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1.  Ophthalmoplegic “Migraine” or Recurrent Ophthalmoplegic Cranial Neuropathy: New Cases and a Systematic Review 
Journal of child neurology  2012;27(6):759-766.
Ophthalmoplegic migraine is a poorly understood neurologic syndrome characterized by recurrent bouts of head pain and ophthalmoplegia. By reviewing cases presenting to our centers in whom the phenotype has been carefully dissected, and systematically reviewing all published cases of ophthalmoplegic migraine in the magnetic resonance imaging (MRI) era, this review sets out to clearly define the syndrome and discuss possible etiologies. We found that in up to one-third of patients, the headache was not migrainous or associated with migrainous symptoms. In three-quarters of the cases involving the third nerve, there was focal nerve thickening and contrast enhancement on MRI. Observational data suggest systemic corticosteroids may be beneficial acutely. The etiology remains unclear, but may involve recurrent bouts of demyelination of the oculomotor nerve. “Ophthalmoplegic migraine” is a misnomer in that it is probably not a variant of migraine but rather a recurrent cranial neuralgia. A more appropriate name might be “ophthalmoplegic cranial neuropathy.”
doi:10.1177/0883073811426502
PMCID: PMC3562350  PMID: 22241707
ophthalmoplegic migraine; headache; aura; neuralgia
2.  Ophthalmoplegic migraine in a 15-year-old Ethiopian: case report and literature review 
The International Headache Society (IHS) defines ophthalmoplegic migraine (OM) as recurrent attacks of headache with migrainous characteristics, associated with paresis of one or more ocular cranial nerves (commonly the third cranial nerve), and in the absence of any demonstrable intracranial lesion other than MRI changes within the affected nerve. According to the IHS criteria, it is diagnosed when at least two attacks with migraine-like headaches are accompanied with, or followed within 4 days of onset by, paresis of one or more of the third, fourth or sixth cranial nerves. Parasellar, orbital fissure and posterior fossa lesions should be ruled out by appropriate investigations. It is unlikely that OM is a variant of migraine, since the headache often lasts for a week or more and there is a latent period of up to 4 days from the onset of headache to the onset of ophthalmoplegia. Furthermore, in some cases MRI shows gadolinium uptake in the cisternal part of the affected cranial nerve and this suggests that the condition may be a recurrent demyelinating neuropathy. In general, patients demonstrated a: (1) prolonged time for symptom resolution to occur (median time 3 weeks); (2) tendency for recurrent episodes to have more severe and persistent nerve involvement; (3) evidence of permanent neurological sequelae with recurrent episodes (30% of patients); (4) rapid improvement and shortened duration with corticosteroid therapy and; (5) transient, reversible MRI contrast enhancement of the affected cranial nerve (86% of patients). Different pathogenetic mechanisms, which include compressive, ischemic and inflammatory, have been suggested for OM. Here, a 15-year-old Ethiopian with recurrent attacks of headache and third nerve palsy is presented. The subsequent discussion focuses on current evidences with regard to the clinical characteristics, possible pathogenetic mechanisms and treatment. Finally, a brief discussion of the situation in Africa will be presented.
Electronic supplementary material
The online version of this article (doi:10.1007/s10194-008-0089-8) contains supplementary material, which is available to authorized users.
doi:10.1007/s10194-008-0089-8
PMCID: PMC3451755  PMID: 19129969
Ophthalmoplegic; Migraine
3.  Ophthalmoplegia starting with a headache circumscribed in a line-shaped area: a subtype of ophthalmoplegic migraine? 
Recurrent painful ophthalmoplegic neuropathy (RPON), formerly named ophthalmoplegic migraine (OM), is a rare condition characterized by the association of unilateral headaches and the ipsilateral oculomotor nerve palsy. The third cranial nerve is most commonly involved in the recurrent attacks. But it is still debated whether a migraine or an oculomotor neuropathy may be the primary cause of this disorder. Here, we report an elder patient who had a recurrent ophthalmoplegia starting with an unilateral headache circumscribed in an area shaped in a line linking the posterior-parietal region and the ipsilateral eye. And the headache had couple of features similar to that of migraine, such as past history of recurrent migraine attacks, accompaniments of nausea, vomiting, and phonophobia, response to flunarizine and sodium valproate. We may herein report a subtype of OM but not a RPON. This case report indicates that OM may exist as an entity and some OM may be wrongly grouped under the category of RPON in the current international headache classification.
