Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
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Review
When should "chronic migraine" patients be considered "refractory" to pharmacological prophylaxis?
Patients with chronic headache forms evolving from a previous episodic migraine ('chronic migraine') are often difficult to treat. In this paper we focus attention on aspects we believe important for producing a definition of "refractory" in relation to this headache form. We propose a "chronic migraine" patient should be considered "refractory" to pharmacological prophylaxis when adequate trials of preventive therapies at adequate doses have failed to reduce headache frequency and improve headache-related disability and, in patients with medication overuse, reduce the consumption of symptomatic drugs. However before a definition of "refractory" chronic migraine can become established, generally accepted diagnostic criteria and treatment guidelines for this condition need to be developed.
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The field of neuromodulation is emerging as a promising and alternative therapeutical option for many drug-resistant clinical conditions, including painful syndromes such as refractory chronic cluster headache (CCH) and trigeminal neuralgia. We here report a series of patients who have undergone Deep Brain Stimulation (DBS) of Posterior Hypothalamus for chronic cluster headache, trigeminal neuralgia and atypical facial pain, matching their corresponding clinical results and also suggesting a role for Great Occipital Nerve Stimulation (which is a much less invasive procedure) in the treatment of CCH. According to us, the refinement of surgical techniques and of metabolic and functional brain neuroradiological investigations will lead to a refinement of the therapeutical strategies in such patients.
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Clinical Trial
Oral contraceptive-induced menstrual migraine. Clinical aspects and response to frovatriptan.
Oral contraceptive-induced menstrual migraine (OCMM) is a poorly defined migraine subtype mainly triggered by the cyclic pill suspension. In this pilot, open-label trial we describe its clinical features and evaluate the efficacy of frovatriptan in the treatment of its acute attack. During the first 3 months of the study 20 women (mean age 32.2+/-7.0, range 22-46) with a 6-month history of pure OCMM recorded, in monthly diary cards, clinical information about their migraine. ⋯ Concomitant nausea and/or vomiting, photophobia and phonophobia decreased significantly after drug intake. OCMM is a severe form of migraine; actually its clinical features are not always exactly identified by the ICHD-II classification. However, treatment with frovatriptan 2.5 mg might be effective in its management.
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Migraine is known to be associated to particular psychological features. Cutaneous allodynia is a painful sensation or discomfort induced by a non-noxious stimulus, and is a frequent complaint during migraine attacks. The aim of this study was to compare the personality profile of allodynic and non-allodynic migraineurs to identify possible relationships between psychological aspects and the presence of allodynia. ⋯ No significant difference was found between the two groups in any area of the personality profile. The psychological profile seems not to affect the presence/absence of cutaneous allodynia in migraine patients. This reinforces the hypothesis that allodynia is a "somatic" symptom, not modified by psychological aspects.