma patients with concomitant migraine or lipid metabolism disorders (1). Of those 180 patients 11 were affected, of whom two reacted to willow and ASA. They were successfully desensitized by using destructive interference (3). This method is used similarly for stimulants such as tree or grass pollen, house dust mites, eiderdown, and synthetic fibers, to prevent nasal polyps and subsequent aspirin sensitive asthma successfully. The author has been using ASA at low dosages since 1985 after testing for thrombocyte hyperaggregability (2). Platelet agglutinating factor (PAF) is released in every allergic reaction and causes microcirculatory disruptions that may manifest as pain or shortness of breath. Mast cells are activated not only by IgE but also by type III reactions (IgG). Immunocomplexes develop that activate complement pathways, thereby releasing slow reacting substances or leukotrienes. The simultaneously released heparin and similar glycosaminoglycans stimulate the matrix to release large basic proteins and arginine and lysine from eosinophils, which pro vides a stimulus to attract more eosinophils. These processes are disrupted by destructive interference, and the mast cell system can calm down. We cannot accept Randerath and Galetke’s statement: Currently there is no reliable in-vitro method to diag nose aspirin sensitive asthma, so that provocation tests are vital. Our own clinical practice has shown that prov ocation tests do not work in such patients. We there fore need leukotriene antagonists for such patients only in the initial phase of their treatment. ASA does not have to present a real problem in practice.

Nebivolol and Metoprolol for Treating Migraine: An Advance on β‐Blocker Treatment?

To evaluate the efficacy of oral treatment with nebivolol and metoprolol in the prophylaxis of migraine attacks. Beta-blockers such as propranolol and metoprolol are known to be effective in preventing migraine attacks. Following earlier observations of successful use of nebivolol in a few hypertensive patients with concomitant migraine, we conducted a prospective study to ascertain whether nebivolol would be effective and better tolerated, in a methodologically strict, randomized and double-blind setting. Randomized, double-blind study in 30 patients with confirmed migraine diagnosis, a minimum 1-year history, onset prior to 50 years of age, written records of attacks for the previous 3 months, and minimum 2 attacks per month. Primary endpoint was frequency of attacks (prevention of migraine attacks) in the final 4 weeks of a 14-week treatment on full dose of metoprolol and nebivolol. Secondary endpoints were time to therapeutic effect, duration of attacks, intensity of headache, consumption of analgesics, evaluation of accompanying symptoms, migraine disability assessment, clinical global impression, quality of life, and responder rates. The statistical analysis was prospectively planned and conducted for all randomized patients. Both metoprolol and nebivolol where similarly effective regarding the main endpoint (prevention of migraine attacks) as well as the secondary ones, and both had a fast onset of action, typically within 4 weeks from starting therapy, with responder rates increasing relatively little over time after the first 4 weeks. Use of acute pain medication decreased on both drugs, as well as accompanying symptoms. Both patients' and physicians' evaluations of disability and disease status were similarly favorable to the 2 treatments. Regarding safety, nebivolol was considerably better tolerated than metoprolol in terms of all reported events, treatment-related events, and event severity. Our results suggest that nebivolol is as effective as metoprolol in the prophylaxis of migraine attacks, with the advantages of being better tolerated and not requiring up-titration to achieve therapeutic levels. Further and larger trials should be conducted on nebivolol in the prevention of migraine attacks as it may provide an improvement in current migraine prophylaxis with beta-blockers.