doi:10.1186/1129-2377-15-19
PMCID: PMC3996493  PMID: 24739597
Recurrent painful ophthalmoplegic neuropathy; Ophthalmoplegic migraine; Migraine; Epicrania fugax; Neuralgia
4.  Is migraine with cranial nerve palsy an ophthalmoplegic migraine? 
The Journal of Headache and Pain  2007;8(2):119-122.
Ophthalmoplegic migraine (OM) is a rare form of primary headache. Because of its rarity, only a few cases, mostly symptomatic, are reported. We analyse nine cases among 52 973 adults who suffer from headaches with an oculomotor palsy firstly considered as OM. The study was retrospective and multicentric in a database set up in France. The aim of our investigation was to describe the clinical and radiological aspects of these cases and to discuss the diagnosis of OM. We demonstrate that the characteristics of the headaches were identical to usual migraine without oculomotor nerve palsy for each case. The study emphasises the difficulty of the OM diagnosis even with the new IHS criteria because of the rarity of having all characateristics. A wide heterogeneity was noted in cranial imagery and blood tests. We suggest adding the code of probable OM in the IHS classification to increase the knowledge and detection of this type of headache. A biological blood test and an MRI are systematically required to help clinicians in their diagnosis and to exclude alternative aetiology of headache with palsy.
doi:10.1007/s10194-007-0371-1
PMCID: PMC3476125  PMID: 17497265
Ophtalmoplegic migraine; Cranial nerve palsy; Migraine and ocular palsy
5.  Childhood steroid-responsive ophthalmoplegic migraine 
Ophthalmoplegic migraine (OM) is characterized by recurrent attacks of headache with paresis of ocular cranial nerves. Previously, it was classified as a variant of migraine, but recently, International Headache Classification (IHCD-II) has reclassified OM to the category of neuralgia. Presently, OM is considered a type of recurrent demyelinating cranial neuropathy. We report an adolescent girl with OM, who had been treated with steroid and showed dramatic improvement.
doi:10.4103/1817-1745.84414
PMCID: PMC3173922  PMID: 21977095
Demyelinating cranial neuropathy; migraine; neuralgia; ophthalmoplegia
6.  Ophthalmoplegic migraine and aberrant regeneration of the oculomotor nerve. 
A patient with ophthalmoplegic migraine developed aberrant regeneration of the oculomotor nerve. This finding supports the view that the oculomotor nerve lesion in ophthalmoplegic migraine is peripheral, but its rarity suggests that the underlying mechanism may be ischaemic rather than compression by an oedematous intracavernous internal carotid artery.
Images
PMCID: PMC1043754  PMID: 7426568
7.  Epigone migraine vertigo (EMV): a late migraine equivalent 
SUMMARY
Migrainous headache is determined by pathogenetic mechanisms that are also able to affect the peripheral and/or central vestibular system, so that vestibular symptoms may substitute and/or present with headache. We are convinced that there can be many different manifestations of vestibular disorders in migrainous patients, representing true different clinical entities due to their different characteristics and temporal relashionship with headache. Based on such considerations, we proposed a classification of vertigo and other vestibular disorders related to migraine, and believe that a particular variant of migraine-related vertigo should be introduced, namely "epigone migraine vertigo" (EMV): this could be a kind of late migraine equivalent, i.e. a kind of vertigo, migrainous in origin, starting late in the lifetime that substitutes, as an equivalent, pre-existing migraine headache. To clarify this particular clinical picture, we report three illustrative clinical cases among 28 patients collected during an observation period of 13 years (November 1991 - November 2004). For all patients, we collected complete personal clinical history. All patients underwent standard neurotological examination, looking for spontaneous-positional, gaze-evoked and caloric induced nystagmus, using an infrared video camera. We also performed a head shaking test (HST) and an head thrust test (HTT). Ocular motility was tested looking at saccades and smooth pursuit. To exclude other significant neurological pathologies, a brain magnetic resonance imaging (MRI) with gadolinium was performed. During the three months after the first visit, patients were invited to keep a diary noting frequency, intensity and duration of vertigo attacks. After that period, we suggested that they use prophylactic treatment with flunarizine (5 mg per day) and/or acetylsalicylic acid (100 mg per day), or propranolol (40 mg twice a day). All patients were again recommended to note in their diary the frequency and intensity of both headache and vertigo while taking prophylactic therapy. Control visits were programmed after 4, 12 and 24 months of therapy. All patients considerably improved symptoms with therapy: 19 subjects (68%) reported complete disappearance of vestibular symptoms, while 9 (32%) considered symptoms very improved. The subjective judgement was corroborated by data from patients diaries. We conclude that EMV is a clinical variant of typical migraine-related vertigo: a migraineassociated vertigo, headache spell independent, following a headache period, during the lifetime of a patient.
