6. DISCUSIÓN
6.2 Metodologías que Facilitan el Aprendizaje
Headache as presenting symptom of neurosarcoidosis
C. Lisotto1, L. Toma2, E. Mampreso3, G. Zanchin4
1Headache Centre, Department of Neurology, Pordenone, Italy, 2
Department of Neurology, Ferrara, Italy,3Headache Centre, Department of Neurology, Piove di Sacco, Italy4Headache Centre, Department of Neurosciences, Padua, Italy
Correspondence:C. Lisotto ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O46
ObjectivesSarcoidosis is a multi-organ granulomatous disease of un-
caseating granulomata in the absence of a defined infective or toxic trigger. Sarcoidosis involving the nervous system (the so-called neu- rosarcoidosis) is infrequent and headache may be the presenting symptom [1]. The diagnosis of headache attributed to neurosarcoido- sis is challenging and requires particular attention from headache specialists.
Materials and methodsThe medical records of patients admitted in
the past 15 years to our Department of Neurology for recent-onset headache with a final diagnosis of neurosarcoidosis were retrospect- ively reviewed. The diagnosis of headache attributed to neurosarcoi- dosis was made according to the International Classification of Headache Disorders, 3rdedition (ICHD-3) [2].
ResultsFour patients, two males and two females, mean age at ob-
servation 40 years (range 31-49), were included in our review. In all the subjects headache was the onset symptom, occurred acutely or subacutely. Two patients (one male and one female) reported head- ache as the only symptom; the pain was diffuse, severe, non- pulsating, with daily or nearly-daily occurrence, mimicking tension- type headache. In the remaining two cases the headache was unilat- eral, periorbital, intense and sharp, associated with third cranial nerve paralysis, resembling Tolosa-Hunt syndrome. All the patients under- went brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination. MRI showed non-enhancing periventricular white matter lesions, enhancement of the leptomeninges with predi- lection for suprasellar and frontal basal meninges and involvement of cavernous sinus ipsilateral to pain in the patients with third cranial nerve palsy. CSF examination revealed lymphocytic pleocytosis and elevated protein. All the patients were treated with oral prednisone, starting from 1 mg/kg daily, with rather rapid clinical improvement. In three patients chest radiography was abnormal, showing bihilar lymphadenopathy; on bronchoalveolar lavage CD4:CD8 lymphocyte ratio was more than 3:5:1.
Discussion The headache in our patients was clinically similar to
tension-type headache in two cases and to Tolosa-Hunt syndrome in the other two. ICHD-3 criteria for headache attributed to neurosarcoi- dosis imply that the clinical features of this secondary headache have a wide range of presentations. As for differential diagnosis versus Tolosa-Hunt syndrome, our patients obtained a remission within 10- 14 days, a longer time than 72 hours for pain and paresis resolution, as required by ICHD-3 diagnostic criteria for this syndrome.
ConclusionsHeadache may rarely herald the diagnosis of neurosar-
coidosis. New case series continue to broaden the phenotype of neu- rosarcoidosis, reinforcing the need for a systematic approach to diagnosis and management.
References
1. Radwan W, Lucke-Wold B, Robadi IA, Gyure K, Roberts T, Bhatia S. Neuro- sarcoidosis: unusual presentations and consideration for diagnosis and management. Postgrad Med J 2017;93:401-5.
2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1-211.
3. Ibitoye RT, Wilkins A, Scolding NJ. Neurosarcoidosis: a clinical approach to diagnosis and management. J Neurol 2017;264:1023-8.
O47
Association of Tanacethum Parthenium, 5 - hydroxy tryptophan and magnesium ( Aurastop) versus Mg tablet impact on aura phenomena and its evolution : an observational study
Lidia Savi ([email protected]) Headache Center LBS, Lugano, Switzerland
The Journal of Headache and Pain2018,19(Suppl 1):O47
BACKGROUND:
A new phytotherapic combination of Tanacethum Parthenium (150 mg), 5 - hydroxy tryptophan (20 mg) and magnesium (185 mg) (Aurastop ®) is now available for migraneous patients. The three com- ponents act on the four main mechanisms involved in the patho- physiology of migraine with aura: cortical Spreading Depression, sensitization of trigeminal vascular system, central sensitization and
activation of “migraine generator” at the brainstem’s level. Since many years Magnesium is well known to interact with the aura phe- nomena and migraine itself.With this study we want to compare the efficacy on the aura phenomenon and its disability of the combin- ation of Tanacethum Parthenium, 5 - hydroxy tryptophan and mag- nesium versus magnesium alone, when taken at the beginning of the aura.
