Daily Headache Research Articles

Secondary nummular headache: Are they more common thanwe thought?

To provide a detailed description of symptomatic nummular headache (NH) and to compare them with primary cases in a large series. While most published cases of NH are primary headache, some 'secondary' cases have been reported since its initial description. It remains uncertain why identical clinical presentations can result from primary and 'secondary' etiologies. Thanks to the possibility of offering specific treatments for symptomatic NH, it is crucial to be able to distinguish between them effectively. This monocentric retrospective study included a cohort of patients diagnosed with NH according to the International Classification of Headache Disorders, Second (ICHD-2) and Third Editions (ICHD-3), and the Pareja etal. first description, over a 20-year period (2002 to 2022). Established ICHD-3 diagnoses were used for each symptomatic case. Causality was attributed if (i) headache had developed in close temporal relation to other symptoms and/or clinical signs, or had led to its diagnosis, and (ii) either the headache had significantly worsened in parallel with other symptoms or clinical or radiological signs of worsening of the underlying disease, or the headache had resolved after treatment of the presumed causative disorder. Symptomatic NH were divided into two groups: "definite" or "probable." A comparison between the "primary" and "secondary" groups is presented. A total of 131 patients (88, 67.2% females) were included in the study. The median (interquartile range) age at onset of symptoms was 52 (36-63.2) years. In all, 34 patients (25.9%) were diagnosed as symptomatic NH (nine post-traumatic, seven attributed to a disorder of the cranial bones, six due to intracranial neoplasia, five attributed to arachnoid cysts, three attributed to vascular malformations, two due to cutaneous disturbances, and two attributed to hypertension). Eight patients were classified as "definite symptomatic NH" and 26 as "probable symptomatic NH." Neuroimaging was performed in all cases. Any previous headache (52.9% vs. 29.9%; p = 0.016), a remote head trauma (26.5% vs. 9.3%; p = 0.015), and a longer disease duration (18 vs. 12 months; p = 0.036) were more likely in patients with symptomatic NH. Preventive treatment was more effective (achieved >50% reduction in monthly headache days) in patients with symptomatic NH (72.2% vs. 30.3%; p = 0.002) due to a cause-specific treatment. Symptomatic NH are frequent. The presence of any previous headache or remote head trauma may suggest a diagnosis of symptomatic NH; however, as certain NH might be an early symptom of intracranial mass lesions, neuroimaging is necessary. Finding the cause of NH is essential to offer the most effective targeted treatment.

Antinociceptive, antineuropathic, and antimigraine-like activities ofFritillariaimperialis L. rich in verticinone on rats: Mechanisms of action

Ethnopharmacological relevanceFritillaria imperialis L. (Fabaceae), commonly known as “Laleh vazhgon”, ethnomedicinally utilized in Iranian traditional medicine to treat joint pain, chronic daily headaches, and back pain. Aim of the studyTo investigate the antinociceptive, anti-neuropathic, and anti-migraine activities of Fritillaria imperialis bulbs essential oil (FIEO) as well as to uncover the potential mechanisms of action involved. Materials and methodsThe antinociceptive activity of FIEO and its main constituent, Verticinone (Vt), was assessed using the formalin-induced paw licking assay. The potential mechanisms of antinociception were investigated through various antagonists. Additionally, their antineuropathic activity was examined using the cervical spinal cord contusion (CCS) technique and the possible role of Stat3 was evaluated using Western blot analysis. The nitroglycerin-induced model (NTG) was also employed for the evaluation of migraine. ResultsFIEO demonstrated significant antinociceptive activity in both phases of the formalin-induced test. However, the FIEO activity was more pronounced effect observed in the second phase. Modulators of the NO-cGMP-K+ channel pathway significantly reversed the antinociceptive activity of FIEO (P < 0.05). Additionally, antagonists of TRPV1, PPARα, dopamine D1, GABAA, and δ-opioid receptors also significantly reversed the antinociceptive effects of FIEO (P < 0.05). In a separate study, both FIEO and Vt were found to attenuate hyperalgesia and mechanical allodynia (P < 0.01) when evaluated using the CCS-induced pain model. Furthermore, FIEO may alleviate migraine behaviors, likely related to the regulation of NO and CGRP levels. ConclusionFIEO exerts an antineuropathic effect through the phosphorylation of Stat3. Furthermore, the antinociceptive activity is partially modulated via the NO-cGMP-K+ channel pathway, as well as the activation of TRPV, PPAR, opioid, and GABA receptors. Vt may be involved in the antinociceptive, antineuropathic, and antimigraine activities induced by FIEO.

Treatment of thoracic outlet syndrome to relieve chronic migraine.