PMCID: PMC3970230  PMID: 24711685
Headache; Migraine vertigo; Epigone migraine vertigo; Motion sickness; Aura
8.  Chronic daily headache: old problems, new vistas 
The Journal of Headache and Pain  2000;1(Suppl 1):S5-S10.
In 1988 the problems concerning chronic daily headache (CDH) were neglected by the classification of the International Headache Society (IHS). More than ten years later, this issue is still debated, also in light of the foreseen revised classification. Several terms have been used to define the clinical picture of CDH, and different criteria have been proposed for the diagnosis of these forms. In most cases, CDH appears to evolve from an episodic migraine, but the temporal limits between an episodic and a no-longer episodic form of migraine are questionable. A decreased threshold for headache recurrence in CDH is currently hypothesized, and it may be due to either an impaired control system or a sensitization of the trigeminal neurons, occurring regardless of the original nature of headache. The identification of genetic alterations and neurobiological changes underlying the different forms of CDH may greatly facilitate any nosographic and therapeutical approach to this broad spectrum of disorders.
doi:10.1007/s101940070018
PMCID: PMC3611796
Key words Chronic daily headache; Tension-type headache; Migraine; Drug abuse; Nosography
9.  Post-epileptic headache and migraine. 
One hundred epileptic patients were questioned about their headaches. Post-ictal headaches occurred in 51 of these patients and most commonly lasted 6-72 hours. Major seizures were more often associated with post-epileptic headaches than minor attacks. Nine patients in this series of 100 also had migraine: in eight of these nine a typical, albeit a mild, migraine attack was provoked by fits. The post-ictal headache in the 40 epileptics who did not have migraine was accompanied by vomiting in 11 cases, photophobia in 14 cases and vomiting with photophobia in 4 cases. Furthermore, post-epileptic headache was accentuated by coughing, bending and sudden head movements and relieved by sleep. It is, therefore, clear that seizures provoke a syndrome similar to the headache phase of migraine in 50% of epileptics. It is proposed that post-epileptic headache arises intracranially and is related to the vasodilatation known to follow seizures. The relationship of post-epileptic headache to migraine is discussed in the light of current ideas on migraine pathogenesis, in particular the vasodilation which accompanies Leao's spreading cortical depression.
PMCID: PMC1032346  PMID: 3117978
10.  Migraine management in pregnancy 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 78.
Abstract:
Background:
Migraine and tension-type headache are primary headache disorders that occur during pregnancy. Most women with migraine improve during pregnancy. Some women have their first attack during pregnancy. Migraine can recur postpartum; it can also begin at that time. Women who have had menstrual migraine and migraine onset at menarche tend to experience no migraine during pregnancy. Not all migraines improve during pregnancy, however. Some women experience migraine for the first time during pregnancy.
Etiology:
Headaches caused by cerebral arteriovenous malformations often present as migraine with aura. Cerebral venous thrombosis (common during pregnancy and the puerperium) may manifest with migraine-like visual disturbance and headache.
Treatment:
Nondrug therapies (relaxation, sleep, massage, ice packs and biofeedback) should be tried first to treat migraine in women who are pregnant. For treatment of acute migraine attacks 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment.