MATERIALS AND METHODS:We selected from the Headache Center
LBS of Lugano (CH) a population of 60 patients aged from 18 to 60 years (mean 32 years ), 31 women and 29 men, suffering from mi- graine with aura, not assuming migraine preventive therapy. They have to refer of an aura with a duration of at least 20 minutes to be included. We gave to the patients a form where they have to de- scribe the aura features of the 4 aura episodes following the adminis- tration of 1 tablet of Aurastop at the beginning of the aura and 1 tablet at the beginning of the headache ( if present ) in the first 2 aura and 1 tablet of magnsium 2,25 gr in the same modality at the 3° and 4° episodes of aura. Patients were evaluated for duration and disability of the aura, need and response to their habitual analgesic drug
RESULTS:A reduction in duration greater than 50% in 54 patients
versus 6 and of disability >50% in 52 patients against 8 were ob- served respectively after taking Aurastop or Magnesium alone .Furthermore 30% of the aurastop group did not have to take pain reliever after the aura as the headache intensity was more tolerable, only 5% of the magnesium group. We also noted a marked improve- ment in the benefit of the usual pain killer in 30 patients that used aurastop .
CONCLUSIONS: By the fact that this combination pass very quickly
the ematoencephalic barrier Aurastop has been shown to have a quick impact on the evolution of aura reducing the duration and dis- ability of symptoms than the magnesium alone.
O48
Hemicrania continua-like headache revealed a subacute internal carotid artery dissection in patient with unrecognized connective tissue disorder
Silvia Ricci, Gaetano Salomone, Francesca Rossi, Alberto Polo Neurology department- Mater Salutis Hospital- ULSS Scaligera, Verona, Italy
Correspondence:Silvia Ricci ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O48
Background It is widely accepted that internal carotid (ICA) dissec-
tion could simulate a cluster headache attack. Conversely, clinical fea- tures resembling hemicrania continua (HC) occurring after cervical artery dissection have rarely been reported in the literature. We de- scribed the case of a patient who developed typical HC-like head- ache after carotid artery dissection.
Case-presentationOn February 2018, a 43 year-old man presented
to our emergency department because of the onset, four days be- fore, of severe continuos right trigeminoautonomic cephalgia with Horner’s syndrome and elevated blood pressure. His familiar and per- sonal medical history were unremarkable except for the cluster head- ache involving the left side few years ago. Neurological examination revealed acute headache fulfilling all IHS criteria for HC (apart from the time criterion) unresponsive to habitual medication for migraine associated with right tongue deviation. The routine laboratory test, CT brain scan and ultrasound examination of neck vessels were nor- mal. Indomethacin 200mg i.v improved the headache but we de- cided to admit the patient to our department because of the continuity of pain. Over the next two days there was complete relief with oral indomethacin 200 mg per day and an improvement of the Horner’s syndrome, nevertheless the patient developed progressive dysphagia, dysphonia, and weak left-turning of the head suggesting 9th through 12th cranial nerve palsy. He underwent brain magnetic resonance imaging (MRI) with MR angiography of head and neck that showed a right ICA dissection with extension into the petrous segment and intramural hematoma causing mass effect upon the in- ternal jugular vein; no hyperintensity was found in DWI sequences .
The patient was started on acetylsalicylic acid 100 mg daily. An ex- tended CT angiography showed extensive luminal irregularities in the main renal arteries, with aneurysm formations and irregularities of iliac vessels. Due to his new diagnosis of arterial hypertension and the other findings we assumed the possibility of a connective tissue disorder and we performed a genetic counseling with test for Ehlers- Danlos syndrome variants. So far, the results received were negative but other test are still ongoing and fibromuscolar dysplasia (FMD) is strongly considered.
