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1.  A systematic review of the psychosocial difficulties relevant to patients with migraine 
The Journal of Headache and Pain  2012;13(8):595-606.
Migraine is a common disease which causes significant burden to individuals, in terms of personal suffering and activity reduction, and to societies, in terms of disease cost. The purpose of this study is to identify the most relevant psychosocial difficulties related to migraine, the variables associated with them and the most relevant determinants of their evolution over time. MEDLINE and PsychINFO were searched for studies published in English between 2000 and 2010 that examined psychosocial difficulties in persons with migraine with and without aura, from clinical trials and observational studies. Information on the description of each difficulty, its determinants of onset and change over time and associated variables were extracted and categorized at a higher level. In total, 34 difficulties have been collected from 51 papers: the most frequent were reduced vitality and fatigue, emotional problems, pain, difficulties at work, general physical and mental health, social functioning and global disability. Evidence exists that pharmacological treatments have an impact toward improvement in patients’ difficulties, in particular emotional problems, physical and mental health, difficulties with employment and global disability. Migraine treatments and decreased headaches frequency are the major determinants of improvements in psychosocial difficulties, while no information is available for determinants of worsening; understanding the role of such factors is of primary public health relevance, given the high prevalence and the relevant personal and societal costs of migraine.
Electronic supplementary material
The online version of this article (doi:10.1007/s10194-012-0482-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s10194-012-0482-1
PMCID: PMC3484254  PMID: 23001069
Migraine; Disability; Preventive treatment; Symptomatic treatment; Pain; Headaches frequency
3.  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
4.  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
5.  Headache, anxiety and depressive disorders: the HADAS study 
The Journal of Headache and Pain  2010;11(2):141-150.
The objective of this paper was to assess prevalence and characteristics of anxiety and depression in migraine without aura and tension-type headache, either isolated or in combination. Although the association between headache and psychiatric disorders is undisputed, patients with migraine and/or tension-type headache have been frequently investigated in different settings and using different tests, which prevents meaningful comparisons. Psychiatric comorbidity was tested through structured interview and the MINI inventory in 158 adults with migraine without aura and in 216 persons with tension-type headache or migraine plus tension-type headache. 49 patients reported psychiatric disorders: migraine 10.9%, tension-type headache 12.8%, and migraine plus tension-type headache 21.4%. The MINI detected a depressive episode in 59.9, 67.0, and 69.6% of cases. Values were 18.4, 19.3, and 18.4% for anxiety, 12.7, 5.5, and 14.2%, for panic disorder and 2.3, 1.1 and 9.4% (p = 0.009) for obsessive–compulsive disorder. Multivariate analysis showed panic disorder prevailing in migraine compared with the other groups (OR 2.9; 95% CI 1.2–7.0). The association was higher (OR 6.3; 95% CI 1.4–28.5) when migraine (with or without tension-type headache) was compared to pure tension-type headache. This also applied to obsessive–compulsive disorder (OR 4.8; 95% CI 1.1–20.9) in migraine plus tension-type headache. Psychopathology of primary headache can reflect shared risk factors, pathophysiologic mechanisms, and disease burden.
doi:10.1007/s10194-010-0187-2
PMCID: PMC3452290  PMID: 20108021
Migraine; Tension-type headache; Depression; Anxiety; Prevalence
6.  Prophylaxis of migraine: general principles and patient acceptance 
Migraine is a chronic neurological condition with episodic exacerbations. Migraine is highly prevalent, and associated with significant pain, disability, and diminished quality of life. Migraine management is an important health care issue. Migraine management includes avoidance of trigger factors, lifestyle modifications, non-pharmacological therapies, and medications. Pharmacological treatment is traditionally divided into acute or symptomatic treatment, and preventive treatment or prophylaxis. Many migraine patients can be treated using only acute treatment. Patients with severe and/or frequent migraines require long-term preventive therapy. Prophylaxis requires daily administration of anti-migraine compounds with potential adverse events or contraindications, and may also interfere with other concurrent conditions and treatments. These problems may induce patients to reject the idea of a preventive treatment, leading to poor patient adherence. This paper reviews the main factors influencing patient acceptance of anti-migraine prophylaxis, providing practical suggestions to enhance patient willingness to accept pharmacological anti-migraine preventive therapy. We also provide information about the main clinical characteristics of migraine, and their negative consequences. The circumstances warranting prophylaxis in migraine patients as well as the main characteristics of the compounds currently used in migraine prophylaxis will also be briefly discussed, focusing on those aspects which can enhance patient acceptance and adherence.
