ICHD-III Beta Research Articles

Headache and sleep quality in mitochondrial diseases

Objective: Describe the characteristics and prevalence of headache in patients with mitochondrial diseases (MDs), as well as sleep quality, trying to observe possible associations. To assess whether these patients are more likely to suffer headaches in relation to poorer quality of sleep. Background: Sleep disorders and headache are considered to be common in MDs. We present the largest sample analyzed to date. Methods: Observational, descriptive, cross-sectional study that analyzed a database of 232 patients with MDs, including age, sex, genotype, phenotype, presence and characteristics of headache. All patients fulfilled the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI) and, in migraine, the Migraine Disability Assessment questionnaire (MIDAS). Headache was divided into two groups: migraine headache, according to criteria of the International Classification of Headache Disorders (ICHD-III beta), and non-migraine headache. Results: A total of 203 cases were analyzed, 124 women (61%) and 79 men (39%). Average age was 46 years. Most frequent DNA mutation was m.3243 A > G in MITL1 gene (33%). Most frequent phenotype was MELAS syndrome: 28 patients (13.8%). Ninety-two patients (45.3%), reported headache, 44 fulfilling migraine criteria (21.7%). Headache was more frequent in MELAS syndrome ( p < 0.01). Statistically significant differences were found in the number of disabling episodes per month in patients with migraine ( p < 0.001). Patients with headache scored higher in Epworth ( p = 0.01) and Pittsburgh scales ( p < 0.001). Conclusions: A higher prevalence of migraine is observed in patients with mitochondrial diseases, independent of genotype and phenotype. MD-associated migraine tends to be chronic and more disabling. A higher frequency of headache, not specifically migraine, has also been observed in patients with MELAS syndrome. Mitochondrial dysfunction could be one of the pathophysiological mechanisms of migraine and a factor of chronification and severity. Poor sleep quality could also be associated with headache in patients with MDs. Assessment of headache and sleep disturbances should be part of the routine workup of patients with mitochondrial disease. Trial registration: N/A.

Primary headache disorders in epileptic adults

BackgroundEpilepsy and primary headache disorders are two relatively common neurological disorders and their relationship is still a matter of debate. We aimed to estimate the prevalence and clinical features of primary headache disorders in patients with epilepsy.Methods62 subjects aged ≥ 18 years were recruited from the hospital’s neurology outpatient clinic in the period from January to April 2018. The subjects were further divided into two equal groups, epileptics and non-epileptics. They underwent a semi-structured interview including the ILAE 2017 epilepsy classification and the ICHD III-beta criteria for headache. Patients' demographic data and clinical characteristics of epilepsy and headache and temporal relationships between them were assessed. Patients who experienced headaches were grouped based on the type of headaches and on whether their headaches occurred in the pre-ictal, post-ictal or inter-ictal period.ResultsPrimary headache disorders were more common in epileptic group (61.3%) than the non-epileptic group (32.2%) (p = 0.021). The tension-type headache was the most common (45.2%) followed by migraine-type headache (12.9%) in the epileptic group. Post-ictal headache was the most common type (29%). Inter-ictal headaches were significantly related to "focal to bilateral tonic–clonic" seizures (p = 0.046). The prevalence of headache among patients on polytherapy (69.2%) was higher than that of patients on monotherapy (52.9%).ConclusionsIn this study, headache was more common in epileptic patients. TTH was the most represented type of headache in patients with epilepsy. Headache occurred in patients with epilepsy most frequently during the post-ictal period.

The efficacy of ultrasound-guided multifidus cervicis plane block versus greater occipital nerve block for cervicogenic headache