Prior case reports have suggested that treating thoracic outlet syndrome (TOS) may relieve intractable migraine headaches, but there has been no case series large enough to show when underlying TOS should be suspected as a contributor to migraine burden. This observational followed by questionnaire study was performed in an outpatient neurology practice to identify clinical features of patients with migraine in which TOS contributed to migraine burden. We report the clinical features of 50 consecutive patients (48 women, 2 men, age = 43.9+/12.7 years) who were treated for chronic migraine and TOS (20 migraine with aura, 28 migraine without aura, two hemiplegic migraines). Headaches had become chronic within 1 year of onset in 21 patients (42%) with characteristics as follows (percentages are based on known data): greater severity ipsilateral to TOS limb pain (38/50=76%), presence of limb swelling (32/48=67%), and worsened by recumbency (32/38=84%). Thirty-two patients eventually needed surgery, which included percutaneous transluminal venoplasty, 1st rib removal, scalenectomy, pectoralis minor tenotomy, and/or vein patching. The mean improvement of headaches on the treated side was 72 ± 26.7%; 12 patients experienced complete resolution of headaches after treatment of TOS (follow-up 7.2 ± 5.2 months). Questionnaire responders reported significant reductions in headache days (18.3 ± 8.6 to 11.1 ± 10.8 days/month, p < 0.0016), severity (7.8+/2.5 to 5.4 ± 2.9, p < 0.00079), and need for emergency care (3.6 ± 4.0 to 0.71 ± 1.3 visits/year, p < 0.0029). Chronic migraines can be important manifestations of TOS. Early transition to a chronic state, lateralized limb pain, and headaches worsened by recumbency are clues to the contribution of TOS pathology. Addressing the TOS contribution to migraine can significantly reduce migraine headache burden.

Effectiveness of a Complementary Telehealth Education Program as a Preventive Treatment for Chronic Migraine: A Randomized Pilot Study.

Background/Objectives: Chronic migraine (CM) is a neurological disorder that causes significant disability, loss of productivity, and economic burden. Preventive treatments, including pharmacological and educational interventions, are crucial for managing CM effectively. The aim of this study was to analyze whether adding a therapeutic telehealth education program (TTEP) to pharmacological treatment achieved a greater reduction in the number of headache days experienced by patients with CM. Methods: A randomized, double-blind, controlled pilot study with two parallel groups was performed. Patients with a diagnosis of CM and who were being treated with Botulinum Toxin were randomly assigned to either the EG (therapeutic education program about the neuroscience of pain, migraine, pain strategies, sleep habits, exercise, nutrition, postural habits, and relaxation strategies) or CG (general health recommendations with no specific content about migraine). The intervention lasted a total of eight weeks and was delivered via a telehealth application (APP). Headache frequency, migraine frequency, pain intensity, headache impact, allodynia, fear of movement, pain catastrophizing, chronic pain self-efficacy, anxiety and depression, sleep quality, and sedentary lifestyle were measured at baseline (M0), one month after the intervention started (M1), at the end of the intervention (M2), and one month after the intervention was completed for follow-up (M3). Results: In total, 48 patients participated. There were differences between the groups in the following outcomes in favor of EG for headache frequency at the one-month follow-up (p = 0.03; d = 0.681); chronic pain self-efficacy at post-treatment (p = 0.007; d = 0.885) and at the one-month follow-up (p < 0.001; d = 0.998); and sleep quality at post-treatment (p = 0.013; d = 0.786) and at the one-month follow-up (p < 0.001; d = 1.086). No differences existed between the groups for the other outcomes examined (p < 0.05). Conclusions: The use of TTEP reduced the number of headache days, improved sleep quality, and increased self-efficacy in managing pain. This pilot study suggests that the addition of a specialized TTPE to pharmacological treatments may be more effective than a general health recommendation program for migraine.

