Avi Ashkenazi

Objective: To determine whether adding triamcinolone to local anaesthetics increased the efficacy of greater occipital nerve block (GONB) and trigger-point injections (TPIs) for transformed migraine (TM). Methods: Patients with TM were randomised to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% + either saline or triamcinolone 40 mg. We assessed the severity of headache and associated symptoms before and 20 minutes after injection. Patients documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were compared between the two groups. Results: Thirty-seven patients were included. Twenty minutes after injection, mean headache severity decreased by 3.2 points in group A (pConclusions: Adding triamcinolone to local anaesthetics when performing GONB and TPIs was not associated with improved outcome in this sample of patients with TM.

Botulinum toxin type A (BoNT-A) has long been used to treat disorders associated with increased muscle tone. Support for an analgesic effect of BoNT-A independe

Migraine in some women is associated with changes in sex hormone levels. Many women suffer from increased frequency of migraine around the time of menses. Menstrual migraine (MM) may be more severe than migraine that occurs at other times of the cycle. The pathogenesis of MM is probably related to declining estrogen levels after exposure to high levels of the hormone for several days. The acute treatment of MM is similar to that of non-menstrually-related attacks. 5-HT(1B/1D) agonists (triptans), ergots, NSAIDs, or combination analgesics may be used, although the response to some drugs may not be as robust as that of non-menstrual attacks. Women who suffer from frequent or debilitating MM attacks may benefit from perimenstrual prophylaxis that can be either hormonal or non-hormonal.

Peripheral nerve blocks have long been used in headache treatment. The most widely used procedure for this purpose has been greater occipital nerve (GON) block. The rationale for using GON block in headache treatment comes from evidence for convergence of sensory input to trigeminal nucleus caudalis neurons from both cervical and trigeminal fibers. Although there is no standardized procedure for GON blockade, the nerve is usually infiltrated with a local anesthetic (lidocaine, bupivacaine, or both). A corticosteroid is sometimes added. Several studies suggested efficacy of GON block in the treatment of migraine, cluster headache, and chronic daily headache. However, few were controlled and blinded. Despite a favorable clinical experience, little evidence exists for the efficacy of GON block in migraine treatment. Controlled studies are needed to better assess the role of GON block in the treatment of migraine and other headaches.

Cutaneous allodynia is common in migraine. In the majority of previous studies on allodynia in migraine, only patients with episodic migraine (EM) were included. Little is known on patterns of allodynia in chronic migraine (CM). Since the presence of allodynia is associated with a poor response to triptans, a clinically practical method to test migraine patients for allodynia would be useful to the clinician. The aim of this study was to assess the prevalence of dynamic mechanical (brush) allodynia (BA) in CM, using a clinically practical method. Eighty-nine CM patients were prospectively recruited. Patients were given a structured questionnaire regarding demographic data and migraine characteristics. Allodynia was tested using a 10 x 10-cm gauze pad to brush various areas of the skin lightly. The prevalence of BA in the entire study population and in different patient subgroups was calculated. BA was present in 42.7% (38/89) of the patients. The presence of allodynia was unrelated to age, disease duration or to the occurrence of an acute headache exacerbation at the time of testing. Allodynia was positively associated with a history of migraine aura. BA was most common in the cephalic area, but was also seen in cervical dermatomes. BA is common in CM and, unlike in EM, is not significantly affected by the occurrence of an acute headache exacerbation. This suggests that central trigeminovascular neurons are chronically sensitized in patients experiencing migraine headache >15 days per month. The testing of BA in the clinical setting is possible using a simple and brief approach. It allows the clinician to determine whether the patient is sensitized, a diagnosis that affects treatment decisions.

Zonisamide is a new antiepileptic drug with multiple mechanisms of action and a favourable pharmacokinetic profile. Preliminary data suggest that zonisamide may be effective in migraine prophylaxis. We evaluated the efficacy and tolerability of zonisamide for migraine prophylaxis in refractory patients. We reviewed the charts of adult patients with International Headache Society-defined episodic migraine (EM) or with transformed migraine (TM) according to the Silberstein- Lipton criteria, who had been treated with zonisamide at our out-patient clinic for at least 60 days. Demographic data, zonisamide dosage and duration of treatment were collected and analysed. Headache frequency, attack duration, headache severity and headache-related disability before and after treatment initiation with zonisamide were compared. Thirty-three patients were included in the study (average age 43.9 ± 8.4 years; 23 (70%) with TM and 10 (30%) with EM). The patients had failed an average of 6.2 migraine prophylactic drugs prior to zonisamide. The average zonisamide daily dose was 337.9 ± 146.3 mg and the average duration of treatment was 186.4 ± 174.0 days. The average number of days with headache per month was reduced in the entire study population from 20.7 ± 9.5 before zonisamide treatment to 18.0 ± 11.3 after its initiation ( P = 0.06) [in TM from 24.7 ± 7.3 to 21.0 ± 10.7 ( P = 0.06); in EM from 11.6 ± 7.6 to 11.0 ± 9.7 ( P = NS)]. No significant changes in other headache parameters were found. Fourteen patients (42.4%) reported adverse events (AEs), the most common of which was fatigue. Most patients (12/14, 85.7%) rated AEs as mild or moderate. In this group of refractory migraine patients, zonisamide therapy did not result in a statistically significant beneficial effect on headache or on associated symptoms.

Allodynia has been described in migraine but has not been fully investigated for the different sensory modalities. The aim of this study was to compare the prevalence of dynamic (brush) and static (pressure) mechanical allodynia in migraine patients and to suggest a practical method of testing them in a clinical setting. Patients with International Headache Society-defined episodic migraine (EM) or with transformed migraine (TM) as defined by Silberstein and Lipton were prospectively recruited from the Jefferson Headache Center out-patient clinic. A questionnaire of migraine features and symptoms of allodynia was administered. Brush allodynia (BA) was tested by cutaneous stimulation with a gauze pad and pressure allodynia (PA) was tested using von Frey hairs (VFH). The prevalence of BA and PA in all patients and in the different subgroups was calculated and correlated with migraine features. We recruited 55 migraine patients. Twenty-five had EM and 30 had TM. BA was present in 18 (32.7±) patients and PA in 18–24 (32.7–43.6±). Allodynia to both brush and pressure was found in 13–17 (23.6–30.9±) patients. If a patient had allodynia to one modality only, it was more likely to be PA than BA. Both BA and PA were more common in patients with TM compared with those with EM [BA 46.7± vs. 16.0±; PA (differences significant for the medium and thick VFHs) 50± vs. 20± and 50± vs. 12±, respectively]. Both types of allodynia were also more common in patients with migraine with aura compared with those with migraine without aura (BA 57.1± vs. 17.6±; PA 57.1–61.9± vs. 17.6–32.7±). There was a positive correlation between allodynia score (as obtained by examination) and allodynia index (as obtained by history) for both BA and PA. The incomplete, although considerable, overlap between BA and PA suggests that allodynia to different sensory modalities is associated with sensitization of different neuronal populations. Because PA was more common than BA, it may be a more sensitive indicator of allodynia in migraine. PA can be tested clinically in a practical and systematic manner.