ConclusionICA dissection may result in an HC-like headache syn-
drome. The history of cluster headache, a specific response to indo- methacin and the absence of neurological focal signs does not rule out dissection as underlying pathology. Screening for connective tis- sue disorder and extracranial manifestations of FMD should be con- sidered even if the brain vasculature is normal.
Consent for publication: Informed consent was obtained from patient for publication.
References
1- Ashkenazi A, Abbas MA, Sharma DK, et al. Hemicrania continua-like head- ache associated with internal carotid artery dissection may respond to indomethacin. Headache 2007; 47: 127–130.
2- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33: 629–808.
3- O’Connor S, Poria N and Gornik H. Fibromuscular dysplasia: An update for the headache clinician. Headache 2015; 55: 748–755
O49
Neurophysiological correlates of clinical improvement after Greater Occipital Nerve (GON) Block in Chronic Migraine: relevance for chronic migraine pathophysiology
Alessandro Viganò1,2, Maria Claudia Torrieri3, Massimiliano Toscano1,4, Francesca Puledda5, Barbara Petolicchio1, Tullia Sasso D’Elia2, Angela Verzina6, Sonia Ruggiero1, Marta Altieri1, Edoardo Vicenzini1, Jean Schoenen7, Vittorio Di Piero1,8
1Headache Centre & Neurocritical Care Unit. Department of Human Neurosciences, Sapienza–University of Rome, Rome, Italy;2Molecular and Cellular Networks Lab. Department of Anatomy, Histology, Forensic medicine and Orthopaedics, Sapienza–University of Rome, Rome, Italy; 3Rita Levi Montalcini Department of Neuroscience, Città della Salute e della Scienza, Turin, Italy;4Department of Neurology–Fatebenefratelli Hospital–Rome, Italy;5Headache Group, Department of Basic and Clinical Neuroscience, King's College London, and NIHR-Wellcome Trust King's Clinical Research Facility, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK;6Department of Neurology, University of Perugia, Perugia, Italy;7Headache Research Unit. Department of Neurology, University of Liège, Citadelle Hospital, Liège, Belgium;8University Consortium for Adaptive Disorders and Head pain– UCADH, Pavia, Italy
Correspondence:Alessandro Viganò ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O49
Background:
Therapeutic management of Chronic Migraine (CM), often associated with Medication Overuse Headache (MOH), is chiefly empirical, as no biomarker predicting or correlating with clinical efficacy is available to address therapeutic choices. The present study searched for neurophysiological correlates of Greater Occipital Nerve Block (GON- B) effects in CM.
Results:
We recruited 17 CM women, of whom 12 with MOH, and 19 female healthy volunteers (HV). Patients had no preventive treatment since at least 3 months. After a 30-day baseline, they received a bilateral betamethasone-lidocaine GON-B of which the therapeutic effect was assessed 1 month later. Habituation of visual evoked potentials (VEP) and intensity dependence of auditory evoked potentials (IDAP) were recorded before and 1 week after the GON-B. At baseline, CM pa- tients had normal VEP habituation, but a steeper IDAP value than HV
(p=0.009), suggestive of a lower serotonergic tone. GON-B signifi- cantly reduced the number of total headache days per month (-34.9%; p=0.003). Eight out 17CM patients reversed to episodic mi- graine and medication overuse resolved in 11 out of 12 patients. One week after the GON-B VEP habituation tended to be reduced (p=0.09) and became inferior to that of HV (p=0.03) like in episodic migraine, while the IDAP slope significantly flattened (p=0.008). GON-B-induced reduction in headache days positively correlated with IDAP slope decrease (rho=0.51, p=0.03).
Conclusions:
GON-B may be effective in the treatment of CM, with or without MOH. The pre-treatment IDAP increase is compatible with a weak central serotonergic tone, which is strengthened after GON-B, sug- gesting that serotonergic mechanisms may play a role in CM and its reversion to episodic migraine. Since the degree of posttreatment IDAP decrease is correlated with clinical improvement, IDAP might be potentially useful as an early predictor of GON-B efficacy.