Conclusions:
Migraine has also been recently postulated as one of the major risk factors for stroke during pregnancy and the puerperium. There is thus an urgent need for prospective studies of large numbers of pregnant women to determine the real existence and extent of the risks posed by migraine during pregnancy.
Keywords:
Migraine, Pregnancy, Headache
PMCID: PMC3571604
11.  Chronic migraine classification: current knowledge and future perspectives 
The Journal of Headache and Pain  2011;12(6):585-592.
In the field of so-called chronic daily headache, it is not easy for migraine that worsens progressively until it becomes daily or almost daily to find a precise and universally recognized place within the current international headache classification systems. In line with the 2006 revision of the second edition of the International Classification of Headache Disorders (ICHD-2R), the current prevailing opinion is that this headache type should be named chronic migraine (CM) and be characterized by the presence of at least 15 days of headache per month for at least 3 consecutive months, with headache having the same clinical features of migraine without aura for at least 8 of those 15 days. Based on much evidence, though, a CM with the above characteristics appears to be a heterogeneous entity and the obvious risk is that its definition may be extended to include a variety of different clinical entities. A proposal is advanced to consider CM a subtype of migraine without aura that is characterized by a high frequency of attacks (10–20 days of headache per month for at least 3 months) and is distinct from transformed migraine (TM), which in turn should be included in the classification as a complication of migraine. Therefore, CM should be removed from its current coding position in the ICHD-2 and be replaced by TM, which has more restrictive diagnostic criteria (at least 20 days of headache per month for at least 1 year, with no more than 5 consecutive days free of symptoms; same clinical features of migraine without aura for at least 10 of those 20 days).
doi:10.1007/s10194-011-0393-6
PMCID: PMC3208036  PMID: 22028184
Chronic migraine; Transformed migraine; Chronic daily headache; Chronic headache; Headache; Migraine
12.  Chronic migraine classification: current knowledge and future perspectives 
The Journal of Headache and Pain  2011;12(6):585-592.
In the field of so-called chronic daily headache, it is not easy for migraine that worsens progressively until it becomes daily or almost daily to find a precise and universally recognized place within the current international headache classification systems. In line with the 2006 revision of the second edition of the International Classification of Headache Disorders (ICHD-2R), the current prevailing opinion is that this headache type should be named chronic migraine (CM) and be characterized by the presence of at least 15 days of headache per month for at least 3 consecutive months, with headache having the same clinical features of migraine without aura for at least 8 of those 15 days. Based on much evidence, though, a CM with the above characteristics appears to be a heterogeneous entity and the obvious risk is that its definition may be extended to include a variety of different clinical entities. A proposal is advanced to consider CM a subtype of migraine without aura that is characterized by a high frequency of attacks (10–20 days of headache per month for at least 3 months) and is distinct from transformed migraine (TM), which in turn should be included in the classification as a complication of migraine. Therefore, CM should be removed from its current coding position in the ICHD-2 and be replaced by TM, which has more restrictive diagnostic criteria (at least 20 days of headache per month for at least 1 year, with no more than 5 consecutive days free of symptoms; same clinical features of migraine without aura for at least 10 of those 20 days).
doi:10.1007/s10194-011-0393-6
PMCID: PMC3208036  PMID: 22028184
Chronic migraine; Transformed migraine; Chronic daily headache; Chronic headache; Headache; Migraine
13.  Brief migraine episodes in children and adolescents-a modification to International Headache Society pediatric migraine (without aura) diagnostic criteria 
SpringerPlus  2013;2:77.
