Cephalalgia最新文献

Background/AimPersistent idiopathic facial pain (PIFP) is a rare condition with a lifetime prevalence of approximately 0.03%. It is characterized by persistent daily facial pain without identifiable cause and presents diagnostic and therapeutic challenges due to unknown pathophysiology, symptom overlap with other painful disorders, and limited evidence-based treatments. The aim of this Delphi study was to establish international consensus-derived guidelines for the management of patients with PIFP.MethodsA three-round Delphi study was conducted with 16 international pain experts, each with ≥10 years of clinical experience in pain management and extensive peer-reviewed publications. The first round involved open-ended questions, and the qualitative data were analyzed using systematic text condensation, resulting in a quantitative questionnaire with 42 statements. Subsequent rounds employed Likert-scale responses to these statements. Consensus was defined as ≥80% agreement or disagreement. In addition, if 11-12 (68-75 percent) out of the 16 experts agreed or disagreed, consensus was not reached, but a majority was considered to have a particular opinion.ResultsConsensus was reached in 35 out of the 42 statements (83%), emphasizing multidisciplinary collaboration and avoidance of invasive procedures in the treatment of PIFP. In an additional three statements (7%) a majority of the experts agreed with each other. In four statements (10%), no consensus or majority was reached. Pharmacological treatments, including tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids, may be considered; however, opioids should generally be avoided in the treatment of PIFP. Patient education and behavioral therapies are important interventions, and the most important measure of therapeutic success is improved quality of lifeConclusionThe present Delphi study has established internationally derived consensus guidelines and recommendations for the evaluation and comprehensive management of patients with PIFP. This is a first step in gathering knowledge for future evidence-based guidelines and more specific treatment recommendations. These international expert consensus guidelines recommend a multi- or interdisciplinary approach in managing PIFP, avoiding invasive interventions and prioritizing patient-centered outcomes.

BackgroundChronic migraine (CM) is highly disabling, and many patients fail to respond to monotherapy with approved preventive treatments. OnabotulinumtoxinA (BoNTA) and atogepant act on distinct but complementary targets within the trigeminovascular system and may exert additive or synergistic effects when used together. Real-world data on their combination remain scarce.MethodsWe prospectively analyzed adult patients with CM who had received at least three prior BoNTA cycles and initiated atogepant 60 mg/day for a minimum of 24 weeks as add on to BoNTA. Co-primary outcomes were changes in monthly migraine days (MMDs) and ≥50% response rate at 24 weeks. Secondary outcomes included disability, medication use, tolerability and subgroup comparisons by prior monoclonal antibodies exposure.ResultsAmong 101 patients, 82 completed 24 weeks of co-treatment. Mean MMDs decreased by 6.5 days (p < 0.001) and 45.1% of patients achieved a ≥50% reduction. Acute medication days decreased by 6.0 (p < 0.001) and Headache Impact Test-6 scores improved significantly (mean change: -4.0; p < 0.001). Patient's Global Impression of Change scores indicated moderate-to-great improvement. Anti-calcitonin gene-related peptide naïve patients experienced larger reductions in MMDs (-7.75 vs. -5.87) and disability scores compared to non-naïve patients. Multivariable analysis identified only baseline acute medication use as predictor of response. Adverse events were mild and consistent with known safety profiles for both drugs separately; no novel safety concerns emerged.ConclusionsThe addition of atogepant to BoNTA might be effective and well tolerated in real-world setting, including CM patients previously exposed to multiple preventives. Prospective controlled trials and health-economic evaluations are warranted to validate these observations and inform future clinical guidelines.

BackgroundEvoked potentials are widely used to investigate sensory and nociceptive processing abnormalities in migraine. However, electrophysiological distinctions between migraine subtypes remain insufficiently characterized in the literature. The aim was to systematically review and summarize neurophysiological abnormalities in evoked potential studies (visual, auditory, brainstem, somatosensory and laser) in migraine patients, with a particular focus on latency, amplitude, habituation and clinical correlations across subtypes and healthy controls.MethodsFollowing PRISMA guidelines, we searched PubMed, EMBASE and Web of Science for studies, terms included "Migraine Disorders," "Migraine," "Vestibular Diseases" and "Evoked Potentials", which were published from 2000 to 2024 were included. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.ResultsIn total, 813 studies were screened, resulting in 55 studies meeting the inclusion criteria. Patients with migraine with aura demonstrated higher amplitudes and asymmetry of visual evoked potentials compared to those with migraine without aura. Habituation deficits were particularly evident across all types of evoked potentials. A few studies compared chronic and episodic migraine, reporting higher brainstem and somatosensory evoked potential amplitudes in chronic migraine.ConclusionsMigraine patients have a consistent habituation deficit on all evoked potential parameters. Migraine with aura and chronic migraine may have higher cortical excitability. Further research with larger sample sizes, standardized methodologies and an accurate comparison of migraine phases will enlighten our understanding of the migraine subtypes.Trial RegistrationPROSPERO ID: CRD42024502803.