O50
Short-Term Psychodynamic Psychotherapy versus
OnabotulinumtoxinA as preventive therapy in Chronic Migraine: a real world study
M. Alessiani1, B. Petolicchio1,2, A. Viganò1, R. Di Giambattista3, M. Altieri1, E. Gilliéron3,V. Di Piero1,2
1
Department of Human Neuroscience, Sapienza University of Rome, 00185 - Rome, Italy;2“Enzo Borzomati”Pain Medicine Unit–University Hospital Policlinico Umberto I, 00161-Rome, Italy;3Istituto Europeo di Psicoterapia Psicoanalitica (IREP), 00187 - Rome, Italy
Correspondence:B. Petolicchio ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O50
Background
The preventive treatment for chronic migraine (CM) is difficult and often complicated by analgesics overuse and poor compliance. Previously, we showed that short-term psychodynamic psychother- apy (STPP), alone or with pharmacological therapies, improved the clinical outcome, the analgesics overuse withdrawal and reduces long-term relapse rate of CM [1,2].
Since OnabotulinumtoxinA (BoNT-A) is one of the most effective op- tions for CM [3,4], we investigated the effect of STPP versus BoNT-A as preventive treatment in a real world CM population, with and without medication overuse headache (MOH).
Results
We consecutively recruited, CM patients who underwent STPP or BoNT-A treatment according to clinical judgment of the attending headache specialist.
STPP consists of 4 exploratory meetings, followed by 8 meetings of freudian-inspired psychotherapy [5]. At the end of the STPP (90 days), if appropriate, a pharmacological therapy was added. BoNT-A was administered according to PREEMPT protocol [3,4]. No additional pharmacological therapies were allowed.
At 90, 180 and 270 days, evaluations were made on the treatment ef- fectiveness by an investigator blinded of the assigned treatment. Ninthy-eight patients with CM (64% with MOH) were treated with STPP and 54 (59% with MOH) with BoNT-A. At baseline, BoNT-A pa- tients had a significant (p <0.001) higher attack rates, more failed preventive therapies, more years of illness and chronicity, and were older.
The first appropriate follow-up to evaluate STPP efficacy is at 90d whereas for BoNT-A is after 180d. At these times, the episodic pat- tern remission rate was 53% (52/98) for STPP and 33% (18/54) for BoNT-A treatment. A pharmacological therapy was added in 27 pa- tients of the STPP group.
With respect to baseline, at 270d STPP and BoNT-A groups showed a significant reduction of headache days (-14,9±0,3 vs –10,8±3,3) and analgesics intake (-12,2±10,3 vs–11,6±13,4, pills/month), respectively (Figs.1 and 2). In both groups, a high headache frequency at baseline (>25 days/month) was a significant negative prognostic factor for re- mission to an episodic pattern (p<0.05). Dropout rate was lower in BoNT-A group than STPP one (11% vs. 29%, p<0.05).
Conclusion
In the real world, both treatments with STPP, alone or combined with drug therapy, and BoNT-A were effective for treating patients with CM, with or without MOH. Treatment with BoNT-A is the physician preferred treatment for patients with more severe CM. Furthermore, the effectiveness of the STPP occurs earlier than BoNT-A but with a higher dropout rate.
Ethics approval
The study was approved by Policlinico Umberto I Ethical Board N° 4604.
Reference
1. Altieri M, Di Giambattista R, Di Clemente L, Fagiolo D, Tarolla E, Mercurio A, Vicentini E, Tarsitani L, Lenzi GL, Biondi M, Di Piero V. Combined pharmacological and short term psychotherapy for probabile medication overuse headache: a pilot study. Cephalalgia 2009;29(3): 29-39
2. Petolicchio B, Viganò A, Di Giambattista R, Squitieri M, Zanoletti N, Tortora D’Amato P, Spensierato A, Baldassarre M, Di Piero V. Short-term psychodynamic psychotherapy versus pharmacological treatment in chronic headache: an observational study. J Headache Pain 2013; 14 (S13-S41): 31
3. Aurora SK, Dodick DW, Turkel CC, et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, random- ized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010;30(7):793–803. 57.