The international Headache Society (I H S) diagnostic criteria (International classification of headache disorders edition 2- ICHD 2) for headache in children and adults improved the accuracy of migraine diagnoses. However many short duration headaches in children, receive an atypical migraine diagnosis. This study is to diagnose children and adolescents who presented with such atypical migraines of less than one hour duration. 1402 children and adolescents aged 5 to 15 years who presented with recurrent brief activity affected head pain, were studied. Known and common migraine triggers and family history of migraine were recorded in all. All the children studied had moderate to severe headache lasting 5 to 45 minutes which forced them motionless during the attacks (thus fulfilling 2 diagnostic pain features). At least one of the ICHD2 pediatric migraine diagnostic symptoms (nausea / vomiting / photophobia / phonophobia) were present in all. Two additional features were diagnostic of brief migraines in all of them- one of the parents or siblings was a migrainer and one of the common migraine triggers as a precipitating factor. This study concludes that if duration of head pain is less than one hour ,two additional features to be included to diagnose definitive migraine in children and adolescents - one migraine parent or sibling and one of the migraine triggers precipitating the head pain.
doi:10.1186/2193-1801-2-77
PMCID: PMC3602609  PMID: 23526480
Brief migraines; ICHD2; Modification; Common migraine triggers family history
14.  Combination of acupuncture and spinal manipulative therapy: management of a 32-year-old patient with chronic tension-type headache and migraine 
Journal of Chiropractic Medicine  2012;11(3):192-201.
Objective
The purpose of this case study is to describe the treatment using acupuncture and spinal manipulation for a patient with a chronic tension-type headache and episodic migraines.
Clinical Features
A 32-year-old woman presented with headaches of 5 months' duration. She had a history of episodic migraine that began in her teens and had been controlled with medication. She had stopped taking the prescription medications because of gastrointestinal symptoms. A neurologist diagnosed her with mixed headaches, some migrainous and some tension type. Her headaches were chronic, were daily, and fit the International Classification of Headache Disorders criteria of a chronic tension-type headache superimposed with migraine.
Intervention and Outcome
After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up.
Conclusion
The combination of acupuncture with chiropractic spinal manipulative therapy was a reasonable alternative in treating this patient's chronic tension-type headaches superimposed with migraine.
doi:10.1016/j.jcm.2012.02.003
PMCID: PMC3437348  PMID: 23449932
Acupuncture; Acupuncture analgesia; Headache disorders; Migraine headaches; Tension-type headaches
15.  Optimal management of severe nausea and vomiting in migraine: improving patient outcomes 
Migraine is a common and potentially disabling disorder for patients, with wide-reaching implications for health care services, society, and the economy. Nausea and vomiting during migraine attacks are common symptoms that affect at least 60% of patients suffering from migraines. These symptoms are often more disabling than the headache itself, causing a great burden on the patient’s life. Nausea and vomiting may delay the use of oral abortive medication or interfere with oral drug absorption. Therefore, they can hinder significantly the management and treatment of migraine (which is usually given orally). The main treatment of pain-associated symptoms of migraine (such as nausea and vomiting) is to stop the migraine attack itself as soon as possible, with the effective drugs at the effective doses, seeking if necessary alternative routes of administration. In some cases, intravenous antiemetic drugs are able to relieve a migraine attack and associated symptoms like nausea and vomiting. We performed an exhaustive PubMed search of the English literature to find studies about management of migraine and its associated symptoms. Search terms were migraine, nausea, and vomiting. We did not limit our search to a specific time period. We focused on clinical efficacy and tolerance of the various drugs and procedures based on data from human studies. We included the best available studies for each discussed drug or procedure. These ranged from randomized controlled trials for some treatments to small case series for others. Recently updated books and manuals on neurology and headache were also consulted. We herein review the efficacy of the different approaches in order to manage nausea and vomiting for migraine patents.
doi:10.2147/PROM.S31392
PMCID: PMC3798203  PMID: 24143125
migraine; nausea; vomiting; management; treatment
16.  Tackling chronic migraine: current perspectives 
Journal of Pain Research  2014;7:185-194.