NCMP-29. BRAIN LESIONS IN A TEEN WITH NEWLY DIAGNOSED T-CELL ALL AND SARS-COV-2 INFECTION

Abstract T-cell Lymphoblastic Leukemia (T-cell ALL) accounts for up to 15% of all newly diagnosed cases of acute lymphoblastic leukemia in pediatric patients (0-18 years old). Patients are at risk of opportunistic infections during induction therapy with up to 2% developing blood stream infections when their absolute neutrophil count is above 1,500. We report a case of a 15-year-old female with High-Risk T-cell ALL, CNS1 (negative CNS disease), presenting with three days of headaches, photophobia, and non-neutropenic fever. She completed induction chemotherapy one week earlier with vincristine, daunorubicin, calaspargase and a 28-day course of dexamethasone. On physical exam, she had no focal deficits or changes in sensation or strength. CBC was notable for a white blood cell count: 7500, hemoglobin: 8.6, platelets: 328,000 and ANC (Absolute Neutrophil Count): 4700. The patient was also COVID positive on admission. A contrast enhanced MRI brain demonstrated multiple diffusion restricting and peripherally enhancing lesions, concerning for intracranial abscesses. Neurosurgery performed a burr hole craniotomy and aspirated 5 mL of purulent drainage, the culture of which grew Aspergillus fumigatus complex. The patient was started empirically on Voriconazole, in addition to broad spectrum antibiotic coverage pending culture results, due to excellent CNS penetration and proven superiority to amphotericin-based therapy for invasive aspergillosis. Micafungin was added due to CT chest demonstrating nodular infiltrates, suggesting primary pulmonary aspergillosis with CNS dissemination. The patient improved symptomatically without further sequelae. Patients with COVID-19 on prolonged courses of corticosteroids are at higher risk of developing fungal co-infections regardless of neutrophil count. While pulmonary aspergillosis is the most common location of a COVID-19 aspergillus coinfection, there have been documented reports of intracranial micro-abscesses. Contrast-enhanced brain MRI should be obtained in any patient with a recent history of COVID-19 presenting with new neurological symptoms, especially in a patient with a recent history of corticosteroids.

Microbiota alterations are related to migraine food triggers and inflammatory markers in chronic migraine patients with medication overuse headache

ObjectiveChronic migraine (CM) patients with medication overuse headache (MOH) were recently shown to be associated with leaky gut and inflammation. We aimed to investigate gut microbiota profiles of CM patients with MOH, and their correlations with inflammatory serum parameters, migraine food triggers, and comorbid anxiety and depression.Materials and methodsThe study included women participants (32 CM patients with NSAID overuse headache, and 16 healthy non-headache sufferers). Migraine duration, monthly migraine headache days, presence of irritable bowel syndrome symptoms, and HADS-D and HADS-A scores were recorded. Serum samples were collected to measure circulating LPS, HMGB1, HIF-1α, and IL-6. The gut microbiota profiles of the patients were evaluated using fecal samples.ResultsSerum LPS, HMGB1, HIF-1α, and IL-6 levels were significantly higher in the CM + MOH group compared to the healthy controls. HADS-A and HADS-D scores were considerably higher in the CM + MOH group compared to the healthy controls. In the microbiota analysis, alpha and beta diversities were similar between the two groups. The class Clostridia, the order Eubacteriales, and the genus Ruminococcus were less abundant in the CM + NSAID overuse headache group compared to the control group. At the genus level Desulfovibrio, Gemmiger, and Dialister and at the species level, Clostridium fessum, Blautia luti, Dorea longicatena, Eubacterium coprostanoligenes, and Gemmiger formicilis were more abundant in the CM + NSAID overuse headache group compared to the control group. Desulfovibrio, Gemmiger, Dialister, Ethanoligenens harbinense, Eubacterium coprostanoligenes, Dorea longicatena, and Thermoclostridium stercorarium showed positive correlations and Clostridia bacteria showed negative correlations with migraine food triggers. Positive correlations were found between LPS and Hapalosiphonaceae, HMGB1 and Melghirimyces, HIF1-α and Rouxeilla and Blautia luti, IL-6 and Melghirimyces and Ruminococcus.ConclusionIn CM patients with MOH, we have revealed the presence of dysbiosis towards an inflammatory state, and positive correlations were shown between altered gut microbiota and inflammatory serum parameters and migraine food triggers.

Greater Occipital Nerve Blockade in Chronic Migraine: Meta-Analysis

Chronic migraine significantly impacts quality of life and remains a therapeutic challenge, with many patients experiencing limited relief from traditional treatments. Greater occipital nerve (GON) blockade has emerged as a potential intervention, utilizing bupivacaine to alleviate migraine frequency and severity. This meta-analysis assesses the efficacy of GON blockade in reducing headache days per month in patients with chronic migraine. A meta-analysis was conducted, encompassing four randomized, placebo-controlled studies published between 2014 and 2024. The studies included a total of 202 participants (105 in the intervention group and 97 in the placebo group) who received GON blockade with bupivacaine or a placebo. The primary outcome measured was the mean difference in monthly headache days between the intervention and placebo groups. Statistical heterogeneity across studies was also assessed. The pooled analysis revealed a statistically significant reduction in monthly headache days in the GON blockade group compared to placebo, with an average difference of -5.7 days (95% CI: -8.5 to -2.9; p &lt; 0.0001). Individual studies demonstrated consistent reductions in headache days in the intervention group, with mean differences ranging from -1.1 to -12.8 days. Heterogeneity was moderate (I² = 30.3%), indicating some variability across studies but an overall trend favoring the intervention. This meta-analysis supports the efficacy of GON blockade with bupivacaine as a promising treatment option for chronic migraine, showing a meaningful reduction in headache frequency. While GON blockade demonstrates short-term benefits, further research with extended follow-up periods and larger, more diverse samples is recommended to evaluate its long-term effectiveness and generalizability. These findings suggest that GON blockade may offer substantial relief for patients suffering from chronic migraines, providing a potential alternative for those who have not responded to conventional therapies.