BackgroundGreater occipital nerve block (GONB) has become an established treatment for migraine. Though numerous systematic reviews and randomised control trials (RCTs) are cited as supporting evidence, the quality and consistency of this data remains unclear.MethodsAn umbrella review of systematic reviews investigating GONB for migraine was conducted. Additionally, an independent systematic review and meta-analysis of relevant RCTs was performed in accordance with PRISMA guidelines. Both evaluated MEDLINE ('PubMed'), Embase, and CENTRAL databases.ResultsNine relevant systematic reviews were identified; all had significant limitations and/or contained methodological errors. The reviews had been cited 256 times. None were eligible for statistical analysis.Sixteen RCTs (930 patients) and seven RCTs (401 patients) were included for qualitative and quantitative analyses respectively. Studies were heterogeneous in their methodologies. No serious adverse effects were identified. With moderate certainty, local anaesthetic (LA) GONB reduces headache severity in acute migraine attacks at 30 min (-2.08; p < 0.001). With low certainty, weekly bilateral LA GONB injections reduce headache severity (-1.33; p < 0.001) and monthly headache days (-4.46; p < 0.001) at one month for chronic migraine. Sustained benefits of GONB remain unclear. Data was insufficient to analyse the efficacy of steroid GONB, LA-steroid GONB, nor unilateral GONB for chronic migraine, and GONB - of any type - for episodic migraine.ConclusionsThere is limited RCT evidence supporting GONB for the treatment of migraine. Existing systematic reviews should be interpreted with caution. RCTs with homogeneous methodologies are required to evaluate GONB in the management of disability in migraine.Trial RegistrationPROSPERO registration ID: CRD42024595492.

BackgroundEmerging evidence highlights the role of microRNAs (miRNAs) in epigenetic mechanisms related to migraine pain. The expression of miR-382-5p and miR-34a is higher in serum and peripheral blood mononuclear cells of people with migraine, but limited data is available regarding their possible alteration in other cell subtypes. Several lines of evidence support a monocyte dysfunction in migraine pathophysiology. To gain deeper insights into cell-specific miRNAs expression in migraine individuals with different disease severity, this study aims to determine the expression levels of miR-34a and miR-382-5p in monocytes.MethodsThis cross-sectional, controlled study included 47 participants with episodic migraine (EM, 72.3% females, 41.4 ± 10.7 years), 32 with chronic migraine with medication overuse (CM-MO, 81.3% females, 46.1 ± 10.9 years) and 30 healthy controls (HCs, 66.7% females, 42.9 ± 14.8 years). We assessed interictal monocyte-specific miR-382-5p and miR-34a expression by qRT-PCR, normalizing the expression with U6 RNA (relative quantification - RQ).ResultsmiR-382-5p monocytic expression was higher in EM (4.21 ± 1.41 RQ) and CM-MO (6.80 ± 4.37 RQ) when compared to HCs (2.02 ± 0.64 RQ) (p = 0.005 for all comparisons). miR-34a monocytic expression was higher in EM (4.50 ± 1.62 RQ) and CM-MO (6.47 ± 1.87 RQ) when compared to HCs (1.94 ± 0.81 RQ, p = 0.005 for all comparisons). Expression of miR-382-5p and miR-34a were higher in CM-MO when compared to EM (p = 0.005 for both comparisons). After adjusting for age, sex, ongoing preventive medications, presence of anxiety or depressive symptoms, and smoking habit, a logistic regression model confirmed the differences in the monocytic expression of miR-34a and miR-382-5p between EM and CM-MO participants.ConclusionsOur findings underscore the relevance of miR-34a and miR-382-5p in migraine pathophysiology, as evidenced by their altered expression in monocytes from migraine participants compared to HCs. These miRNAs were also associated with disease severity, being higher in CM-MO when compared to EM individuals.Trial RegistrationThe study protocol was registered at ClinicalTrials.gov (NCT05891808).

BackgroundMigraine headache and complex regional pain syndrome share mechanisms, such as neuroinflammation, central sensitization and loss of inhibitory pain controls, that could provoke or exacerbate symptoms in both disorders. In the present study, it was hypothesized that headaches would worsen after the onset of complex regional pain syndrome and that limb pain would be more severe in patients with co-morbid headaches than in patients who remained headache-free. Notably, complex regional pain syndrome is associated with ipsilateral cranial symptoms such as photophobia and forehead hyperalgesia. Whether shared mechanisms might drive these symptoms was also explored.MethodsEighty-eight patients with complex regional pain syndrome were asked about their previous and current headache experience. The spatial distribution of pain was quantified from pain drawings, and hyperalgesia to mechanical and thermal stimulation was assessed in the limbs and forehead. In addition, the visual discomfort threshold was measured separately for each eye.ResultsSixty-six percent of patients reported that headaches (primarily migraine) had developed or worsened after the onset of complex regional pain syndrome and 22 percent now had daily or near-daily headaches. Limb pain and hyperalgesia were greater in such cases than in those with stable headaches or who remained headache-free. Photophobia and forehead hyperalgesia were greater ipsilateral than contralateral to symptoms of complex regional pain syndrome in patients with stable or worsening headaches but were symmetrical in headache-free patients. In addition, photophobia was symmetrical in patients with recurrent tension-type headaches. Patients with worsening headaches were younger at the onset of complex regional pain syndrome than patients with stable headaches or who were headache-free, in line with greater vulnerability to migraine in younger than older adults. In a subgroup of patients, the pain of complex regional pain syndrome extended from the upper limb to the ipsilateral dorsal cervical region, a documented source of pain in migraine. However, headaches ipsilateral to complex regional pain syndrome also recurred in patients with lower limb pain, indicating involvement of other pain mechanisms.ConclusionsTogether, the findings indicate that headaches with features of migraine develop after the onset of complex regional pain syndrome. In turn, this is associated with ipsilateral cranial symptoms and heightened limb pain. We suggest that shared pathophysiology increases susceptibility to ipsilateral cranial symptoms and exacerbates pain in both disorders, potentially in a positive loop. Breaking this cycle might permit otherwise intractable symptoms and pain to subside.