IntroductionTraditionally, non-invasive and invasive techniques were used for the treatment of cervicogenic headache (CH). Greater occipital nerve block is the most frequent peripheral nerve block invasive technique used for the management of cervicogenic headache. The purpose of this prospective, double-blinded study was to compare the efficacy of two different techniques: multifidus cervicis plane block and greater occipital nerve block in the treatment of refractory cervicogenic headache by using ultrasound.MethodsSixty patients with cervicogenic headache were recruited and diagnosed according to the ICHD-III beta version. The patients were divided into two groups, one group was for greater occipital nerve block and the other group was for multifidus cervicis plane block with ultrasound-guided.ResultsVisual analog scale (VAS) was 2.09% in the multifidus cervicis plane block (MCPB) group and was 2.22% in the greater occipital nerve block (GONB) group with a median reduction of − 4.33 and − 3.048, respectively, at 2-week visits with a statistically significant difference better in the MCPB group (P < 0.001). At 4 weeks visits, VAS scale was better in the MCPB group than in the GONB group (3.79 and 4.44, respectively) with a median reduction in VAS scale (− 3.27 and − 3.095, respectively) and statistically significant differences between both groups (P = 0.020).ConclusionBoth the ultrasound-guided multifidus cervicis plane block and greater occipital nerve block are effective as intervention techniques in the treatment of refractory cervicogenic headache. These techniques are simple, safe, more reliable with less side effects, and often reduce the requirements of analgesic drugs.

The role of obesity and vitamin D deficiency in primary headaches in childhood.

This study evaluates the role of obesity, overweight and vitamin D deficiency in primary headaches in childhood. This retrospective observational study included pediatric patients aged 5-17years admitted to the pediatric neurology clinic with headaches between January 2015 and August 2018 and diagnosed with primary headache based on ICHD III-beta criteria. The control group consisted of healthy children without headache admitted to the pediatric outpatient clinic for check-ups before engaging in athletic or school activities. The control and patient groups were at the same risk of low 25(OH)D3 levels. The study population was divided into three groups-patients with migraine (group A), patients with tension-type headache (TTH) (group B) and the control group (group C). Participants' demographic data, medical histories, physical examination findings and laboratory results were retrieved retrospectively from the patient charts. BMI was significantly higher in patients with primary headache, the risk of primary headache increasing in patients with a BMI in excess of 25. Comparison of the patients with primary headache and the control group revealed lower 25(OH)D levels in the primary headache group, although the difference was not statistically significant. Girls with primary headache had significantly lower 25(OH)D levels than boys. A relationship may be present between overweight, obesity and primary headache, while female gender may be suggested as a negative factor for primary headache. Patients should be advised to lose weight if BMI indicates overweight or obesity.

Diagnostic and classification tools for chronic headache disorders: A systematic review.

Background or aimDespite guidelines and the International Classification of Headache Disorders (ICHD-III beta) criteria, the diagnosis of common chronic headache disorders can be challenging for non-expert clinicians. The aim of the review was to identify headache classification tools that could be used by a non-expert clinician to classify common chronic disorders in primary care.MethodsWe conducted a systematic literature review of studies validating diagnostic and classification headache tools published between Jan 1988 and June 2016 from key databases: MEDLINE, ASSIA, Embase, Web of Knowledge and PsycINFO. Quality assessment was assessed using items of the Quality of Diagnostic Accuracy Studies (QUADAS-2).ResultsThe search identified 38 papers reporting the validation of 30 tools designed to diagnose, classify or screen for headache disorders; nine for multiple headache types, and 21 for one headache type only. We did not identify a tool validated in a primary care that can be used by a non-expert clinician to classify common chronic headache disorders and screen for primary headaches other than migraine and tension-type headache in primary care.ConclusionsDespite the availability of many headache classification tools we propose the need for a tool that could support primary care clinicians in diagnosing and managing chronic headache disorders within primary care, and allow more targeted referral to headache specialists.

Headache secondary to cervical artery dissections: practice pointers.

Cervical artery dissections may present with mild and misleading symptoms such as a headache or cervical pain. In the absence of early diagnosis and therapy, such patients may have a high risk of cerebrovascular events. In order to refine evaluation of cervical artery dissections, we report the experience of a single center, focusing on clinical findings (e.g., headache and pain-related features at onset). From 2012 to 2017, 49 patients with cervical arteries dissections were admitted to our institution; 28 out of 49 patients (57%) presented with a headache or cervical pain, which were evaluated according to the International Classification of Headache Disorders (ICHD-III beta). Item C3a of ICHD-III beta ("pain is severe and continuous for days or longer") was present in all patients symptomatic for a headache. Another common characteristic was the recent onset, with an average (± SD) timing from the onset of a headache to the first neurologic evaluation of 3 (± 2) days (range 1-5). A refined clinical evaluation of patients presenting with a headache at the Emergency Department could improve the early detection and management of patients with cervical artery dissections, in particular when presenting without other associated neurological symptoms.