PMCID: PMC2646645  PMID: 19337456
migraine; prophylaxis; preventive therapy; acceptance; adherence
7.  Topiramate in the prevention of migraine: a review of its efficacy, tolerability, and acceptability 
This paper reviews the results of placebo-controlled trials on topiramate (TPM) in the prophylaxis of migraine, focusing particularly on efficacy and tolerability of the target dose (100 mg/day). Data from well-conducted trials and analyses of pooled data show that TPM is effective against migraine, confirming the experience of physicians in various countries. High responder rate and good tolerability following slow titration suggest TPM as a first-line option for migraine prophylaxis. Patient acceptability may be enhanced by lack of weight gain, lack of major contraindications, and positive effects on quality of life.
PMCID: PMC2671823  PMID: 19412473
migraine; topiramate; prophylaxis; clinical trials; tolerability; acceptability
8.  Disability and migraine: recent outcomes using an Italian version of MIDAS 
The Journal of Headache and Pain  2003;4(Suppl 1):s42-s46.
Migraine is associated with functional impairment. The migraine disability assessment (MIDAS) questionnaire is a scientific instrument which captures headache-related disability. The Italian version of MIDAS was developed through a multistep standardized methodology. Studies on Italian clinical samples confirmed that migraine patients are disabled in all activity domains. Migraine exhibits a peculiar disability pattern: non-work activities are more affected than work activities; among patients in paid work, most continue working with a headache attack. We also found that MIDAS disability grades correlate with health-related quality of life scores at the SF-36 survey, namely with the extent to which physical health, emotional state and pain interfere with functioning in different roles. We conclude that MIDAS (also in its Italian version) is a reliable and useful instrument for assessing the impact of migraine on patients' daily activities, and that it can used not only in clinical practice but also in clinical research.
doi:10.1007/s101940300008
PMCID: PMC3611676
Key words Migraine; Disability; Migraine disability assessment questionnaire (MIDAS); Italian version; Disability pattern; Health-related quality of life
9.  The serotonergic system in migraine 
The Journal of Headache and Pain  2001;2(Suppl 1):s43-s46.
Serotonin (5–HT) and serotonin receptors play an important role in migraine pathophysiology. Changes in platelet 5–HT content are not casually related, but they may reflect similar changes at a neuronal level. Seven different classes of serotoninergic receptors are known, nevertheless only 5–HT2B–2C and 5HT1B–1D are related to migraine syndrome. Pharmacological evidences suggest that migraine is due to an hypersensitivity of 5–HT2B–2C receptors. m–Chlorophenylpiperazine (mCPP), a 5–HT2B–2C agonist, may induce migraine attacks. Moreover different pharmacological preventive therapies (pizotifen, cyproheptadine and methysergide) are antagonist of the same receptor class. On the other side the activation of 5–HT1B–1D receptors (triptans and ergotamines) induce a vasocostriction, a block of neurogenic inflammation and pain transmission.
doi:10.1007/s101940170008
PMCID: PMC3451809
Serotonin; Migraine; Triptans; m–Chlorophenylpiperazine; Pathogenesis
10.  Disability in migraine patients: Italian experience 
The Journal of Headache and Pain  2001;2(Suppl 1):s29-s31.
Migraine is associated with functional impairment. The migraine disability assessment (MIDAS) scale is a scientific instrument which captures headache–related disability. The Italian version of MIDAS was developed through a multi–step standardized methodology. Studies on Italian clinical samples showed that migraine patients were disabled in all activity domains. Non–work activities were more affected than work activities. Among patients in paid work, most continued working with a headache attack, although productivity was significantly reduced. The Italian MIDAS was used also in patients with transformed migraine and drug overuse. These patients were markedly disabled. MIDAS scores were higher than those found in migraine patients. When disability was assessed after 6 months from withdrawal therapy, MIDAS scores were significantly lower than at baseline. Our results confirmed the negative impact of the lives of headache patients, and suggest the use of MIDAS as a sensitive outcome measure for monitoring patients’ progress.
doi:10.1007/s101940170006
PMCID: PMC3451815
Migraine; Disability; Transformed migraine; Migraine disability assessment (MIDAS); Outcome measure
11.  Disability and migraine: MIDAS 
The Journal of Headache and Pain  2001;2(Suppl 1):s25-s27.
Migraine is an heterogeneous disorder. Most patients are disabled both in work and in non–work activities. Different instruments to assess migraine–related disability have been developed. Among these, the migraine disability assessment (MIDAS) questionnaire is the most studied. Population–based studies have shown that MIDAS is a simple but reliable and scientifically sound instrument. This instrument improves patient–physician communication. It can help healthcare professionals to understand migraine severity in individual patients, and rapidly assess treatment needs (screening instrument). Furthermore, reduction in headache–related disability is a major goal of migraine treatment. Change in MIDAS score after treatment intervention may be a useful end point, both in everyday practice and in clinical trials. Ongoing studies will confirm the potential of MIDAS as a valid outcome measure.
doi:10.1007/s101940170005
PMCID: PMC3451820
Migraine; Disability; Migraine disability assessment (MIDAS) questionnaire; Communication; Outcome measure
12.  Menstrual migraine 
The Journal of Headache and Pain  2001;2(Suppl 1):s117-s119.