4. Diener HC, Dodick DW, Aurora SK, et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, random- ized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010;30(7):804–814
5. Gilliéron E. Setting and motivation in brief psychotherapy. PsychotherPsychosom 1987; 47:105–12
O51
Resting-state between-networks functional connectivity is abnormal in chronic migraine patients
Gianluca Coppola1*, Barbara Petolicchio2, Antonio Di Renzo1, Emanuele Tinelli2, Cherubino Di Lorenzo3, Vincenzo Parisi1, Mariano Serrao4, Valentina Calistri2, Stefano Tardioli2, Gaia Cartocci2, Francesca Caramia2, Vittorio Di Piero2, and Francesco Pierelli4,5
1
G.B. Bietti Foundation IRCCS, Research Unit of Neurophysiology of Vision and Neurophthalmology, Rome, Italy;2Sapienza University of Rome, Department of Neurology and Psychiatry, Rome, Italy;3Don Carlo Gnocchi Onlus Foundation, Milan, Italy;4Sapienza University of Rome Polo Pontino, Department of Medico-Surgical Sciences and Biotechnologies, Latina, Italy;5IRCCS-Neuromed, Pozzilli (IS), Italy Correspondence:Gianluca Coppola ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O51
Background
The functional connectivity (FC) between default mode network (DMN), the executive control network (ECN), and the dorsal/ventral attention systems was found to be abnormal using resting state functional magnetic resonance imaging (RS-fMRI) in episodic mi- graine depending on migraine phase (ictal/interictal) and the fre- quency of the attacks. Here, we investigated RS between networks connectivity using independent component analysis (ICA) in chronic migraine (CM) patients.
Materials and methods
Twenty patients with untreated de-novo chronic migraine (CM) underwent 3T MRI scans and were compared to a group of 20 healthy controls (HC). We used MRI to collect RS data among three selected resting state networks, identified using group ICA: the DMN, the ECN, and the dorsal attention system (DAS).
Results
Compared to HCs, CM patients showed significant reduced functional connectivity between the DMN and the ECN. Moreover, in patients, the DAS showed significant stronger FC with the DMN and weaker FC with the ECN. The severity of headache attacks was correlated positively with the strength of DAS connectivity, and negatively with the strength of ECN connectivity.
Conclusions
These results suggest that the brain of CM patients is characterized by a large-scale reorganization at the level of the functional net- works. Our data further suggest that the severity of migraine pain is associated with proportional inverse pattern of frontal executive and dorsal attentive networks connectivity.
O52
New daily persistent headache in a pediatric cohort
Laura Papetti, Barbara Battan, Romina Moavero, Giorgia Sforza, Samuela Tarantino, Massimiliano Valeriani
Headache Center Bambino Gesù Children Hospital, Rome Italy Correspondence:Laura Papetti ([email protected]) The Journal of Headache and Pain2018,19(Suppl 1):O52
Introduction
Primary new daily persistent headache (NDPH) is a rare disorder of children and adults defined by the onset of daily headaches with distinct and clearly-remembered onset, with pain becoming continuous and unremitting within 24 hours and present for >3 months. The pain lacks characteristic features, and may be migraine-like or tension-type-like, or have elements of both. Our aim was to investigate the clinical features of NDPH in a cohort of pediatric patients.
Methods
We retrospectively reviewed the charts of patients attending the Headache Centre of Bambino Gesú Children from the last ten years with history of persistent daily headache. The ICHD-III criteria were used for diagnosis. Statistical analysis was conducted by SPPS version 22.0 andχ2 test was used to study possible correlations between: - NDPH and population features (age and sex); - NDPH and headache qualitative features; - NDPH and response to prophylactic therapies. Fig. 1 (abstract O50).Headache days per month analgesics (p<0.001)
Results
We included 377 patients with CPH (66.4% female, 33.6% male, age between 0 and 18 years). The frequency of NADPH was 13% (49/