Assessment of Migraine Disability Using the Migraine Disability Assessment Questionnaire in Young Nigerians

Background and purpose: Migraine is a common debilitating condition with variable prevalence in young Nigerians with significant deterioration in normal daily functioning and in the quality of life. Few data exist on the disability of migraine in Nigeria. The aim of this study was to measure the headache related disability of patients with migraine using the MIDAS among young Nigerians. Methods: This was a cross sectional study conducted in Enugu South East Nigeria. The questionnaire was designed to assess headache profiles according to ICHD-III beta and disability using the Migraine Disability Assessment Questionnaire. Results: About 40.6% of migraineurs were concerned about headache attacks and 39.1% consulted a doctor because of migraine. Most students were affected due to reduced effectiveness at school and number of days missed from housework—18.8% and 20.3% respectively. Overall, 47.8% had at least one day affected by headache in the last three months. The mean number of days disabled by headache was 14.3 days. The mean headache frequency was 5.7 days and the mean pain intensity was 4.2. About 27.5% of the migraineurs had moderate to severe disability due to migraine. There were no significant differences between males and females. Conclusion: Most with migraine experienced reduction in effectiveness at school and number of days missed from housework. Overall, 47.8% had at least one day affected by headache with an average of 14.3 days disabled by headache and 27.5% of the migraineurs had moderate to severe disability due to migraine.

Giant Virchow- Robin spaces may play a role at headache attributed to hypoxia and/or hypercapnia

According to International Classification of Headache Disorders (ICHD-III Beta version) headache attributed to hypoxia and/or hypercapnia is classified under the 4 title: 10.1.1 High altitude headache, 10.1.2 Airplane travel associated headache, 10.1.3 Diving headache and 10.1.4 Sleep apnoea headache. Headache associated with airplane travel is encountered infrequently in our clinical practice and firstly reported in 2004 as a case in the literature. The pathophysiology of headache associated with airplane travel is not yet clear. We presented this case in the aspect of the patient having both airplane travel and high altitude headaches and seen giant Virchow-Robin spaces in cranial MRI and disappearence of pain with a preventive treatment.

Clinical characteristics and overuse patterns of medication overuse headache: Retrospective case-series study

According to Eurolight project’s results, frequency of medication overuse headache in Lithuania is similar to other European countries. However, data on the characteristics of the disorder is lacking. ObjectiveThe aim was to analyze clinical characteristics and overuse patterns of patients with medication overuse headache. Patients and methodsRetrospective study was conducted in out-patient department of university hospital. 57.0% of the patients were from Vilnius and 43.0% from other cities and districts of Lithuania. Medical histories of patients consulted by headache specialist on private (86.2%) or public basis from 2008 to 2015 were analyzed. Diagnoses prior to 2013 were revised according to ICHD-III beta criteria. Overuse patterns were calculated only for patients with migraine. Results87 patients (90.8% female) with mean age of 43.78 years were included in the study and 67 of them had primary diagnosis of migraine. Mean duration of overuse was 4.00 years. Mean headache frequency was 24.11days per month. Triptans more often were overused by younger patients (p=0.049). 41.8% of migraine patients with MOH overused triptans, 38.8% simple, and 38.8% combination-analgesics. 1 (1.5%) patient overused ergotamines, 7.5% were poly-overusers and no pure opioid overuse was found. Among patients with migraine most common overused medications were sumatriptan (38.8%), caffeine containing combination-analgesics (35.8%) and ibuprofen (20.9%). ConclusionTriptans were most commonly overused drugs among patients with migraine. Fairly frequent overuse of combination-analgesics for migraine should raise concern.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.

Primary Headache Disorders Part I- Migraine and the Trigeminal Autonomic Cephalalgias

In Primary Headache Disorders, Part 1, we discuss three of the primary headache disorders using the headache definitions from ICHD-III (Beta): Migraine, with and without aura; its pathophysiology and treatment are discussed. We then discuss the Trigeminal Autonomic Cephalalgias (TACs), including Cluster Headache and Hemicrania Continua, two more primary headache disorders, as well as the other TAC Headaches. We discuss pathophysiology as well as diagnosis, treatment, and pharmacotherapeutic management of these headache diatheses.