An association between migraine and menstruation can be ascertained by use of a diary for a minimum of three cycles. The pathophysiological and clinical peculiarities of menstrual migraine indicate that its management should differ from that of non–menstrual migraine. NSAIDS or migraine-specific medications (e.g. triptans) are often effective for the acute management of menstrual migraine. Preventive treatment is indicated when the attacks are long–lasting, severe and disabling and do not respond to acute treatments. Short–term prophylaxis (at the time of headache vulnerability) employs standard drugs such as magnesium, ergotamine or NSAIDs; triptans are currently being evaluated for short–term prophylaxis. If severe menstrual migraine attacks cannot be controlled by these, hormone therapy (percutaneous or transdermal estrogen) may be indicated. Antiestrogen agents (danazol, tamoxifen) are indicated only in rare resistant cases.
doi:10.1007/s101940170023
PMCID: PMC3451824
Menstruation; Migraine; Therapy; Sex hormones
13.  New strategies for the treatment of migraine attacks 
The Journal of Headache and Pain  2001;2(Suppl 1):s113-s115.
There is no consensus on which treatment strategy should be used in the acute therapy of migraine. A stratified care approach based on patient’s disabilty assessed by a valid instrument (the MIDAS questionnaire) has been proposed. An international controlled study, the DISC trial, showed that stratified care provided better clinical outcomes than step care across attacks or within attacks. An Italian study invited migraine patients with moderate– severe disability to treat 9 attacks according to one of two strategies: stratified care (i.e. triptans from the outset) or step care across attacks (i.e. with drug escalation from non–specific drugs to triptans, if the response was not satisfactory). This study should provide data useful for assessing the optimal treatment strategy in migraine.
doi:10.1007/s101940170022
PMCID: PMC3451825
Migraine;  Acute treatment; Step care; Stratified care; Triptans
14.  Quality of life and illness behaviour in chronic daily headache patients 
The Journal of Headache and Pain  2000;1(Suppl 1):S61-S65.
Chronic pathologies, above all those in which is present pain, can induce a considerable impairment in quality of life. The concept of illness behaviour is closely related to that of quality of life. It can be defined as the way to estimate and to react to one's own health status. In this study on chronic headache patients, the sickness impact profile (SIP) was used as a measure of illness-related quality of life. The way of experiencing the disease was moreover quantified by means of the illness behaviour questionnaire (IBQ). Patients with chronic headache showed a remarkable impairment in most of their daily activities. At the same time, they lived their illnesses poorly. The longer was chronic headache duration, the more disability was marked. Fermale gender was associated with a more severe profile, both in SIP and in IBQ.
doi:10.1007/s101940070029
PMCID: PMC3611797
Key words Quality of life; SIP; IBQ Disability; Illness; Behaviour; Chronic daily headache; Drug abuse
15.  Personality factors in chronic headache: evaluation with SCL-90R 
The Journal of Headache and Pain  2000;1(Suppl 1):S53-S56.
The psychopathological approach is fundamental in the study of chronic headache because it integrates the diagnosis of a pathology in which the symptom (headache) is the disease itself hiding in itself the deep message to decode. The Symptom Check List 90R(SCL-90R) is a scale of general evaluation of current psychopathology which can be self-administered by the patient. The scales of SCL-90R are correlated with those of the Minnesota Multiphasic Personality Inventory. Moreover the former test has the advantage of being shorter and more pratical so it was chosen to be used in this study on chronic headache. The results showed that the psychopathological profile of chronic headache patient is rather impaired in all the dimensions and indices measured by the test. No difference was found in the occurrence of psychopathological symptoms either between analgesic abusers and nonabusers, or among the three subtypes of chronic headache.
doi:10.1007/s101940070027
PMCID: PMC3611799
Key words SCL-90R; Psychopathological symptoms; Somatization; Chronic headache
16.  Clinical and descriptive analysis of chronic daily headaches 
The Journal of Headache and Pain  2000;1(Suppl 1):S27-S31.
With an ad hoc, previously validated clinical record, we analysed the headache characteristics in 245 patients (F, 78.4%, M, 21,6%; mean age, 43.1±12.9 years) affected by chronic daily headache (CDH) attending 9 Italian headache centers. Migraine without aura was the episodic headache preceding CDH in 72.3% of the cases. We divided CDH into 3 categories: chronic tension-type headache (CTTH), chronic coexisting migraine and tension-type headache (CCMTTH), and chronic migraine (CM). CCMTTH accounted for 46.5% of the cases, followed by CM (30.2%) and CTTH (23.3%). Female prevalence was more marked in CCMTTH and CM groups, in which episodic headache started earlier. Migraine without aura was the episodic headache preceding CDH not only in most cases of CCMTTH (83.0%) and CM (91.9%), but also in 25% of CTTH patients.