Background/AimPost-traumatic headache often resembles migraine or tension-type headache, but distinct phenotype and clinical characteristics necessitate further delineation. We aimed to characterize the clinical phenotype, headache patterns, associated features and comorbidities, medication patterns and functional impact of post-traumatic headache in an adult population following mild traumatic brain injury.MethodsThis is a cross-sectional analysis of a cohort of adults with post-traumatic headache after mild traumatic brain injury, by any mechanism, evaluated by a neurologist at an outpatient specialized concussion and headache center in Ontario, Canada between February 2021 and October 2023. Data were collected through standardized pre- and during-visit questionnaires. Descriptive statistics are presented.ResultsAmong 405 patients assessed by a neurologist for post-traumatic headache, median time since injury was 37 days (IQR: 13-126). Most patients reported headache 26 + days per month (292, 72.1%). Headache was continuous in 114 (28.1%), whereas in 215 (53.1%) it lasted hours to days. Headache location was unilateral in 174 (43.0%) and bilateral in 159 (39.3%). Headache quality was described as pulsating/throbbing in 260 (64.2%). The median severity was 7/10 (IQR 5-8). Aggravation by routine physical activity was reported in 287 (70.9%), nausea/vomiting in 279 (69.0%), photophobia in 358 (88.4%) and phonophobia in 337 (83.2%). There was no positional preference for 147 patients (36.3%), while 216 (53.3%) preferred lying down/reclined. Acute medication use frequency was reported as 3 + days per week in 218 (53.8%) and daily in 143 (35.3%). Within this cohort, 201 (49.6%) endorsed one or more psychiatric comorbidities. Only 66 (16.3%) had returned to full work/school attendance, while 169 (41.7%) were completely off usual occupational activities post-injury. One hundred seventy-eight (44.0%) reported pending litigation or insurance claims related to their injury, and/or having a work-related injury. Among the 183 (45.2%) who had undergone neuroimaging, 160 (87.9%) studies were reportedly normal, while there were 13 (7.1%) incidental findings and eight (4.3%) injury-related.DiscussionWhile select migraine features such as photophobia, phonophobia and worsening with routine physical activity are common in post-traumatic headache, there are also distinct features, including daily or near daily headache of long duration. The latter may suggest early sensitization in post-traumatic headache. There is an associated high risk of medication overuse headache, given frequent administration of acute medications, as well as high rates of psychiatric comorbidities and functional impairment. Future studies should aim to further delineate the longitudinal clinical, pathophysiological, and treatment response differences between post-traumatic headache and primary migraine.

BackgroundTo examine national trends in medication-overuse headache (MOH) hospitalisation rates, length of hospital stays, and patient demographics in Australia in the context of evolving access to medications implicated in MOH.MethodsA retrospective analysis of national hospital admissions data from the Australian Institute of Health and Welfare (AIHW), focusing on cases with a principal diagnosis of MOH from 2009 to 2024. MOH hospitalisation rates per 100,000 population and length of hospital stay were analysed over time and stratified by age group and sex.ResultsA total of 2480 MOH cases were identified over 16 years, including 1661 (67%) females and 954 (38.5%) individuals aged > 60 years. Overall MOH-related hospitalisation rates declined (IRR: 0.97; 95% CI: 0.96-0.98), as did the average length of stay per admission (-0.035 days/year; p = 0.036). Females were more likely to be admitted (IRR: 1.95; 95% CI: 1.79-2.12), as were older patients (IRR: 8.08; 95% CI: 6.77-9.65); however, longer stays were observed only among older patients (mean [SD]: 2.74 [0.48] vs. 2.21 [0.37] days; p = 0.005).ConclusionThis trend, occurring alongside rising migraine-related hospitalisations, the phasing out of ergotamine, and increased triptan use, may be partially attributed to the 2018 codeine rescheduling. Future studies using detailed prescription data are warranted to assess the long-term impact of medication policy changes on MOH trends.