Occipital transcranial magnetic stimulation discriminates transient neurological symptoms of vascular origin from migraine aura without headache

The diagnosis of transient neurological attacks (TNA) relies on medical history. Transient ischemic attack is often considered until proven otherwise, because of lack of objective paraclinical tools that can help discriminate TIA from differential diagnoses such as migraine aura. This may lead to needless and potentially harmful stroke secondary prevention in many cases. This study aimed at determining the yield of occipital transcranial magnetic stimulation (oTMS) in discriminating TNA of vascular origin from migraine aura without headache (MAWH). Ten patients with acute TNA of vascular origin and ten patients with migraine aura without headache (MAWH), without prior history of migrainous headache, were prospectively included. TNA of vascular origin were considered for individuals presenting unilateral focal symptoms with full resolution within 24hours and positive diffusion weighted imaging (DWI+). For individuals with MAWH, diagnostic criteria were either ICHD-III beta or Fischer criteria for a first episode of MAWH. All participants underwent one session of oTMS. Induction and threshold of phosphene induction were recorded. In TNA of vascular origin, MRI disclosed cortical lesions in nine and one sub-cortical lesion. Phosphenes were induced in 9/10 subjects with MAWH with a mean threshold of 66% of the maximal intensity, whereas oTMS induced phosphenes in only one subject with TNA of vascular origin at a threshold of 85%. In this pilot study, oTMS was found to be an effective tool to discriminate between MAWH and transient neurological symptoms of vascular origin.

Cyclic Vomiting Syndrome in Adults and Children: A Hypothesis.

To see how patients' clinical descriptions compare to the third classification of International Classification of Headache Disorders (ICHD-III beta). CVS is an episodic syndrome associated with migraine. It is a rare disorder of childhood and adulthood. New criteria are proposed in the third classification of International Classification of Headache Disorders. This study describes children and adults' CVS characteristics at a French tertiary-care center, according to the ICHD-II and ICHD-III beta criteria. Clinical features, and results of paraclinical tests were characterized. Fifteen patients were included: 8 adults, 2 children, and 5 adolescents. Familial history of migraine or CVS was respectively noticed in 12 and 4 patients. The duration of premonitory, emetic, and postdromal phases was evaluated from hours to days. Some symptoms described in theses phases are also described in migrainous population, with a comparable frequency. Cranial or systemic autonomic symptoms were respectively reported in 47% and 93%. Nine patients described a circadian periodicity, and six patients described a circannual periodicity. The predictable periodicity was from 1 week to 12 months. A brain perfusion SPECT showed an increased hypothalamic perfusion during emetic phase in one patient. CVS is a rare episodic syndrome associated with migraine. Some clinical features and paraclincal tests suggest a chronobiological disease.

Impulsivity among migraine patients: Study in a series of 155 cases

IntroductionImpulsivity is a psychological phenomenon that has not been extensively studied in headache patients. We aim to assess the presence of impulsivity in patients with chronic migraine (CM) and medication overuse (MO). PatientsAll patients examined in an outpatient headache clinic between January 2013 and March 2014 were included. Episodic migraine, CM, and MO were diagnosed according to ICHD-III beta criteria. We prospectively gathered demographic and clinical characteristics. Mood disorders were evaluated using the Hospital Anxiety and Depression Scale (HADS) and impulsiveness was assessed with the Plutchik Impulsivity Scale. ResultsA total of 155 patients were included (22 men, 133 women). The mean age (SD) was 38.2 (11.7) years (range, 18-70); 104 patients (67.1%) presented CM and, among them, 74 (71.1%) had MO. Of the patient total, 28.4% met criteria for anxiety, 7.1% for depression and 16.1% for impulsivity. The CM group showed higher scores for HADS-anxiety (8.5 [SD 4.5] vs 6.4 [SD 3.6], P=.003) and HADS-depression (4.4 [4.3] vs 1.9 [2.3], P<.001). Among CM cases only, scores for HADS-anxiety (9.3 [4.4] vs 6.8 [4.3], P=.01) and HADS-Depression (5.1 [4.6] vs 2.7 [2.9], P=.002) were higher in patients who also had MO. We found no associations between Plutchik scale scores or presence of impulsivity with either CM or MO. ConclusionImpulsivity is a common trait in our population of migraine patients, but unlike mood disorders, it is not correlated with either CM or MO.