Reduction of neck pain severity in patients with medication-overuse headache

BackgroundNeck pain and primary headache disorders are highly prevalent in populations and clinical cohorts. Medication-overuse headache (MOH) is a treatable secondary headache, mainly developing in migraine sufferers, that accounts for the majority of patients presenting to headache clinics. Nevertheless, the association between neck pain and MOH has not been reported. This study evaluated the prevalence and clinical course of neck pain in patients with MOH before and after MOH treatment.MethodsWe analyzed 635 MOH patients enrolled in a nationwide, prospective, multicenter MOH registry. Demographics and clinical data were collected at baseline and 3 months to evaluate changes in the status and severity of neck pain and headache. Severity of neck pain was graded into 4 groups, and severe neck pain was defined as grade 3 or 4.ResultsAmong 635 patients with MOH, 366 (57.6%) reported neck pain at baseline. MOH patients with neck pain had an earlier onset of their primary headache disorder (23.4 ± 12.7 vs. 26.2 ± 13.3 years, p = 0.007). Although monthly headache days were comparable between the patients with neck pain and those without neck pain, the neck pain group had higher levels of anxiety (7.4 ± 5.8 vs. 6.4 ± 5.4, p = 0.017), more severe cutaneous allodynia (2.4 ± 3.3 vs. 1.8 ± 3.0, p = 0.038), and poorer quality of life (171.7 ± 70.4 vs. 184.0 ± 68.9, p = 0.029). At 3 months, 456 (71.8%) were followed-up, and 257 (56.4%) were recovered from MOH. Compared to the baseline, the proportion of severe neck pain (40.4% vs. 19.4%, p < 0.001) was decreased. The proportion of severe neck pain was much lower in patients with recovery from MOH compared to those without (4.7% vs. 15.1%, p < 0.001).ConclusionsNeck pain in MOH patients was associated with earlier onset of headache, higher levels of anxiety and allodynia, and poorer quality of life. Improvement in neck pain improvement was linked to recovery from MOH. These findings suggest the potential importance of integrating and management of neck pain into clinical practice for MOH.

Morphological similarity and white matter structural mapping of new daily persistent headache: a structural connectivity and tract-specific study

BackgroundNew daily persistent headache (NDPH) is a rare primary headache disorder characterized by daily and persistent sudden onset headaches. Specific abnormalities in gray matter and white matter structure are associated with pain, but have not been well studied in NDPH. The objective of this work is to explore the fiber tracts and structural connectivity, which can help reveal unique gray and white matter structural abnormalities in NDPH.MethodsThe regional radiomics similarity networks were calculated from T1 weighted (T1w) MRI to depict the gray matter structure. The fiber connectivity matrices weighted by diffusion metrics like fractional anisotropy (FA), mean diffusivity (MD) and radial diffusivity (RD) were built, meanwhile the fiber tracts were segmented by anatomically-guided superficial fiber segmentation (Anat-SFSeg) method to explore the white matter structure from diffusion MRI. The considerable different neuroimaging features between NDPH and healthy controls (HC) were extracted from the connectivity and tract-based analyses. Finally, decision tree regression was used to predict the clinical scores (i.e. pain intensity) from the above neuroimaging features.ResultsT1w and diffusion MRI data were available in 51 participants after quality control: 22 patients with NDPH and 29 HCs. Significantly decreased morphological similarity was found between the right superior frontal gyrus and right hippocampus. The superficial white matter (SWM) showed significantly decreased FA in fiber tracts including the right superficial-frontal, left superficial-occipital, bilateral superficial-occipital-temporal (Sup-OT) and right superficial-temporal, meanwhile significant increased RD was found in the left Sup-OT. For the fiber connectivity, NDPH showed significantly decreased FA in the bilateral basal ganglion and temporal lobe, increased MD in the right frontal lobe, and increased RD in the right frontal lobe and left temporal-occipital lobe. Clinical scores could be predicted dominantly by the above significantly different neuroimaging features through decision tree regression.ConclusionsOur research indicates the structural abnormalities of SWM and the neural pathways projected between regions like right hippocampus and left caudate nucleus, along with morphological similarity changes between the right superior frontal gyrus and right hippocampus, constitute the pathological features of NDPH. The decision tree regression demonstrates correlations between these structural changes and clinical scores.

Outcomes, unmet needs, and challenges in the management of patients who withdraw from anti-CGRP monoclonal antibodies: A prospective cohort study.

