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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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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Improvement in the biomedical and biotechnological research fields have allowed refinement of the neuromodulation approach in the treatment of a subgroup of medical disorders otherwise refractory to pharmacological treatment, such as chronic primary headaches. Chronic pain conditions imply central sensitisations and functional reorganisation that cannot be quickly or easily reversed. It appears evident that conventional treatment can sometimes be unsuccessful or only partially successful, and that relapse is common. ⋯ In 2000 these findings prompted a functional neurosurgery approach, with the first case of deep brain hypothalamic stimulation (DBS) in a severely disabled chronic CH patient. Since then, 18 implants in our centre and many others in different countries have been performed. Although the outcomes are encouraging, the invasive nature of the technique and the occurrence of rare but major adverse events have suggested a safer peripheral approach with occipital nerve stimulation (ONS).
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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 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.