Repetitive transcranial magnetic stimulation versus botulinum toxin injection in chronic migraine prophylaxis: a pilot randomized trial.

BackgroundChronic migraine is a prevalent disabling disease, with major health-related burden and poor quality of life. Long-term use of preventive medications carries risk of side effects.ObjectivesThe aim of this study was to compare repetitive transcranial magnetic stimulation (rTMS) to botulinum toxin-A (BTX-A) injection as preventive therapies for chronic migraine.MethodsA pilot, randomized study was conducted on a small-scale sample of 29 Egyptian patients with chronic migraine, recruited from Kasr Al-Aini teaching hospital outpatient clinic and diagnosed according to ICHD-III (beta version). Patients were randomly assigned into two groups; 15 patients received BTX-A injection following the Phase III Research Evaluating Migraine Prophylaxis Therapy injection paradigm and 14 patients were subjected to 12 rTMS sessions delivered at high frequency (10 Hz) over the left motor cortex (MC, M1). All the patients were requested to have their 1-month headache calendar, and they were subjected to a baseline 25-item (beta version) Henry Ford Hospital Headache Disability Inventory (HDI), Headache Impact Test (HIT-6), and visual analogue scale assessment of headache intensity. The primary efficacy measures were headache frequency and severity; secondary measures were 25-item HDI, HIT-6, and number of acute medications. Follow-up visits were scheduled at weeks 4, 6, 8, 10, and 12 after baseline visit.ResultsA reduction in all outcome measures was achieved in both the groups. However, this improvement was more sustained in the BTX-A group, and both the therapies were well tolerated.ConclusionBTX-A injection and rTMS have favorable efficacy and safety profiles in chronic migraineurs. rTMS is of comparable efficacy to BTX-A injection in chronic migraine therapy, but with less sustained effect.

Post procedure headache in patients treated for neurovascular arteriovenous malformations and aneurysms using endovascular therapy.

BackgroundThough endovascular therapy (EVT) is increasingly applied in the treatment of intracranial vascular lesions, little is known about the effect of EVT on post-procedure headache. We aimed to investigate the prevalence of headache in patients who have undergone EVT for cerebral arteriovenous malformations (AVMs) and aneurysms.MethodsA total of 324 patients underwent EVT treatment for aneurysms and AVMs at the Danish National Hospital from January 2012 to December 2014. We applied strict exclusion criteria in order to minimize the effect of other factors on headache occurrence, e.g., craniotomy. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire. Headaches were classified according to ICHD-III beta criteria.ResultsThe 59 patients underwent treatment of aneurysms (n = 43), cranial dural fistulas (n = 11), and AVMs (n = 5). There was a significant increase in overall headache (p = 0.017) and tension-type headache (TTH) (p = 0.012) within the first 3 months after EVT compared to 1 month before EVT. However, at interview time (median 2.5 years post-EVT), the increase in overall headache, migraine, and tension-type headache was not statistically significant. A minority of patients experienced headaches for the first time within 3 months of their EVT (migraine 4, TTH 10). At interview time, 50 % of these new headaches still persisted.ConclusionOur results suggest a temporary increase in headache in the first 3 months after EVT, which normalizes over time. Clinicians may use this knowledge to better inform their patients of functional outcomes after their EVT procedure.

Effects of onabotulinumtoxinA treatment on efficacy, depression, anxiety, and disability in Turkish patients with chronic migraine.

Chronic migraine causes a serious labour loss and disability in the society and increases the risk of depression and anxiety by negatively affecting the quality of life. The purpose of this study was to investigate the effects of onabotulinumtoxinA (BoNT-A) treatment on efficacy before and after treatment in our cases with chronic migraine as well as on depression, anxiety and disability caused by migraine. According to the International Headache Classification (ICHD-III beta version), 60 adult patients who were diagnosed with chronic migraine were included in the study. A total of 155 IU BoNT-A treatment from 31 regions was administered in accordance with the protocol of PREEMPT study. Information about the characteristics of patients' headaches, background and family history, drugs they used was recorded. At the baseline and in the first and third month after the BoNT-A injection, VAS scores, the number of both headache days and attacks, the headache duration, the frequency of application to emergency services and the intake of both analgesics and triptans during attacks were evaluated. MIDAS, BDI and BAI were evaluated at the baseline and in the third month after the BoNT-A injection. BoNT-A injection provided a significant decrease in the number of days and severity of headaches, MIDAS disability scores and psychiatric complaints in cases with chronic migraine who did not respond to prophylactic treatments in the third month of the treatment.