In the last decade, several diagnostic criteria and definitions have been proposed for chronic migraine (CM). The third edition of the International Classification of Headache Disorders–3 beta, published in 2013, has revised CM diagnostic criteria. CM is defined as “headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month.” Patients who meet the criteria for CM and for medication-overuse headache should be given both diagnoses. Worldwide, CM prevalence ranges 1%–3%, and its incidence has been estimated to be 2.5% per year. CM is associated with disability and poor quality of life. Modifiable risk factors include (among others): migraine progression (defined as an increase in frequency and severity of migraine attacks); medication and caffeine overuse; obesity; stressful life events; and snoring. CM patients have a significantly higher frequency of some comorbid conditions, including chronic pain, psychiatric disorders, respiratory illness, and some vascular risk factors. Management includes identification and control of comorbidities and risk factors that predispose to CM; treatment and prevention for medication overuse; early treatment for migraine attacks; and an adequate preventive therapy for CM. Several randomized controlled clinical trials have shown the efficacy of topiramate, amitriptyline, onabotulinumtoxinA, and cognitive-behavioral therapy in CM.
Video abstract
doi:10.2147/JPR.S61819
PMCID: PMC3986300  PMID: 24748814
chronic daily headache; chronic migraine; epidemiology; medication overuse headache; risk factors; treatment
17.  The prognosis of childhood abdominal migraine 
Archives of Disease in Childhood  2001;84(5):415-418.
AIMS—To determine the clinical course of childhood abdominal migraine, seven to 10 years after the diagnosis.
METHODS—A total of 54 children with abdominal migraine were studied; 35 were identified from a population survey carried out on Aberdeen schoolchildren between 1991 and 1993, and 19 from outpatient records of children in the same age group who had attended the Royal Aberdeen Children's Hospital. Controls were 54 children who did not have abdominal pain in childhood, matched for age and sex, obtained from either the population survey or the patient administration system. Main outcome measures were presence or resolution of abdominal migraine and past or present history of headache fulfilling the International Headache Society (IHS) criteria for the diagnosis of migraine.
RESULTS—Abdominal migraine had resolved in 31 cases (61%). Seventy per cent of cases with abdominal migraine were either current (52%) or previous (18%) sufferers from headaches that fulfilled the IHS criteria for migraine, compared to 20% of the controls.
CONCLUSIONS—These results support the concept of abdominal migraine as a migraine prodrome, and suggest that our diagnostic criteria for the condition are robust.


doi:10.1136/adc.84.5.415
PMCID: PMC1718772  PMID: 11316687
18.  Clinical diagnosis and computer analysis of headache symptoms. 
The headache histories obtained from clinical interviews of 600 patients were analysed by computer to see whether patients could be separated systematically into clinical categories and to see whether sets of symptoms commonly reported together differed in distribution among the categories. The computer classification procedure assigned 537 patients to the same category as their clinical diagnosis, the majority of discrepancies between clinical and computer classifications involving common migraine, tension-vascular and tension headache. Cluster headache emerged as a clearly-definable syndrome, and neurological symptoms during headache were most prevalent in the classical migraine group. However, the classical migraine, common migraine, tension-vascular and tension headache categories differed in terms of the number, rather than the nature, of common migraine features. Whether the two extremes of this migraine-tension headache spectrum are different disorders can be determined only by studies of their pathophysiology.
Images
PMCID: PMC1027680  PMID: 6707652
19.  Migraine and behavior in children: influence of maternal headache frequency 
The Journal of Headache and Pain  2012;13(5):395-400.
We took advantage of a large population study in order to measure child behavior, as captured by the Child Behavior Checklist (CBCL) as a function of headache status in the children and their mothers. Of the target sample, consents and analyzable data were obtained from 1,856 families (85.4 %). Headache diagnoses were defined according to the second edition of the International Classification of Headache Disorders, and behavioral and emotional symptoms were assessed by the validated Brazilian version of the CBCL. We calculated the relative risk of abnormalities in the CBCL domains as a function of headache status in the children, after adjusting by a series of main effect models. Children with migraine were more likely to present abnormal scores in several of the CBCL scales, relative to children without migraine, and maternal migraine status contributed little to the model. However, when the mother had daily headaches, both children with and without migraine had similar CBCL scores. In multivariate analyses, migraine status in the children predicted CBCL scores (p < 0.01). Headache status and headache frequency in the mother did not predict CBCL scores in children with migraine but predicted in children without migraine (p < 0.01). The burden of migraine to the family is complex. Children with migraine are more likely to have behavioral and emotional symptoms than children without migraine. Children without migraine may be affected, in turn, by frequent headaches experienced by their mothers.
doi:10.1007/s10194-012-0441-x
PMCID: PMC3381068  PMID: 22460944
Headache; Migraine; Psychiatric comorbidity; Maternal headache; Childhood; Epidemiology
20.  Migraine, cerebrovascular disease and the metabolic syndrome 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S72-S77.