The anti-calcitonin gene-related peptide (CGRP), or its receptor (CGRP/R) monoclonal antibodies (mAbs), offer targeted, effective, and tolerated drugs for migraine. However, about 25% of patients fail to achieve a clinically meaningful response, usually leading to discontinuation. These patients often have a lengthy migraine history and multiple prior preventive treatment failures, resulting in limited therapeutic options. Herein, we describe the cause for and outcome of withdrawal of anti-CGRP/R mAb and evaluate the treatment course until discontinuation. We conducted a prospective analysis on migraine patients attending the Florence Headache Center in Italy, who discontinued treatment with anti-CGRP/R mAbs. The primary objectives were to describe the reasons for anti-CGRP mAbs discontinuation and the treatment course. Secondary objectives were the evaluation of the absolute change from baseline in monthly headache days, response rates, persistence in medication overuse, absolute change from baseline of the overall number and days of analgesics use per month, change of MIDAS and HIT-6 at three, six, and 12 months, and the last month of treatment. Among 472 patients, 136 (28.8%) discontinued mAb treatment after an average of 9.0 ± 6.1 (mean ± SD) months. The majority (96/136, 70.6%) discontinued due to ineffectiveness, followed by lost to follow-up during treatment (18/136, 13.1%) and adverse events (10/136, 7.3%). In total, 77.9% of the 136 patients ceased treatment within the first year. Following discontinuation, 48.5% initiated new pharmacological treatment, 39.7% were lost to follow-up, and 11.8% opted not to start another treatment. The majority of patients that started a new pharmacology treatment switched to another anti-CGRP/R (46/68, 67.6%). The second most-used treatment was onabotulinumtoxinA (7/68, 10.2%; all patients in this subgroup were naïve to this treatment), followed by an anticonvulsive medication (7/68, 10.2%). The response status (≥50% reduction in monthly headache days) was achieved by 30.5%, 34.6%, and 40.0% of patients at month 3, 6, and 12 of treatment, respectively. Considering only the comprehensive last month of treatment before withdrawn the percentage of responders was 16.9%. Although anti-CGRP/R mAbs have provided a substantial amelioration of migraine management, a relevant proportion of patients remains unresponsive and requires additional therapeutic support. Further research is required to identify non-responder features and address unmet needs in migraine treatment.

Randomized Trial of Self-Guided, Internet-Based, Cognitive Behavior Therapies for Migraine.

Self-guided Internet-based cognitive behavior therapy (iCBT) for migraine interventions could improve access to care, but there is poor evidence of their efficacy. A three-arm randomized controlled trial compared: iCBT focused on psychoeducation, self-monitoring and skills training (SPHERE), iCBT focused on identifying and managing personal headache triggers (PRISM) and a waitlist control. The primary treatment outcome was a ≥ 50% reduction in monthly headache days at 4 months post-randomization. 428 participants were randomized (mean age = 30.1). 240 participants (56.2%) provided outcome data at 4 months. Intention-to-treat (ITT) analysis with missing data imputed demonstrated that the proportion of responders with a ≥ 50% reduction was similar between combined iCBTs and waitlist (48.5/285, 17% vs. 16.6/143, 11.6%, p = 0.20), but analysis of completers showed both iCBT programs to be superior to the waitlist (24/108, 22.2% vs. 13/113, 11.5%, p = 0.047). ITT analysis with missing data imputed showed no difference between the two iCBTs (SPHERE: 24.8/143, 17.3% vs. PRISM: 23.7/142, 16.7%, p = 0.99). Uptake rates of the iCBTs were high (76.9% and 81.69% logged in at least once into SPHERE and PRISM, respectively), but adherence was low (out of those who logged in at least once, 19.01% [21/110] completed at least 50% modules in SPHERE and 7.76% [9/116] set a goal for trying out a given trigger-specific recommendation in PRISM). Acceptability ratings were intermediate. Self-guided iCBTs were not found to be superior in our primary ITT analysis. Low adherence could explain the lack of effects as completer analysis showed effects for both interventions. Enhancement of adherence should be a focus of future research.

Patient self rated pain: headache versus migraine a retrospective chart review

BackgroundThe International Classification of Headache Disorders (ICHD-3) uses moderate or severe pain intensity in the diagnostic criterion for migraine. However, few studies have analyzed pain rating on a visual analog scale to identify the numerical intensity that correlates with migraine.ObjectiveTo evaluate the impact of daily self-rated headache pain among patients with either episodic or chronic migraine. This study specifically aims to evaluate the probability of patients labeling their head pain as a headache vs. migraine based on the pain level reported.MethodsA retrospective chart review was conducted on patients with a clinical diagnosis of migraine from July 1, 2014, to July 1, 2019.ResultsData of 114 subjects (57 episodic migraine and 57 chronic migraine) were used for analysis. Patients with episodic migraine on average rated a migraine more severe than a headache (4.1 vs. 6.4; p < 0.001). Patients with chronic migraine on average also rated migraine more severe than a headache (4.3 vs. 6.8; p = 0.0054). Chronic migraine patients transitioned from calling head pain a headache to a migraine significantly later than episodic migraine patients (4.5 vs. 6.8; p < 0.05).ConclusionA migraine is perceived as having higher pain intensity than a headache in patients with both episodic and chronic migraine. On average, patients with chronic migraine had a higher pain rating at which they report head pain to be considered a migraine.