Scent of aura? Clinical features of olfactory hallucinations during a migraine attack (OHM).

Introduction Olfactory hallucination during a migraine attack (OHM) is a rare phenomenon. At present, it is not considered a manifestation of migraine aura. Material and methods The clinical features of OHM were collected in 11 patients. Results Of the 11 patients, 10 had migraine without aura and one migraine with aura associated with OHM. Mean age at onset of headache and at appearance of OHM were respectively 17.8 and 32.3 years. Migraine average frequency was 3.9 attacks/month, 19% of them being associated with OHM. The temporal pattern of OHM maintained the same characteristics in the different attacks. OHM onset was described as sudden ( n = 5), gradual ( n = 3), initially sudden and then gradual ( n = 2), or developing in a few seconds ( n = 1). In most of the cases ( n = 8) OHM lasted from 3 to 10 minutes; it persisted during the pain phase (2-24 hours) in only three patients. The type of the perceived smell was invariably constant in nine patients. Conclusion OHM features fulfilled the ICHD-III beta criteria for typical aura.

Does monosodium glutamate really cause headache? : a systematic review of human studies.

Although monosodium glutamate (MSG) is classified as a causative substance of headache in the International Classification of Headache Disorders 3rd edition (ICHD-III beta), there is no literature in which causal relationship between MSG and headache was comprehensively reviewed. We performed systematic review of human studies which include the incidence of headache after an oral administration of MSG. An analysis was made by separating the human studies with MSG administration with or without food, because of the significant difference of kinetics of glutamate between those conditions (Am J Clin Nutr 37:194–200, 1983; J Nutr 130:1002S–1004S, 2000) and there are some papers which report the difference of the manifestation of symptoms after MSG ingestion with or without food (Food Chem Toxicol 31:1019–1035, 1993; J Nutr 125:2891S-2906S, 1995). Of five papers including six studies with food, none showed a significant difference in the incidence of headache except for the female group in one study. Of five papers including seven studies without food, four studies showed a significant difference. Many of the studies involved administration of MSG in solution at high concentrations (>2 %). Since the distinctive MSG is readily identified at such concentrations, these studies were thought not to be properly blinded. Because of the absence of proper blinding, and the inconsistency of the findings, we conclude that further studies are required to evaluate whether or not a causal relationship exists between MSG ingestion and headache.

P066. Migraine with aura in the locker room: 4 case reports.

We describe four cases of young men 19, 21, 23 and 25 years old with recurrent episodes of migraine with aura occurring shortly after the end of physical activities (football match, swimming, gym training, physical education activities at school), when they were in the locker room. Since these types of symptoms could mime some important pathologies in approximately 10% of these headaches, it is mandatory, in this kind of patient, to exclude a form of secondary headache [1]. No other subtypes of headache, or head trauma were reported by the patients. It is well known that physical activity can lead to an aggravation of the intensity of the headache, but the pathophysiological relationship between exertion and aura is unknown and still debated. There are anecdotal reports of episodes of migraine preceded by head trauma and visual symptoms (with a past history of non-sports-related migraine) [2, 3], migraine prodrome symptoms after unusually strenuous running with no following head pain [4] or recurrent attacks of hemiplegic migraine induced only by exertion [5]. According to the present version of the International Classification of Headache Disorders, (ICHD-III beta), the headache subtype presented by the four patients fulfilled criteria for “migraine with aura” (ICHD-III beta code: 1.2) and for “primary exertional headache” (pulsating headache, lasting from 5 minutes to 48 hours, brought on by and occurring only during or after physical exertion; ICHD-III beta code: 4.2) [6]. To date, in the IHS Classification (ICHD-III beta), there is no mention of sport/exercise-induced migraine with aura episodes as primary headache, and there is the need of a double diagnosis, although there are anecdotal reports of attacks of migraine with aura shortly after sports. Written informed consent to publish was obtained from the patient(s).