Evidence is emerging that migraine is not solely a headache disorder. Observations that ischemic stroke could occur in the setting of a migraine attack, and that migraine headaches could be precipitated by cerebral ischemia, initially highlighted a possibly association between migraine and cerebrovascular disease. More recently, large population-based studies that have demonstrated that migraineurs are at increased risk of stroke outside the setting of a migraine attack have prompted the concept that migraine and cerebrovascular disease are comorbid conditions. Explanations for this association are numerous and widely debated, particularly as the comorbid association does not appear to be confined to the cerebral circulation as cardiovascular and peripheral vascular disease also appear to be comorbid with migraine. A growing body of evidence has also suggested that migraineurs are more likely to be obese, hypertensive, hyperlipidemic and have impaired insulin sensitivity, all features of the metabolic syndrome. The comorbid association between migraine and cerebrovascular disease may consequently be explained by migraineurs having the metabolic syndrome and consequently being at increased risk of cerebrovascular disease. This review will summarise the salient evidence suggesting a comorbid association between migraine, cerebrovascular disease and the metabolic syndrome.
doi:10.4103/0972-2327.100015
PMCID: PMC3444221  PMID: 23024568
Comorbidities; metabolic syndrome; migraine; obesity; stroke
21.  Improvement of migraine headaches in severely obese patients after bariatric surgery 
Neurology  2011;76(13):1135-1138.
Objectives:
Research increasingly suggests that obesity is an exacerbating factor for migraine. However, it is less clear whether weight loss may help to alleviate migraine in obese individuals. We examined whether weight loss after bariatric surgery is associated with improvements in migraine headaches.
Methods:
In this prospective observational study, 24 patients who had migraine according to the ID-Migraine screener were assessed before and 6 months after bariatric surgery. At both time points, patients had their weight measured and reported on frequency of headache days, average headache pain severity, and headache-related disability over the past 90 days via the Migraine Disability Assessment questionnaire. Changes in headache measures and the relation of weight loss to these changes were assessed using paired-sample t tests and logistic regression, respectively.
Results:
Patients were mostly female (88%), middle-aged (mean age 39.3), and severely obese (mean body mass index 46.6) at baseline. Mean (±SD) number of headache days was reduced from 11.1 ± 10.3 preoperatively to 6.7 ± 8.2 postoperatively (p < 0.05), after a mean percent excess weight loss (%EWL) of 49.4%. The odds of experiencing a ≥50% reduction in headache days was related to greater %EWL, independent of surgery type (p < 0.05). Reductions in severity were also observed (p < 0.05) and the number of patients reporting moderate to severe disability decreased from 12 (50.0%) before surgery to 3 (12.5%) after surgery (p < 0.01).
Conclusions:
Severely obese migraineurs experience marked alleviation of headaches after significant weight reduction via bariatric surgery. Future studies are needed to determine whether more modest, behaviorally produced weight losses can effect similar migraine improvements.
Classification of evidence:
This study provides Class III evidence that bariatric surgery is associated with reduction of migraine headaches in severely obese individuals.
doi:10.1212/WNL.0b013e318212ab1e
PMCID: PMC3068014  PMID: 21444898
22.  Pure menstrual migraine with sensory aura: a case report 
The Journal of Headache and Pain  2012;13(5):431-433.
