Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
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Chronic daily headache that does not respond or no longer responds to prophylaxis is commonly encountered at specialist headache centres. Animal and brain imaging studies indicate that peripheral neurostimulation affects brain areas involved in pain modulation, providing a rationale for its use in these conditions. We examine problems related to the selection of chronic daily headache patients for peripheral neurostimulation. ⋯ These considerations suggest the need for extensive characterisation of patients proposed for neurostimulation. We propose that patients being considered for neurostimulation should be followed for at least a year, and that their headache over this time should consistently be frequent (all or most days) and drug refractory. We also propose that only completely drug-resistant (as opposed to partially drug-resistant) patients be considered for neurostimulation unless there are other indications.
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The diagnosis of medication overuse headache (MOH) is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications. Properly treating medication overuse and preventing relapse require recognition of the different factors that contribute to its development and perpetuation, including some behaviours and psychological elements that are important in sustaining the overuse of medication. This article reviews current clinical experiences of MOH patients treated with different approaches. Moreover, initial outcomes and long-term durability of treatments are discussed.
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Migraine is an episodic brain disorder that results in significant morbidity. Antiepileptic drugs (neuromodulators) are increasingly recommended for migraine prevention because of placebo-controlled double-blind trials that prove them effective. ⋯ Inhibition of trigeminocervical complex directly, or neurons that modulate sensory input, are also plausible mechanisms for the actions of neuromodulators in preventive therapy in migraine. Although it is unlikely that a single phenomenon serves as the only link between migraine and epilepsy, the neuronal hyperexcitability that may contribute to each condition may explain the effect of these drugs for both conditions.
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This paper reviews non-invasive behavioural approaches - broadly construed as cognitive, affective, behavioural and psychophysiological interventions - and examines whether they can impact central, peripheral or autonomic nervous system components responsive to pain in general and headache in particular. It focuses on two developing bodies of literature - neurophysiology of migraine and fMRI studies of pain networks. The available literature suggests behavioural interventions can affect neuromodulation, although further research is clearly warranted.
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Liability to spontaneous and experimental pain is genetically determined and there is considerable variability in the antinociceptive effects of drugs commonly used in treating pain conditions and migraine attacks. The causes for variability involve still unknown genetic aspects. Recently, a third gene, SCN1A, was discovered as a cause of familial hemiplegic migraine (FHM). ⋯ Catechol-O-methyltransferase (COMT) and the cytochrome P450 variant allele CYP3A5 modulate the genetic response to opioid medications in humans. Variability in drug pharmacokinetics and adverse drug reactions of pain medications are also very much related to genetic variation, especially in CYP genes. Pharmacogenomic studies of headache and pain are still in their infancy, but these recent advances in the genetics of migraine and pain arguably hold the promise of individualised treatments and prevention of adverse drug reactions.