One-Year and Five-Year Outcomes in Medication Overuse Headache: A Real-World Study.

Medication overuse headache (MOH) is one of the global health-related problems that imposes significant morbidity. Effective management requires the abrupt cessation of the overused medications, transition therapy in the initial days, and initiation of preventive treatment. The objective of this study is to provide one-year and five-year follow-ups of study participants diagnosed with chronic migraine and MOH. The study will examine the efficacy of withdrawal therapy, the use of conventional preventive medication, and the use of anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies. We conducted a single-center, prospective, and descriptive study at a tertiary center in Brazil. The population was included by convenience sampling of consecutive subjects diagnosed with chronic migraine and MOH. Demographics and clinical data at baseline and one-year and five-year follow-ups were collected in the clinical records. Among 142 subjects, 116 were females and 26 were males, with a mean age of 42.1±14.3. They were followed for five years. The diagnosis was performed at the mean age of 24.9±14.7 years after the headache onset, and the time with headache ≥15 days per month was 6.3±7.6 years. On baseline, the average number of headache days per month (HDM) was 25.2±5.9. There was a reduction in HDM. At one-year and five-year follow-ups, a ≥75% reduction in HDM was observed, respectively, in 51.4% and 70.4% of the sample. The five-year follow-up of chronic migraine and MOH treated with the discontinuation of excessive medication, the use of preventative pharmacological agents, and the optional inclusion of anti-CGRP pathway monoclonal antibody led to a significant decrease in the initial occurrence of HDM.

IIH, SIH and headache: Diagnosis and treatment update

Idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) are two major secondary headache disorders resulting from abnormal intracranial pressure (ICP). This short communication outlines the pathophysiology, diagnostic criteria, and management strategies for IIH and SIH. IIH predominantly affects obese women of childbearing age and presents with daily headaches, visual disturbances, and papilledema. It is characterized by elevated cerebrospinal fluid (CSF) pressure, with diagnosis supported by imaging and lumbar puncture. Treatment includes weight reduction, medications, and surgical interventions in refractory cases. SIH, conversely, is caused by spontaneous spinal CSF leaks and presents with acute orthostatic headaches. Diagnosis is supported by neuroimaging and lumbar puncture, revealing low CSF pressure. Treatment includes supported care, (targeted) epidural blood patch, with surgical repair considered in refractory cases. Advances in imaging and treatment have significantly improved outcomes for both conditions.

Is the combination of propranolol and flunarizine better than propranolol, flunarizine and amitriptyline alone in prophylaxis of migraine? An observational study at a tertiary care centre of North India

Background: Migraine is a primary headache disorder marked by recurrent attacks of pain and associated symptoms. Propranolol is traditionally considered highly effective for migraine prophylaxis, but other drugs have recently shown promise. Methods: This study was a prospective, observational, randomized, parallel-arm, unicentric trial conducted in the neurology department of a tertiary care hospital in North India. Patients with migraine without aura were randomly assigned to one of four treatment groups. After obtaining consent, patients were randomized using a random number table. Group 1 received propranolol (80 mg), group 2 received flunarizine (10 mg), group 3 received a combination of propranolol (40 mg) and flunarizine (10 mg), and group 4 received amitriptyline (10 mg) daily. The primary outcome was a change in the frequency of migraine days, while secondary outcomes included changes in moderate-to-severe headache days and disability levels. Results: The combination of propranolol (40 mg) and flunarizine (10 mg) was significantly more effective in reducing the frequency of migraine attacks at the end of 3 months compared to the group receiving amitriptyline (10 mg). However, no significant differences between the groups were observed at baseline, 1 month, and 2 months. For other outcomes, including adverse drug reactions (ADRs), there were no significant differences between the groups. Conclusions: The combination of propranolol (40 mg) and flunarizine (10 mg) demonstrated superior efficacy over amitriptyline (10 mg) after prolonged treatment, while its effectiveness was comparable to other groups at earlier time points. ADRs were similar across all groups.