Hormonal changes related to the menstrual cycle have a great impact on migraines in women. Menstrual migraine attacks are almost invariably without aura. Categorizing migraines into menstrual or non-menstrual types is one way to stratify migraines without aura according to the appendix criteria of the International Classification of Headache Disorders. We report a peri-menopausal woman whose sensory aura exclusively heralded menstrual migraine. A 51-year-old woman had suffered from monthly episodic headaches since the age of 46. Before a headache, and within 1 h on the first day of her menstruation, she always experienced numbness in her entire left upper limb. After the sensory aura, migrainous headaches occurred with nausea and photophobia. In the postmenopausal period, she no longer had sensory aura, and her headache pattern changed and became less severe. Her physical and neurologic exams as well as electroencephalography, brain magnetic resonance imaging, and conventional angiography were all normal. She fulfilled the diagnosis of pure menstrual migraine with typical sensory aura. To our knowledge, this is the first formal case report of pure menstrual migraine with aura.
doi:10.1007/s10194-012-0450-9
PMCID: PMC3381070  PMID: 22527036
Menstrual migraine; Migraine aura; Sensory aura; Peri-menopausal
23.  Persistent negative visual aura in migraine without headache: a case report 
Introduction
Persistent migraine aura without headache is an extremely rare condition. The International Headache Society defines various subtypes of migraines, including “persistent migraine aura without infarction” and “typical aura without headache.”
Case presentation
We describe the case of a 21-year-old Asian woman with a history of migraine without aura who had (as her first aura episode) persistent negative visual symptoms without headache for 6 months. We detected no lesions that could cause her persistent visual symptoms. Based on the patient’s history of migraine without aura and responsiveness to furosemide and lamotrigine, we concluded that the visual symptoms in this case were related to migraine visual auras.
Conclusions
Persistent visual aura without headache overlapped the criteria for the two migraine subtypes mentioned above and thus did not fit an exact diagnosis. Therefore, we assert that new criteria are needed to encompass uncertain visual symptoms of migraine aura.
doi:10.1186/1752-1947-8-61
PMCID: PMC3938319  PMID: 24552492
Aura; Cortical spreading depression; Criteria; Headache; Migraine
24.  Frequent analgesics consumption in migraineurs: comparison between chronic and episodic migraineurs 
To assess the frequent consumption of symptomatic medications in migraineurs, we consecutively recruited 536 migraineurs from a headache clinic. Among them, 194 (36.2%) had chronic migraine and 342 had episodic migraine. When grouped according to duration of headache, the proportion of patients with chronic migraine increased from 25.5% to 50.9% as headache history increased from <1 to >20 years. The percentage of patients with frequent analgesics consumption also increased with the duration of headache, in patients with both chronic migraine (from 25.0% to 85.7%) and episodic migraine (from 20.0% to 59.3%). Nonetheless, patients with chronic migraine had a higher prevalence of frequent consumption of abortive medications than patients with episodic migraine regardless of duration of headache history, and the common odds ratio across strata of headache duration was 2.8 (95% confidence interval, 1.9–4.1). However, we found that a long headache history is an important risk factor for frequent consumption of symptomatic medications in migraineurs in patients with both episodic migraine and chronic migraine.
doi:10.1007/s10194-004-0065-x
PMCID: PMC3452147
Chronic daily headache; Chronic migraine; Drug overuse
25.  The primary headaches: genetics, epigenetics and a behavioural genetic model 
The primary headaches, migraine with (MA) and without aura (MO) and cluster headache, all carry a substantial genetic liability. Familial hemiplegic migraine (FHM), an autosomal dominant mendelian disorder classified as a subtype of MA, is due to mutations in genes encoding neural channel subunits. MA/MO are considered multifactorial genetic disorders, and FHM has been proposed as a model for migraine aetiology. However, a review of the genetic studies suggests that the FHM genes are not involved in the typical migraines and that FHM should be considered as a syndromic migraine rather than a subtype of MA. Adopting the concept of syndromic migraine could be useful in understanding migraine pathogenesis. We hypothesise that epigenetic mechanisms play an important role in headache pathogenesis. A behavioural model is proposed, whereby the primary headaches are construed as behaviours, not symptoms, evolutionarily conserved for their adaptive value and engendered out of a genetic repertoire by a network of pattern generators present in the brain and signalling homeostatic imbalance. This behavioural model could be incorporated into migraine genetic research.
doi:10.1007/s10194-008-0026-x
PMCID: PMC2276243  PMID: 18345478
Migraine; Tension-type headache; Cluster headache; Genetics; Epigenetics

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