Analgesics misuse (abuse of weak analgesics and/or combination drugs in almost all the cases) prevailed among CCMTTH (61%) and CM (89%) patients with respect to CTTH patients (37%).
doi:10.1007/s101940070022
PMCID: PMC3611800
Key words Chronic daily headache; Chronic tension-type headache; Chronic coexisting migraine and tension-type headache; Chronic migraine
17.  Chronic daily headache: a Rorschach study 
The Journal of Headache and Pain  2000;1(Suppl 1):S57-S60.
The aim of this study was to describe the distinctive personality traits and their interest to the development of a chronic form of headache, by means of the Rorschach test, a projective approach, in an automated version compiled by a trained system (PRALP3). This study did not show the existence of a pathological structure in the chronic headache sufferer personality (in the psychiatric sense of the word). The most important finding is the admission that both neurosis associated with anxious-depressive elements and inhibited emotional overflowing are important factors in the genesis of chronic daily headache. This study does not exclude that other factors different from personality traits may also play a pathogenetic role in headache worsening. In other words, the development of chronic daily headache may be a patterned or learned response generated by the brain in relation to multiple inciting causes (stress, drug abuse) or individual predisposition (personality traits).
doi:10.1007/s101940070028
PMCID: PMC3611801
Key words Rorschach; Chronic daily headache; Abuse; Personality traits
18.  The importance of anxiety and depression as factors in chronicization of primary headaches 
The Journal of Headache and Pain  2000;1(Suppl 1):S45-S48.
A multicenter study was carried out in 10 Italian headache centers to investigate the prevalence of anxiety and depression in patients with chronic daily headache(CDH). The study investigated 219 patients (171 F; 48 M) including 53 cases of chronic tension-type headache (CTTH), 99 cases of CTTH+ migraine and 67 cases of transformed migraine (TM). The type of headache diagnosed at the beginning was episodic tension-type headache (ETTH, n=32), ETTH + migraine (n=2), CDH ab initio (n=22), migraine with/without aura (n=151), not classifiable migraine (n=7) and not classifiable headache (n=3). The assessment of anxiety and depression was carried out using a Zung self-rating scale for anxiety (Zung A) and for depression (Zung D). The results show that anxiety and depression levels, in each group, were related to sex (F>M). Anxiety, but not depression, was related to the length of chronicization process. Anxiety and depression did not correlate with type of headache at onset, with ongoing headache or, surprisingly, with the abuse of anti-inflammatory drugs. These data suggest the chronicization is a biological and psychological trait.
doi:10.1007/s101940070025
PMCID: PMC3611803
Key words Chronic daily headache; Anxiety; Depression; Overuse of analgesics; Zung scale
19.  Stress and chronic headache 
The Journal of Headache and Pain  2000;1(Suppl 1):S49-S52.
The aims of this study were to assess how stress affects chronic headaches, and in particular to determine whether events play a role in the transformation of an episodic headache into a chronic form. A population of 267 Italian patients with chronic headache (headache present on average more than 15 days per month) was studied. Our results confirm a triggering role of stress on headache. We also found that episodic headache (migraine in most patients, 74.1%) preceded the development of a chronic form in about 90% cases. Among these patients, in 44.8% a stressful event correlated with the transformation. Analysis of these events revealed that minor events played a greater role than major life events, suggesting that patients with transformed headache are characterised by a different way of reacting to stress.
doi:10.1007/s101940070026
PMCID: PMC3611807
Key words Chronic headache; Stress; Life events; Trigger factor; Migraine; Transformation of headache
20.  An Italian pilot study on the use of the migraine disability assessment questionnaire 
The migraine disability assessment questionnaire (MIDAS) is a recently developed, validated questionnaire for assessing the impact of migraine on individual patients. We carried out a pilot study to assess the stability and reliability of a preliminary Italian version of MIDAS, based on the original 6-item version. One hundred four patients with migraine without aura completed the MIDAS form during a session with a neurologist and again 21 days later. Eighhty-six patients (83%) returned the second form. Pearson's (r = 0.8) and Spearman's (r = 0.7) tests showed a good test-retest reliability for the scores obtained at first and second compilations. In the majority of patients, the disability grade was stable after 21 days (Wilcoxon signed rank test p > 0.05). Our preliminary adaptation of the MIDAS questionnaire is satisfactorily stable and highly reliable, preparing the way for definitive Italian version.
doi:10.1007/s101940050010
PMCID: PMC3611698
Key words Migraine; Disability; Migraine disability assessment questionnaire; MIDAS; Italian version; Reliability

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