Comparative analysis of the efficacy of different treatment strategies in medication overuse headache: an open-label prospective trial

Medication overuse headache (MOH) is a common form of chronic headache with a high risk of relapse after therapy. Excessive use of analgesics most frequently leads to the development of MOH in migraine patients.Objective: to analyze the short- and long-term efficacy of MOH therapy in patients with chronic migraine (CM) using different programs to discontinue the abused drug and a detoxification regimen.Material and methods. The study included 44 patients with MOH and CM who were divided into two groups. Group A comprised 18 patients who discontinued the drug that triggered MOH and were simultaneously prescribed preventive treatment for migraine without undergoing "detoxification" therapy". Group B comprised 26 patients who received a multimodal therapeutic strategy including "detoxification treatment".Results. The strategy of complex therapy with a "detoxification treatment" was significantly more effective during the 12-month observation period. In group B, a significant (p&lt;0.01) decrease in the number of days with migraine per month was observed (before therapy – 22.6±7.4 days, after 3 months – 15.1±8.9 days, after 6 months – 12.7±9.1 days and after 12 months – 10.2±8.7 days). In the first 6 months, a similar dynamic was observed in group A, whereby the frequency of migraine increased in the 12th month of observation. Twelve months after the start of therapy, migraine occurred in episodes in the majority (84%) of patients in group B, which is significantly more than in group A (58.9%; p&lt;0.01).Conclusion. A comprehensive approach in the treatment of patients with CM and MOH with "detoxification" therapy" showed high efficacy in terms of reducing the number of headache days per month and converting CM to episodic migraine.

Acupuncture Treatment for Chronic Post-Traumatic Headache in Individuals with Mild Traumatic Brain Injury: A Pilot Study.

Chronic post-traumatic headache (CPTH) after a mild traumatic brain injury (mTBI) has been reported in up to 60% of patients and can be extremely debilitating. While pharmacological treatments are typically used for CPTH, they frequently cause side effects and have limited effectiveness, leading individuals with CPTH to be unsatisfied with current treatment options and to seek nonpharmacological options. Acupuncture has been identified as a potential treatment option; however, the evidence in this population remains limited. The overall goal of this study was to examine the effect of a once weekly (e.g., low dose) versus twice weekly (e.g., high dose) of acupuncture treatment on CPTH in individuals with mTBI. Thirty-eight individuals were randomized to receive either 5 or 10 acupuncture treatments using a standard protocol over 5 weeks. The protocol consisted of 14 points using traditional acupuncture and 4 points using electroacupuncture. Headache outcomes, safety, treatment adherence, sleep quality, and quality of life (QOL) were assessed. The results showed that while there were no differences between dose groups for any of the outcomes assessed, acupuncture significantly reduced the number of headache days and headache pain intensity in individuals with CPTH. There were no significant changes in acute medication use or sleep quality. While there were some QOL improvements identified, these results should be interpreted with caution. Overall, acupuncture was shown to be safe and well-tolerated in people with CPTH after mTBI, and five acupuncture treatments using a standardized protocol shows promise in providing headache relief for this population.

Effect of Xuefu zhuyu oral liquid on tension-type headache: A randomized clinical trial

BackgroundTension-type headache (TTH) is the most common neurological disorder worldwide, incurring immense social and economic costs and affecting quality of life. However, due to adverse reactions and inadequate effectiveness, there is still an unmet need for treatment. Xuefu zhuyu oral liquid (XZOL) is a Chinese patent medicine widely used for TTH in China, but evidence of its efficacy remains scant. PurposeThe aim of this study was to assess the efficacy and safety of XZOL for TTH patients. MethodsThis multicenter, double-blind, randomized placebo-controlled trial enrolled 174 patients with TTH in six centers in China from March 2020 to October 2021. Patients were randomly assigned to receive XZOL or a matched placebo for 4weeks. The primary outcome was the change in the mean headache intensity as measured by a visual analogue scale (VAS) from baseline to the end of treatment (Week 4). Secondary outcomes were the change in VAS from baseline to Week 12, the area-under-the-headache curve (AUC), response rate, number of headache days, average headache duration, rescue medication use proportion, etc. ResultsOf the 174 patients who were randomized, 160 completed the study. There was no significant difference in the mean change in VAS from baseline to the end of treatment between the XZOL group and the placebo group (-0.29; (95 % CI:0.81 to 0.23; p = 0.279) in the full analysis set (FAS), while there were statistically significant results (-0.9; 95 % CI:1.47 to -0.33; p = 0.002) in the per-protocol set (PPS). There were no significant differences in any of the secondary outcomes. The incidence of adverse events was similar in the two groups. ConclusionXZOL may be an alternative option to relieve pain for TTH patients with high compliance in clinical practice. However, XZOL did not improve headache measurements in the FAS population.

8168 From Salt to the Sella- Discovering Empty Sella Syndrome as a Rare Cause of Severe Hyponatremia

Abstract Disclosure: P. Vemparala: None. S. Challagulla: None. Introduction: Hyponatremia is a common electrolyte disorder with potentially life-threatening consequences. Careful evaluation of hyponatremia can uncover significant underlying conditions. We present an interesting case of a patient who presented with symptoms of severe hyponatremia and a workup led us to the discovery of empty sella syndrome as the etiology. Case Presentation: A 54-year-old male with hypertension presented with 2 days of left-sided headache, blurred vision, generalized weakness, and vomiting. Pertinent medication history revealed the use of thiazide diuretic, bupropion and varenicline. Physical examination was unremarkable. Laboratory data showed severe hyponatremia with a serum sodium of 118 meq/L. Initial improvement with fluids was followed by a decline (106-112 meq/L). CT head without contrast showed a prominent empty sella turcica. Workup revealed urine osmolality and elevated urine sodium. A low AM cortisol level of 1.0 mcg/dl (reference range- AM- 7.0 - 25.0 mcg/dl), and decreased adrenocorticotropic hormone (ACTH) level of 5.2 pg/ml (reference range- 7.2 - 63.3 pg/ml) suggested secondary adrenal insufficiency. All other anterior pituitary hormones were normal. Brain magnetic resonance imaging (MRI) confirmed the diagnosis of partial empty sella. Treatment with hypertonic saline, fluid restriction, and steroids led to symptom resolution. Conclusion: Empty sella syndrome is a rare pituitary condition that can be primary- characterized by herniation of the subarachnoid space within the sella, or secondary- which occurs when the sella is empty due to damage to the pituitary gland by tumor, radiation, etc. It can cause potential hypopituitarism, be asymptomatic, or present with symptoms of raised intracranial pressure. In patients with hypopituitarism, deficiencies of ACTH and TSH are rarer and appear to be more common with a complete empty sella. This case emphasizes the need for a comprehensive hyponatremia workup, awareness of secondary adrenal insufficiency, and recognition of the life-threatening potential of even partial empty sella syndrome when untreated. Presentation: 6/1/2024

7405 A Case of Pituitary Apoplexy in Pregnancy

Abstract Disclosure: Y. Esaki: None. G.E. Vates: None. I. Shafiq: None. Pituitary apoplexy is a rare cause of headache during pregnancy. The prevalence of pituitary apoplexy during gestation and the peripartum period is estimated to be 1 in 10,000 term pregnancies. Approximately 42-47% of these patients were known to have a pituitary lesion especially history of prolactinoma. Here we report a pregnant female developing pituitary apoplexy after discontinuation of dopamine agonist. A 27-year-old female was initially diagnosed with prolactinoma with elevated prolactin of 158.1 ng/ml (3.0-300 ng/ml). MRI revealed a 1.3 cm x 1.5 cm x 1.4 cm pituitary mass with solid and cystic components. Treatment with cabergoline 0.25 mg twice weekly was started. After 2 years of treatment, prolactin was 74.2 ng/ml and the size of the adenoma decreased to 1.0 cm x 1.2 cm x 1.3 cm. One year later, she became pregnant at age 30 and discontinued cabergoline after 7 weeks of gestation. At 12 weeks of gestation, she presented to the Emergency Department for 3 days of severe headaches associated with emesis. The ED work up includes prolactin &amp;gt; 2,000 ng/ml. MRI head without contrast demonstrated an interval increase in size to 1.5 cm x 1.7 cm with hemorrhagic component. Urgent evaluation by a Neuro-ophthalmologist revealed no clinical evidence of optic neuropathy. Blood work showed AM cortisol 2.3 mcg/dl (4.0-22.0 mcg/dl), TSH 0.5 mIU/L (0.4-0.5 mIU/L), FT4 0.6 ng/dl (0.8-1.8 ng/dl). Cabergoline 0.25 mg twice weekly was restarted to control the size of the tumor as well as hydrocortisone and levothyroxine for central adrenal insufficiency and hypothyroidism respectively. Four weeks later, she was 17 weeks pregnant. MRI showed a further increase in the size of the adenoma, now measuring 1.8 cm x 2.0 cm x 1.3 cm. The lesion now extended into the suprasellar cistern, affecting the optic chiasm. She underwent the transsphenoidal resection of the pituitary adenoma at 18 weeks of gestation due to the increase in size of the tumor. The final pathology was consistent with pituitary adenoma, lactotroph cell type, WHO grade 1. MRI obtained 3 months post-operation showed no residual T1 hyperintense tumor signal. There was a cyst-like expansion of the sella turcica with a decreased mass effect on the optic chiasm. She delivered her healthy baby at 40 weeks and 5 days via vaginal delivery. She received stress dose steroid during labor, then was discharged home with hydrocortisone 10 mg twice daily. She is doing well following the delivery and breastfeeding the baby. This case illustrates a rare case of pituitary apoplexy during pregnancy in a patient with prolactinoma. Pituitary apoplexy should be considered as a differential diagnosis when pregnant patients develop an acute, severe headache, especially those with an underlying pituitary adenoma. It is critical to assess and treat the hormonal deficiencies. For prolactinoma, pharmacological therapy can be initiated. Surgery is considered if the medical therapy fails. Presentation: 6/3/2024